Fonseca Ingles 4 PDF

oral &
maxillofacial
trauma fourth edition
ERRNVPHGLFRVRUJ
oral &
maxillofacial
trauma fourth edition
ERRNVPHGLFRVRUJ
EDITORS
RAYMOND J. FONSECA, DMD H. DEXTER BARBER, DDS
Private Practice Private Practice
Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery
Asheville, North Carolina Mesa and Laveen, Arizona
Clinical Professor, Department of Oral Adjunct Associate Professor
and Maxillofacial Surgery Temple University Hospital
University of North Carolina Department of Oral and Maxillofacial Surgery
Chapel Hill, North Carolina Philadelphia, Pennsylvania
ROBERT V. WALKER, DDS, FACD† MICHAEL P. POWERS, DDS, MS

Professor Emeritus Private Practice
Division of Oral and Maxillofacial Kent, Ohio
Surgery Robinson Memorial Hospital
University of Texas Southwestern Ravenna, Ohio
Medical Center
Dallas, Texas DAVID E. FROST, DDS, MS
Chairman, Board of Directors Private Practice
American Trauma Society Chapel Hill and Durham, North Carolina
Upper Marlboro, Maryland Clinical Adjunct Assistant Professor
University of North Carolina
Chapel Hill, North Carolina
†
Deceased
3251 Riverport Lane
St. Louis, Missouri 63043
ORAL AND MAXILLOFACIAL TRAUMA ISBN: 978-1-4557-0554-2

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Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Marilyn, the love of my life.
Ray
To Cam, Aubrey, and Katharine with love and admiration.

Michael P. Powers
To my loving wife, Claudia, who stands behind me when

I need support; in front of me when I need a shield; and
always beside me as my best friend, lover, soul-mate,
and spiritual guide. TAUIR! To our children: Ryan, Holly,
and Kyle, who survived my absences as I dedicated myself to
surgery. Thank you. And to R.V. Walker, who mentored and
guided Ray Fonseca and others, who in turn, helped me
and many others become surgeons in the truest sense of the
word. Gig ‘Em R.V. You are missed.
David E. Frost
I would like to dedicate this book to my wife, Kymberly;

my children, Taylor, David, and Noah; and to my parents,
Jesse and Hargrow Barber.
H. Dexter Barber
In Memoriam
D
r. Walker, fondly referred to as “R.V.,” dedicated
his long career to the discipline of oral and maxil-
lofacial surgery and the promotion of the spe-
cialty through research, education, administration and
service to patients. Robert V. Walker, “Bob” Walker,
R.V.Walker, was born September 21, 1924 in Satin, Texas.
Son of a hard-working farmer father and an education-
oriented mother, R.V. learned skills and attributes that
took him off the farm and well beyond. He started college
at Texas A&M in 1941, and his athletic abilities earned
him a place on the baseball team and a letter.
He won the Best-Drilled Cadet award due to motiva-
tion and dedication to the task at hand. When World War
II started, R.V., as a member of the Corps of Cadets, was
inducted into the military, went through basic training
and was sent back to Texas A&M until the army assigned
him to Baylor College of Dentistry in 1944. He graduated
from dental school in 1947, the same year he married
Emily Berger. One year of minor league baseball for the
Tulsa Oilers convinced him that dentistry was a more
reliable form of employment, so after dental school at
Baylor College of Dentistry, he started a general practice
in Waco, Texas. Being called to serve in the military once
more in the Korean War, he was assigned to Brook Army
Medical Center in San Antonio, mostly for his baseball
skills. While at San Antonio, he was introduced to oral
surgery and facial trauma in a major way and developed
his lifelong connection to trauma as a facet of oral and
maxillofacial surgery. Dr. Walker completed an oral
surgery residency in 1956 at Parkland Memorial Hospi-
tal. He joined the UT Southwestern faculty that same the American Cancer Society, and the Southwest Society
year, and 2 years later was named as professor of surgery of Oral and Maxillofacial Surgeons. He was chairman of
and chairman of oral and maxillofacial surgery, a posi- the Oral and Maxillofacial Surgery Foundation, which
tion he held until 1984. He remained on the full-time established the Robert V. Walker Society in his honor
faculty until 1997, when he was named professor in 1997.
emeritus. Dr. Walker received many awards, including distin-
He developed one of the top training programs in the guished service awards from the Texas Dental Association
country. While shaping a solid curriculum during his (2003), American Trauma Society (1992), and the
early years as chairman, he also worked diligently at the AAOMS (1981); the William J. Gies Foundation Award
national level. He helped establish essentials for the edu- in Oral and Maxillofacial Surgery (1976); and the Robert
cation and training of oral surgeons across the country V. Walker Chair in Oral and Maxillofacial Surgery at the
and helped create an accreditation system through the University of Texas Southwestern Medical School at
Council on Dental Education of the American Dental Dallas (1992). The annual meeting of the AAOMS was
Association (ADA), the American Board of Oral and dedicated to him in 1987, and he was elected to the
Maxillofacial Surgery (ABOMS), and the American Asso- Baylor College of Dentistry Hall of Fame in 1999. He was
ciation of Oral and Maxillofacial Surgeons (AAOMS). appointed professor emeritus of oral and maxillofacial
His early work with these associations eventually led to surgery at the University of Texas Southwestern Medical
the creation of a seat for the ADA on the Board of Com- School at Dallas in 1997.
missioners of the Joint Commission on Accreditation of Dr. Walker has received nearly three dozen awards and
Hospitals. He worked on the committee that helped honors from his peers in dentistry and oral surgery
launch the First International Conference on Oral and worldwide. Most notably, he was made a fellow of the
Maxillofacial Surgery, which was held at the Royal College Royal College of Surgeons of Ireland in 1973 and a fellow
of Surgeons in London in 1962. This led to the formation of the Royal College of Surgeons of England in 1984,
of the International Association of Oral and Maxillofacial where he gave the prestigious Charles Tomes Lecture.
Surgeons, of which Dr. Walker was a founding fellow. He He also served on the Baylor College of Dentistry Oral
served as president of that organization for many years. Health Foundation board of trustees. In September
He also served as president of the American Trauma 2012, Dr. Walker was posthumously named Distinguished
Society, the AAOMS, the ABOMS, the Texas Division of Alumni of Texas A&M University.
vi
In Memoriam vii
“There are 217 proud alumni of the program, of of oral and maxillofacial surgery are immeasurable,” said
whom 29 have been or are deans, chairs or program Dr. John Zuniga, current Chair of the program R.V. made
directors in the United States and beyond. Many of our internationally recognized.
graduates refer to him as the reason for their success, His leadership, mentorship, and friendship have
and RV knew each and every one of them by name— shaped and guided generations of Oral and Maxillofacial
where they lived, who they were married to, and what Surgeons and have helped us to treat patients and
their children were doing. That was the kind of man he educate peers throughout the world.
was. His contributions to our program and to the field
Robert V. Walker
1924 –2011
The Following JADA Article Appeared in May 1973
ix
Contributors
TARA L. AGHALOO, DDS, MD, PhD SHAHROKH C. BAGHERI, DMD, MD, FACS
Associate Professor Clinical Associate Professor
Section of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
UCLA School of Dentistry Georgia Health Sciences University
Los Angeles, California Augusta, Georgia
Clinical Assistant Professor
ISAM AL-QURAINY, PhD, MRCOPHTH, DO Department of Surgery
Associate Specialist in Ophthalmology Emory University School of Medicine
Department of Ophthalmology Emory University
Moorfields Eye Hospital Atlanta, Georgia
London, England Chief
Division of Oral and Maxillofacial Surgery
SAMUEL ALLEN, DDS Northside Hospital
Staff Member Atlanta, Georgia
Oral and Maxillofacial Surgery
British American Hospital H. DEXTER BARBER, DDS
Lima, Peru Private Practice
HARRY L. ANDERSON, III, MD Mesa and Laveen, Arizona
Attending Surgeon Adjunct Associate Professor
Department of Surgery, Division of Trauma and Temple University Hospital
Surgical Critical Care Department of Oral and Maxillofacial Surgery
St. Joseph Mercy Hopsital Philadelphia, Pennsylvania
Ann Arbor, Michigan
BRIAN BAST, DMD, MD
KEVIN ARCE, DMD, MD, FACS Associate Clinical Professor, Residency Program
Instructor in Surgery Director
Division of Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery
Department of Surgery University of California, San Francisco
Mayo Clinic San Francisco, California
Rochester, Minnesota
BARRY W. BECK, DDS, MD
SHARON ARONOVICH, DMD, FRCD(C) Former Resident
Clinical Assistant Professor Department of Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery and Hospital Dentistry Case Western Reserve University
Section Cleveland, Ohio
Department of Surgery Private Practice
University of Michigan Nashville, Tennessee
Ann Arbor, Michigan
R. BRYAN BELL, DDS, MD, FACS
MOHAMED K. AWAD, BDS, DDS Affiliate Professor
Temple University Hospital Oregon Health and Science University
Philadelphia, Pennsylvania Medical Director
Oral, Head, and Neck Cancer Program
SHAHID R. AZIZ, DMD, MD, FACS
Providence Cancer Center; Robert W. Frainz Cancer
Associate Professor
Research Center
Department of Oral and Maxillofacial Surgery
Attending Surgeon
New Jersey Dental School
Trauma Service/Oral and Maxillofacial Surgery Service
Division of Plastic Surgery
Legacy Emanuel Medical Center
Department of Surgery
Portland, Oregon
New Jersey Medical School
University of Medicine and Dentistry of New Jersey JEFFREY D. BENNETT, DMD
Newark, New Jersey Professor and Chair
Oral Surgery and Hospital Dentistry
Indiana University School of Dentistry
Indianapolis, Indiana
xvii
xviii Contributors
JAMES A. BERTZ, AB, MS, DDS, MD, FACS GORDON N. DUTTON, MD, FRCS (Hon) Ed, FRCOphth
Professor Doctor
Oral and Maxillofacial Surgery Tennent Institute of Ophthalmology
University of Texas, Dental Branch Gartnavel General Hospital
Houston, Texas Royal Hospital for Sick Children
Staff Professor
Oral and Maxillofacial Surgery Department of Vision Sciences
Scottsdale Health Care Glasgow Caledonian University
Scottsdale, Arizona Glasgow, Scotland
NORMAN J. BETTS, DDS, MS EDWARD ELLIS, III, DDS, MS

Adjunct Associate Professor Professor and Chair
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
School of Dentistry University of Texas Health Science Center at San
University of Michigan Antonio
Ann Arbor, Michigan San Antonio, Texas
Private Practice
Plymouth/Ann Arbor, Michigan HANY A. EMAM, BDS, MSc
Resident
JON P. BRADRICK, DDS Department of Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery Medical College of Georgia
Metrohealth Medical Center Georgia Health Sciences University
Cleveland, Ohio Augusta, Georgia
JACOB G. CALCEI RUI FERNANDES, MD, DMD, FACS

Medical Student Assistant Professor of Surgery
New York University School of Medicine University of Florida College of Medicine at
NYU Langone Medical Center Jacksonville
New York, New York Jacksonville, Florida
BERNARD J. COSTELLO, DMD, MD, FACS DERRICK FLINT, MD, DDS

Professor and Program Director Chief Resident
University of Pittsburgh University of California, San Francisco
Chief San Francisco, California
Department of Pediatrics Oral and Maxillofacial
Surgery MARILYN FONSECA
Children’s Hospital of Pittsburgh Asheville, North Carolina
Pittsburgh, Pennsylvania
RAYMOND J. FONSECA, DMD
LARRY L. CUNNINGHAM, JR., DDS, MD, FACS Private Practice
Professor and Chief, Division of Oral and Maxillofacial Oral and Maxillofacial Surgery
Surgery Asheville, North Carolina
Oral Health Sciences Clinical Professor, Department of Oral
University of Kentucky College of Dentistry and Maxillofacial Surgery
Lexington, Kentucky University of North Carolina
Chapel Hill, North Carolina
ROBERT I. DELO, DDS, MD
Colonel, US Air Force Medical Service EARL G. FREYMILLER, DMD, MD
Consultant to the US Air Force Surgeon General for Clinical Professor and Chair
Oral and Maxillofacial Surgery Section of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery UCLA School of Dentistry
Wilford Hall USAF Medical Center Los Angeles, California
Lackland AFB, Texas
DAVID E. FROST, DDS, MS
ATUL M. DESHMUKH, DMD Private Practice
Resident Chapel Hill and Durham, North Carolina
Oral and Maxillofacial Surgery Clinical Adjunct Assistant Professor
Temple University Hospital University of North Carolina
Philadelphia, Pennsylvania Chapel Hill, North Carolina
Contributors xix
MICHAEL GLADWELL, DMD, MD DEEPAK KADEMANI, DMD, MD, FACS

Resident in Training Associate Professor
Division of Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery
Department of Surgery University of Minnesota Medical Center
Mayo Clinic Minneapolis, Minnesota
Rochester, Minnesota
HUSAIN ALI KAHN, MD, DMD
BRENT A. GOLDEN, DDS, MD Private Practice
Assistant Professor Georgia Oral and Facial Surgery
Department of Oral and Maxillofacial Surgery McDonough, Georgia
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina VASILIKI KARLIS, DMD, MD, FACS
Associate Professor
PAUL E. GORDON, DMD, MD Director of AD Education Program in OAAS
Fellow Oral and Maxillofacial Surgery
Pediatric Oral and Maxillofacial Surgery NYU College of Dentistry
Massachusetts General Hospital NYU Langone Medical Center
Oral and Maxillofacial Surgery New York, New York
Boston, Massachusetts
BARRY D. KENDELL, DMD, MS
JAMES B. HOLTON, DDS, MSD Adjunct Assistant Professor
Clinical Associate Professor Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery University of North Carolina at Chapel Hill
University of Texas Health Sciences Center Chapel Hill, North Carolina
San Antonio, Texas
Chairman RUBA N. KHADER, BDS
Department of Oral and Maxillofacial Surgery Clinical Assistant Professor
East Texas Medical Center Division of Oral and Maxillofacial Surgery
Tyler, Texas University of Kentucky
Lexington, Kentucky
PAMELA HUGHES, DDS
Assistant Professor, Advanced Training Program ARASH KHOJASTEH, DMD, OMFS
Director Assistant Professor
Division of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
University of Minnesota Director of Basic Science Research
Minneapolis, Minnesota Faculty of Dentistry
Dental Research Center
MICHAEL S. JASKOLKA, DDS, MD Shahid Beheshti University of Medical Science
Clinical Instructor Tehran, Iran
Department of Surgery
Charleston Area Medical Center ANTONIA KOLOKYTHAS, DDS, MS
Charleston, West Virginia Assistant Professor
Adjunct Clinical Instructor Associate Program Director, Director of Research
University of North Carolina, School of Dentistry University of Illinois at Chicago
Chapel Hill, North Carolina Chicago, Illinois
Cleft, Oral and Craniomaxillofacial Surgeon
Co-Director, FACES, First Appalachian Craniofacial KYLE J. KRAMER, DDS, MS
Deformities Specialists Clinical Assistant Professor
Facial Surgery Center, FACES Oral Surgery and Hospital Dentistry
Charleston Area Medical Center Indiana University School of Dentistry
Charleston, West Virginia Indianapolis, Indiana
LEONARD B. KABAN, DMD, MD JANICE S. LEE, DDS, MD, FACS

Chair Associate Professor
Massachusetts General Hospital University of California at San Francisco
Walter C. Guralnick Professor San Francisco, California
Harvard School of Dental Medicine
xx Contributors
STUART E. LIEBLICH, DMD MARIA B. PAPAGEORGE, DMD, MS

Associate Clinical Professor Professor and Chair
University of Connecticut, School of Dental Medicine Tufts University School of Dental Medicine
Farmington, Connecticut Boston, Massachusetts
Private Practice
Avon Oral and Maxillofacial Surgery ASHISH A. PATEL, DDS, MD
Avon, Connecticut Resident
KRISTIAN I. MACDONALD, MD, FRCSC New York University Langone Medical Center
Doctor of Otolaryngology New York, New York
Department of Otolaryngology
Head and Neck Surgery DMITRY PEYSAKHOV, DMD
University of Toronto Resident
Toronto, Ontario, Canada Department of Oral and Maxillofacial Surgery
Temple University Hospital
MICHAEL R. MARKIEWICZ, DDS, MPH, MD Philadelphia, Pennsylvania
Resident
Department of Oral and Maxillofacial Surgery KIMBERLY PINGEL, DDS
Oregon Health and Science University Oral and Maxillofacial Surgery
Portland, Oregon University of Minnesota
Minneapolis, Minnesota
JANELLE E.K. MEUTEN, BS
Graduate Student PHILLIP PIRGOUSIS, DMD, MD
University of North Carolina at Chapel Hill Head/Neck Microvascular Fellow
Chapel Hill, North Carolina College of Medicine
University of Florida
MICHAEL MILORO, DMD, FACS Jacksonville, Florida
Professor and Chairman
Oral and Maxillofacial Surgery DAVID B. POWERS, DMD, MD, FACS, FRCS (Ed)
University of Illinois Colonel, US Air Force Medical Service
Chicago, Illinois Director, USAF Center for Sustainment of Trauma and
Readiness Skills (C-STARS)
ALISHA MORENO, BA Division of Plastic, Reconstructive and Maxillofacial
College of Medicine Trauma Surgery
The Ohio State University R Adams Cowley Shock Trauma Center
Columbus, Ohio Baltimore, Maryland
Research Assistant
Heart and Vascular Institute KATHARINE POWERS, BA
Cleveland Clinic Foundation Department of Neuroscience
Cleveland, Ohio Kenyon College
Gambier, Ohio
CHRISTOPHER D. MORRIS, DDS, MD School of Dental Medicine
Oral and Maxillofacial Surgery Case Western Reserve University
University of Texas Southwestern Center/Parkland Cleveland, Ohio
Dallas, Texas
MICHAEL P. POWERS, DDS, MS
HOSSEIN MORTAZAVI MD, DMD, MOFS, FICD Private Practice
Chairman and Head Kent, Ohio
Department of Oral and Maxillofacial Surgery Robinson Memorial Hospital
Shahid Beheshti University Ravenna, Ohio
Taleghni University Hospital
President SRINIVAS RAMACHANDRA, DMD
Iranian Society of Oral and Maxillofacial Surgeons Vascular Surgery
Tehran, Iran Kaiser Permanente Medical Center
Hayward Medical Center
DANIEL OREADI, DMD Hayward, California
Assistant Professor
Oral and Maxillofacial Surgery JOEL S. REYNOLDS, DDS
Tufts University School of Dental Medicine Chief Resident
Boston, Massachusetts Oral and Maxillofacial Surgery
Christiana Care Health System
Wilmington, Delaware
Contributors xxi
MICHAEL T. REYNOLDS, DDS RAQUEL M. ULMA, DDS, MD

Chief Resident Resident
Endodontics Oral and Maxillofacial Surgery
University of Iowa College of Dentistry UCLA School of Dentistry
Iowa City, Iowa Los Angeles, California
EDUARDO D. RODRIGUEZ, MD, DDS ALLAN VESCAN, MD, FRCSC
Associate Professor and Chief Lecturer
Plastic, Reconstructive and Maxillofacial Surgery Department of Otolaryngology
R Adams Cowley Shock Trauma Center Head and Neck Surgery
University of Maryland School of Medicine University of Toronto
Baltimore, Maryland Toronto, Ontario, Canada
BRIAN M. SMITH, DMD, MD CLIFFORD R. WEIR, BSc (Hons), MD, FRCOphth
Professor and Division Head Doctor
Surgery, Division of Oral and Maxillofacial Surgery Department of Ophthalmology
Cooper Medical School of Rowan University Tennent Institute of Opthalmology
Camden, New Jersey Bartnavel General Hospital
Chair and Program Director Glasgow, Scotland
Temple University Hospital SCOTT C. WOODBURY, DMD, MD
Philadelphia, Pennsylvania Private Practice
Saginaw, Michigan
IVAN J. SOSA, MD, FAANS
Chief DAVID M. YATES, DMD, MD
Department of Neurosurgery Resident
HIMA/San Pablo Hospital University of Texas Southwestern Medical
San Juan, Puerto Rico Center/Parkland
Dallas, Texas
THOMAS A. STARK, MD
Resident in Surgery CHARLES J. YOWLER, MD
Department of Surgery Director
St. Joseph Mercy Hospital Comprehensive Burn Care Center
Ann Arbor, Michigan MetroHealth Medical Center
Professor
MARK R. STEVENS, DDS Case Western Reserve University School of Medicine
Professor and Chairman Cleveland, Ohio
Georgia Health Sciences University VINCENT B. ZICCARDI, DDS, MD
Augusta, Georgia Professor and Chair
JAMES R. TAGONI
University of Medicine and Dentistry of New Jersey
Student
Newark, New Jersey
Department of Oral and Maxillofacial Surgery MICHAEL ZIDE, DMD
Massachusetts General Hospital Clinical Assistant Professor
Boston, Massachusetts Surgery
PAUL S. TIWANA, DDS, MD, MS, FACS University of Texas Southwestern Medical Center
Associate Professor Dallas, Texas
Graduate Program Director and Chief JOHN R. ZUNIGA, DMD, MS, PhD
Pediatric Oral and Maxillofacial Surgery Prefessor and Chief
Division of Oral and Maxillofacial Surgery Division of Oral and Maxillofacial Surgery
Department of Surgery Department of Surgery
University of Texas Southwestern Medical Center University of Texas Southwestern Medical Center at
Dallas, Texas Dallas
MARIA TROULIS, DDS, MSc Dallas, Texas
Residency Program Director
Massachusetts General Hospital
Associate Professor
Preface
T
his text represents the fourth edition of Oral and Part II: Systematic Evaluation of the Traumatized Patient
Maxillofacial Trauma. Our goal is still to provide follows the ATLS principles of evaluating the trauma
the reader with a comprehensive text on the victim. There are chapters on emergency and intensive
subject of oral and maxillofacial trauma. This field is care, airway management, non-penetrating chest trauma,
evolving, and a fourth edition is required to update those and shock.
areas where the body of knowledge has changed or where Part III: Management of Head and Neck Injuries is written
new areas are needed to be included. We realize that by authors who are unquestionably the most knowledge-
there will always be some area that will not be addressed able in their field. The chapter on applied surgical
as thoroughly as some readers would like, but we have anatomy remains unchanged. We feel that this chapter
tried to be as comprehensive as possible. We apologize is “state of the art.” The next three chapters are essential
in advance for any areas that we did not cover as thor- reading to develop expertise in clinical and radiographic
oughly as our readers would have liked. evaluation of traumatic head and neck injuries. The
Our over-arching concept is that the best care of the remainder of this part covers traumatic injuries to spe-
traumatically injured patient is through the well-informed cific areas of the head and neck. Three chapters on the
and educated trauma team. Many patients present with diagnosis and treatment of dentoalveolar, mandibular,
injuries to various organs. It is incumbent on the indi- zygomatic complex, midface, orbital, frontal sinus, and
vidual who is managing these patients to understand, nasal fractures. The management of soft tissue injuries,
recognize, and triage their injuries appropriately. Hope- including human and animal bites and salivary gland and
fully, our fourth edition continues to build our efforts in nerve trauma is included in this part.
this regard. Part IV: Special Consideration in the Management of Trau-
Our chapter contributors have again done a remark- matic Injuries covers topics that are essential if one is to
able job. Their expertise is exhibited by the excellent have an understanding of the comprehensive manage-
coverage of their assigned topics. Authors new to the ment of the traumatized patient. Topics such as firearm
fourth edition have written half of the chapters. This and burn injuries are discussed in detail. The manage-
adds a new perspective to the material covered. Much of ment of the growing and geriatric patient and the spe-
what made the first three editions successful has been cific considerations for these patients are presented.
retained in the fourth edition. The text remains clinically The book has numerous new color illustrations and
relevant and useful for both the resident and the practic- clinical photographs. The artwork is excellent and helps
ing clinician. the reader grasp the anatomical and surgical details.
The text maintains the basic format of the first three Lastly, this edition is dedicated to the outstanding
editions. We start with Part I: Basic Principles in the Man- career and contributions of Dr. Robert V. Walker.
agement of Traumatic Injury. In this section the metabolic
response to trauma, surgical nutrition, and healing of the
traumatic wound are discussed. This is an imperative
pre-requisite to understanding how to care for the trau-
matically injured patient.
xxii
Acknowledgments
T
he fourth edition of Oral and Maxillofacial Trauma Richard Haug, Vasiliki Karlis, Faisal A. Quereshy, Cyrus
represents the work of many dedicated individu- A. Ramsey, Fonda G. Robinson, Keith E. Silverstein, and
als. The contributors to each chapter have donated Michael D. Turner.
their expertise and time to create a comprehensive text. Additionally, many residents have contributed to this
This endeavor was truly the result of teamwork and it edition as they did in the previous editions. They have
demonstrates what can be accomplished when people stimulated us to revise and update this text and have
work together. We cannot begin to thank all of the expert provided us with inspiration and friendship. For this and
contributors for their efforts. Perhaps the greatest reward much more we extend our thanks.
is the possibility that through this text we have improved Our thanks are also extended to the individuals at
the quality of the traumatically injured victim. Elsevier who worked closely with us to help us accomplish
We also would like to acknowledge the work of previ- our goal. Executive Content Strategist, John Dolan,
ous contributors to the first three editions of the text, for Senior Content Development Strategist, Brian Loehr,
much of their work was the foundation for many chap- and Senior Project Manager, Marquita Parker, are equally
ters: Ramin Bahram, Hans Bosker, Robert J.I. Bosker, contributors to this text and without them this book
Mark A. Cesta, Kelly R. Cottrell, Robert S. Glickman, would not have been written.
xxiii
PART ONE
Principles in the Management of
Traumatic Injuries
CHAPTER
1 Metabolic Response to Trauma

Thomas A. Stark
| Harry L. Anderson, III
OUTLINE
Physiologic Response Clinical Implications
Mediators of the Response Modulation of the Response
Neuroendocrine Response Adult Respiratory Distress Syndrome
Lipid-Derived Mediators Nutrition As Therapy
Cytokines Deep Vein Thrombosis Prophylaxis
Polymorphonuclear Neutrophils Stress Gastritis
I
njury produces profound systemic effects. Hormones, or leukopenia, tachycardia, and tachypnea. When the
the autonomic nervous system, and cytokines all inflammatory response impairs function of organs or
produce a series of responses that are teleologically organ systems, the term multiple organ dysfunction syndrome
designed to help defend the body against the insult of (MODS) is used. As greater sophistication in the care of
trauma and promote healing. Classically, these responses the multiply injured patient has permitted careful obser-
have been described as the stress response, a term coined vation and analysis of the metabolic changes that accom-
by the Scottish chemist Cuthbertson in 1932.1 However, pany trauma; similar advances in the field of molecular
some of these responses may be counterproductive. The biology have allowed the identification and measure-
cascade of interactions is orchestrated in the severely ment of the precise hormones and inflammatory media-
traumatized patient to produce a host of responses that tors involved in the body’s response to trauma. This
follow a recognizable pattern, but the depth and dura- chapter reviews the mechanisms and consequences of
tion of these changes are variable, usually proportional the metabolic response to traumatic injury and some
to the extent of the injury and the presence of ongoing common approaches to the problems produced by these
stimulation. Stresses other than major trauma produce metabolic derangements.
alterations in the metabolic responses; examples are
burns, sepsis, and starvation. Each results in marked PHYSIOLOGIC RESPONSE
variations in the metabolic response, and this variability
persists during the later chronic and recovery phases of Tissue damage produces an inflammatory reaction that
the original injury (Fig. 1-1). causes local effects, such as tissue edema, vasoconstric-
The body’s initial response to insult (the acute phase) tion, and thrombosis. Other mediators released into the
is directed at maintaining adequate substrate delivery to systemic circulation act at sites removed from the injury.
the vital organs, in particular oxygen and energy. Cuth- For example, they stimulate the autonomic nervous
bertson’s pioneering work recognized the increases in system, with concomitant production of hormones, cyto-
basal temperature, energy expenditure, and oxygen con- kines, and arachidonic acid metabolites. The orches-
sumption, and also the loss of potassium and nitrogen.2,3 trated response seen with severe injury has been
The term systemic inflammatory response syndrome (SIRS) is described as having two phases that overlap, the ebb
used to describe the body’s response to infectious and phase, which occurs immediately and may last as long as
noninfectious causes and consists of two or more of the 24 hours after injury, and the flow phase, which may last
following—hyperthermia or hypothermia, leukocytosis for weeks.
1
2 PART I Principles in the Management of Traumatic Injuries
venous catheter, near-infrared spectroscopy (NIRS), and

continuous cardiac output monitoring by arterial wave-
Change from baseline
+ form analysis are as effective at guiding therapy.8-10

The measured serum lactate level may help guide
therapy and additional resuscitation. During shock states,
tissue perfusion is decreased and increasing numbers of
Time cells depend on anaerobic metabolism for energy. Nor-
malization of serum lactate levels can indicate a return
to global aerobic metabolic states and serve as an end
Death point for resuscitation. Partly because of the reversible
nature of hypoperfusion in the trauma setting, initial
serum lactate levels are not themselves independent pre-
Acute phase Chronic phase Recovery
dictors of morbidity and mortality.11
FIGURE 1-1 Phases of metabolism after critical illness and injury. Similar injuries to different body regions can produce
(Adapted from Mongardon N, Singer M: The evolutionary role of dramatic differences in metabolic requirement (Fig.
nutrition and metabolic support in critical illness. Crit Care Clin 1-2). Two injuries in particular are worth special mention
26:443–450, 2010.) because of their notable metabolic consequences. The
first is injury caused by head trauma. When brain injury
is superimposed on multisystem trauma, the risk of death
more than doubles.12 Increased mortality may not be
The first, or ebb, phase is characterized by the release directly caused by neurologic injury per se, but rather by
of catecholamines and vasoactive hormones. Cardiac the systemic consequences of deranged metabolism.13 In
output is elevated by increases in heart rate and cardiac addition, many methods whereby brain-injured patients
contractility. Peripheral and splanchnic vasoconstriction are managed after injury have themselves profound
occurs and extravascular fluids are mobilized to maintain effects on metabolism. Examples of these interventions
blood volume. These hemodynamic consequences act to include steroids, systemic dehydration, muscle paralysis,
preserve blood volume. The respiratory rate is also hyperventilation, hypothermia, hyperbaric oxygen
increased and this increase, in concert with the hemody- therapy, and barbiturate coma. The effectiveness of these
namic changes, drives maximal oxygen delivery. treatments has been challenged but they continue to
The blood glucose level is also elevated through a remain in use.14-16
complex and tissue-specific insulin resistance pathway.4 The second injury is the clinical entity of classic fat
The maintenance of blood glucose levels supports the embolism syndrome, seen particularly after long bone
obligate glucose-metabolizing tissues—brain, bone fractures. Fatty acid and triglyceride-rich fat globules
marrow, erythrocytes, granulation tissue, and the immune enter venous sinusoids at the fracture site. These fat
system. Free fatty acids are mobilized by the catabolic droplets migrate to the lung, where they are converted
hormones and become the main source of energy for by pulmonary lipase to free fatty acids, which can damage
peripheral tissue. Stored hepatic glycogen is limited and the pulmonary microvasculature. In addition, platelets
may be depleted within 1 day. are activated, aggregate, and attach to the fat droplet, a
As the catabolic or flow phase is established, the meta- process that may lead to a consumptive coagulopathy.
bolic emphasis is on the provision of substrate for healing.
The basal metabolic rate is elevated, and thereafter the
patient catabolizes muscle to make glucose. Birkhahn MEDIATORS OF THE RESPONSE
and colleagues found an almost 80% rise in catabolism
after skeletal trauma, and Kien and associates have NEUROENDOCRINE RESPONSE
reported elevations as high as 103% in burn patients.5,6 An early response of the neuroendocrine system is the
The total body nitrogen balance becomes negative. Some upregulation of the sympathoadrenal axis, which gener-
of the earlier changes of the ebb phase may be reversed; ates high plasma concentrations of epinephrine, norepi-
for example, a diuresis may occur, or the heart rate may nephrine, vasopressin, and dopamine. The peak and
slow. duration of the response parallel the severity of the
It may be difficult to separate the effects of the meta- trauma.17 These substances directly affect blood glucose
bolic response to trauma from the effects of shock or levels and also produce inhibition of glucose uptake by
incomplete resuscitation, but clearly such a distinction is tissue, which stimulates glucagon secretion. Sympathetic
necessary. The initial phase of the trauma response is activity promotes lipolysis within adipose tissue, which
complicated by an ongoing deficiency in tissue perfu- begins to provide an energy source for gluconeogene-
sion. The clinician must respond to dynamic changes in sis.18 Gluconeogenesis in the liver is stimulated by
physiology to make time-sensitive interventions. The pul- glucagon.
monary artery or Swan-Ganz catheter offers a continuous The hypothalamic-pituitary axis is stimulated at the
window into the minute to minute mechanics of the same time as the sympathetic nervous system after
severely injured patient. More recently, the safety and trauma.19 The pituitary releases adrenocorticotropic
usefulness of Swan-Ganz catheters in trauma resuscita- hormone (corticotropin, or ACTH), which stimulates
tion has been scrutinized and their routine use has the adrenal cortex to secrete glucocorticoid hormones
declined.7 Less invasive modalities such as the central such as cortisol and aldosterone. Epinephrine and
Metabolic Response to Trauma CHAPTER 1 3
Burn size
115 70%
2800 6875 5500 110
2700 105 60%
6250 5000
2600 100 50%
2500 5625 4500 95
2400
2300 5000 4000 90
40%
2200 85
2100 4375 3500 90
2000
Estimated caloric intake (MR + 25%) Kcal/day

75
1900 3750 3000 70 30%
1800 3500 2800
Estimated metabolic rate Kcal/day
Percent change in metabolic activity

3250 2600 65 Multiple trauma with
1700
Daily basal metabolic rate Kcal/day
3000 2400 60 patient on ventilator

1600
2750 2200 55
1500
2500 2000 50 20%
1400
2250 1800 45 Severe infection,
1300 40
2000 1600 multiple trauma
1200 35
1750 1400
1100 30
1500 1200 25 10%
1000 1100 Long bone fracture
20
900 1250 1000
1125 900 15
800 1000 800 10 Peritonitis
875 700 5
700 Postoperative
750 600 Normal 0
600 -5
625 500 Mild starvation
-10
500 500 400

-15
FIGURE 1-2 Changes in resting energy expenditure associated with trauma, burns, and other common clinical conditions. (Adapted From
Wilmore DW: The metabolic management of the critically ill, New York, 1977, Plenum Press.)
cortisol promote muscle breakdown, protein catabolism, platelet aggregation, altered pulmonary vascular reactiv-
and amino acid release. ity, and changes in endothelial permeability.
The effects of the flow phase of the metabolic response
to trauma are partly attributable to hormones such as CYTOKINES
glucagon and cortisol, but not entirely, because the cata- Protein mediators, collectively called cytokines, are pro-
bolic consequences extend beyond measurable elevated duced at the site of injury and by diverse circulating
levels of these hormones.20,21 This finding has implicated immune cells. Monocytes, lymphocytes, macrophages,
other factors such as cytokines or the suppression of and other cells release cytokines. They can act locally as
other hormonal axes such as those of somatostatin and paracrines by way of direct cell to cell communication or
growth hormone. systemically when produced in excess by way of endo-
crine mechanisms. The most important cytokines in
LIPID-DERIVED MEDIATORS trauma are tumor necrosis factor (TNF), the interleukins
Cyclooxygenase products of arachidonic acid metabo- (IL-1, IL-2, IL-6, and IL-8), the interferons, and various
lism are present in increased amounts in human studies growth factors such as granulocyte-macrophage colony-
of injury. Thromboxane A2 accentuates neutrophil stimulating factor (GM-CSF), and platelet-derived growth
aggregation and, with prostacyclin, has potent and oppos- factors (PDGFs). They enhance immune cell function
ing vascular effects that may have a role in pulmonary and are responsible for the systemic effects of inflamma-
hypoxic vasoconstriction and systemic vasodilation. tion and sepsis, such as fever, leukocytosis, hypotension,
Lipoxygenase products are also released in large quanti- delayed gastric emptying, and malaise.
ties and affect the permeability of the pulmonary vascu- Thought to be the most proximal mediator of the
lar bed. inflammatory response, TNF was originally described as
Platelet-activating factor (PAF) is a phospholipid the catabolic factor cachectin.22 At least two forms of TNF
metabolite released by a number of cells, including neu- exist.23,24 TNF influences cellular attraction as part of the
trophils. The response to PAF at the endothelial surface local inflammatory response, leukocyte migration, and
results in enhanced superoxide production, enhanced systemic hypotension.25,26 It also promotes muscle
catabolism, free fatty acid release, and hepatic synthesis

of acute-phase reactants. TNF free receptor is a glycosyl-
ated protein found in membrane-bound and free-floating
forms. In contrast to IL-1, TNF appears to act peripher-
ally and has no direct effect on lymphocyte activation.27
The interleukins are polypeptides released from lym-
phocytes; each is numbered according to the amino acid
sequence that elicits its action.28 Circulating free recep- sTNFr
tors are known for IL-1 and IL-6. Free receptors may exist
for all cytokines. They appear to function in the regula- IL-1RA
tion of cytokine activity. IL-1, which can be detected in
the circulation within a few hours after injury, has mul-
sIL-2r
tiple biologic effects, including the activation of resting
T lymphocytes and macrophages, induction of hemato-
Control 1 2 4 12 1 3 7
poietic growth factors, stimulation of chemotaxis of neu- hour hour hour hour day day day
trophils, and synthesis of collagen and collagenases.
More profound systemic effects include fever and changes Time post-injury
in protein metabolism. Originally described as pyrexin,
IL-1 was shown in subsequent studies to act via the pro- FIGURE 1-3 The sequential release of cytokine receptors and
duction of prostaglandins in the hypothalamus and to receptor agonists after injury. IL-1RA, interleukin-1 receptor
alter the set point of the thermoregulator in the hypo- antagonist; sIL-2r, soluble interleukin-2 receptor; sTNFr, soluble
thalamus.29,30 It is in this way that antiprostaglandin TNF receptor. (Adapted from Cinat M, Waxman K, Vaziri ND,
agents, such as aspirin, can block the fever effect of et al: Soluble cytokine receptors and receptor antagonists are
IL-1.31 A byproduct of IL-1 metabolism can increase pro- sequentially released after trauma. J Trauma 39:112–118,1995.)
teolysis of human muscle and induce hepatic protein
synthesis.32,33 Identified as a B cell differentiation factor,
IL-6 is now recognized as the final common mediator in mediators of the stress response that multiplies the effect
a cascade of cytokine activity that alters hepatocyte of the already enhanced PMNs.42,43
protein synthesis.34,35
The interactions of cytokines with one another and CLINICAL IMPLICATIONS
the stress response hormones have been increasingly
studied. Cytokines are potent stimulators of the release The successful management of the metabolic changes
of other mediators (e.g., IL-1 acting on the hypothala- that accompany severe trauma influences and may
mus). Evidence exists for convoluted positive-feedback prevent some of the major complications of trauma—
relationships organized within the cytokine cascade. namely impaired immune function, multiple organ
Release of early mediators, for example TNF, triggers failure, and sepsis.44
release of the complete aggregate of cytokines, which
then combine to elicit the host response. MODULATION OF THE RESPONSE
The cytokine receptors and cytokine agonists may Researchers have tested novel therapeutic strategies and
have several roles in trauma patients. Both are released options aimed at selectively inhibiting the undesirable
in a sequential manner, paralleling the release of cyto- actions of cytokines while allowing the appropriate
kines, and they modulate the body’s response to trauma.36 responses to be expressed. Some effects of cytokines on
Figure 1-3 demonstrates the fluctuating levels of cytokine target tissue have been successfully blocked by the use of
receptors over time. Quantitative serum cytokine levels, anticytokine antibodies and specific cytokine receptor
particularly IL-6, correlate with injury severity and serve antagonists. Animal studies, in particular, have suggested
as a predictor of adverse outcomes and mortality.37,38 significant efficacy of these agents, but the results in
Although highly sensitive, lack of specificity has limited humans have been largely disappointing, particularly
their use in clinical settings. when they have been used in septic patients.45 Most of
the work, however, has focused on multicenter trials of
POLYMORPHONUCLEAR NEUTROPHILS patients who have sepsis from many causes, rather than
Catecholamines and glucocorticoids marginalize periph- solely the multiply injured. Caution must nonetheless be
eral polymorphonuclear neutrophils (PMNs) and recruit exercised because of the risk that these agents may neu-
them from the bone marrow.39,40 Lipids and cytokines tralize the beneficial, survival-enhancing effects of the
(e.g., IL-1, TNF, PAF) then prime these cells for enhanced cytokines and other elements of inflammation. Another
superoxide anion release and sequestration in end- problem with these therapies is that cytokines are rapidly
organs.41 Capillary endothelial integrity is disrupted, released after injury, and the administration of antibod-
leading to the formation of edema, defects in oxygen ies, by necessity, occurs later—after the initiation of the
delivery, hypoxic cellular injury, and other adverse con- cytokine cascade.
sequences for cellular homeostasis. This derangement Pharmacologic manipulation of the end-organ
leads to the clinical entity of multiple-organ failure. response to stress is also accomplished with some drug
Human studies have supported this sequence and also classes that act on specific mediators of the response. For
suggested that additional stress results in a rerelease of example, cyclooxygenase inhibitors such as ibuprofen
Critical illness
Catabolism Impaired GI motility Starvation for

medical reasons
Risk of aspiration
Unsuitable
nutrition protocols
Increased energy
requirements
Insufficient coverage of energy target by EN alone
Negative protein-energy balance Supplemental

Undernutrition parenteral
nutrition
Increased morbidity
?
Increased mortality
Longer length of stay
Longer recovery
FIGURE 1-4 Factors whereby enteral nutrition may result in undernutrition of critically ill and injured patients—the potential role of
supplemental parenteral nutrition. (Adapted from Thibault R, Pichard C: Parenteral nutrition in critical illness: Can it safely improve
outcomes? Crit Care Clin 26:467–480, 2010.)
inhibit the production of eicosanoids and may thus blunt hydrocortisone therapy attenuates the stress response
the physiologic response to cytokines, such as fever, asso- and decreases the likelihood of hospital-acquired pneu-
ciated with TNF, IL-1, and IL-6. In patients with sepsis, monia.54 Further research is needed to establish practical
ibuprofen has shown some improvement in clinical therapeutic strategies, particularly in traumatic brain
parameters, but has not been proven to decrease the injury, in which high-dose steroids have been associated
duration of shock or improve mortality.46 with an increase in mortality.55
Control of hyperglycemia in critically ill surgical Human activated protein C (drotrecogin alfa [acti-
patients has been shown in a large, prospective, random- vated]) was one of the first approved recombinant agents
ized trial to decrease morbidity and mortality. Intensive targeting the procoagulant and generalized inflamma-
insulin therapy (IIT) requires maintenance of blood tory response that occurs during sepsis. It had been ini-
glucose levels below 110 mg/dL.47 Subsequent analysis tially found to reduce death rates in patients with severe
found that increased mortality from hypoglycemic events sepsis.56 Ongoing surveillance proved that there was no
negates the benefits of IIT in clinical practice. Trauma survival benefit in patients with severe sepsis when com-
patients, however, were a subset found to having bene- pared with placebo, and the drug has since been with-
fited the most from IIT.48 Further investigation is neces- drawn from the market.57
sary to determine safe and effective mechanisms for Pharmacologic manipulation of the response to trau-
glycemic control in trauma patients. matic injury has been met with limited success. Research
The role of glucocorticoids in modulating the stress continues to attempt to identify agents that protect the
response remains unclear. In severe cases of injury, sepsis, patient from the deleterious effects of the host response.
and critical illness, the adrenal system is unable to supply Knowing which patient may benefit from a particular
the overwhelming demand for glucocorticoids, and a medication may be a function of that individual’s unique
relative adrenal insufficiency ensues.49 Pharmacologic DNA. Current studies have identified specific genetic
factors such as even a single dose of etomidate have also polymorphisms that are predictors of adverse outcomes
proven to increase rates of adrenal insufficiency and in severe trauma and sepsis.58 Future investigation may
mortality in the critically ill.50 Multiple trials have failed help develop individually tailored treatments.
to identify a definite improvement in mortality, although
low-dose corticosteroid therapy may decrease the dura- ADULT RESPIRATORY DISTRESS SYNDROME
tion of shock states and improve short-term survival.51-53 The adult respiratory distress syndrome (ARDS) is an
In trauma patients, there is some evidence that acute illness characterized by noncardiogenic pulmonary
edema. This refractory hypoxemia arises in part as a A recent study comparing a special enteral formula-
consequence of lung inflammation secondary to the tion of eicosapentaenoic acid, gamma-linolenic acid, and
mediators of the acute response to trauma. Damage to antioxidants versus a standard formulation to patients
the alveolar-capillary interface results in intrapulmonary during the early stages of sepsis (without organ failure)
shunting of blood, raised pulmonary vascular pressures, yielded different results.69 The study, funded in part by
and surfactant depletion. the product manufacturer, revealed no significant differ-
The syndrome is primarily treated by mechanical ven- ence in mortality between the two groups. A significant
tilation, and the National Institutes of Health Acute reduction in the appearance of cardiac and respiratory
Respiratory Distress Syndrome Network has identified failure occurred in the study population given the special
that low tidal volume ventilation (6 mL/kg predicted enteral formulation versus those given the standard
body weight) was superior to using traditional tidal formula control. Subjects in the test arm also experienced
volumes (12 mL/kg of predicted body weight) in treat- a benefit of fewer days on mechanical ventilation, fewer
ing hypoxemia.59 When therapy fails to keep pace with days in the intensive care unit, and shorter length of hos-
progressive lung dysfunction, alternative therapies— pital stay. The concept of immunonutrition continues to
such as high-frequency oscillatory ventilation, prone evolve and, particularly within the last 5 years, the approach
positioning, and extracorporeal life support (ECLS) or to the modulation of nutrition by timing to feed, amounts,
extracorporeal membrane oxygenation (ECMO)—may route of administration,and composition of the nutri-
be indicated.60-63 tional product have yielded new information regarding
how to optimally feed injured and critically ill patients.
NUTRITION AS THERAPY
The advantages of enteral nutrition over parenteral DEEP VEIN THROMBOSIS PROPHYLAXIS
nutrition have been clearly demonstrated, and the gas- The hypercoagulable state exists immediately following
trointestinal tract should be used whenever possible. severe traumatic injury, and an even more severe injury
Recently, a role for supplemental parenteral nutrition may be followed by increases in the hypercoagulable
has been advocated (Fig. 1-4). The traditional prefer- state.70 When this condition exists in combination with
ence is to feed patients by the enteral route for reasons patient immobility and direct venous injury, Virchow’s
that include a reduction of the number of enteric organ- triad for venous thrombosis is complete. Tissue injury
isms that may be responsible for bacterial translocation. may be responsible for the release of tissue thromboplas-
Stimulation of the enterocyte brush border and gut- tin, which initiates the conversion of factor VII to enzyme
associated lymphoid tissue is an important protective factor VIIa. Therefore, it is important to provide deep
mechanism against the proliferation of the offending venous thrombosis (DVT) prophylaxis with subcutane-
organisms.64 The route of feeding may also have an ous mixed or low-molecular-weight heparins when pos-
impact on the production of cytokines after injury; sible, except in cases in which specific contraindications
thus, use of the enteral route may confer an additional exist, such as intracranial hemorrhage, known peptic
advantage.65 ulcer, solid organ laceration, and hematoma. An alterna-
Considerable attention has focused on nutrients that tive is the placement of a sequential compression device
attenuate the metabolic response to injury. Nutrients on the limbs. The overall efficacy of DVT prophylaxis is
that appear to enhance the immune system include argi- well established; it is important that prophylaxis be main-
nine, glutamine, and nucleic acids. The immune system tained for the duration of the hospital stay or at least
may be enhanced by altering the relative amounts of until the patient is fully mobile.71
omega-6 versus omega-3 unsaturated fatty acids.66,67 Traumatic brain injury with intracranial hemorrhage
Other nutrients may act as oxidants, preventing damage prohibits the use of chemoprophylaxis. Recent data have
by free radicals, such as the common antioxidants vita- demonstrated a three- to fourfold increased risk of DVT
mins A, C, E, and the trace element selenium. in brain-injured patients. This patient population
There has been lukewarm interest in the concept of requires early application of appropriate nonpharmaco-
“immunonutrition”to ameliorate the end-organ damage logic measures and an early decision on the placement
from critical illness and sepsis, which may later result in of inferior vena cava filters (removable, if possible) for
acute renal failure and ARDS. A study of supplementa- pulmonary embolism prophylaxis.72
tion with an enteral diet of omega-3 fatty acid, gamma-
linolenic acid, and antioxidants versus an isocaloric STRESS GASTRITIS
enteral formulation was reported in 2011. These nutri- Stress gastritis is common to the multiply injured inten-
ents are typically thought to modulate the systemic sive care unit population, and patients left untreated may
inflammatory response.68 The study randomized 272 have clinically significant gastrointestinal bleeding. The
adults who had developed acute lung injury and required principal risk factors for stress gastritis are head injury,
mechanical ventilation. Enteral nutrition was provided to mechanical ventilation, and abnormal coagulation pro-
both patient groups using a standard protocol, and the files. Prophylaxis using histamine-2 receptor antagonists
study supplement was provided twice daily to the study or proton pump inhibitors is very effective.73
cohort of patients. The study was halted early because of
futility. The ventilator-free and intensive care unit-free SUMMARY
days were lower in the omega-3 group and, although not
significant, hospital and 60-day mortality were higher in Injury produces a series of physiologic changes mediated
the omega-3 group. by local and systemic agents and systemic effects, mainly
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CHAPTER
2 Wound Healing
Raquel M. Ulma
| Tara L. Aghaloo
| Earl G. Freymiller
OUTLINE
General Concepts of Wound Healing Diabetes
Normal Soft Tissue Healing (Repair) Smoking
Abnormal Soft Tissue Healing (Repair): Keloids and Malnutrition
Hypertrophic Scars Immunosuppression
Wound Repair in Other Tissues of the Head and Neck Radiation and Chemotherapy
Normal Bone Healing (Repair) Wound Management
Complications in Bone Healing Healing by Primary Intention or Primary Wound Closure
Normal Cartilage Healing (Repair) Delayed Primary Closure or Wound Repair
Normal Nerve Healing (Repair) Healing by Secondary Intention
Skin Grafting Dressings and Topical Agents
Factors in Suboptimal Wound Healing
Aging
Infection
T
he capacity for self-repair is crucial for the survival Wounds are classified as acute or chronic. Acute
of any organism, because without it the organism wounds have surgical, traumatic, pathologic, or ischemic
would likely perish after minimal injury. A wound causes. Surgical wounds, intentionally created in the
is a disruption in the normal anatomic structure and operating room environment, vary in their degree of
function of tissue and is accompanied by cellular damage. contamination, depending on their anatomic location
Wound healing is an intricately coordinated series of and presence of local microbial flora. Subsequent healing
processes that involve cellular and subcellular responses is affected by the level of cleanliness or contamination of
to tissue injury, leading to the release of cytokines and the wound. Traumatic injuries caused by blunt or pene-
growth factors, cell activation, and resultant tissue regen- trating trauma result in tissue laceration, abrasion, or
eration.1,2 The large variation in repair capacity of differ- even tissue avulsion. Other mechanisms of traumatic
ent tissue types is intriguing. For example, hepatic tissue injury include tissue exposure to extremes of tempera-
has a high capacity to regenerate, whereas nerve tissue ture, radiation, or caustic chemicals that cause injury by
has an exceptionally low repair potential, given its inabil- altering tissue pH, denaturing proteins, and causing
ity to replicate. A solid understanding of the repair local ischemia.1,2 Pathologic processes such as neoplasms
process is essential for optimizing patients’ perioperative and nonhealing ulcers also cause tissue disruption. Skin
healing and is the basis for minimizing iatrogenic injury. breakdown or ulceration secondary to ischemia is related
It is especially important for surgeons treating maxillofa- to impaired blood flow to an area by vascular occlusion,
cial injuries to possess a thorough knowledge of the compression, stasis or pressure. Traumatic handling of
wound-healing process, because nowhere else in the tissues during treatment, including crush injuries and
body are the effects of poor healing more noticeable and desiccation, can add further insult to the initial injury.
potentially disfiguring. To optimize the restoration of In the state of health, wound healing occurs in three
function and esthetic harmony after facial trauma, the distinct but overlapping phases—inflammation, prolif-
surgeon must also be cognizant of patient-specific comor- eration, and remodeling (Table 2-1).1-4,6 When the tis-
bidities and understand how health status influences the sue’s normal healing process experiences a disruption or
healing process.3,4 delay, a chronic wound forms. Delays usually arrest
The challenge to optimize healing has placed wound healing at the inflammatory phase and result in excessive
physiology at the forefront of clinical and laboratory collagen deposition and scarring. Local factors impairing
research.5 The understanding of the remarkable cascade wound healing include the presence of foreign bodies or
of events involved in wound repair and healing is necrotic tissue within the wound, a high microbial
advancing exponentially with the ongoing discoveries of burden, ischemia secondary to venous or arterial insuf-
the roles of growth factors and signaling pathways. There ficiency, and tissue hypoxia secondary to radiation
is growing interest in stem cell research, regenerative fibrosis. Some systemic factors that reduce healing capac-
medicine applications, and bioactive wound healing ity include aging, malnutrition, vitamin deficiencies,
products. diabetes, immunocompromised states, atherosclerosis,
9
the site of injury. As platelets continue to aggregate, they

TABLE 2-1 Phases of Repair in Soft Tissue Wounds form a platelet plug within the vessel. The complement,
kinin, plasminogen, and clotting cascades are activated.
Phase Function The clotting cascade results in the deposition of fibrin,
I. Inflammation Vascular response a key component that strengthens the platelet plug and
Cellular infiltrate acts as a scaffold for wound healing.
Polymorphonuclear leukocytes Vasodilation and inflammation follow hemostasis.
Macrophages This process is mediated by a variety of cytokines and
Neovascularization factors, including histamine from mast cells (Fig. 2-3;
Synthesis of granulation tissue Table 2-2), prostaglandins PGI2 and PGE2, prostacyclin,
II. Proliferation Cellular proliferation platelet-activating factor (PAF), bradykinin, leukotrienes,
Macrophages and nitric oxide. These chemicals cause leukocytes and
Fibroblasts plasma proteins to permeate into the wound. The endo-
Collagen synthesis thelial cells of the small venules and capillaries tran-
Endothelial cell proliferation siently change shape and become rounded, creating gaps
Mature formation of granulation tissue within the vessel wall that allow for leaking of plasma and
Increase in mechanical strength fibrinogen.3,4 Leukocytes migrate to the extravascular
III. Maturation Collagen remodeling space via diapedesis (Fig. 2-4). Histamine, produced by
Increase in wound strength mast cells and basophils, increases vascular permeability
Decrease in vascularity by inducing endothelial cell contraction and exposing
Macrophages the endothelial basement membrane. Consequently, his-
Fibroblasts tamine receptor blockers can prevent early changes in
Formation of scar tissue vascular permeability. Increased vascular permeability
leads to the clinical findings of calor, rubor, dolor and
tumor.1 Wound heat and redness are a result of vasodila-
tion and the presence of blood-borne cells. Pain, a nerve
peripheral artery disease, collagen vascular disease, and response caused by vasoactive amines or pressure
chemotherapy.7 from edema, protects the site from further tissue injury.
Finally, wound swelling is caused by increased volume at
the site of injury, secondary to edema from vascular
GENERAL CONCEPTS OF WOUND HEALING permeability.
Some of the first cells to be recruited to the site of
NORMAL SOFT TISSUE HEALING (REPAIR) injury are neutrophils, which move across the endothe-
Normal wound healing results in tissue regeneration lium via diapedesis within minutes of injury (Fig. 2-5).
and takes place in three separate but overlapping The neutrophil concentration within the wound peaks
phases—inflammation, proliferation and remodeling by 24 hours. They autolyse to release intracellular con-
(Fig. 2-1).1-4,8-10 tents into the wound, including lysosomic proteases for
The inflammatory phase of wound healing begins at degradation of nonviable tissue, debris, and bacteria
the time of injury and lasts for 3 to 5 days. Vasoconstric- (Table 2-3). Collagenases, elastases, cathepsin, and bac-
tion initiates the process, because catecholamines and tericidal cationic proteins are also released from neutro-
prostaglandins (epinephrine and thromboxane) cause phil granules. Collagenases and cathepsin G activate
small blood vessels to constrict for initial hemostasis. complement and aid in the conversion of kininogens to
Hemostasis via vasoconstriction is short-lived but is soon kinins. Monocytes follow and concentrate at the site of
followed by the formation of a blood clot. The clotting inflammation within 2 to 3 days. These cells are para-
cascade, prompted by vessel disruption, is initiated by mount in directing wound healing because they trans-
platelets. Platelets, fragments of megakaryocytes that cir- form into macrophages that continue wound débridement
culate in the blood for 9 to 11 days, contain glycogen, via the secretion of hydrolytic enzymes into the extracel-
dense granules, and alpha granules (Fig. 2-2). When lular space. Collagenases, elastases, and cathepsins cata-
platelets adhere to the exposed subendothelial collagen lyze the conversion of plasminogen to plasmin to begin
of injured vessels with the aid of von Willebrand factor, clot breakdown. Macrophages engage in microbial
they degranulate, releasing adenosine triphosphate, phagocytosis, a process enhanced by infiltrating opso-
serotonin, prostaglandins, and thromboxane A2.3,4 Sero- nins. Macrophages release additional chemoattractant
tonin, prostaglandins, and kinins increase vascular per- substances and growth factors that recruit fibroblasts and
meability. Platelets also release interleukins (ILs) and stimulate collagen production. Growth factors necessary
growth factors (transforming growth factor β [TGF-β], for the formation of granulation tissue include TGF-α,
platelet-derived growth factor [PGDF] and vascular TGF-β1, PDGF, epidermal growth factor (EGF), fibro-
endothelial growth factor [VEGF]), which further poten- blast growth factor (FGF), IGFs, TNF-α and IL-1. Neutro-
tiate platelet activation and aggregation. Insulin-like phils and macrophages continue to release cytokines that
growth factor 1(IGF-1), TGF-α, TGF-β, and PGDF attract will initiate the proliferative phase of healing.
leukocytes and fibroblasts to the wound. These factors Continuing after the inflammatory phase, the prolif-
also serve as chemoattractants when released into the erative phase (also known as the fibroblastic stage) is
bloodstream, recruiting neutrophils and monocytes to established by the fourth or fifth day and lasts 2 to 3
Wound Healing CHAPTER 2 11
Epithelium
Injury
Collagen lysis
Inflammation
Debridement
resistance
to infection Remodeling Healed wound
Granulocytes
Macrophages
Collagen fibril
Neovascular
growth
Coagulation
Platelets Tropollagen
polymerization
Collagen
synthesis
Contraction Fibroblast
Proteoglycan Procollagen
synthesis
FIGURE 2-1 Overview of the process of soft tissue healing.
weeks. It is characterized by the ingrowth and prolifera- factors such as hypoxia, elevated tissue lactate levels, and
tion of granulation tissue within the wound. Granulation cytokines, such as FGF, VEGF, and PDGF.1-4 Angiogenesis
tissue, a loose connective tissue matrix formed by is crucial because new vasculature is required for the
collagen-secreting fibroblasts, supports neovasculature influx of oxygen and nutrients and the removal of meta-
and inflammatory cells (Fig. 2-6). Fibroplasia, angiogen- bolic waste products. The granulation tissue contains
esis, and subsequent epithelialization further typify the inflammatory cells and fibroblasts in a matrix of collagen
proliferative phase. Responding to the release of PDGF and new vasculature. Epithelialization is promoted by
and TGF-β, fibroblasts arrive at the wound on the third EGF, TGF-α, and keratinocyte growth factor, and is itself
day and peak in concentration within 1 week. They composed of three phases—epithelial migration, prolif-
actively produce proteoglycans and collagen, with force, eration, and differentiation. The dermal layer is reepi-
stress, strain, and motion directing the collagen and pro- thelialized and the contractile forces exerted by fibroblasts
teoglycan alignment. Fibroblasts synthesize mostly type and myofibroblasts aid in reapproximating wound
III collagen for approximately 3 weeks, until equilibrium margins. Skin-grafting open soft tissue wounds can limit
is reached between the production and breakdown of the amount of granulation tissue produced, thereby
collagen (Table 2-4). Budding vessels closely follow fibro- reducing scarring and tissue contracture. In the head
blast activity. Neovascularization is enhanced by local and neck region, reepithelialization occurs faster in
Ab-Ag complex Surfaces:

Collagen and other TABLE 2-2 Chemical Mediators Derived from the
nonimmunological Mast Cell
with complement materials
in some species Preformed Unstored
Histamine Slow-reacting substance of
Heparin anaphylaxis (SRS-A)
Aggregated G Enzymes: Eosinophil chemotactic factor Platelet-activating factors
Thrombin,
of anaphylaxis (ECF-A) (PAFs)
trypsin
Neutrophil chemotactic factor Lipid chemotactic factor
PAF (NCF) (LCF)
Chymase
Antiplatelet N-Acetyl-beta-glucosaminidase
antibody
From Yurt RW: Role of the mast cell in trauma. In Dineen P, Hildrick-Smith
G, editors: The surgical wound, Philadelphia, 1981, Lea & Febiger,
pp 37–62.
Release of vasoactive amines
FIGURE 2-2 Stimuli that can induce release of vasoactive amines
from platelets. 1. Chemotaxis 2. Adherence
Vessel
Tissue
Chemotactic
factors
3. Phagocytosis 4. Digestion
Release of
lysosomal Tissue
enzymes and injury
oxygen radicals
FIGURE 2-4 Sequence of reactions leading to tissue injury

associated with influx of polymorphonuclear leukocytes. Note that
in addition to chemotaxis, adherence, phagocytosis, and the
digestion process, which normally result in particle inactivation,
the release of neutrophilic constituents (lysosomal enzymes) may
also result in tissue injury.
to 80% of the preinjury tensile strength. Tensile strength

is defined as the load per cross-sectional area that can be
FIGURE 2-3 Stimuli that can induce release of vasoactive amines supported by a wound; the increase in tensile strength is
and other material from mast cells. proportional to the rate of collagen synthesis. Over time,
a decrease in the number of fibroblasts and macrophages
is seen, with scar vascularity also decreasing as tissue
mucosa than in skin. Mucosal reepithelialization occurs proliferation declines.1,2 These changes are clinically cor-
over a moist surface whereas reepithelialization in skin related to a less erythematous, flatter, softer scar.
occurs under a dry scab. The mechanical strength of the
wound increases through the proliferative phase.
Tissue remodeling finalizes the wound healing process. ABNORMAL SOFT TISSUE HEALING (REPAIR):
Also known as maturation, the remodeling phase is char- KELOIDS AND HYPERTROPHIC SCARS
acterized by an increase in wound tensile strength related Keloids and hypertrophic scars are aberrant forms of
to increased collagen production and breakdown. The wound healing that result in proliferative scarring.11
remodeling process begins after the third week and Although clinically similar, they differ in their formative
usually lasts 6 to 12 months. Initial scar tissue becomes timeline and boundaries. Keloids are benign growths of
stronger as type I collagen replaces type III collagen. The fibrous tissue that grow beyond wound boundaries. They
augmented collagen deposition and subsequent collagen more commonly occur over the sternum, ear lobes, back,
cross-linking increase the scar’s tensile strength to 75% trunk, and extremities. Keloids are firm and rubbery and
TABLE 2-3 Injurious Constituents of Neutrophils

Skin-first Constituent Activity
line of
defense Collagenase, elastase, Hydrolysis of basement membranes,
and cathepsin A internal elastic laminae, cartilage and
Pathogenic other connective tissue; generation
bacteria of C5 fragments, angiotensin II
PMN Basic proteins (three) Increased vascular permeability
Tissue Basic protein (one) Activation of mast cells, release of
macrophage vasoactive amines
PMN Leukotrienes C4 and Increased vascular permeability,
emerging D4 contraction of smooth muscle
from blood
vessel Kininogenase Hydrolysis of kininogen with release
of vasoactive kinin
Procoagulant activity Generation of fibrin, activation of
platelets
FIGURE 2-5 Phagocytosis by polymorphonuclear leukocytes
(PMNs, neutrophils) and tissue macrophages following penetration Platelet activation Activation of platelets, increased
of the skin and introduction of pathogenic bacteria into deeper factor (PAF) vascular permeability, contraction of
tissue. The PMNs are more efficient in phagocytosis than the smooth muscles, activation of
macrophages. Note that the PMNs are mobilized into tissue from neutrophils
blood vessels during the inflammatory process. Leukotriene B4 Attraction of leukocytes
Lysosomal enzymes Digestion of tissue constituents
Oxygen radicals Damage to cells
From Bellanti JA: Immunology, ed 3, Philadelphia, 1985, WB Saunders,
p 258.
Injury
Thrombin Intimal
thrombosis
Platelet
Platelet
factor
Inflammation coagulation
Antigen-antibody
complex interaction
with complement
Antigen processing
Proteoglycans
Fibroblast Lymphokines
Macrophage
Fibronectin
Angiogenic Lymphocyte
factor
Collagen
Leak? Endotoxin
Foreign body
Tbc
Endothelial cell
proliferation
FIGURE 2-6 Cell interactions that lead to wound healing. The macrophage plays a central role that involves its activation by lymphokines,
release of angiogenic factor, and collaborative roles with platelets, lymphocytes, and fibroblasts.
TABLE 2-4 Different Types of Collagens
Type Tissue Distribution Cells Chemical Characteristics

I Bone, tendon, skin, dentin, Fibroblasts Hybrid composed of two kinds of chains; low content
ligament, fascia, arteries, of hydroxylysine and glycosylated hydroxylysine
and uterus
II Hyaline cartilage Chondrocytes Relatively high content of hydroxylysine and
glycosylated hydroxylysine
III Skin, arteries, and uterus Fibroblasts High content of hydroxyproline and low hydroxylysine;
Smooth muscle contains interchain disulfide bonds
IV Basement membranes Epithelial cells High content of hydroxyproline and glycosylated
hydroxylysine; may contain large globular regions
A chain, B chain Basement membranes Uncertain Similar to [alpha (IV)], but may contain larger globular
domains
From Prockop DJ: Collagen biochemistry and the design of agents to inhibit excessive accumulation of collagen during wound repair. In Dineen P,
Hildrick-Smith G, editors: The surgical wound. Philadelphia, 1981, Lea & Febiger, p 97.
can be erythematous, painful, or pruritic. They develop to 5 days. Inflammation is stimulated by vessel injury in
months after trauma, piercing, or surgical incisions and the haversian canals and periosteum and by the presence
are caused by an overproduction of connective tissue, of bony debris or necrotic material in the fracture site.
likely secondary to altered apoptosis or hyperprolifera- Vasoconstriction allows a blood clot to form, and inflam-
tion of keloidal fibroblasts. Genetic causes have also been matory cells phagocytize debris and bacteria. A hema-
implicated in keloid formation. Keloids occur more com- toma is formed within the fractured bone. The necrotic
monly in certain ethnic populations. The incidence of bone edges are resorbed. The proliferative fibroplastic
keloid formation is correlated with increased skin pig- stage follows. Pleuripotential mesenchymal cells and
mentation. Keloids rarely improve without treatment and fibroblasts enter the site of injury to lay down fibrous
a variety of treatment modalities have been described. tissue, cartilage, and immature bone fibers (Table 2-5).
First-line treatment is intralesional injection of cortico- These components permit the wound to gain some
steroids into the scar to reduce fibroblastic production strength over the 2 to 3 weeks following injury. Granula-
of collagen and extracellular matrix proteins. Localized tion tissue forms as a matrix of fibrin, collagen, and
pressure therapy, interferon, or fluorouracil can be neovasculature is laid down. If the fracture segments are
used in combination with intralesional corticosteroid not precisely reduced to the preinjury anatomic position,
injections. Keloids can also be surgically excised or or if bone is avulsed, leaving a residual space between the
treated with radiation, cryosurgery, or topical imiqui- two bony segments, the fracture will heal by secondary
mod. The use of calcineurin inhibitors is currently under intention. Greater collagen deposition is then required
investigation. Nevertheless, regardless of treatment to bridge the gap, resulting in callus formation at the
modality, keloids commonly recur to some degree after surface and within the fractured bone. The soft cartilage
treatment.12 callus calcifies into woven bone as osteoblast and osteo-
Hypertrophic scars have a similar appearance to clast concentrations increase within the fracture site (Fig.
keloids but differ from keloids in that they do not extend 2-7). Osteoblasts continue to deposit osteoid on spicules
beyond the margins of the original wound. They also of calcified cartilage and this osteoid is later calcified to
appear shortly after injury and may recede over time. immature bone (Fig. 2-8). The callus, much like a rudi-
Hypertrophic scars, characterized by prolonged inflam- mentary splint, offers the fractured bone some minor
mation and collagen deposition, are red, firm, and stability against bending and torsion (Fig. 2-9). However,
elevated. Hypertrophic scars are also treated with intra immobilization is required for healing to proceed; oth-
lesional corticosteroid injections and are less likely than erwise, a fibrous union will result.
keloids to recur after treatment.13 In areas adjacent to endosteum, where the vascular
supply and osteoprogenitor cells abound, no intermedi-
ate fibrocartilage is seen. Instead, the endosteal osteo-
WOUND REPAIR IN OTHER TISSUES OF THE blasts form a direct bony callus. Similarly, no cartilaginous
HEAD AND NECK callus is formed when minimally displaced fractures heal
under immobilization or when acute fractures are ana-
NORMAL BONE HEALING (REPAIR) tomically reduced without a gap between the segments
Normal bone healing parallels soft tissue healing. Both and immobilized with rigid fixation. This type of fracture
tissue types undergo three phases of wound healing— healing is known as primary intention (Fig. 2-10).
inflammation, proliferation, and remodeling.3,10,14,15 As long as the fracture site remains immobilized,
However, bone healing also undergoes calcification. As maintains an adequate blood supply, and remains free of
with soft tissue repair, the inflammatory stage in bone infection, the remodeling stage will complete the frac-
healing begins immediately after the injury and lasts up ture healing process,. The callus completely ossifies as
TABLE 2-5 Polypeptide Growth Factors Involved in Bone Healing
Stage of Bone Healing Growth Factor Function(s)

I. Vascular Plasma fibronectin Anchors cells in the ground substance; ingrowth required for
collagen formation
Endothelial cell–derived Mitogen
growth factor
II. Callus Platelet-derived growth factor Mitogen—fibroblasts, bone cell formation; activates monocytes;
promotes bone resorption
Epidermal cell growth factor Mitogen—cartilage, bone; inhibits type I bone collagen synthesis
Fibroblast growth factor Mitogen—fibroblasts, chondrocytes
Insulin-like growth factor Chondrocyte proliferation; chondrocyte proteoglycan synthesis
Nerve growth factor Mitogen
III. Bone formation, Epidermal growth factor Promotes bone resorption
remodeling phase
Fibroblast growth factor Promotes bone resorption in high doses
Insulin Synergistic effect with bone growth factors
Interleukins (monocyte IL-1: Fibroblast proliferation, collagenase production, prostaglandin
products) production
IL-2: T cell growth factor, stimulation of bone resorption by osteoclastic
activation factor (OAF) production
From Simmons DJ: Fracture healing perspectives. Clin Orthop Relat Res 200:100, 1985.
osteoclasts gradually resorb the immature bone and it forces and repeated trauma can occur if the patient mas-
becomes remodeled into lamellar bone. The gradual ticates before bone healing is complete.18 Tobacco use
osteoclastic resorption of immature woven bone with and excessive alcohol intake increase the risk of non-
osteoblastic bone formation and maturation to lamellar union.19 Nicotine impairs bone healing by preventing
bone is known as creeping substitution.3,10,14 vascular ingrowth and diminishing osteoblast function
Dental extraction sites heal by secondary intention. during the proliferative stage.20,21 Use of certain anti-
The socket first fills with blood that quickly coagulates inflammatory or cytotoxic medications (e.g., nonsteroi-
within the first 24 hours to form a blood clot that seals dal anti-inflammatory drugs [NSAIDs], glucocorticoids,
the alveolar socket from the oral cavity. Inflammation chemotherapeutic agents, fluoroquinolone antibiotics)
ensues soon after the injury of dental extraction. During during the inflammatory phase of bone healing has also
the first week of healing, leukocytes débride the extrac- been implicated in an increased risk of nonunion,22 but
tion site, phagocytose bacteria, and débride bony frag- the actual clinical significance may be negligible. A non-
ments. Osteoclasts resorb the marginal bone along the union of the mandible can lead to severe pain, instability
extraction socket (Fig. 2-11). Meanwhile, epithelial cells of the mandibular fracture segments, and malocclusion.
begin migrating along the socket wall to reepithelialize A nonunion requires open surgical treatment, with
the socket surface. During the second week of healing, removal of the fibrous callus and adequate fixation of the
granulation tissue is generated while osteoid is deposited fracture segments for stability. In cases in which the
by osteoblasts to form woven bone. By the fourth week defect between the fracture segments are large, a bone
of healing, full epithelialization is achieved. The alveolar graft may be required to promote proper bone healing
bone is remodeled over 4 to 6 months. During this time, and help bridge the gap between these fracture
the alveolar cortical bone and trabecular woven bone are segments.
resorbed and replaced by lamellar bone.10,14 Open fractures, especially those in communication
with oral or respiratory secretions or those exposed to
COMPLICATIONS IN BONE HEALING exogenous debris from trauma, are at risk of infection.
Repeated trauma to an area undergoing bone healing Contaminated open fractures are also at risk of develop-
can result in malunion or nonunion of a bone fracture ing osteomyelitis. Osteomyelitis is an infection of bone
(Fig. 2-12). A malunion results when the bony fracture that extends to the medullary space (Fig. 2-13). Osteo-
segments heal in an incorrect or nonanatomic position, myelitis can be painful and debilitating, and requires
which can lead to a deformity.16 For fractures of the jaws, surgical débridement of the involved bones and long-
malunion will create a malocclusion. A bony nonunion term antibiotic therapy. Osteomyelitis can be post-
results when the fracture segments do not form bone to traumatic or can be a result of the hematogenous spread
bone contact, but instead remain bridged by fibrous of infectious organisms. In the jaws, osteomyelitis can
tissue. In the maxillofacial region, bony nonunion is occur secondary to chronic odontogenic infection. When
most commonly seen in inadequately treated mandible osteomyelitis occurs post-traumatically, the bone fracture
fractures.17 The mandible is a bone with high functional will not heal appropriately and a nonunion often occurs.
A
Parathyroid Basophilic IL-1
hormone cytoplasm IL-6+++
Alkaline phosphatase TNFα
Estrogen CSFs
Vitamin D IL-1ra
Receptors for IL-6, IL-1
TNFα/LT, LIT, PTHrP,
VIP, Prostaglandins,
CGRP
Matrix Growth Factors:

TGFβ IL-6 +
IGF (constitutive)
FGF
BMP
PDGF Golgi Osteoblast
EGF Endoplasmic
reticulum
Bone matrix
B
Calcified bone
CALCITONIN: binds to
receptor inhibiting ruffled
border Tartrate-resistant acid
phosphatase (TRAP) Factor(s) released from
M-CSF: binds to tyrosine (-) OSTEOBLASTS induce
kinase receptor c-fms osteoclastic bone
FIGURE 2-7 A, Osteoblast engaged in inducing ruffled border (+) resorption
(+)
synthesis. The cytoplasm is indicative of a cell Binding of TGF-β
actively involved in the export of proteins. An (-) to receptor inhibits
IL-6 bone resorption
elaborate Golgi complex and rough
Ruffled border
endoplasmic reticulum are evident. The
unmineralized front containing collagen fibrils
ATPase pump Acid
is adjacent to the mineralized matrix, which is lysosomal
the site of release of the internally produced proteases
matrix. B, An osteoblast secreting bone matrix
proteins. Secretory products, including matrix
Ca2+
proteins, cytokines, and membrane and
intracellular receptors, are indicated. C, A H+ Howship's lacuna
mature osteoclast in a resorption pit. Binding (+) Osteoclast
at the clear (sealing) zone is indicated, Tyrosine kinase receptor c-src Vitronectin receptor in clear
together with specific receptors and factors C required to form ruffled border zone binds to RGD sequence
involved in the formation of the ruffled border. in osteopontin in the matrix
A B
FIGURE 2-8 A, Photomicrograph of an osteocyte with its cytoplasmic processes visible on the periphery (arrows). B, Longitudinal section
of cytoplasmic process of osteocyte in A. Through this extensive canalicular system, osteocytes are able to transfer oxygen and
metabolites (e.g., calcium) from blood to nourish the surrounding bone.
FIGURE 2-9 Various loading models (stress) seen on

Normal Tension Compression Bending Shear Torsion bone.
Osteoclast
(cutting cone)
Contact Space
healing Osteoblast
New bone
Gap healing
FIGURE 2-10 Gap healing has occurred opposite to the compression plate, with direct bone deposition between the cortical ends.
Contact healing is taking place within the cortical bone in the area of compression. The osteoclastic cutting cones have produced cores
into which osteoblasts lay down new bone (inset).
A B
FIGURE 2-11 A, An osteoclast. Osteoclasts are relatively large multinucleated cells. Their cytoplasm is laden with lysosomal enzymes, a
well-developed Golgi process, mitochondria (M), and rough endoplasmic reticulum (RER). The active process of bone resorption occurs
at the convoluted membrane of the osteoclast (ruffled border). B, Photomicrograph of an osteoclast with a prominent ruffled border.
Cortical
bone
Medullary
Endosteal Cortical
bone
osteoblasts bone
Granulation Osteoblasts
Cartilaginous tissue External
external callus callus Residual islands
Periosteal
osteoblasts of cartilage
New bone Internal
formation in callus
Internal bony
cartilaginous
callus
callus
A B
Cortical
bone
Internal
callus Osteoblasts
Granulation Hematoma
tissue External
Residual callus
islands of
cartilage
C
FIGURE 2-12 A, Late cartilaginous callus stage. The internal bony callus has bridged the defect with direct bone formation by endosteal
osteoblasts. The cartilaginous callus has formed peripherally and is undergoing ossification. B, Bony callus stage. The internal bony callus
is complete. Ossification of the cartilaginous callus has left small islands of residual cartilage. C, Bony callus stage—fracture with notable
displacement illustrating adaptation of the callus.
NORMAL CARTILAGE HEALING (REPAIR)

In the maxillofacial region, cartilage is found in the artic-
ular surfaces of the temporomandibular joint (TMJ) and
in the auricular and nasal cartilages. Facial cartilaginous
defects are generally caused by traumatic injury,
infection, pathology, or chronic degeneration. Cartilage
repair is challenging, given its limited inherent capacity
for self-repair secondary to its low cellular density and
minimal vascular supply. Large defects in nasal and
auricular cartilage usually require autologous cartilage
grafting.26,27
Although cartilage is a metabolically active tissue, it
has no inherent vascularity or lymphatic vasculature. A
poor inflammatory response is elicited after cartilage
injury because progenitor cells from the blood or bone
marrow are unable to access the damaged cartilage.
Therefore, cartilage healing and repair is significantly
FIGURE 2-13 A comminuted mandibular body fracture that more limited than with other tissues of the oral and
resulted from a high loading force. The force was dissipated at maxillofacial region.27,28
the point of impact, resulting in the comminution. This patient Damage to articular cartilage initiates a healing
suffered no other mandibular fractures. response in areas in which cartilage and bone are in
direct contact. If the damage extends from the articular
surface into the subchondral bone, bleeding from the
Osteomyelitis is more common in the mandible than in bone into the cartilaginous defect occurs. This bleeding
the maxilla because of the relatively poorer vascular activates the normal bone-healing process.26 A hema-
supply. Mandibular osteomyelitis can be exquisitely toma is formed and fibroblasts subsequently lay down
painful and can be associated with anesthesia, hypoesthe- collagen. The resultant fibrous tissue is not consistent
sia, or dysesthesia of the inferior alveolar nerve.23-25 with the structural and functional properties of articular
FIGURE 2-14 Structure of a myelinated peripheral nerve.

(From Patton K, Thibodeau G: Anatomy and Physiology,
ed 7, Mosby, St. Louis, 2010.)
cartilage. Alternatively, partial-thickness cartilage injuries sixth classification was later added by Mackinnon. A first-
do not reach the subchondral bone, so there is no access degree injury, similar to neuropraxia, involves a nerve
for blood or cells to the site of injury. Therefore, a partial- conduction block. Second- to fourth-degree injuries are
thickness cartilage injury will not undergo repair and similar to axonotmesis injuries and wallerian degenera-
the defect will remain. This significant challenge tion occurs in these. In a second-degree injury, some
with cartilage healing has clinicians and researchers nerve fibers are damaged, without injury to endoneu-
searching for techniques to regenerate damaged carti- rium. Endoneurium involvement without perineurium
lage successfully.14,29,30 damage is seen in a third-degree injury. Perineurial
damage within an intact epineurium is seen in fourth-
NORMAL NERVE HEALING (REPAIR) degree injuries. Fifth-degree injuries are complete nerve
Nerve injuries (Fig. 2-14) can be categorized by the transections, much like neurotmesis injuries. Surgical
Seddon or Sudderland classification. The Seddon clas- intervention is recommended for fourth- and fifth-degree
sification describes three types of nerve injury— injuries.
neuropraxia, axonotmesis, and neurotmesis (Fig. 2-15). Examples of traumatic nerve injuries in oral and max-
Neuropraxia is a transient interruption in nerve conduc- illofacial surgery include transection of the inferior alve-
tion, sometimes described as nerve bruising. Axonal olar nerve or infraorbital nerve with a fracture of the
continuity is preserved in neuropraxia. Recovery is spon- mandible or midface, respectively, transection of the
taneous but may take weeks to months. In axonotmesis, lingual nerve during third molar removal, and transec-
individual axons are damaged within the nerve, with the tion of the facial nerve or trigeminal nerve branches with
epineurium being preserved. Wallerian degeneration, penetrating trauma to the face.31-33
the degradation of distal axons with concomitant loss of
Schwann cells, occurs (Fig. 2-16). As long as the proximal SKIN GRAFTING
nerve body survives, axonal regeneration may occur at a Skin grafts may be used to cover traumatic defects that
growth rate of 1 mm/day. Complete nerve transection cannot be adequately repaired with primary closure
without preservation of nerve continuity occurs in neu- alone or defects that are otherwise not expected to resur-
rotmesis. Wallerian degeneration ensues after neurotme- face quickly.34 Skin grafts can be classified as split-
sis. Nerve transection injuries rarely recover spontaneously thickness or full-thickness, depending on the extent of
and therefore require surgical intervention for improved dermis included in the graft. Full-thickness skin grafts
outcomes. After neurotmetic injuries, neuromas often (FTSGs) are composed of epidermis and the entire
form as the axons attempt to regenerate in a random dermis. Split-thickness grafts, on the other hand, are
fashion.10 composed of epidermis and a variable thickness of partial
Alternatively, nerve injuries can be described by the dermis. Split-thickness skin grafts (STSGs) are further
Sudderland classification. The original Sudderland clas- subdivided based on the thickness of harvested dermis.
sification encompassed five degrees of nerve injury. A Approximate measurements for split-thickness grafts are
Axon Epineurium Cell body

1 Axon Endoneurium
Endoneurium Perineurium Myelin sheath Schwann

cell
A
2 Injury Digestion
site chambers
Cell body and proximal stump of axon

enlarge as metabolic activity necessary
for regeneration commences
3
B
Schwann cells in distal stump
grow toward proximal stump
Macrophages
clear debris
4 C
Schwann cells envelop axon

and form myelin sheath
5 D
FIGURE 2-15 Sunderland classification system. Shown is a

schematic representation of the first through fifth degrees of nerve E
injury.
FIGURE 2-16 Stages of peripheral nerve healing. A, Normal nerve
cell and axon. B, Early wallerian degeneration. C, Phagocytosis
thin (0.2 to 0.3 mm), intermediate (0.3 to 0.5 mm) and and Schwann cell proliferation. D, Axon growth. E, Repaired
thick (0.5 to 0.8 mm). Skin grafts differ in more than just nerve fiber.
thickness; full-thickness and split-thickness grafts have
different properties that can be exploited for the patient’s
reconstructive needs. Full-thickness grafts undergo more secondary contracture than full-thickness grafts. Thinner
initial primary contracture because of the presence of split-thickness skin grafts have better survival than thicker
more elastic fibers in the dermal layer, but significantly grafts because the epithelium is in closer contact with the
less secondary contracture. Therefore, full-thickness skin underlying graft bed vasculature. Split-thickness grafts
grafts are placed in areas in which tissue contraction also have the advantage of ease of harvesting and grafts
would otherwise cause a deformity, such as the face or with a much larger surface area can be obtained.
hands, or over joints. These grafts also have the benefit Graft donor sites are selected with the type and appear-
of maintaining more normal skin characteristics, such as ance of the recipient site in mind.35 Donor site morbidity,
texture, pigmentation, and presence of dermal append- aesthetics, and ease of donor site closure are also consid-
ages (e.g., hair, sweat glands). Split-thickness grafts have ered. Usual donor sites for STSGs include the thigh,
less primary contracture because fewer elastic fibers are abdomen, buttocks, and inner arms. FTSG donor sites
present in partial dermis, but they undergo more include the forehead, neck, groin, and periauricular or
supraclavicular skin. Skin grafts can be harvested free-

hand with a scalpel or a variety of specialized blades, or TABLE 2-6 Impediments to Wound Healing
with a powered dermatome. Free- hand skin grafts are of
variable thickness and tend to have irregular borders. Local Systemic
Those harvested with a powered dermatome are of more Foreign bodies Smoking
consistent thickness and have less irregular borders. Venous insufficiency Diabetes
Meshing of split-thickness grafts increases the graft area
Pressure, trauma Corticosteroids
for resurfacing and allows fluid egression from the graft
bed, thereby reducing the risk of hematoma or seroma Ischemia, hypoxia Malnutrition
formation under the graft. However, meshing increases Radiation Cytotoxic chemotherapy
graft contraction and can produce a less cosmetic or less Salivary contamination Vitamin deficiency
functional result. In cosmetic areas or high-function sites Scarring Chronic illness
(e.g., over joints), unmeshed sheet grafts should be used. Hematoma
The resultant skin graft is sutured to the recipient site
and covered with a bolster dressing for gentle pressure
to prevent fluid from collecting under the graft and to
protect from inadvertent trauma to the grafted site.36,37 TABLE 2-7 Criteria for Bacterial Infection Based on
A skin graft initially adheres to the graft bed by fibrin. Quantitative Wound Culture
For the first 2 to 3 days, skin graft survival is dependent
Microorganism Criterion for Infection
on the imbibition of nutrients from the underlying graft
bed capillaries. The graft bed must therefore have an General flora >105 bacteria/cm3
adequate blood supply to ensure its survival. Graft revas- Enterococcus >103 bacteria/cm3
cularization begins early. Capillaries of the skin graft and Group B streptococcus Any
graft bed reanastomose in a process known as inoscula-
tion. Graft neovascularization also occurs, with random
vascular ingrowth of new vessels. Reinnervation follows
as nerve fibers subsequently grow into the graft. Initial include infection or a high bacterial burden, presence of
return of skin sensation over a grafted site takes approxi- foreign bodies or necrotic tissue within a wound, isch-
mately 2 months, although grafted sites generally do not emia secondary to vascular obstruction or pressure,
regain sensation equal to that of unaffected normal skin. venous or arterial insufficiency, and hypoxia related to
Full-thickness skin grafts are slower to revascularize radiation changes. Systemic factors include aging, diabe-
than split-thickness grafts because of the presence of a tes mellitus, malnutrition or vitamin deficiencies, immu-
thicker dermal component. For the same reason, imbibi- nocompromised states, peripheral artery disease, and use
tion occurs more slowly in full-thickness grafts. Full- of chemotherapeutic agents.7
thickness skin grafts therefore are at a greater risk of graft
failure. Defatting the underside of a full-thickness graft AGING
improves imbibition and increases the rate of revascular- As with most metabolic processes, the capacity for wound
ization. Causes of skin graft failure include hematoma or repair declines with age. Aging results in generalized
seroma formation (separation of graft from graft bed), tissue thinning caused by collagen loss, as well as vascular
presence of high bacterial load, inadequate débridement compromise and poor perfusion. These changes cause
prior to graft placement, and inadvertent trauma to the tissues to be friable and more easily damaged. Thus,
graft site. As discussed in the following section, the injuries in older adults have compromised repair poten-
patient’s health and nutritional status should be opti- tial. In addition, older patients are more likely to have
mized to allow for proper healing and graft take. Grafted associated health conditions that adversely affect healing.
sites should be dressed with a bolster dressing that dis- To reduce the risk of poor wound healing associated with
courages hematoma or seroma formation, helps main- advanced age, patients should undergo preoperative
tain contact between the graft and recipient site bed, and optimization of comorbid conditions.1,7
prevents micromotion. The split-thickness donor site can
be dressed with occlusive or semiocclusive dressings, INFECTION
whereas the full-thickness donor site should be closed Infection is a major cause of impaired wound healing.38
primarily.36,37 Wounds are described as being sterile, contaminated,
colonized, or infected, depending on the mechanism of
FACTORS IN SUBOPTIMAL WOUND HEALING injury (e.g., bite wound) and its location with respect to
normal bacterial flora. If not properly addressed, con-
Chronic wounds arise when healing is compromised. taminated wounds can become infected (Table 2-7). A
These wounds generally have extended inflammatory high microbial burden in a wound increases the host’s
phases with resultant fibroplasia that increases tissue scar- inflammatory response to the area. Bacteria release
ring and wound contracture. Common risk factors for endotoxins and metalloproteases that destroy the extra-
poor healing in the inpatient or trauma setting are cellular matrix of healing tissue and cause cell lysis.
advanced age, wound infection, diabetes, history of Therefore, bacterial infection and increased inflamma-
smoking, and malnutrition. These risk factors can be tion can lead to further tissue damage. Bacteria also
classified as local or systemic (Table 2-6). Local factors compromise wound healing by competing with the
healing tissue for nutrients and oxygen. Infected wounds carbon monoxide, and nitrosamine. Nicotine reduces
should be addressed with adequate débridement, removal oxygen delivery to peripheral tissues secondary to
of foreign bodies and necrotic tissue, and irrigation. vasoconstriction by epinephrine and norepinephrine.
Such measures decrease bacterial burden and optimize Hypoxia is exacerbated by carbon monoxide binding to
host defenses. Infected soft tissues wounds are character- hemoglobin. Nicotine also causes collagen deposition
ized by erythema, edema, warmth, and tenderness, and and prostacyclin formation. It increases platelet aggrega-
a patient with a wound infection may further demon- tion, causes neutrophil dysfunction, and increases blood
strate leukocytosis and fever. Fluid collections, abscesses, viscosity, all of which adversely affect wound healing.
and hematomas should be drained to avoid bacterial Prior to elective surgery, patients should be advised to
growth. Topical or systemic antibiotics can be adminis- discontinue tobacco use for at least 2 weeks and should
tered in conjunction with incision and drainage or refrain from smoking until wound healing is com-
débridement when wounds appear infected. Whenever plete.1,7,20 However, these presurgical precautions are
possible, cultures should be obtained prior to initiating rarely feasible when treating patients with acute trau-
empirical antibiotic therapy. Targeted antibiotic therapy matic injuries.
should be instituted based on the risk of developing
antibiotic-resistant organisms. When appropriate, wound MALNUTRITION
dressings should be used as part of the wound manage- Nutritional status is an extremely important consider-
ment regimen. Wet to dry (or wet to moist) dressings can ation in wound healing.7,40 It is likely the greatest con-
be used as a form of wound débridement because a layer tributor to poor wound healing, especially in older adults.
of the wound will be removed with each wound dressing Healthy adults require 35 kcal/kg/day and 0.8 to 2.0 g
change. protein/kg/day. These requirements are greater in
Adherence to surgical principles is also crucial for the injured patients, especially those with large wounds or
prevention of postsurgical wound infections.38 Skin burns. In hypermetabolic states, protein replacement is
should be sterilely prepped prior to repair of traumatic 2.5 to 3 g/kg/day in adults and 3 to 4 g/kg/day in chil-
wounds and before creating surgical incisions. Whenever dren.2,4 Inadequate protein stores lead to prolongation
possible, skin incisions should be made on intact, non- of the inflammatory phase of healing and promotes
compromised tissue and be closed primarily in layers in protein catabolism. Unless adequately addressed, hospi-
a tension-free manner to avoid dehiscence.1 talized patients’ nutritional status can easily drop, par-
ticularly in older patients. Patients suffering maxillofacial
DIABETES trauma are at a much greater risk because of their inabil-
Diabetic patients are at an increased risk for compro- ity to chew and swallow normally. Such patients warrant
mised wound healing, because poor glucose control a dietary evaluation. Modified consistency diets are indi-
brings about inadequate tissue perfusion secondary to cated in patients with chewing or swallowing difficulties.
microvascular disease. Microvascular disease adversely Enteral feeding should be reinstated as soon as possible
affects the blood supply of healing tissue, thereby delay- and the trauma surgeon should have a low threshold for
ing wound healing and rendering diabetics susceptible placement of a feeding tube. Nutritional supplements,
to wound infection. Release of oxygen to tissues is also such as high-calorie or high-protein drinks can help
reduced, because glycosylated hemoglobin has a higher patients with inadequate intake improve their nutritional
affinity for oxygen than nonglycosylated hemoglobin. status. Protein stores should be evaluated by measuring
Hyperglycemia also adversely affects the immune system serum albumin and prealbumin levels. The normal
by impairing neutrophil and lymphocyte function, che- serum albumin concentration is higher than 3.5 g/dL
motaxis, and phagocytosis. In addition, an uncontrolled and the normal range for prealbumin is 17 to 45 g/dL.
blood glucose level decreases red blood cell permeability Serum prealbumin is a better indicator of short-term
and decreases blood flow through the small vessels of the nutritional status and a better predictor of wound healing
wound surface. The combination of poor cell recruit- than serum albumin, given its half-life of 2 to 3 days, as
ment and wound ischemia creates a suboptimal healing compared with the albumin half-life of 20 days.1
environment.39 Vitamin deficiencies are also common in older or mal-
In the immediate post-traumatic period, a diabetic nourished patients and in patients with special dietary
patient’s blood glucose level may prove difficult to requirements, malabsorption syndrome, or chronic alco-
control. Those with peripheral neuropathy have holism. Vitamins are needed for normal metabolism and
decreased pain sensation and are more prone to develop have important roles in many biologic processes.41-43 For
pressure ulcers. Areas vulnerable to injury should be example, vitamin A (retinol and carotenoids) decreases
routinely inspected. In the diabetic population, failure oxidative damage and aids in healing by stimulating
to protect the patient from pressure injuries and inade- fibroplasia, collagen cross-linking, cellular differentia-
quately addressing existing wounds may result in a dev- tion, and epithelialization. Vitamin B complex aids in
astating limb amputation. Tight serum glucose level antibody formation and leukocytic function, making
control is recommended to improve the likelihood of wounds less susceptible to infection.44,45 Vitamin C (ascor-
wound healing. bic acid) is another antioxidant that aids in wound
healing and in boosting the immune system. It is required
SMOKING for appropriate collagen synthesis. Deficiency (scurvy) of
Smoking tobacco causes tissue hypoperfusion and vitamin C is associated with the formation of fragile capil-
hypoxia. Tobacco releases chemicals such as nicotine, laries and a reduced rate of collagen synthesis. Vitamin
D is required for calcium absorption and is crucial for in vessel walls and connective tissues of skin and mucosa.
bone repair. Vitamin D deficiency causes rickets in chil- Tissues exposed to radiation may be injured permanently
dren and osteomalacia and osteoporosis in adults, con- because radiation causes irreversible tissue fibrosis and
tributing to an increased risk of fractures. Vitamin E obliteration of small vessels. Postradiation trauma
constitutes a family of compounds that includes the patients are more likely to have wound breakdown; they
tocopherols; it is a potent antioxidant that protects from may require soft tissue flaps to bring blood vessels to
cell membrane oxidation. Deficiency leads to poor inadequately perfused areas to allow for adequate healing
immune response and has been associated with the to occur.53,54
development of myopathies or neuropathies. Vitamin E Chemotherapeutic drugs inhibit wound repair.55
(α-tocopherol) has been used in conjunction with pent- Chemotherapy causes bone marrow suppression, with
oxifylline in the management of osteoradionecrosis and decreased production of inflammatory cells increasing
bisphosphonate-associated osteonecrosis of the jaws. the risk for infection. Some chemotherapeutic agents
Vitamin K is vital in the synthesis of prothrombin (factor target VEGF, an important mediator of angiogenesis.
II) and factors VII, IX, and X of the coagulation cascade. Given its role in tumor angiogenesis and neovasculariza-
Vitamin K deficiency may lead to increased bleeding and tion, suppressing VEGF is a good target for combating
hematoma formation. Deficiency also impairs healing neoplasia. However, this will also have detrimental effects
and predisposes to infection. Patients with liver disease on wound healing.56
or fat malabsorption diseases may require vitamin K
supplementation. WOUND MANAGEMENT
A comprehensive review of nonprescription vitamin
and herbal supplements is beyond the scope of this Wound care begins by optimizing the healing environ-
chapter. However, surgeons are encouraged to review the ment.1,55,57 Wounds must be properly addressed to opti-
patient’s medication list, including vitamins, herbal sup- mize healing and avoid complications such as infection,
plements, and alternative medications. Medication rec- excessive scarring and contracture, tissue maceration,
onciliation before embarking in surgery is important and wound dehiscence. Wounds should be débrided and
because certain vitamins and nutritional supplements closed when appropriate. Adherence to surgical princi-
may have side effects that can lead to undesired periop- ples and observance of wound care standards are crucial.
erative events, such as increased bleeding and altered Tissues should be handled with care to avoid additional
metabolism of other medications.40,46-50 injury and avoid compromising vascular perfusion.
Wounds should not be dessicated or exposed to caustic
IMMUNOSUPPRESSION chemicals. When a wound is closed, it should be done in
Patients can be immunosuppressed for a variety of a tension-free manner. Wounds should be closed in
reasons. They may have a medical condition causing layers, with appropriate suture selection. All dead space
immunosuppression or may take medications that induce should be obliterated and vital structures covered with
immunosuppression. Immunosuppression is the hall- well-vascularized tissues.58 Bone fractures should be
mark of HIV and AIDS and may be seen in cancer patients reduced and adequately immobilized. A patient’s medical
and poorly controlled diabetics. Immunosuppressed comorbidities, as well as volume and nutritional status,
states can also be encountered in older and malnour- should be optimized.
ished patients and, to a lesser extent, in pregnancy and Wounds should be initially addressed with adequate
situations of extreme stress. Medication-induced immu- débridement.57 Necrotic tissue and foreign bodies should
nosuppression is seen in transplant recipients and in be removed to decrease the bacterial burden. Hemato-
patients being treated for autoimmune and collagen vas- mas and abscesses should be drained. Infections can be
cular diseases such as rheumatoid arthritis, systemic treated with systemic or topical antibiotics or by débride-
lupus erythematosus, Crohn’s disease, and ulcerative ment of infected tissue.59-61
colitis.51 Patients with asthma or severe allergic reactions Débridement involves the removal of nonvital tissue,
may be taking glucocorticosteroids as anti-inflammatory foreign bodies, and biofilm.57 This can be done surgically
immunosuppressant drugs. Use of glucocorticosteroids with sharp excision until viable tissue is reached or hydro-
can cause a variety of adverse side effects and complica- dynamically via low-pressure irrigation. Wound irrigation
tions, such as delayed wound healing, osteoporosis, helps decrease bacterial load and washes out foreign
hypertension, and susceptibility to infection. Glucocorti- bodies and debris. Débridement can also be accom-
coids reduce the normal inflammatory response and plished with wet to dry (wet to moist) dressings. Other
adversely affect wound healing by suppressing protein methods include mechanical or chemical débridement
synthesis and cell proliferation.52 by application of topical agents such as silver sulfadia-
zine, cadexomer iodine, or topical collagenase.61
RADIATION AND CHEMOTHERAPY Surgical wounds are described as clean, clean-
Radiation therapy induces many deleterious effects in contaminated, contaminated, or dirty. The type of surgi-
tissue, including hypocellularity, hypovascularity, and cal wound closure performed is dependent on the level
hypoxemia. The adverse effects of radiation are dose- of contamination of the wound. For example, clean and
dependent. Radiation therapy can have acute and chronic clean-contaminated wounds are usually closed primarily,
effects. Acute radiation changes in the oral region whereas closure of contaminated and dirty wounds is
include mucositis, tissue erythema, and desquamation. often delayed until the wound has been decontaminated
Chronic radiation changes are irreversible and are seen through appropriate débridement or packing. Open
wounds, on the other hand, heal by secondary intention. also available. AlloDerm, an acellular cadaveric dermal
There are three types of wound healing or wound matrix, and Integra, a bovine collagen dermal matrix,
closure—primary intention, delayed primary closure and can be used when the patient has inadequate or insuffi-
secondary intention. cient skin graft donor sites.55
In regenerative medicine and tissue engineering
applications, living cells and growth factors are added to
HEALING BY PRIMARY INTENTION OR PRIMARY a scaffold to produce tissue for a bioactive wound dress-
WOUND CLOSURE ing.55,63-68 The cells used can be of autologous or alloge-
Healing by primary intention occurs in wounds with neic origin. The matrix can vary in consistency, depending
minimal tissue loss and occurs when the edges of an on the material used—blood, cartilage, or bone. Apligraf
acute surgical or traumatic wound are approximated. is an engineered, bioactive, composite wound healing
Surgical closure can be done successfully shortly after product that contains epidermal and dermal compo-
appropriate wound management. Healing by primary nents. It is made up of living allogenic keratinocytes and
intention results in rapid healing and minimal scarring. fibroblasts, suspended in a bovine collagen matrix, and
Primary wound closure is not recommended in grossly is approved by the U.S. Food and Drug Administration
contaminated wounds that cannot be adequately (FDA) for the treatment of diabetic foot ulcers and
débrided. venous leg ulcers. Other bioactive wound healing prod-
ucts, such as the Oral LCC or living cellular construct, is
DELAYED PRIMARY CLOSURE OR WOUND REPAIR currently under FDA study for oral mucosa applications.
Delayed primary closure is recommended for wounds Human skin equivalents, grown from cultured human
that require more extensive decontamination or débride- infant foreskin, are dermal matrix dressings that contain
ment. The wound edges are apposed only after a period a layer of live allogenic fibroblasts, covered by a second
of wound management to optimize healing. A delay in outer layer of live allogenic keratinocytes. Cultured all-
closure may also allow for host defenses to control con- human bilayered bioengineered skin is also under devel-
tamination. As with primary wound closure, the wound opment. VCT01 is an example of an all-human
edges should be undermined to obtain a tension free bioengineered skin product that has de novo dermal
closure. Tissue grafts may also be used for wound closure. matrix generated from human dermal fibroblasts.
HEALING BY SECONDARY INTENTION Negative-Pressure Wound Therapy

Secondary intention is healing by the body’s natural Negative-pressure dressings apply subatmospheric pres-
mechanisms, without surgical intervention. This is done sure to a wound.55,69-71 The negative- pressure dressing
in large wounds with tissue loss or avulsion, so that wound system is comprised of several elements—an open-pore
edges are widely separated and cannot be apposed. polyurethane foam sponge that can be cut to the size of
Healing occurs by clot formation, granulation, deposi- the open wound, a semiocclusive dressing that adheres
tion of collagen, and eventual epithelialization. Wound to and covers the sponge, tubing that connects the
contracture brings the wound margins together. Healing sponge to the vacuum system, and a vacuum pump with
by secondary intention results in very slow healing and a fluid collection canister. A silver-containing sponge can
notable scarring. also be used with the polyurethane foam sponge. The
negative-pressure dressing should be changed every 24
DRESSINGS AND TOPICAL AGENTS to 36 hours.
Wound Management: Dressings A negative-pressure dressing promotes wound healing
Dressings are an important aspect of wound care.55,62 by creating a moist wound environment. This is achieved
Dressings are used to maintain a moist environment that by a pressure gradient that allows for fluid egression from
encourages faster wound resurfacing by allowing migra- the wound, with excess fluid collected in a vacuum pump
tion of epithelial cells over the moist surface and by canister. This also permits wound exudates, which contain
preserving growth factors exuded at the wound surface. growth factors and cytokines, to travel through the wound
Dressings can aid in the delivery of topical antimicrobials bed. In addition to promoting a moist environment,
or recombinant growth factors to the wound bed, protect negative-pressure wound therapy increases blood flow
the wound from friction or shearing trauma, and collect into the wound and decreases the wound’s inflammatory
exudate or drainage. Alternatively, they can be used as a response.
form of débridement with frequent dressing changes,
especially when used in conjunction with topical agents. Topical Agents
Dry dressings are often not recommended because they Topical agents may be beneficial as an adjunctive wound
allow tissues to desiccate easily and form dry scabs. Dress- care treatment.55,59-61 Some commonly used topical anti-
ings can be categorized as open (e.g., no dressing with microbials are Bacitracin zinc ointment, cadexomer
scab formation), semiopen, occlusive, semiocclusive, and iodine, and silver sulfadiazine. They help reduce bacte-
biologic. Examples of dressing types include wet to moist rial load within a wound and keep the wound moist.
gauze, Xeroform or petroleum impregnated gauze Silver sulfadiazine has broad gram-negative and gram-
(semiopen), Duoderm and hydrocolloid dressings positive bacterial coverage, whereas Bacitracin zinc
(occlusive), Op-Site or Tegaderm (semiocclusive), and ointment has gram-positive coverage. Silver is also
autologous or cadaveric skin grafts (biologic dressings). toxic to bacteria. These topical applications may be
Skin equivalents, another form of biologic dressings, are used in conjunction with dressings for gentle wound
TABLE 2-8 Growth Factors—Origins and Actions
Factor Cells of Origin Action

PDGF (AA, AB, BB) Platelets, macrophages, endothelial Mitogenic for fibroblasts, smooth muscle cells, and endothelial
cells, fibroblasts cells; chemotactic for fibroblasts and macrophages
FGF (acidic, FGF1; Fibroblasts Mitogenic and chemotactic for endothelial cells and
basic, FGF2) keratinocytes; angiogenic
EGF Multiple Chemotactic for epithelial cells and fibroblasts. Mitogenic for
fibroblasts and epithelial and endothelial cells
VEGF Epithelial cells, macrophages Angiogenic
TGF-α Macrophages, keratinocytes, Chemotactic for epithelial cells and fibroblasts; mitogenic for
platelets fibroblasts and epithelial and endothelial cells
TGF-β Platelets, macrophages Chemotactic and mitogenic for fibroblasts; stimulates collagen,
fibronectin, and proteoglycan synthesis; angiogenic; and wound
contraction
IGF-1, IGF-2 Plasma, fibroblasts, keratinocytes, Mitogenic for fibroblasts, keratinocytes, endothelial cells, and
macrophages smooth muscle cells
Adapted from Lawrence WT: Wound healing biology and its application to wound management. In O’Leary JP, editor: Physiologic basis of surgery,
ed 3, Baltimore, 2002, Williams & Wilkins.
débridement during dressing changes. Nonadherent wound healing by promoting cellular proliferation and
silver-impregnated dressings are also available and may angiogenesis.75 Recombinant PDGF has also been shown
be useful in the granulation stage of healing. Sulfamylon, to reduce periodontal defects. GEM 21S is an example
or 10% mafenide acetate, is used for burn wounds and of a growth factor-enhanced product used to stimulate
care of exposed cartilage. Topical collagenases, such as periodontal wound healing and alveolar bone regenera-
Santyl, can be used to débride necrotic wounds with tion. It contains recombinant human PDGF (rhPDGF-BB)
dressing changes enzymatically. within an osteoconductive matrix (beta-tricalcium phos-
phate [β-TCP]).76
Growth Factors bFGF is a potent angiogenic stimulator that is pro-
Wound healing is orchestrated by intercellular commu- duced by fibroblasts, vascular smooth muscle cells, adre-
nication via chemical signaling within a wound. Growth nocortical cells, chondrocytes, and osteoblasts. It aids in
factors are signaling peptides that are found in wound tissue repair by stimulating cellular differentiation and
exudates. They act through specific cell receptors and proliferation. It promotes neovascularization and mito-
can cause cellular differentiation, cellular proliferation, genesis and stimulates epithelialization and collagen syn-
and cellular migration. Some of the more well-known thesis. Its role in alveolar bone repair, as well as
growth factors involved in healing are PDGF, TGF-β, mandibular and long bone fractures, is well established.
EGF, VEGF, basic FGF (bFGF), insulin-like growth Recent animal studies77 and other reports78,79 have shown
factors (IGF-1 and IGF-2), and TNF-α. Growth factors preliminary success of bFGF in the repair of large osteo-
continue to be extensively studied for their potential to chondral defects.
accelerate the healing process. Clinically, the use of IGF-1 and IGF-2 are synthesized by various organs,
recombinant growth factors is likely to become an including the liver, heart, lung, kidney, pancreas, carti-
increasingly common practice for improving healing in lage, brain, and muscle. IGFs are mitogens for osteoblasts
chronic wounds (Table 2-8).14 and osteoblast precursors, thus stimulating bone forma-
PDGF is known to play a role in all phases of wound tion. They also stimulate mitosis in fibroblasts, osteocytes,
healing. Many cells secrete PDGF, including fibroblasts, and chondrocytes. IGFs work synergistically with PDGF
endothelial cells, smooth muscle cells, platelets, and in the regeneration of dermal connective tissue and epi-
inflammatory cells. PDGF is a chemoattractant for neu- thelium. IGF-1, when used in combination with TGF-β,
trophils and macrophages. It promotes chemotaxis and has been shown to improve bone healing in healthy and
stimulates mitogenesis in fibroblasts and smooth muscle diabetic animals. Dental implants coated with IGF-1 and
cells. It induces the synthesis of collagen, fibronectin, TGF-β demonstrate an increased bone to implant
and hyaluronan. It also increases collagenase activity for contact.80-82
the breakdown of necrotic tissue, but has no direct effect TGF-β has a role in embryonic development and has
on epithelial or endothelial cell function.72,73 In animal also been shown to regulate tissue repair after injury.
studies, PDGF has even been shown to induce bone TGF-β is found in platelet alpha granules that are released
regeneration in calvarial defects when implanted on a at the site of injury on platelet degranulation. TGF-β has
poly(l-lactide) scaffold.74 In humans, recombinant PDGF chemotactic and mitogenic properties. It promotes
is used to decrease the size of pressure ulcers. Becapler- osteoblast differentiation and inhibits osteoclastic bone
min, commercially known as Regranex, is a PDGF gel resorption. It has bone-specific properties, but is not as
used for the treatment of diabetic foot ulcers. It aids in potent as bone morphogenetic protein-2 (BMP-2), a
TABLE 2-9 Growth Factors Found in the Fracture Callus
Growth Factor Source Matrix Location Responding Cells

TGF-β Platelets, inflammatory cells Bone is the most abundant source Most cells have TFG-β
(monocytes, macrophages, of TFG-β in the receptors body
osteoblasts, chondrocytes)
BMPs Chondrocytes, urinary bladder, BMPs originally identified in bone, Unknown
epithelium, brain but distributed throughout body
Fibroblast growth Inflammatory cells, osteoblasts, Bonds bone and cartilage matrix Most cells of mesodermal or
factors chondrocytes neuroectodermal origin
Platelet-derived growth Platelets, monocytes, activated Interactions unknown Most cells of mesodermal origin
factors macrophages, endothelial cells
TGF-β, Transforming growth factor-β; BMP, bone morphogenetic protein.
From Bolander ME: Regulation of fraction repair and synthesis of matrix macromolecules. In Hollinger J, Seyfer AE, editors: Portland Bone Symposium,
Portland, Oregon, Oregon Health Sciences University, 1995, p 165.
member of the larger TGF-β superfamily. TGF-β also SUMMARY

stimulates the synthesis of collagen and extracellular
matrix.83,84 When treating facial injuries, knowledge of the wound
Growth factors play a crucial role in bone healing healing process is crucial to maximize healing and mini-
(Table 2-9).14 BMP-2, bFGF, PDGF, TGF-β, and VEGF mize adverse outcomes such as infection, malunion, and
have all shown positive effects in promoting fracture disfiguring scarring. In the trauma arena, oral and maxil-
healing. The BMPs make up a large portion of the TGF-β lofacial surgeons must not only treat acute traumatic
super family. BMPs induce the expression of osteoblast wounds appropriately, but must also do everything
markers and stimulate bone formation. They also regu- possible to optimize the wound healing conditions.
late key steps in the differentiation, proliferation, and Knowledge of the technologic advances in wound care,
morphogenic processes of bone and cartilage.85-87 BMPs regenerative medicine, and tissue engineering will allow
are among the most potent of the known regulators of the surgeon treating maxillofacial trauma to achieve the
osteoblast differentiation, and BMP-2, 4, 6, and 7 all have best possible outcome in these potentially devastating
osteoinductive properties in vivo.88-90 BMP-2 released facial injuries.
from various carriers has been shown to regenerate cal-
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CHAPTER
Nutrition for the Oral and
3 Maxillofacial Surgery Patient
Pamela Hughes
| Jon P. Bradrick
| Charles J. Yowler
OUTLINE
Fasting- and Starvation-Induced Malnutrition Physiology Mechanics of Enteral Feeding
Trauma-, Stress-, and Sepsis-Induced Malnutrition Physiology Enteral Formula Delivery
Substrate Depletion and Requirements Enteral Diets
Protein Requirements Polymeric Enteral Formulas
Amino Acids Oligomeric Enteral Formulas
Electrolyte Requirements Monomeric Enteral Formulas
Glucose and Insulin Osmolarity
Assessment Tools for Diagnosis of Nutritional Failure Energy Sources in Enteral Formulas
Clinical Assessment Complications of Enteral Nutritional Therapy
Laboratory Assessment Parenteral Nutritional Therapy
Nutritional Support Methods for Patients with Functioning Peripheral Parenteral Nutrition and Total Parenteral
Gastrointestinal Systems Nutrition
Indications for the Use of Nutritional Therapy Initiating Nutritional Support in the Critically Ill Patient
Oral Methods of Nutritional Therapy Intermaxillary Fixation
Nonoral Methods of Nutritional Therapy
Nasogastric Feeding Tubes
Transcutaneous Enteral Feeding Tubes
A
mong the many functions the oral cavity provides, FASTING- AND STARVATION-INDUCED
one of the most important is the entry of nutrients MALNUTRITION PHYSIOLOGY
into the gastrointestinal (GI) tract. The ability of
a patient to ingest a normal diet by mouth can be altered A healthy 75-kg man normally stores 200 to 300 g of
by many things, including neoplasia, infection, congeni- carbohydrate, equal to 800 to 1200 kcal (4 kcal/g),
tal deformities, and injury. Oral and maxillofacial mostly as glycogen.3 Fat is normally 15% to 30% (11 to
surgeons provide form- and function-altering surgical 22 kg) and protein 14% to 20% (10 to 15 kg) of body
procedures to correct these problems, and these proce- weight. The average total caloric reservoir is therefore
dures themselves may limit function of the oral cavity. approximately 200,000 kcal, of which 75% is fat. In the
Most patients are well nourished before their visit. complete absence of nutritional intake, an otherwise
However, those patients with chronic illness, alcoholism, healthy person could catabolize 1 to 2 g/kg of protein
or anorexia and those who are older, institutionalized, or and 2 to 3 g/kg of fat/day. Theoretically, this caloric
homeless may be in various stages of malnutrition. The reserve could sustain life for 3 to 5 months. Realistically,
mortality and morbidity of these malnourished patients death would occur after burning about 140,000 kcal
is clearly higher than well-nourished patients who have (75% body fat and 50% body protein).4
sustained maxillofacial or multisystem trauma, or are Starvation involves a cascade of substitution of energy
undergoing the same operation. Evaluation and correc- substrates as the body attempts to conserve energy
tion of malnutrition are time-consuming and not dra- resources and cellular functions. With the onset of star-
matic, yet its correct recognition and application can vation, glycogenolysis provides most of the necessary
reduce postoperative complications. This chapter will blood glucose. The available glycogen stores are rapidly
compare the physiology of slow compensated starvation depleted, and amino acids become the prime source of
to the all-consuming hypermetabolism of the critically carbon for hepatic gluconeogenesis. The amino acid
injured trauma victim. As is true in many clinical areas, sources are muscle, connective tissue, and visceral pro-
the literature can be contradictory and can offer oppos- teins. As starvation continues, the rate of gluconeogen-
ing opinions. Some believe that early enteral feeding in esis diminishes, coincident with a decrease in metabolic
trauma patients results in decreased morbidity and com- rate and increase in ketone use as fuel by the central
plications.1 Others conclude that nutritional support is nervous system. The early loss of body mass is slowed
currently overused, improperly used, and has failed to and accompanied by a decrease in urinary nitrogen
show an improvement in clinical outcome.2 excretion. In a healthy patient, nitrogen intake equals
30
Nutrition for the Oral and Maxillofacial Surgery Patient CHAPTER 3 31
urinary excretion, about 10 to 30 g/day. In fasting star-

vation, urinary nitrogen excretion falls to 3 to 4 g/day, TABLE 3-1 Physiologic Summary of Starvation to
reflecting protein and therefore amino acid conserva- Hypermetabolism
tion.4 Because hepatic and GI function are more acutely Hypermetabolic
affected by decreased protein intake, compromised Characteristic Fasting Starvation Catabolism
function of both will rapidly develop. One kg of muscle Neuroendocrine activation − +
equals roughly 800 kcal, and 1 kg fat equals 7000 kcal, Resting energy expenditure − ++
resulting in greater weight loss when muscle is used as
Protein catabolism + +++
an energy source. This is the basis for the correlation of
anthropometric measurements with malnutrition (see Protein anabolism
Total body − −
later).5 Hepatic + +++
The brain normally uses glucose as its sole energy
Amino acid oxidation + +++
source. During starvation, the central nervous system
(CNS) converts to the use of fat. Fatty acids cannot cross Ureagenesis + +++
the blood-brain barrier for use as fuel, but ketones and Gluconeogenesis + +++
ketoacids provided by hepatic metabolism of fatty acids Ketone production ++++ +
can. As starvation continues, the glucose requirement of Malnutrition development + +++
the CNS falls about 70% and the requirement for gluco- rate
neogenesis by the body falls about 50%. This results in Simple mathematical total 7 21
significant sparing of lean body mass.
(From Cerra FB: Nutrition in trauma, stress and sepsis. In Shoemaker WC,
Ayres S, Grenvik O, et al, editors: Society of Critical Care Medicine: Text-
book of critical care, ed 2, Philadelphia, 1989, WB Saunders.)
TRAUMA-, STRESS-, AND SEPSIS-INDUCED
MALNUTRITION PHYSIOLOGY
Malnutrition can be thought of as a spectrum. One end
is the conservative rationing of body energy resources in
fasting starvation. The other end is hypermetabolism develop because hypermetabolic patients have increased
induced by stress, such as trauma or sepsis. This hyper- susceptibility to infection and poor wound healing. The
catabolic state is a neuroendocrine-mediated response to response will once again subside if these complications
dead tissue, injured tissue, severe perfusion deficits, and can be controlled. With repeated episodes or persistent
invading microorganisms.6 The components of the hypermetabolic state, organ failure will result.7 End-stage
response are the CNS, macroendocrine hormones, and organ failure is manifested by liver failure, triglyceride
microendocrine cytokines.7 The macroendocrine media- intolerance, rapid rise in lactate levels, reduced amino
tors are the anti-insulin, counterregulatory stress acid clearance, reduced hepatic protein synthesis, and
hormones—cortisol, glucagon, and catecholamines. marked increase in catabolism, with ureagenesis with
Together, their actions are considered synergistic in this prerenal azotemia. Once this occurs, it is unresponsive
response.8 Especially in large wounds, such as cutaneous to any nutritional supportive efforts.12 Table 3-1 is a
burns, the microendocrine response is mediated on a summary of fasting starvation compared with hypermeta-
cellular level by interleukin-1, tumor necrosis factor, and bolic catabolism.
interleukin-6.9 However, the total degree and severity of
the hypermetabolic response cannot be predicted based
only on the severity of the injury. SUBSTRATE DEPLETION AND
The manifestations of the neuroendocrine response REQUIREMENTS
are increased basal metabolic rate, increased core tem-
perature, increased oxygen consumption, hyperdynamic Given the spectrum from fasting starvation to hypermet-
circulation, loss of lean body mass, reduced insulin abolic catabolism, the clinician must understand the
release, marked lipolysis with reduced hepatic ketogen- difference between nutritional and metabolic support,
esis, increased gluconeogenesis unresponsive to glucose as described by Cerra.7 In both, the patient’s energy
administration, increase in lactate and pyruvate produc- and substrate requirements must be met. The proper
tion and release, increased amino acid oxidation and nutritional support, however, is dependent on how the
efflux from peripheral stores, increased hepatic protein patient’s neuroendocrine axis was activated. In fasting
synthesis, and ureagenesis.7,10 These hypermetabolic starvation, the hormonal response is activated not by
responses can be duplicated in normal patients who are starvation, but by the reintroduction of nutritional
given levels of epinephrine, cortisol, and glucagon in support. In stress the hormonal response is activated by
concentrations seen in stressed patients.11 After activa- the stress insult and subsequent nutritional support.
tion, the hypermetabolic response peaks at 48 to 72 Nutritional support therapy of the stressed hyper
hours. It then subsides over another 3 to 4 days. Loss of metabolic patient is more appropriately termed meta-
important vitamins, trace elements, and minerals occurs bolic support because the substrate doses are adjusted
very rapidly. Malnutrition will result within days. Com to accommodate the metabolic response to injury.
plications such as infection will prevent the hypermeta- Table 3-213,14 compares substrate use in starvation to
bolic response from subsiding. A vicious circle may hypermetabolism.
TABLE 3-2 Substrate Use in Starvation Compared with Hypermetabolism
Substrate Fasting Starvation (Nutritional Support) Hypermetabolism (Metabolic Support)

Carbohydrate Maximum usable glucose is 5 mg/kg/min Resting energy expenditure and oxidation
20 nonprotein kcal/kg/day effective Glucose production is increased, with normal peripheral uptake
150 : 1 nonprotein cal/g nitrogen or greater in Glucose entrance into the Krebs cycle is reduced
diabetics; fat can replace glucose Reduced fraction of total caloric production is from glucose
Decreased ability of exogenous glucose to reduce the rate of
gluconeogenesis
In stress states, the wound itself has an extreme requirement for
glucose
Fat Major long-term energy source in starvation; 75%-90% of energy supplied is by oxidation of fat
10% of energy requirement should be fat Plasma changes diagnostic of essential fatty deficiency present
Necessary to prevent fatty acid deficiency from onset of stress
secondary to insulin inhibition of lipolysis Fatty acid intolerance develops in higher levels of stress;
from high glucose infusions important to monitor triglyceride clearance
2-3 g/kg/day of fat supplementation can
cause hepatic steatosis7
Protein Body attempts to spare the amino acid Decreased total body protein synthesis
reserve by using other sources of carbon Increased hepatic protein synthesis
for energy Increased catabolism, increased amino acid oxidation (up to
30% of caloric expenditure in high-level stress)
Exogenous amino acids ineffective in reducing rate of catabolism
Branched-chain amino acids constitute most of the amino acid
oxidation
Amount of muscle catabolism related to brain’s need for glucose,
rather than the wound
Estimated 40 mg/kg/day nitrogen required to avoid negative
balance
Resultant lowering of nonprotein calorie-to-nitrogen ratio to
100 : 1
Adapted from references 7, 13, and 14.
PROTEIN REQUIREMENTS function, and the release of hormones. Branched-chain

In an uninjured healthy patient, daily protein losses amino acids (e.g., leucine, isoleucine, valine) have
approximate 20 to 30 g/day. In a critically ill patient in been shown to have anticatabolic effects in muscle, but
a hypermetabolic state, the protein losses are greater. there is no evidence that supplementation after injury
The net losses can be 1% of the total body protein each is beneficial.15
day. Therefore, daily protein supplementation should be
1.5 to 2.0 g/kg of ideal body weight. There have been no ELECTROLYTE REQUIREMENTS
studies showing that there is benefit to the patient beyond The phosphorus-dependent metabolic pathways are
2 g/kg, no matter the degree of injury and insensible numerous. Significant shifts in phosphorus can critically
protein losses. affect normal body function. The diaphragm is depen-
dent on the energy that phosphorus stores provide; thus,
AMINO ACIDS hypophosphatemia can lead to respiratory failure. Total
Glutamine and arginine are semiessential amino acids body stores of intracellular electrolytes are significantly
that are important in times of stress and injury. Gluta- depleted in the malnourished state. The clinician should
mine is significantly upregulated and serves as a nitro- be aware that refeeding will cause shifts of the already
gen donor important in the formation of ammonia and depleted electrolytes (phosphorus, magnesium, and
in the control of acid-base balance by the kidney, as potassium) intracellularly, and thus must be monitored
well as other anabolic processes. Glutamine is also an closely to avoid cardiovascular complications.
important amino acid for cellular energy—most signifi-
cantly, for various immunologic cells and enterocytes GLUCOSE AND INSULIN
lining the GI tract. In a hypermetabolic state, gluta- There is no argument that hyperglycemia is detrimental
mine supplementation becomes essential for prevent- to wound healing and immunologic status. Insulin resis-
ing muscle catabolism and muscle glutamine depletion. tance is common in the critically ill,16 and tight control
Arginine plays an important role in cell division, of the blood glucose level has been shown to reduce
the healing of wounds, ammonia excretion, immune mortality in intensive care unit (ICU) patients.17
triceps skin fold, and midarm muscle circumference

ASSESSMENT TOOLS FOR DIAGNOSIS OF are some of the measurements used for nutritional esti-
NUTRITIONAL FAILURE mates. Some anthropometric measurements have been
combined together, or with laboratory data, to create
CLINICAL ASSESSMENT predictive indices. The prognostic nutritional index and
As in many areas of clinical diagnosis, there are no reli- the creatinine height index have been correlated with
able absolute methods for the measurement of nutri- postoperative complication rates.24
tional failure. Most of the methods available are too
difficult or tedious to use in the clinical arena. Most Energy Expenditure
produce results no better than a well-considered clinical Estimation of energy expenditure and requirements is
judgment based on history and physical examination.18,19 the first step in determining the nutritional needs of a
Table 3-3 summarizes the physical findings of patient. The balance between energy intake and expen-
malnutrition.20 diture determines the daily energy requirements (calo-
ries).16 Underestimation, and subsequent underfeeding,
Ideal Body Weight is associated with delayed wound healing, organ failure,
A medical history and review of systems revealing nausea, and infection.25 Overfeeding can produce hyperglyce-
anorexia, diarrhea, or weight loss is suggestive of nutri- mia, increased carbon dioxide production, respiratory
tional abnormality. Change in body weight, intentional failure, and hepatic steatosis.26 Energy requirements are
or unintentional, is important. Normal ideal body dependent on a number of variables, such as body surface
weight (IBW) for patients can be calculated by the area, age, gender, and clinical disease state. Energy
formulas21: expenditure is the body’s need for adenosine triphos-
• Healthy males: 106 lb for initial 5 feet, plus 6 lb for phate (ATP) to meet metabolic needs. Total energy
every inch over 5 feet, plus 10% if over 50 years expenditure (TEE) is the sum of basal energy expendi-
old. ture (BEE), the thermic effect of food, physical activity,
• Healthy females: 100 lb for initial 5 feet, plus 5 lb and the disease process itself. BEE is further defined as
for every inch over 5 feet, plus 10% if older than 50 the energy expended by a patient in the resting, non-
years. stressed state after an overnight fast and is commonly
A decreasing ratio of actual to normal weight reflects referred to as resting energy expenditure (REE) in hos-
increasing malnutrition. Greater than 80% to 90% is pitalized patients.27 In situations in which measured
mild malnutrition, 70% to 85% is moderate malnutri- energy expenditure is not readily attainable, an estimated
tion, and less than 75% is severe malnutrition.4 As an caloric requirement may be used (104.67 to 146.54kJ/kg
alternative, the U.S. National Center for Health Statistics of ideal body weight); however, more sophisticated
has compiled normal tables of weight as a function of approaches to measuring requirements exist.16
height for men and women (Table 3-4). Indirect Calorimetry. The gold standard of assessment
Body Mass Index. In 1998, the National Institutes of of energy expenditure is indirect calorimetry. This tech-
Health published new guidelines for the determination nique is expensive, requires trained personnel, and has
of healthy weight. These guidelines for defining the significant error at higher inspired oxygen concentra-
point at which someone is overweight or obese are tions.28 Indirect calorimetry calculates a patient’s energy
stricter than previous guidelines. The guidelines are expenditure by measuring oxygen consumption and
based on the body mass index (BMI). The BMI uses a carbon dioxide production. It can be performed in spon-
person’s height and weight to establish a value that sug- taneously breathing and mechanically ventilated patients;
gests a statistical health risk based on weight alone. The however, inaccuracy occurs in patients with an inspired
following is used to determine the BMI value: oxygen concentration higher than 60%.27 This method
measures REE and reflects the clinical situation at the
BMI = body weight (in kg ) /height (in m2 ) time the measurement is made; it may not reflect true
energy expenditure over a 24-hour period.7,19
A BMI of 26 to 27 is thought to carry moderate health
risk and a BMI of 30 increases the risk of death from any Energy expenditure = (cardiac output × VO2 )
cause by 50% to 150%, according to some estimates. The + (1.11)( VCO2 )
average American woman has a BMI of 26; fashion
models typically have BMIs of 18. Conversely, a BMI of Estimating energy requirements is necessary in clinical
less than 18.5 has been proposed as an indication to practice when indirect calorimetry is impractical.29
screen for malnutrition; a BMI less than 15 is also associ- Several standardized prediction equations to measure
ated with increased mortality.22 energy expenditure have been developed, with the intent
Anthropometric Measurements. Anthropometric means to estimate energy requirements accurately in the absence
the study of human body measurements on a compara- of indirect calorimetry. Each has its limitations, and none
tive basis. When applied to nutrition, anthropometric have been shown to correlate statistically with indirect
measurements estimate stores of subcutaneous fat and calorimetry on a consistent basis.
lean skeletal muscle mass, which are assumed to reflect Harris-Benedict Equation. This equation was published
protein and caloric intake.23 Because the comparative 85 years ago and was developed through the analysis of
control data are based on healthy subjects, clinical data indirect calorimetry obtained from healthy, young, lean
may not apply to trauma patients. Subscapular skin fold, body mass male and female volunteers. This equation,
TABLE 3-3 Nutrition-Focused Physical Examination
Possible Nutritional or
System Normal Findings Abnormal Findings Metabolic Associations Non-Nutritional Examples
general survey weight for height loss of excess weight, protein-calorie deficiency endocrine disorders,
appropriate, well- muscle mass and fat osteogenic disorders,
nourished, alert, and stores, growth menopausal disorders
cooperative retardation secondary to estrogen
depletion
excess fat stores excess calorie intake
fatigue, anemia iron deficiency
skin pink, soft, moist, turgor poor wound healing, protein, vitamin C, or zinc diabetes, steroids
with instant recoil, ulcers deficiency
smooth appearance dry with fine lines and essential fat or vitamin A environmental or hygiene
shedding, scaly (xerosis) deficiency factors
spinelike plaques around vitamin A or essential fat
hair follicles on deficiency
buttocks, thighs, or
knees (follicular
hyperkeratosis)
pellagrous dermatitis niacin or tryptophan thermal, sun, or chemical
(hyperpigmentation of deficiency burns; Addison’s
skin exposed to disease
sunlight)
pallor iron or folic acid skin pigmentation
deficiency disorders, hemorrhage
yellow pigmentation carotene excess jaundice
poor skin turgor fluid loss
petechiae, ecchymoses vitamin K or C deficiency aspirin overdose, liver
disease, or trauma
nails smooth, translucent, spoon-shaped iron deficiency COPD, heart disease,
slightly curved nail (koilonychia) aortic stenosis
surface and firmly dull, lackluster protein or iron deficiency chemical effects
attached to nail bed; pale, mottled vitamin A or C deficiency infection, chemical effects
nail beds with brisk
capillary refill
scalp pink, no lesions, softening of craniotabes vitamin D deficiency
tenderness; fontanels open anterior fontanel vitamin D deficiency hydrocephalus
without softening, (usually closes by 18
bulging months of age)
hair natural shine, lack of shine and luster, protein, zinc, biotin, or hypothyroidism,
consistency in color thin, sparse linoleic acid deficiency chemotherapy,
and quantity, fine to psoriasis, color
coarse texture treatment
easily plucked protein, zinc, or biotin hypothyroidism,
deficiency chemotherapy,
psoriasis, color
treatment
color change zinc deficiency chemically processed or
bleached hair
brittle hair biotin deficiency
hair loss protein, B12, or folate
deficiency
face skin warm, smooth and diffuse depigmentation, protein deficiency steroids and other
dry, soft moist with swollen medications
instant recoil pallor iron, folate, or B12 low perfusion, low volume
deficiency states
moon face protein-calorie deficiency Cushing’s disease
bilateral temporal wasting protein-calorie deficiency neuromuscular disorders
TABLE 3-3 Nutrition-Focused Physical Examination—cont'd
eyes evenly distributed brows, pale conjunctiva iron, folate, or B12
lids, lashes, deficiency
conjunctiva pink night blindness vitamin A deficiency
without discharge, dry, grayish, yellow, or vitamin A deficiency pterygium, Gaucher’s
sclerae without spots, white foamy spots on disease
cornea clear, skin whites of eyes (Bitot’s
without cracks or spots)
lesions dull, milky, or opaque vitamin A deficiency
cornea (corneal xerosis)
dull, dry rough vitamin A deficiency chemical, environmental
appearance to whites of
eyes and inner lids
(conjunctival xerosis)
softening of cornea vitamin A deficiency
(keratomalacia)
cracked and reddened riboflavin or niacin infection, foreign objects
corners of eyes (angular deficiency
palpebritis)
nose uniform shape, septum scaly, greasy, with gray or riboflavin or niacin,
slightly to left of yellowish material pyridoxine deficiency
midline, nares patent around nares (nasolabial
bilaterally, mucosa pink seborrhea)
and moist, able to inflammation, redness of need to reconsider if
identify smells sinus tract, discharge, placing feeding tube
obstruction or polyps
lips, mouth pink in color, bilateral cracks, redness riboflavin, niacin, poor fitting dentures,
symmetrical, smooth, of lips (angular pyridoxine, iron, or herpes, syphilis
intact stomatitis) protein deficiency
vertical cracks of lips riboflavin, niacin, iron, or AIDS (Kaposi’s sarcoma),
(cheilosis) protein deficiency environmental exposure
tongue pink color, moist, midline, magenta in color riboflavin deficiency
symmetrical with rough smooth, slick, loss of folate, niacin, riboflavin,
texture papillae (atrophic filiform iron, or B12 deficiency
papillae)
beefy red color, atrophied niacin, folate, riboflavin, Crohn’s disease, infection
taste buds, and mucosa iron, B12, or pyridoxine
red and swollen deficiency
decreased taste zinc deficiency cancer therapy
(hypogeusia)
gums pink, moist without spongy, bleeding, vitamin C deficiency dilantin and other
sponginess receding medication, poor
hygiene, lymphoma,
polycythemia
thrombocytopenia
teeth repaired, no loose teeth, missing, poor repair, excess sugar trauma, syphilis, aging,
color may be various caries, loose poor dental hygiene,
shades of white radiation therapy
white or brownish patches excess fluoride enamel hypoplasia,
(mottled) erosion
parotid gland located anterior to bilateral enlargement protein deficiency bulimia, cysts, tumors,
earlobe, no hyperparathyroidism
enlargement
neck nodules trachea midline, freely enlarged thyroid iodine deficiency cancer, allergy, cold,
movable without infection
enlargement or nodules
Continued
chest, lungs anterior and posterior somatic muscle and fat protein-calorie deficiency, respiratory disease (e.g.,
thorax: adequate wasting, labored metabolic acidosis, COPD)
muscle and fat stores, respirations, metabolic alkalosis
respirations even and adventitious breath
unlabored, symmetrical sounds such as
rise and fall of chest crackles, rhonchi, and
during inspiration and wheezing; evaluate for
expiration, lung sounds fluid status vs.
clear tenacious secretions
that may labor breathing
and increase energy
expenditure. Also
consider increased rate
and depth, decreased
rate and depth
heart rhythm regular and rate irregular rhythm potassium deficiency or cardiopulmonary disease
within normal range; excess, calcium states
S1 and S2 heart deficiency, magnesium
sounds heard deficiency/excess, or
phosphorus deficiency
pounding pulse fluid overload cardiopulmonary disease
(hypervolemia)
small, weak pulse fluid deficiency
(hypovolemia)
palpitations hypoglycemia
tachycardia thiamine deficiency
enlarged heart thiamine deficiency
associated with anemia
and beri-beri
abdomen soft, nondistended, generalized symmetric obesity enlarged organs, fluid, or
symmetrical, bilateral distention gas
without masses, protruding, everted influence protein, fluid,
umbilicus in midline, no umbilicus, tight sodium concerns of
ascites, bowel sounds glistening appearance feeding
present and (ascites)
normoactive; tympanic scaphoid appearance protein-calorie deficiency
on percussion; feeding increased bowel sounds influences nutrition of
device intact without gastroenteritis (normal
redness, swelling if hunger pains)
high-pitched tinkling influences nutrition if
intestinal fluid and air
present indicating early
obstruction
decreased bowel sounds influences nutrition if
peritonitis, or paralytic,
ileus present
kidney, ureter, urine golden yellow decreased output, dehydration
bladder (range from pale yellow extremely dark,
to deep gold), clear concentrated
without cloudiness,
adequate output
musculoskeletal full range of motion inability to flex, extend, influences nutrition by
without joint swelling and rotate neck interfering with ability
or pain, adequate adequately to feed or make
muscle strength hand-to-mouth
contact
decreased range of protein-calorie deficiency
motion, swelling,
impaired joint mobility,
or other of upper
extremities; muscle
wasting on arms, legs,
skin folding on buttocks
swollen, painful joints vitamin C connective tissue disease
enlargement of epiphyses vitamin D or C deficiency trauma, deformity, or
at wrist, ankle, or knees congenital cause
bowed legs vitamin D deficiency or
calcium deficiency
beading of ribs vitamin D deficiency or renal rickets,
calcium deficiency malabsorption
pain in calves, thighs thiamine deficiency deep vein thrombosis,
other neuropathy
neurologic alert, oriented, hand-to- decreased or absent influences nutrition by
mouth coordination; no mental alertness; the ability to feed or
weakness or tremors inadequate or absent make hand-to-mouth
hand-to-mouth contact
coordination
psychomotor changes, protein deficiency trauma, neurologic
confusion disease
peripheral neuropathy thiamine, pyridoxine, or
B12 deficiency
cranial nerves intact: tetany calcium or magnesium
primary nutritionally deficiency
focused ones include
trigeminal, facial,
glossopharyngeal,
vagus, and hypoglossal
reflexes (biceps, hyperactive reflexes hypocalcemia (R/O
brachioradialis patella, tetanus, upper motor
and Achilles’ common neuron disease)
in exam), functioning
within normal range of
2++
hypoactive reflexes hypokalemia associated with
metabolic diseases
such as diabetes
mellitus and
hypothyroidism
hypoactive Achilles’, thiamine or B12 deficiency neurologic disorders
patellar reflex
COPD, Chronic obstructive pulmonary disease.
Adapted from Hammond K: Physical assessment: A nutritional perspective. Nurs Clin North Am 32:779, 1997.
TABLE 3-4 U.S. National Center for Health Statistics—Male and Female Ideal Weight
18-24 YR 25-34 YR 35-44 YR 45-54 YR 55-64 YR

Height M F M F M F M F M F
4’10” 114 123 133 132 135
4’11” 118 126 136 136 138
5’00” 121 130 139 139 142
5’01” 124 133 141 143 145
5’02” 130 128 139 136 146 144 148 146 147 148
5’03” 135 131 145 139 149 146 154 150 151 151
5’04” 139 134 151 142 155 149 158 153 156 154
5’05” 143 137 155 146 159 151 163 157 160 157
5’06” 148 141 159 149 164 154 167 160 165 161
5’07” 152 144 164 152 169 156 171 164 170 164
5’08” 157 147 168 155 174 159 176 168 174 167
5’09” 162 173 178 180 178
5’10” 166 177 183 185 183
5’11” 171 182 188 190 187
6’00” 175 186 192 194 192
6’01” 180 191 197 198 197
6’02” 185 196 202 204 201
therefore, underestimates the energy requirements of

trauma patients. Modifiers were developed to account for TABLE 3-5 Stress Factor Modifiers for Estimating Energy
this; however, it is thought that the modifiers significantly Expenditure
overestimate requirements.16,30,31 Table 3-5 illustrates Injury Factor
some stress factor modifiers. Simple starvation 0.85
Males: Elective surgery 1.05-1.15
BEE = 66 + (13.7)( weight in kg) + ( 5)(height in cm) Sepsis 1.2-1.4
− (6.8 )(age in years) Closed head injury 1.3
Multiple trauma 1.4
Females: Major burn 2.0
BEE = 655 + (9.6 )( weight in kg) + (1.7)(height in cm) Data from Malone AM: Methods of assessing energy expenditure in the
intensive care unit. Nutr Clin Pract 17:21, 2002.
− ( 4.7)(age in years)
Ireton-Jones Equation. Another predictive equation is

= 1), B = diagnosis of burn (absent = 0, present = 1), and
the Ireton-Jones equation.32 Two hundred patients with
EEE = estimated energy expenditure (kcal/day).
a variety of medical and surgical diagnoses were mea-
These and several other equations have been pro-
sured by indirect calorimetry. Ventilator-dependent
posed to estimate energy requirements, but these equa-
patients had a higher REE than spontaneously breathing
tions have shown poor predictive value, have been
patients.27
formulated from subjects who are not representative of
The Ireton-Jones equation for spontaneously breath- the general population, or have large standard errors for
ing patients is as follows: the estimate. However, these equations continue to be
used in clinical practice despite a lack of evidence or
EEE = 629 − 11( A ) + 25( W ) − 609(O ) supporting research.29
The Ireton-Jones equation for ventilator-dependent

patients is as follows: LABORATORY ASSESSMENT
Nitrogen Balance
EEE = 1784 − 11( A ) + 5( W ) + 244(G) + 239( T ) + 804(B) The ultimate goal of any nutritional support regimen is
the provision of positive nitrogen (N) balance. There-
where A = age (years), W = weight (kg), O = presence of fore, it is necessary to assess the adequacy of nitrogen
obesity (>30% above ideal body weight; absent = 0, delivery and loss. One of the more common methods
present = 1), T = diagnosis of trauma (absent = 0, present involves the 24-hour collection of urine for the
determination of urinary nitrogen loss. In the absence of study concluded that albumin levels are a strong predic-
abnormal nitrogen loss from intestinal fistulas, diarrhea, tor of surgical mortality and morbidity, especially the risk
and wound exudates, total nitrogen loss may be calcu- of sepsis and major infections.34 The clinician must be
lated. In general, a positive nitrogen balance greater aware that serum albumin can be significantly altered
than 2 is satisfactory. A balance less than 2 requires an with excessive protein losses, catabolism, decreased
additional protein supplement to the diet. A positive hepatic protein synthesis, and fluid resuscitation, creat-
nitrogen balance is difficult to achieve in the critically ing dilutional effects; especially in the multisystem trauma
injured patient, and is simply not attainable when severe victim.
hypermetabolism is present.16
Visceral protein reserves can be estimated by the mea-
surement of specific serum proteins.5 NUTRITIONAL SUPPORT METHODS FOR
PATIENTS WITH FUNCTIONING
The following are equations for nitrogen output and GASTROINTESTINAL SYSTEMS
balance:
In oral and maxillofacial surgery patients who are not
Nitrogen output: nutritionally compromised, mild and transient nitrogen
losses are easily tolerated. Nitrogen losses can readily be
24-hour urine urea nitrogen (UUN) (g/day ) replaced by oral feeding. Recovery from moderate injury
= UUN (mg/day ) × urine output (mL/day ) or uncomplicated elective surgery increases the meta-
× 1 g/1000 mg × 1 dL/100 mL bolic rate only by about 10%. In the absence of hyper-
Total nitrogen loss (g/day ) 24-hour UUN (g/day ) metabolism, nitrogen losses are minimal. If a patient is
+ (0.2 × 24-hour UUN g/day ) + 2 g/day estimated to return to oral intake within a week, it is
appropriate to provide only 5% dextrose solutions
Nitrogen balance: (500 kcal/day) as the only supplement. Additional nutri-
tional support in such patients does not further improve
24-hour intake protein (g) / 6.25 (g) outcome.2
− urinary nitrogen (g/day ) = N/day However, the clinician will encounter the hypermeta-
bolic, critically ill patient who will require aggressive
Serum Albumin
nutritional support. In these patients, IV administration
Albumin is not stored in the liver but is continuously of only 5% dextrose with electrolytes is equivalent to
secreted by the hepatocytes at approximately 17 g/day. starvation.4 Nitrogen excretion can reach 200 to 400 mg/
Albumin levels fall slowly in starvation because of their kg/day in stressed patients receiving only 5% dextrose.
long half-life. Once hepatic synthesis is slowed, the rate Ten days of such losses will result in severe malnutrition
of serum decline of a protein is inversely proportional to in a previously well-nourished patient.35 Without proper
its half-life.5 Thus, serum proteins with shorter half-lives, supplementation, outcome has been shown to be worse
such as prealbumin, transferrin, ceruloplasmin, and in major surgery patients unable to eat for 14 days. As a
retinol-binding protein, respond to dietary changes threshold, nutrition supplementation should be given to
much faster. Table 3-6 summarizes levels for some of previously well-nourished patients not expected to eat for
these proteins. 1 1 2 to 2 weeks after injury or surgery.2
These short half-life secretory proteins provide more
sensitive indication of acute protein and energy deple- INDICATIONS FOR THE USE OF
tion, but have not been shown to make a significant dif- NUTRITIONAL THERAPY
ference in the prediction of outcome.16 Clinical studies Souba, in a review and meta-analysis of clinical trials, has
have shown a direct correlation between low albumin described indications for the use of nutritional therapy.2
levels and 30-day hospital mortality.33 Gibbs et al, in a Established indications are as follows: patients unable to
multicenter Veterans Administration (VA) prospective eat or absorb nutrients for an indefinite period of time;
study of 54,215 noncardiac surgery patients found that a well-nourished, minimally stressed patients unable to eat
decrease in serum albumin from concentrations greater for more than 10 to 14 days; severely malnourished
than 46 g/liter to less than 21 g/liter was associated with patients undergoing major elective surgical procedures;
an exponential increase in mortality rates from less than and patients with major trauma and bone marrow trans-
1% to 29% and in morbidity rates from 10% to 65%. The plant recipients undergoing intensive anticancer therapy.
TABLE 3-6 Hepatic Protein Markers
MALNUTRITION (G/DL)
Protein Half-Life (days) Normal Mild Moderate Severe
Albumin 20 3.5-5.0 2.8-3.5 2.1-2.7 <2.2
Prealbumin 2-3 16-43 10-15 5-9 <5
Transferrin 8 200-400 150-200 100-149 <100
Unproved indications for the use of nutritional therapy Nutritional Assessment

include cancer, AIDS and other immunodeficiencies, GI
tract dysfunction, liver failure, renal failure, and critically Maintenance Therapy Repletion Therapy
ill patients (excluding trauma).
ORAL METHODS OF NUTRITIONAL THERAPY Gastrointestinal tract can be used safely

Oral feedings using a functioning GI tract are the optimal
route for nutritional therapy. Problems that may inter- Parenteral
Yes No nutrition
fere with or limit adequate oral feeding include poor
appetite, nausea and vomiting, and inability to swallow. Adequate Intestinal Absorption
Oral and maxillofacial surgery patients are especially vul-
nerable to oral dysfunction secondary to diseases, defor-
mities, injuries, and the nature of the procedures used Yes No
to treat them. Oral dietary supplementation (ODS)
seems to be an attractive and easy nutritional therapy, but Defined Formula Diets Protein Isolate Diet
definitive proof of its efficacy is lacking. MacFie et al,36
in a randomized, prospective, clinical trial of 100 patients Alimentation longer than 6 weeks
undergoing laparotomy, found no significance between
controls and ODS patients regarding weight loss or clini- Yes No
cal outcome. They concluded that the routine use of
perioperative ODS in well-nourished patients undergo- Feeding by tube enterostomy Nasogastric tube feeding
ing major GI surgery provides no clinical or functional
benefit.
At risk for aspiration
NONORAL METHODS OF NUTRITIONAL THERAPY
Nutritional support methods that bypass the oral cavity Yes No
include enteral (tube feeding) and parenteral (IV
feeding). Enteral feeding requires a functioning GI tract, Nasoduodenal or Nasogastric
whereas parenteral support is specifically used when the nasojejunal tube tube
GI tract is nonfunctional. Sometimes, a patient’s unique
needs may be satisfied by the use of both methods con- Adequate nutrient delivery
currently. Enteral feeding has several advantages over
parenteral feeding. Enteral feeding maintains gut struc- Yes No
ture and function by providing the gut mucosa with sub-
strates essential for epithelial integrity. It does not require
Continue same Add peripheral
a central venous catheter for administration; therefore, feeding parenteral nutrition
there are fewer infectious or metabolic complications.
FIGURE 3-1 Enteral feeding method algorithm. (From Guenter P,
Enteral feeding is less costly than parenteral support. For
Jones S, Ericson M: Enteral nutrition therapy. Nurs Clin North Am
equivalent nutritional supplementation, parenteral
32(4):651, 1997.)
support will cost $75 to $350, whereas enteral feedings
will cost only $18 to $30/day.37 Contraindications to
enteral feedings include ileus, initial short bowel syn-
drome, intestinal obstruction beyond the duodenum, Nasogastric Tube Insertion
intractable vomiting and diarrhea, acute GI bleeding, Every clinician has his or her own favorite methods for
intestinal ischemia, and severe inflammatory bowel nasogastric tube insertion. General guidelines are as
disease.38 Enteral feedings should be initiated after initial follows40:
resuscitation from shock. Bowel necrosis has been • Place the patient in an upright or semiupright
reported following the delivery of enteral nutrition to position.
patients in profound metabolic acidosis accompanying • For conscious patients, topically anesthetize the
uncompensated shock. Figure 3-1 demonstrates an nasopharynx.
enteral feeding method algorithm. • Use caution with rigid stylet tubes because they can
puncture hollow viscera.
NASOGASTRIC FEEDING TUBES • Lubricate the tube well with a water-soluble
Nasogastric feeding tubes are small-diameter polyure- lubricant.
thane or silicone tubes.39 They can have weighted or • Have the patient swallow some water to facilitate tube
nonweighted tips and removable internal stylets or none. passage through the esophageal opening; use caution
These tubes are designed for only 4 to 6 weeks of use or with aspiration risk in dysphagia patients.
less. Do not confuse these with the larger stiffer tubes • Clinically verify correct tube placement by ausculta-
that are only for temporary stomach decompression. All tion during insufflation of air, aspiration of stomach
tubes have radiopaque stripes for tube location verifica- contents, or irrigation with small volume of water.
tion on radiographs and length verification markings on • Secure the tube to the nose with tape without exerting
the side of the tube. pressure on the nasal alae.
• Confirm tube position by abdominal radiography. procedure-related mortality of 3.2%, 0%, and 2.9%,
• A 45-degree head of bed elevation will reduce reflux respectively. Procedure-related morbidity was 16%, 8%,
and aspiration during tube feeding.41 and 20%%, respectively.
Verification of correct tube placement in the stomach, Advantages of PEG. The advantages of PEG compared
and not in the lungs, can involve a variety of maneuvers. with traditional open gastrostomy are no laparotomy pro-
The most traditional method, auscultation of air insuffla- cedure or scar, decreased peritoneal adhesions, shorter
tion, is not reliable. Clinical studies have revealed that anesthesia time, less postoperative pain, may be done as
this method is unreliable in differentiating GI versus an outpatient procedure, immediate feeding, decreased
respiratory tract placement.42 Air insufflation does prove expense, decreased complication rate, and decreased
the tube is not kinked. Aspiration of fluid and pH testing stomal leakage. The primary indications for PEG in head
of aspirates have also proven to be unreliable in clinical and neck surgery include neoplasia, neurologic dyspha-
trials.43 Abdominal radiographs verifying the positioning gia, cancer cachexia, and esophageal and pharyngeal
of the nasoenteric tube remain the gold standard. Correct obstruction. Contraindications to PEG include previous
interpretation of these x-rays is important, with attention gastric surgery, morbid obesity, peritonitis, massive
to differentiating the nasogastric tubes from the many ascites, peritoneal dialysis, sepsis, inability to transillumi-
other tubes that a critically ill patient may have,. For nate the abdominal wall, poor gastric emptying, high risk
patients with a significant risk of aspiration, postpyloric of aspiration, and anatomic restrictions on endoscopy.50
placement is recommended. Weighted nasogastric PEG Procedure. The following is a brief description of
feeding tubes spontaneously enter the duodenum only the PEG procedure. The reader should consult general
15% of the time.46 To improve passage into the duode- surgery texts and literature for a complete discussion.
num, place the patient in the right side–down decubitus After induction of a general anesthetic and tracheal
position. Administration of promotility agents such as intubation, the patient is placed in a reverse Trendelen-
metoclopramide or erythromycin before the nasogastric burg position. This allows the migration of abdominal
feeding tube is inserted will increase motility of the upper contents toward the pelvis. The upper left abdominal
GI tract while relaxing the pylorus. These agents are not quadrant is prepared for a sterile procedure. A flexible
effective if administered after the tube is inserted in the video gastroscope is inserted through the esophagus into
stomach. A 90% postpyloric passage has been achieved the stomach. The stomach is then insufflated to approxi-
with unweighted tubes using this method.47 Endoscopic mate the visceral wall of the stomach to the parietal wall
or fluoroscopic assistance can also be used to facilitate of the peritoneal cavity. The lights of the operating room
postpyloric passage. Repeat x-rays should be obtained are turned off to allow the light of the gastroscope to
after episodes of emesis, violent coughing, or any other transilluminate the gastric and abdominal walls. External
factor that might cause displacement of the tube.44 digital palpation and indentation of the illuminated spot
on the abdominal wall, usually several centimeters under
Nasogastric Tubes in Patients with Midface or the left costal margin, is confirmed through the gastro-
Skull Fractures scope. A 16-gauge angiocatheter is inserted percutane-
Caution should be exercised when passing nasogastric ously at the transillumination spot, and its entry into the
tubes in patients with midface or base of skull fractures. stomach is confirmed with the gastroscope. A wire loop
In these patients, the passage course should parallel and or suture is passed through the catheter and retrieved in
track along the floor of the nose. An alternative is first the stomach by the gastroscope’s snare. The gastroscope
to insert a soft nasal airway and use this as a guide for with the wire or suture is removed through the mouth.
passage of the nasogastric feeding tube through it. The The wire loop or suture is then attached to the external
nasal airway can then be removed once the nasogastric end of a gastrostomy tube. A 1-cm incision is made in the
feeding tube is in place.45 Be cautious with patients who abdominal wall catheter puncture site to release the
have existing tracheotomy or endotracheal tubes because dermis. The gastrostomy tube is pulled by the wire or
the feeding tubes have a propensity to follow these tubes suture through the mouth and stomach to emerge at the
into the trachea.7 small skin incision. A flange is attached to the tube at the
skin level for tube retention. The stomach and tube are
TRANSCUTANEOUS ENTERAL FEEDING TUBES examined by reinsertion of the gastroscope, followed by
Surgically placed enteral feeding tubes are indicated stomach decompression.
when the anticipated needs of the patient for nutritional PEG Complications. A review of four articles, encom-
support are longer than 4 to 6 weeks. This includes open passing a total of 637 PEG procedures, has revealed a
or laparoscopic gastrostomy, surgically placed jejunos- minor complication rate of 7% to 13% and a major com-
tomy tubes, percutaneous endoscopic gastrostomy plication rate of 2% to 4%.51-54 Minor complications
(PEG), and percutaneous endoscopic jejunostomy. included superficial wound infection, transient ileus,
stomal leaks, accidental dislodgment of the tube, pneu-
Percutaneous Endoscopic Gastrostomy moperitoneum, and clogged lumens. Major complica-
The most popular option is the PEG.48 A gastrostomy can tions included gastric perforations, gastric bleeds,
also be performed with fluoroscopic or endoscopic assis- aspiration followed by pneumonia, peritonitis, esopha-
tance or the traditional open approach. Moller et al49 has geal injury, colonic perforation, and gastric erosion. A
compared 147 gastrostomy procedures performed with particularly disastrous complication for head and neck
fluoroscopic or endoscopic assistance or the traditional surgeons is oral or pharyngeal tumor transplantation
open procedure. The results were a 30-day postoperative, to the PEG stoma site on the abdominal wall. There
have been eight reported cases of head and neck formulas contain up to 2 kcal/mL. Concentrated formu-
squamous cell carcinoma appearing at the PEG stoma. las are used for patients requiring fluid or volume restric-
These seeding episodes were primarily in patients tion or for patients who cannot tolerate the volume
with bulky hypopharyngeal, laryngeal, or esophageal necessary to meet energy requirements with the less con-
tumors.55,56 centrated formulas.
Harbrecht et al compared hospital costs for 6 years of The normal distribution of macronutrients in poly-
PEG procedures versus traditional open gastrostomy. meric formulas is 40% to 60% carbohydrate calories,
They concluded that both have equivalent complication 30% to 40% fat calories, and 14% to 18% protein calo-
rates (a view not supported by other investigators), but ries. The proteins in polymeric formulas are mostly high-
significantly less cost was associated with PEG when per- biologic value milk or soy protein isolates. Use of these
formed in the ICU or endoscopy suite.57 PEG gastros- formulas may not be suitable for patients with malabsorp-
tomy is also appropriate for pediatric cases, with tion, because they may not be able to hydrolyze them.
documentation in patients as young as 2.4 months.58 The Carbohydrates are the main source of energy in normal
mean useful life span of PEG tubes is approximately 4 diets and in polymeric enteral formulas. Derivatives from
months.59 Current design of PEG tubes allows simple the hydrolysis of cornstarch are the source of these car-
traction removal followed by dressing placement in an bohydrates. Sucrose is sometimes added for sweetness.
ambulatory clinic. PEG tubes should not be removed Lactose is not included in most nutritional products
until the stoma has matured, which is approximately 6 secondary to the prevalence of lactose intolerance. Fat
weeks at the earliest. PEG gastrostomy should therefore calories are derived from vegetable oils alone or in com-
not be done indiscriminately but only if the need exists bination with medium-chain triglycerides from coconut
for prolonged enteral nutritional support. or palm oils. Vegetable oils contribute the long-chain
fatty acids and the essential fatty acid linoleic acid,
whereas the medium-chain triglycerides contribute
MECHANICS OF ENTERAL FEEDING calories.
ENTERAL FORMULA DELIVERY OLIGOMERIC ENTERAL FORMULAS

Delivery of enteral formulas into the stomach can be Oligomeric enteral formulas contain protein that has
intermittent or continuous. Intermittent, bolus feeding been hydrolyzed into dipeptides, tripeptides, oligopep-
using manual syringes or gravity feeding is more psycho- tides, and free amino acids. These peptides do not
logical, with less chance of contamination. Continuous require enzymatic digestion and can be absorbed directly
delivery using a volumetric pump is mandatory when the by gut mucosal cells. Unless a patient has GI dysfunction
feeding tube tip is in the small bowel. Interestingly, bolus that compromises the ability to absorb proteins, there
feedings increase the REE of the patient by 8% to 10%, is no advantage to prescribing an oligomeric enteral
but continuous infusion does not significantly increase formula.
REE over the fasting level.60 Volumetric pumps can also
assist when the stomach is the enteral destination by MONOMERIC ENTERAL FORMULAS
decreasing gastric distention and associated risks of Monomeric enteral formulas contain free, crystalline l-
emesis and aspiration.61 Highly stressed patients with amino acids. The free amino acids are poorly absorbed
gastric atony have a high incidence of aspiration. Jejunos- and may contribute to gut mucosal atrophy. The indica-
tomy, either surgically placed or endoscopically assisted tions for prescribing monomeric enteral formulas are
(e.g., a PEG/PEJ arrangement), works well in these situ- limited.63
ations, even in the presence of mild ileus.7 Regardless of
the delivery method, all enteral feeding tubes require OSMOLARITY
frequent flushing with water to maintain patency. Recom- Osmolarity is the concentration of an osmotic particle–
mendations include flushing every 4 hours with continu- containing solution per liter of the solution. A formula
ous feedings, and before and after intermittent feedings is usually considered hyperosmolar if its osmolarity
or medication delivery.62 exceeds that of blood (300 mOsm/liter). The oligomeric
and monomeric formulas usually are hyperosmolar; the
ENTERAL DIETS polymeric formulas are mainly iso-osmotic. Enteral osmo-
larity can affect patient tolerance of the formula and use
Enteral formulas can be broadly classified according to of hyperosmolar formulas can result in diarrhea. Some
the type of protein they contain. Three basic categories polymeric enteral formulas contain fiber. Fiber is added
are intact protein (polymeric), hydrolyzed protein (oligo- for the beneficial physiologic effects on bowel function,
meric), and crystalline amino acids (monomeric).45 such as prevention of diarrhea or constipation.
POLYMERIC ENTERAL FORMULAS ENERGY SOURCES IN ENTERAL FORMULAS

Polymeric enteral formulas are considered nutritionally Glucose and fat are the major sources of energy in enteral
complete because they contain sufficient fat, protein, formulas. In the hypermetabolic critically ill patient, the
carbohydrate, minerals, vitamins, and trace elements to normal response to exogenous nutrients found in starva-
prevent deficiencies when administered to meet the tion is absent.7 Unlike in fasting starvation, exogenous
caloric requirements of the patient.45 Most polymeric nutrients do not decrease hepatic gluconeogenesis and
formulas contain 1 kcal/mL, but some concentrated lipolysis and have little effect on muscle and visceral
proteolysis.64 In stress states, increased carbon dioxide 2.5 g of protein/kg/day, depending on existing nutri-
levels, hepatic necrosis, hepatomegaly, and reactivation tional status, disease state, trauma, planned surgical pro-
of the neuroendocrine axis can result from excess admin- cedures, and presence or absence of multisystem organ
istration (>500 g/day) of glucose.7,40 Adults should failure. Protein intake should be restricted in patients
receive about 100 to 150 g/day of glucose, with sliding with renal failure unless dialysis is initiated.40
scale insulin or insulin drips used to maintain the serum Vitamin and mineral requirements are difficult to
blood glucose level between 100 and 140 mg/dL.65 quantitate in starvation and stress states. General recom-
Table 3-7 indicates that starving patients treated with mendations are to administer 1 mL in children younger
nutritional resuscitation will tolerate greater than 150 than 1 year old and 15 mL in adults of a multivitamin
nonprotein cal/g of nitrogen. Stressed patients requiring preparation per day with enteral feedings.40 Vitamin C
metabolic resuscitation will need no more than 100 non- deficiency produces defective collagen cross-linking.
protein cal/g of nitrogen.7 Stressed patients require Vitamin A deficiency also produces defective collagen
more protein calories than carbohydrate calories. Fat can cross-linking and affects cell morphology and ground
be administered in amounts of 1 to 3 g/kg/day in enteral substance production. Vitamin E functions as an antioxi-
nutritional therapy. Patients should receive about 1.0 to dant and as a free radical scavenger.8 Nathens et al have
documented that early administration of antioxidant
vitamin supplementation reduces organ failure, shortens
ICU stay, and speeds recovery when administered to
trauma patients.66
TABLE 3-7 Stress Level Determinate of Nonprotein
Calorie/Nitrogen Ratio COMPLICATIONS OF ENTERAL
Stress Level Example Nonprotein/Nitrogen Ratio
NUTRITIONAL THERAPY
Enteral nutritional therapy may result in technical, func-
0 Starvation >150 : 1
tional, or metabolic complications.30 Of enterally fed
1 Elective surgery 100 : 1 patients, 5% have technical complications, 15% to 30%
2 Multiorgan trauma 100 : 1 have functional complications, and 5% have metabolic
3 Sepsis/burns 80 : 1 abnormalities. Box 3-1 lists enteral nutritional therapy
(From Hickey MS: Nutritional management of the critically ill patient. In
complications in these three general categories. Table
Weigelt JA, Lewis FR, editors: Surgical critical care, Philadelphia, 1996, 3-8 summarizes the physiologic and metabolic complica-
WB Saunders.) tions from enteral nutritional therapy.
BOX 3-1 Enteral Nutritional Therapy Complications
TECHNICAL Nausea
Abscess or erosion of nasal septum Vomiting
Acute sinusitis from obstruction of midface sinus drainage
METABOLIC
orifices
Dehydration
Aspiration pneumonia
Essential fatty acid deficiency
Bacterial contamination of formula
Hyperglycemia
Esophageal ulceration, distal stenosis or erosion
Hyperkalemia
Gastrointestinal perforation
Hypernatremia
Gastrostomy, jejunostomy dislodgment
Hyperosmolar nonketotic coma
Hemorrhage
Hyperphosphatemia
Hoarseness
Hypocupremia
Inadvertent tracheobronchial intubation
Hypoglycemia
Intestinal obstruction
Hypokalemia
Intracranial passage of tube
Hypomagnesemia
Knotting of tube
Hyponatremia
Laryngeal ulceration
Hypophosphatemia
Nasal alar rim erosions
Hypozincemia
Necrotizing enterocolitis
Liver function test elevation
Otitis media
Overhydration
Pharyngolaryngeal inflammation
Vitamin K deficiency
Pneumatosis intestinalis
Rupture of varices
Skin excoriation
FUNCTIONAL
Abdominal distention
Constipation
Diarrhea
TABLE 3-8 Complications of Enteral Nutrition Therapy
Complication Treatment
Diarrhea Rule out infectious diarrhea (e.g., C. difficile)
Check the actual serum albumin (ASA) level. If the ASA level is <2.5 g/dL, calculate the
albumin deficit (AD) per the Andrassy formula:
AD = (2.5 = ASA) × 0.3 ×10 × wt kg
Then administer 25 g of 25% albumin intravenously q6h until the calculated albumin deficit is
replaced. Recheck the serum albumin level. If the serum albumin level is ≥2.5 g/dL, no
further albumin therapy is necessary. If the level is <2.5 g/dL, recalculate the albumin deficit
and administer additional albumin intravenously until the serum albumin is ≥2.5 g/dL.
or
Hespan, 250 mL/day × 1 to 2 days
Administer antidiarrhea agents:
Deodorized tincture of opium (DTO) 15-20 drops PO or per nasointestinal tube q4-6h prn
or
Lomotil 1-2 capsules (2.5-mg/tablet) PO q4-6h or 5-10 mL (2.5 mg/5 mL) per nasointestinal
tube q4-6hr prn
or
Imodium 1-2 capules (2 mg/capsule) PO q4-6h or 10-20 mL (1 mg/5 mL) per nasointestinal
tube q4-7h prn
or
Sandostatin 50-350 µg SC or IV q6h prn
If nos. 1 and 2 fail to treat the diarrhea, discontinue the current enteral diet and begin an
oligomeric protein formula.
If nos. 1, 2, and 3 fail, discontinue enteral nutritional therapy and begin parenteral nutritional
therapy.
Residual (>150 mL) Examine the patient and rule out the possibility of either a mechanical intestinal obstruction or
paralytic ileus.
Confirm the position of the feeding tube in the small bowel per kidney-ureter-bladder
radiograph.
Check the serum potassium and calcium levels.
Consider a pharmacologic cause.
Hyperglycemia (>160 mg/dL) Reduce the oral glucose intake and administer regular insulin subcutaneously per a sliding
scale regimen. If this fails to maintain the serum glucose ≤160 mg/dL, consider an insulin
drip. It may be necessary to reduce the rate of the enteral feedings temporarily until blood
glucose control is obtained and then slowly advance back to goal rate.
Hypoglycemia (<70 mg/dL) Administer (immediately) 1 ampule of D50W intravenously and then recheck the serum glucose
level. If the serum glucose level remains <70 mg/dL, administer additional intravenous D50W
until the serum glucose is ≥ 70mg/dL. If the patient continues to require intravenous glucose
supplements, discontinue the current full-strength enteral diet and begin a new full-strength
diet that has a greater glucose content at the previous infusion rate.
Hypernatremia (>145mEq/liter) Evaluate need for increasing or decreasing water intake. If needed, reduce or discontinue all
oral and intravenous sodium intake. If this fails to maintain the serum sodium to ≤145 mEq/
liter, discontinue the current full-strength enteral diet and begin a less concentrated infusion
of the current diet or begin a new full-strength diet that has a lower sodium content at the
previous infusion rate.
Hyponatremia (<135 mEq/liter) Evaluate need for increasing or decreasing water intake. If needed, administer additional
sodium using NaCl tablets or salt packets until the serum sodium level is >135 mEq/liter.
Laboratory testing to exclude SIADH.
Hyperkalemia (>5 (mEq/liter) Discontinue all oral and intravenous potassium intake. If this fails to maintain the serum
potassium level at ≤5 mEq/liter, discontinue the current full-strength enteral diet and begin a
new full-strength diet that has a lower potassium content at the previous infusion rate.
Hypokalemia (<3.5 mEq/liter) Administer additional potassium orally or intravenously until the serum potassium level is
≥3.5 mEq/liter. If the patient continues to require excessive oral or intravenous potassium
supplements, discontinue the current full-strength enteral diet and begin a new full-strength
diet that has a higher potassium content at the previous infusion rate.
Hyperphosphatermia Discontinue all oral and intravenous phosphate intake. If this fails to maintain the serum
(>4.5 mEq/liter) phosphate level to ≤4.5 mEq/liter, discontinue the current full-strength enteral diet and begin
a new full-strength diet that has a lower phosphate content at the previous infusion rate.
Hypophosphatemia (<2.5 mg/ Administer additional phosphate orally as NeutrA-Phos 1-2 packets up to 4 times per day, or
dL) intravenously as sodium or potassium phosphate to maintain the serum phosphate ≥ 2.5mg/
dL. (Note: The daily intravenous phosphate dosage should not exceed 60 mM.)
TABLE 3-8 Complications of Enteral Nutrition Therapy—cont'd
Complication Treatment
Hypermagnesemia (>2.7 mg/ Discontinue all intravenous and oral magnesium intake. If this fails to maintain the serum
dL) magnesium level ≤2.7 mg/dL, discontinue the current full-strength enteral diet and begin a
new full-strength diet that has a lower magnesium content at the previous infusion rate.
Hypomagnesemia (<1.6 mg/dL) Administer additional magnesium orally or intravenously to maintain the serum magnesium
level ≥ 1.6 mg/dL. Consult the Physicians’ Desk Reference for the various enteral and
parenteral magnesium preparations.
Hypercalcemia (>10.5 mg/dL) Discontinue all oral and intravenous calcium supplements. If this fails to maintain the serum
calcium level ≤ 10.5 mg/dL, discontinue the current full-strength enteral diet and begin a
new full-strength diet that has a lower calcium content at the previous infusion rate.
Hypocalcemia (<8.5 mg/dL) Administer additional calcium orally as Titralac or intravenously as calcium gluconate,
10-30 mEq daily to maintain the serum calcium level ≥ 8.5 mg/dL.
High serum zinc (>150 µg/dL) Discontinue all oral and intravenous zinc intake until the serum zinc level is ≤150 µg/dL.
Low serum zinc (<55 µg/dL) Administer additional zinc orally as zinc sulfate 200 mg three or four times daily or
intravenously as elemental zinc 2-5 mg daily to maintain a serum zinc level ≥ 55 µg/dL.
High serum copper (>140 µg/ Discontinue all oral and intravenous copper intake until the serum copper level is ≤140 µg/dL.
dL)
Low serum copper (<70 µg/dL) Administer additional copper orally or intravenously as elemental copper 2-5 mg daily to
maintain a serum copper level > 70 µg/dL.
(Adapted from Hickey MS: Nutritional management of the critically ill patient. In Weigelt JA, Lewis FR, editors: Surgical critical care, Philadelphia, 1996,
WB Saunders.)
Small-diameter nasogastric feeding tubes tend to clog, only was there no effect of osmolarity or dilution on
especially when used as a portal for medication delivery. incidence of diarrhea, but adequate nutritional supple-
Instillation of water, meat tenderizer, sodium bicarbon- mentation was delayed by deliberate dilution.
ate, and digestive enzymes has been described in attempts The most common cause of diarrhea associated with
to dissolve clogs in enteral feeding tubes. Use of low-pH enteral nutrition therapy is medication. Many elixir med-
liquids, such as carbonated beverages or citrus juices, ications commonly administered to enterally fed patients
tends to precipitate proteins further and worsen feeding contain sorbitol. A 500-mg dose of acetaminophen elixir
tube blockage. The following steps for unclogging a may contain as much as 5.47 g of sorbitol.67 Twenty g of
feeding tube have been recommended by Lord44: sorbitol will cause diarrhea in most patients. Edes et al
• Aspirate as much fluid as possible with a 30- to 60-mL used the calculation of stool osmotic gap compared with
syringe attached to the enteral device. Discard the stool osmolarity to determine whether diarrhea in enter-
fluid. ally fed patients is related to medications. They con-
• Refill the syringe with 5 mL of warm water and instill cluded if the stool osmotic gap was more than 140 mOsm/
the water into the enteral tube using manual pressure liter, osmotic medications or additives should be sus-
for 1 minute, using a back and forth motion with the pected. If the stool osmotic gap was less than 140 mOsm/
syringe plunger. liter, nonosmotic causes are likely.68
• Clamp the tube for 15 minutes and again try to aspi-
rate fluid or flush with warm water. PARENTERAL NUTRITIONAL THERAPY
• If this fails, repeat the procedure with a commercial
solution marketed to unplug enteral feeding tubes. Parenteral nutrition therapy is indicated when the patient
• Mechanical reaming devices should be used only with has severe bowel dysfunction or cannot absorb required
great caution because they can easily perforate the calories and supplementation orally, enterally, or both.
tube and/or hollow organs. Parenteral nutrition therapy is contraindicated in patients
Diarrhea is a common complication of enteral nutri- with normal bowel function.
tional therapy. Various causes have been postulated,
including intrinsic bowel disease, intestinal bacterial PERIPHERAL PARENTERAL NUTRITION AND TOTAL
overpopulation, mechanical intestinal dysfunction, poly- PARENTERAL NUTRITION
pharmacy, osmolarity of the diet, and hypoalbumin- Parenteral therapy has two forms, peripheral parenteral
emia.30 Typically, the cause is assumed to be hyperosmolarity nutrition (PPN) and total parenteral nutrition (TPN).
of the enteral formula, and the feeding is stopped or The main difference between PPN and TPN is the route
diluted. Keohane et al randomly assigned patients to of delivery. PPN is delivered through a large-bore peri
hyperosmolar and iso-osmolar enteral nutritional pheral IV catheter; TPN requires a central venous
therapy.67 Patients in the hyperosmolar arm were further catheter.
randomly assigned to a diluted or nondiluted initial PPN is indicated when parenteral supplementation is
feeding regimen. The investigators discovered that not required for 10 days or less. Because PPN is administered
through a peripheral vein, the osmolarity of the solution tional status has an effect on outcomes in patients
is limited to 1150 mOsm/liter. PPN solutions contain who have altered diets or IMF following maxillofacial
20% dextrose and must be supplemented with fat emul- surgery.
sions. Fat then becomes the major source of calories.
TPN is indicated for the hypermetabolic, critically ill SUMMARY
patient with bowel dysfunction. It is also indicated for the
less severely ill patient if it is estimated that enteral intake In summary, the physiologic response to starvation is
will be delayed beyond 7 to 10 days. TPN solutions typi- markedly different than that seen in the hypermetabolic,
cally contain more concentrated glucose solutions, amino critically ill patient. Nutritional assessment must examine
acids, and fat emulsions. A minimum of 2% to 4% of the the preexisting nutritional state and the degree of
total kilocalories should be administered as lipid to avoid ongoing hypermetabolism. While a healthy, well-
essential fatty acid deficiency. The resultant hyperosmo- nourished patient may tolerate 7 to 10 days of inadequate
lar solution requires a central venous line for delivery. oral intake, both the malnourished and the hypermeta-
Complications of TPN include central line infections, bolic patient may require early nutritional support, pref-
hyperglycemia, and electrolyte disorders. To prevent the erably by the enteral route. It is the responsibility of the
latter complication, daily adjustment of electrolytes in surgeon to identify patients requiring such support and
the solution may be required. Vitamins are added to the to initiate a suitable nutritional support regimen.
solution daily. Insulin may also be added to the solution
to help control serum glucose levels. REFERENCES
INITIATING NUTRITIONAL SUPPORT IN THE 1. Moore FA, Feliciano DV, Andrassy RJ, et al: Early enteral feeding,
CRITICALLY ILL PATIENT compared with parenteral, reduces postoperative septic complica-
tions: The results of a meta-analysis. Ann Surg 216:172, 1992.
Although no randomized clinical trials exist regarding 2. Souba WW: Nutritional support. N Engl J Med 336:41, 1997.
when to initiate feeding in the trauma patient, it is well 3. Brozek JD, editor: Human body compositions: Approaches and applica-
accepted that nutritional support is necessary to attenu- tion, New York, 1965, Pergamon Press.
ate the hypermetabolic response to injury, reduce the 4. Parsa MH, Shoemaker WC: Nutritional failure. In Shoemaker WC,
rate of infection, and maintain the integrity of the intes- Ayres S, Grenvik O, et al, editors: Textbook of critical care, ed 2, Society
of Critical Care Medicine, Philadelphia, 1989, WB Saunders.
tinal mucosa along with its immunologic defenses.16 Early 5. Jeejeebhoy KN: Nutrition in critical illness. In Shoemaker WC,
feeding (<72 hours) in the hemodynamically stable ICU Ayres S, Grenvik O, et al, editors: Textbook of critical care, ed 2, Society
patient is associated with a decrease in infection and a of Critical Care Medicine, Philadelphia, 1989, WB Saunders.
decrease in the length of hospital stay, without a signifi- 6. Wiles JB, Cerra FB, Siegel JH, Border JR: The systemic septic
response: Does the organism matter? Crit Care Med 6:55, 1980.
cant difference in morbidity. 7. Cerra FB: Nutrition in trauma, stress and sepsis. In Shoemaker WC,
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8. Meyer NA, Muller MJ, Herndon DN: Nutrient support of the
One of the most frequently performed oral and maxil- healing wound. New Horizons 2:202, 1994.
9. Cerra FB: Hypermetabolism, organ failure and metabolic support.
lofacial surgery procedures that interfere with oral nutri- Surgery 101:1, 1987.
tion is intermaxillary fixation (IMF). Patients with IMF 10. Meyer NA, Muller MJ, Herndon DN: Nutrient support of the
face formidable dietary obstacles. IMF has been used as healing wound. New Horizons 2:202, 1994.
a weight loss technique in place of, preceding, or after 11. Bessey PQ, Watters JM, Aoki TT, Wilmore DW: Combined hor-
monal infusion simulates the metabolic response to injury. Ann
traditional bariatric surgery. In the literature, IMF for Surg 200:264, 1984.
weight loss is applied for a longer time than its traditional 12. Cerra FB, Siegel JH, Coleman B, et al: Septic autocannibalism. A
use after fractures or after elective maxillary and/or man- failure of exogenous nutritional support. Ann Surg 192:570, 1980.
dibular surgery. IMF for weight loss implies starvation by 13. Wolfe R, Allsop J, Burke J: Glucose metabolism in man: Responses
default. to intravenous glucose infusion. Metabolism 28:210, 1979.
14. Elwyn DH: Nutritional requirements of stressed patients. In
However, in several obesity studies, IMF was applied Shoemaker WC, Ayres S, Grenvik O, et al, editors: Textbook of
for 1 1 2 months to 18 months. Mean weight loss across all critical care, ed 2, Society of Critical Care Medicine, Philadelphia, 1989,
studies was 8 to 30 kg, with more weight loss in males WB Saunders.
than females.69-71 Most of the weight was regained after 15. Meyenfeld MF, Soeters PB, Vente JP: Effect of branch-chain amino
acid enrichment of total parenteral nutrition on nitrogen sparing
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enough of an impediment to oral intake to result in 16. Slone DS: Nutritional support of the critically ill and injured
nutritional deficits. Worrall73 has compared weight loss patient. Crit Care Clin 20:135, 2004.
in 13 patients with IMF to 9 patients with rigid fixation 17. Van Den Berghe G, Wouters P, Weekers F, et al: Intensive insulin
therapy in critically ill patients. N Engl J Med 345:1359, 2001.
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after surgery, there was a 4.5 kg total weight loss for the comparision of clinical judgement and objective measures. N Engl
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22. Jensen GL, Binkley J: Clinical manifestations of nutrient deficiency. 49. Moller P, Lindberg CG, Zilling T: Gastrostomy by various tech-
J Parenteral Enteral Nutr 26:529, 2002. niques: Evaluation of indications, outcome, and complications.
23. Howard L, Meguid MM: Nutritional assessment in total parenteral Scand J Gastroenterol 34:1050, 1999.
nutrition. Clin Lab Med 4:611, 1981. 50. Santos PM, McDonald J: Percutaneous endoscopic gastrostomy:
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25. Barton RG: Nutrition support in critical illness. Nutr Clin Pract for enteral nutrition: Long-term follow-up of 176 procedures. Can
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28. Flancbaum L, Choban P, Sambuco S, et al: Comparison of indirect 54. Lin HS, Ibrahim HZ, Kheng JW, et al: Percutaneous endoscopic
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69:461, 1999. 55. Schneider AM, Loggie BW: Metastatic head and neck cancer to the
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1996, WB Saunders. 57. Harbrecht BG, Moraca RJ, Saul M, Courcoulas AP: Percutaneous
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for the estimation of energy expenditures in patients with special 30:671, 1995.
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15:872, 1980.
PART TWO
Systematic Evaluation of the
Traumatized Patient
CHAPTER
Initial Assessment and Intensive Care of
4
the Trauma Patient
Raymond J. Fonseca
Marilyn Fonseca
| Samuel Allen
| Mohamed K. Awad
|
OUTLINE
Patient Transport Other Potentially Life-Threatening Injuries
History of Medical Transportation Abdominal and Pelvic Trauma
Types of Transport Spine and Spinal Trauma
Initial Assessment Maxillofacial Injuries
Assessment Principles Extremities and Fractures
Primary Survey Initial Management of the Trauma Patient in the Intensive Care
Airway Maintenance with Cervical Spine Control Unit
Breathing Initial and Ongoing Assessment.
Circulation Management Types of Intensive Care Units
Assessment Mechanical Ventilation
Treatment Nonrespiratory Issues to Monitor in the Intensive Care Unit
Disability Vascular Access
Exposure Gastrointestinal Stress Ulcer Prophylaxis
Secondary Assessment Venous Thromboembolism Prophylaxis
Face, Head, and Skull Injuries Enteral Nutrition
Neck Injuries Electrolyte Management
Chest Injuries Dialysis
ambulancia (mobile field hospitals) to provide rapid

PATIENT TRANSPORT medical aid to their soldiers. In January 1777, George
Washington instructed the army’s Hospital Department
HISTORY OF MEDICAL TRANSPORTATION Director General, Dr. John Cochran, to consult with
Prior to the 1600s, several methods of moving the debili- another well-known physician of the day and his succes-
tated were in use around the world. In what would sor, Dr. William Shippen, to reorganize the medical
become the United States, Native Americans used the system, including the flying hospitals, to accompany his
travois (Fig. 4-1), which was essentially a stretcher affixed armies in the field. Flying hospitals were equivalent to
at one end to a horse or large dog to pull as a conveyance today’s MASH units (mobile army surgical hospitals).
for material or disabled people. In Egypt, camel stretch- They were semitransient field hospitals that were moved
ers called panniers, which were used in many regions with the regiment or divisional army, providing immedi-
around the world with other beasts of burden such as ate care to those wounded after a battle and to those who
mules, were the method of choice, even through the were ill.
Napoleonic period, to move the nonambulatory. The next significant development of U.S. emergency
In the fifteenth century, King Ferdinand and Queen medical services (EMS) and medical transport took place
Isabella of Spain were instrumental in the deployment of during the Civil War (1861-1865). The Union Medical
48
Initial Assessment and Intensive Care of the Trauma Patient CHAPTER 4 49
System of Ambulances in the Armies of the United

States.” This legislation established a standardized system
of ambulance service throughout the military. The law
also mandated the use of special uniforms for the ambu-
lance corps and special signs for the ambulances. Regula-
tions issued during the war by both sides, and incorporated
into this law, also conventionalized specific insignia
and signage for the recognition of ambulances and
hospitals.
In addition to litters, cacolets, and wagons, trains and
boats were also used as medical transportation vehicles
on a regular basis. Ambulance wagons took the wounded
and sick from field hospitals to trains or hospital ships
instead of directly to the general hospital. This would
occur if the general hospital was too far to allow for rea-
sonable transport by wagon, train, or ship. Thus, a strati-
FIGURE 4-1 A travois, which was essentially a stretcher affixed at fied system of medical transport and transport vehicles
one end to a horse or large dog to pull, was used by Native developed.
Americans to transport material or the injured. The first civilian-manufactured ambulance in the
United States, a specialized medical transport vehicle,
was built in 1890 by the Hess-Eisenhardt Company of
Cincinnati, Ohio. It was a horse-drawn wagon specifically
designed to move the incapacitated in need of medical
care. Shortly thereafter, the first motorized ambulance
was made in Chicago and donated to the Michael Reese
Hospital by five local businessmen in 1899. This was
quickly followed by St. Vincent’s Hospital of New York,
which began operating an automobile ambulance in
1900. In 1910, the first known aircraft ambulance, a
plane modified to carry a patient lying down, was built
in North Carolina and tested in Florida. It failed shortly
following take-off and crashed after flying only 400 yards
in Fort Barrancas, Florida. By 1929, the U.S. Army Air
Corps had been organized and designed three planes to
perform as ambulances. They were built and equipped
A to carry two patients on stretchers, a pilot, and an
attendant.
World War II, the Korean Conflict, and the Vietnam
War all brought advances in trauma medicine to the
military, which were then used in the civilian sector.
Some improvements in military EMS organization and
operations occurred; the most noteworthy was the use of
helicopters to retrieve critically injured patients rapidly
from the battlefield, transporting them to field hospitals
(MASH units). Reducing the time from injury to surgical
intervention, with on-scene advanced medical treatment
B such as the administration of IV fluids by nonphysicians,
marked a milestone in the progression of clinical care.
FIGURE 4-2 A, The Union Medical Department during the Civil War A convergence of several landmark events occurred in
implemented the use of committed, customized, horse-drawn the mid-1960s that altered the foundations of EMS in the
wagons as ambulances. B, Stretcher litters and pack animal United States, commencing a new era of modernity and
cacolets. organization. For decades, a crescendo had been build-
ing regarding the carnage experienced from automobile
Department implemented the use of committed, custom- accidents on the nation’s highways. Finally, in 1961, Presi-
ized horse-drawn wagons as ambulances (Fig. 4-2A) as dent John F. Kennedy noted that traffic accidents were
well as stretcher litters and pack animal cacolets (see Fig. one of the greatest of the nation’s public health prob-
4-2B). In addition, a dedicated group of stretcher bearers lems. Instantly, a new focus was established on the need
and ambulance wagon attendants and drivers was formed. for emergency medical aid for motor vehicle accident
They received specialized training by the medical depart- (MVA) victims.
ment and a tiered transport system was developed. On Several crucial events took place during President
March 11, 1864, President Lincoln signed a law that Johnson’s administration. First, in 1965, Medicare was
was passed by Congress, “An Act to Establish a Uniform created by an act of Congress. In the original legislation,
50 PART II Systematic Evaluation of the Traumatized Patient
ambulance transportation was recognized as a covered transport. Helicopters have landing requirements, which
beneficiary service. In so doing, the federal government is a disadvantage when compared with ground transport,
established a long-term funding mechanism for EMS and but they can access more regions than fixed-wing trans-
medical transportation. The introduction and propaga- port. Helicopter cabins are not pressurized and, as a
tion of prehospital medical care, especially advanced result, patients being transported are at some risk for
clinical treatment, would not wait for government regula- barotrauma. Another disadvantage is that in most trans-
tions. Often with no legislation regarding their activities, port programs, helicopters are only permitted to fly
U.S. physicians were spearheading the use of medica- under visual flight rules. Hence, weather conditions can
tions, defibrillators, and other advanced medical treat- limit this operation. However, some programs are now
ment modalities in the field, at the scene of incipient implementing instrument flight rules, which give greater
need. Most of these services started with a single-minded flexibility to flying in less than ideal weather.5
focus of cardiac emergencies, but rapidly expanded into The widespread use of helicopters for patient trans-
treating other medically urgent conditions. The empha- port has led to increased accident rates (three times
sis was shifting from the rapid recovery and transport of higher) when compared with general helicopter avia-
victims to the rapid response of specialized personnel tion.6 Another study has demonstrated a lower accident
and apparatus, and the stabilization of patients before rate among busier flight programs and programs that
movement to a hospital. implement instrument flight rules.7 Helicopter ambu-
The first advanced life support ambulance in the lances are best used when hospital ground transport time
United States was used by St. Vincent’s Hospital in New is expected to be longer than 35 minutes or when ground
York. The first nonphysician, mobile, advanced medical transport is not a viable option. Helicopter transport of
treatment service in America began in Miami in 1968. critically injured patients from remote areas may be life-
Dr. Eugene Nagel blended the training of surrogate qua- saving; however, there is a large potential for its misuse.
siphysicians with radiotechnology to devise the concept The annual cost of helicopter transport service can be at
of a paramedic using telemetry communication to receive least $1 million for an institution. For effective use of this
real-time medical commands from a physician at the transport modality, it is generally recommended that
hospital. This service was followed shortly thereafter helicopter transport should be integrated into the
by similar programs in Columbus, Ohio, Jacksonville, regional EMS system, staffed to provide advanced life
Florida, Seattle, and Los Angeles. By the end of the support, and used based on medical need.
1970s, EMS was firmly established in the medical infra- Severely injured patients transported by helicopter
structure of the United States as its own discipline, with from the scene of an accident are more likely to survive
its own science. During the next several decades, it would than patients brought to trauma centers by ground
become more sophisticated, evolving into an industry. ambulance, according to a recent study. This study was
the first to examine the role of helicopter transport on
TYPES OF TRANSPORT a national level and includes the largest number of heli-
Helicopter copter transport patients in a single analysis. The finding
Helicopters offer several advantages over other transport that helicopter transport positively affects patient survival
vehicles (Fig. 4-3). They can travel at speeds of 120 to comes amid an ongoing debate surrounding the role of
180 mph, allowing for transport times to be up to 75% helicopter transport in civilian trauma care in the United
shorter when compared with ground transport. They States, with advocates citing the benefits of fast transport
can avoid traffic delays and ground obstacles and fly times and critics pointing to safety, use, and cost con-
into locations inaccessible by other modes of patient cerns. The new national data show that patients selected
for helicopter transport to trauma centers are more
severely injured, come from greater distances, and
require more hospital resources, including admission to
the intensive care unit (ICU), use of a ventilator to assist
breathing, and urgent surgery compared with patients
transported by ground ambulance. Despite this, helicop-
ter transport patients are more likely than ground trans-
port patients to survive and be sent home following
treatment.
Air medical transport is a valuable resource that can
make trauma center care more accessible to patients who
would not otherwise be able to reach these centers. The
study included patients transported from the scene of an
injury to a trauma center by helicopter or ground trans-
portation in 2007. The team used the National Trauma
Databank to identify 258,387 patients; 16% were trans-
ported by helicopter and 84% were transported by
FIGURE 4-3 Rescue helicopters allow for transport times to be up ground. The helicoptertransport patients were younger,
to 75% shorter when compared with ground transport. (From Day more likely to be male, and more likely to be victims of
MW: Transport of the critically ill: The Northwest Medstar MVAs or falls compared with ground transport patients.
experience. Crit Care Nurs Clin North Am 17:183, 2005.) Overall, almost 50% of the helicopter transport patients
were admitted to the ICU, 20% required assistance in trainee interest in this field. The ACS-COT applies rigor-
breathing for an average of 1 week, and almost 20% ous standards to performance improvement prior to veri-
required surgery. Even though they were more debili- fying U.S. trauma centers. For this improvement to occur,
tated when they arrived at the hospital, they ultimately the ongoing application of the unique principles and
fared better than those transported by ground. practice of intensive care medicine is necessary. Patient
Although the study has shown that air transport does outcomes after major trauma have improved in regions
make a difference in patient outcomes, there are no data in which comprehensive trauma systems have evolved.
available to explain why patients transported by helicop- Crucial components of such a system should include a
ter do better than those transported by ground. The coordinated approach to prehospital and hospital care
authors assumed that the speed of transport—helicopters and to training providers in both areas. Paramedics and
are capable of higher speeds over longer distances, medical staff should be provided with a clear and objec-
regardless of terrain—and the ability of air medical crews tive framework for assessing patients, establishing and
to provide therapies and use treatment modailities not engaging treatment protocols, following triage guide-
universally available to ground unit crews are the main lines, engaging in transportation, and using communica-
drivers of positive patient outcomes. However, the study tion protocols.
has some limitations. It is not possible to evaluate the The accurate and systematic assessment of injury is
many factors that drive the decision to transport a patient essential to establish the extent of injury to vital struc-
by helicopter in all cases. In addition, the general nature tures. This forms the basis of Advanced Trauma Life
of the data set limits specific conclusions that could be Support (ATLS) protocols. It is estimated that approxi-
applied to any individual trauma system. mately 25% to 30% of deaths caused by trauma can be
Helicopter transport has been an integral component prevented when a systematic and organized approach is
of trauma care in the United States since the 1970s, used.8 Trauma patients should undergo an initial assess-
mainly because of the military’s experience in transport- ment and treatment that is prioritized and corresponds
ing sick or injured soldiers during wartime. The avail- to their injuries and stability of their vital signs. When
ability of helicopters in the civilian setting has been critical injuries are present, lifesaving measures necessi-
credited with improving trauma center access for a sig- tate that a logical and sequential treatment priority
nificant percentage of the population. be established, based on the overall assessment of the
patient.
Fixed-Wing Air Ambulance Trauma injuries can generally be divided into three
This mode of patient transport is usually implemented categories—severe, urgent, and nonurgent.
for distances longer than 150 miles. One of the biggest • Severe injuries are those that are an immediate
disadvantages is that fixed-wing aircraft require landing threat to life because they interfere with vital physi-
strips and airports. This type of service is ideal for long ologic functions. These severe injuries make up
distance transport of donors, organs, and patients to approximately 5% of all patient injuries, but repre-
specialized institutions, such as burn and transplanta- sent more than 50% of all trauma deaths.
tion centers. Various types of fixed-wing aircraft are • Urgent injuries constitute 10% to 15% of all inju-
available for patient transport. Light single-piston or ries and are not an immediate threat to life. These
twin-piston engine planes are typically unpressurized patients will usually require surgical intervention,
and provide minimal room for patient care. These air- but they have stable vital signs.
craft generally fly at speeds of 100 to 160 mph. Medium- • Nonurgent injuries account for the remaining 80%
range aircraft (600 to 1200 miles), which may be of all trauma cases. These do not constitute an
powered by pistons or turboprops, are usually pressur- immediate threat to life. These patients will gener-
ized and have a speed of 200 to 300 mph. Small jets ally require medical or surgical intervention after
have pressurized cabins, have the longest range (1500 to significant evaluation and/or observation.
2500 miles), and can travel at speeds of 400 to 550 mph. The main goal of the initial assessment of the trauma
Pressurized cabins help prevent the development of patient is to recognize the patient who does have life-
barotrauma in the patient. threatening injuries, establish treatment priorities, and
manage them aggressively.
INITIAL ASSESSMENT ASSESSMENT PRINCIPLES

These principles are involved in the initial assessment of
Trauma annually affects hundreds of thousands of indi- a patient with major trauma and have been outlined by
viduals and costs billions of dollars in direct expenditures the American College of Surgeons (ACS) in their guide-
and indirect losses. Trauma care has improved over the lines regarding ATLS protocols.43 These principles are as
past 20 years, largely from improvements in trauma follows:
systems, assessment, triage, resuscitation, and emergency 1. Preparation and transport
care. 2. Primary survey and resuscitation, including monitor-
The American College of Surgeons Committee on ing and radiography
Trauma (ACS-COT) and the American Association for 3. Secondary survey, including special investigations,
the Surgery of Trauma (AAST) acute care surgery initia- such as CT scanning or angiography
tive is designed to integrate trauma, emergency general 4. Ongoing reevaluation
surgery, and surgical critical care and to bolster new 5. Definitive care
Preparation and Communication

TABLE 4-1 Glasgow Coma Score
A variety of EMS systems exist based on the level of need
of a community or jurisdiction. Prehospital medicine Eye Opening (E) Verbal Response (V) Motor Response (M)
exists in two levels of care, basic life support and advanced 4 = Spontaneous 5 = Normal 6 = Normal
life support services. Services are provided by emergency 3 = To voice conversation 5 = Localizes to pain
medical technicians (EMTs) who are trained at these two 2 = To pain 4 = Disoriented 4 = Withdraws to
different levels of care.9 1 = None conversation pain
Hospitals receiving trauma patients should receive 3 = Words, but not 3 = Decorticate
advance communication from emergency medical ser- coherent posture
vices care providers about the impending arrival of seri- 2 = No words only 2 = Decerebrate
ously injured patients. The patient’s mechanism of injury, sounds 1 = None
vital signs, field interventions, and overall status should 1 = None
be communicated. This allows for the in-house trauma Total = E + V + M
team to be called and for the emergency department
staff to make appropriate preparations.
On the patient’s arrival, a concise but comprehensive Abbreviated Injury Score, Injury Severity Score). No uni-
transfer of the patient from the paramedics should occur. versally accepted scoring system has been developed;
One person should be talking while everyone else is lis- each system has unique limitations. These limitations
tening. In many trauma centers, the team leader is a have resulted in the use of a various scoring systems in
senior or chief resident in surgery or emergency medi- different centers worldwide.
cine, with close supervision from appropriate attending Glasgow Coma Scale. This scale is commonly used and
staff. Most trauma centers use a system of prehospital was developed by Teasdale and Jennet. The Glasgow
triage that categorizes patients into those with physio- Coma Scale (GCS) was the first system to attempt to
logic derangements and those who have a suggestive quantify the severity of a head injury.10 There are three
mechanism of injury. Those with obvious derangements variables used with the scale—best motor response, best
should prompt a full team response, whereas patients verbal response, and eye opening. The key to calculating
with less injury may be cared for by a modified team the GCS is to determine the best response in each cate-
complement. gory. The motor response is used to assess the level of
central nervous system (CNS) function, whereas a verbal
Hospital Phase response shows the ability of the CNS to integrate infor-
Once the trauma patient arrives to the hospital, it is of mation. Eye opening will demonstrate brainstem activity.
paramount importance to pay attention to every detail. Each category is given a score, as outlined in Table 4-1,
This could mean the difference between life and death. with total scores ranging from 3 to 15. Higher scores
A fully equipped resuscitation area must be available. represent increased levels of consciousness. The letter T
The equipment has to be organized, tested, and stored is used to designate that the patient was intubated at the
where it is immediately accessible. Airway equipment time of examination. A GCS of 8 or less is generally
(e.g., laryngoscopes, endotracheal tubes, suction, trache- accepted as a definition of coma. At this level, there will
ostomy and cricothyrotomy kits, bougies) and IV resusci- often be a monitor placed to measure intracranial pres-
tation equipment (e.g., warmed IV crystalloid solutions, sure (ICP) because it is difficult to monitor these patients
different gauge IV needles, central line and arterial line for neurologic deterioration as compared with a patient
kits) need to be readily available. Adequate monitors and with a higher GCS. Of patients with a moderate head
radiologic and laboratory resources are an integral part injury (GCS, 9 to 13), approximately 10% to 20% will
of this phase. Transfer agreements between institutions deteriorate and lapse into a coma. This can influence the
have to be established and operational. timing of the management of maxillofacial injuries.
Protective precautions are mandatory for the person- Unless the maxillofacial injures compromise the airway,
nel who have contact with the patient (e.g., gowns, face these patients are not routinely intubated as long as the
mask, eye protection, gloves, shoe covers or boots). The airway can be protected. For patients with a severe head
Centers for Disease Control and Prevention (CDC) con- injury (GCS, 3 to 8), urgent management is critical.
sider these to be minimum precautions. Standard pre- These patients are at the greatest risk for mortality and
cautions are also included in Occupational Safety and morbidity. They will generally have an endotracheal tube
Health Administration (OSHA) requirements in the placed to protect their airway. Airway protection can be
United States. complicated in the head-injured patient because there
are often concomitant maxillofacial injuries.
Trauma Scoring Trauma Score and Revised Trauma Score. The Trauma
Trauma scoring systems describe injury severity and cor- Score was initially developed in 1981 by Champion et al.
relate with survival probability. Various systems facilitate The purpose of the score was to assess the extent of injury
the prediction of patient outcomes and the evaluation of to vital systems and the severity of injury quickly to aid
aspects of care. The scoring systems vary widely, with with triage and the treatment of the trauma patient.11 In
some relying on physiologic scores (e.g., Glasgow 1989, Champion et al revised this scoring system, which
Coma Scale [GCS] score, Revised Trauma Score), and became the Revised Trauma Score.12 The Trauma Score
others relying on descriptors of anatomic injury (e.g., and Revised Trauma Score quantify the physiologic status
Percentage of Patients and Injury Severity Score (ISS) Percentage of Deaths by Injury Severity Score (ISS) Range
70 35
Percentage of patients
Percentage of deaths
60 30
50 25
40 20
30 15
20 10
10 5
0 0
1–9 10–15 16–24 >24 Unknown 1–9 10–15 16–24 >24 Unknown
ISS Range Injury Severity Score
FIGURE 4-4 Percentage of patients by injury severity score (ISS) FIGURE 4-5 Percentage of deaths grouped by ISS range.
range. (The percentage of patients = number of patients for each (Percentage of deaths = number of deaths divided by the total
ISS range divided by the total number of patients × 100.) number of patients × 100 by ISS range.) (Data Courtesy American
(Courtesy American College of Surgeons, National Trauma Data College of Surgeons, National Trauma Data Bank, 2003)
Bank, 2004.)
Average Hospital LOS and Injury Severity Score (ISS)

14
Average hospital LOS in days

of the patient’s respiratory, cardiovascular, and neuro- 12
logic systems. The revised trauma score has a coded value 10
for three variables—respiratory rate, systolic blood pres-
sure, and GCS. Each variable is coded from 0 to 4, with 8
a total score ranging from 0 to 12. Lower scores represent 6
an increased severity of injury. 4
Injury Severity Score. The Injury Severity Score (ISS)
was developed to deal with multiple traumatic injuries to 2
multiple organ systems. Scoring is based on the severity 0
of injury to the three most injured organ systems, includ- 1–9 10–15 16–24 >24 Unknown
ISS Range
ing respiratory cardiovascular systems, CNS, abdomen,
extremities, and skin. Each of the three most injured FIGURE 4-6 Average hospital length of stay for each category of
organ systems is graded from 1 (minor) to 6 (fatal). The ISS range. (Average hospital length of stay = total hospital length
grades are then squared and added to come up with a of stay for each ISS range divided by the total number of
total score from 3 (12 + 12 + 12) to 108 (62 + 62 + 62). patients.) (Courtesy American College of Surgeons, National
The ISS has a practical range from 1 to 75; the risk of Trauma Data Bank, 2004.)
death increases with a higher score. ISS rates have been
used to predict mortality rates by comparing ISS with
mortality by age group. The National Trauma Data Bank BOX 4-1 Factors Highly Correlated with
(NTDB) uses this scoring system and categorizes an ISS Life-Threatening Injuries
from 1 to 9 as minor, 10 to 15 as moderate, 16 to 24 as
• Collisions involving high-energy dissipation or rapid
severe, and more than 24 as very severe. Figures 4-4 and
deceleration
4-5 show NTDB data as they relate to the ISS. The average • Falls > 20 feet
length of stay increases approximately 3 days for each • Dangerous environments (burning building, icy waters)
level of severity, as outlined in Figure 4-6. • Automobile accidents that result in > 20 min to remove the
Other Scoring Systems. Other scoring systems have also patient
been created to aid triage and outcome prediction in the • Significant damage to passenger compartments
trauma patient. These include the Pediatric Trauma • Rearward displacement of front axle
Score (PTS), the Trauma Injury and Injury Severity Score • Automobile rollover
(TRISS) method, A Severity Characteristic of Trauma • Death of other passengers in the automobile
Score (ASCOT) and, more recently, the International • Patient ejection
Classification of Diseases, 9th edition, which uses ICD-9
nomenclature. Data from Committee on Trauma of the American College of Surgeons:
Hospital and pre-hospital resources for optimal care of the injured patient.
Mechanism of Injury Bull Am Coll Surg 68:11, 1983.
The mechanism of injury can provide insight into other

possible injuries that have not yet resulted in significant
changes in vital signs or physiologic function. The mech- Other Factors
anism of injury is usually one of the first issues commu- Various anatomic factors that correlate with high mortal-
nicated by EMS to the trauma team as a patient enters ity include those listed in Box 4-2. Other factors that have
the trauma bay. Factors with a high correlation with life- been shown to worsen prognosis of a trauma patient with
threatening injuries are outlined in Box 4-1. only a moderately severe injury include concurrent
long-term use of medications can alter the physiologic

BOX 4-2 Anatomic Factors Correlated with High Mortality response to injury.
AIRWAY MAINTENANCE WITH CERVICAL
• Penetration trauma to head
• Penetration trauma to neck
SPINE CONTROL
• Penetration trauma to groin On initial evaluation, ascertaining patency of the airway
• Penetration trauma to thigh is of the highest priority. The perfusion of the brain and
• Flail chest other vital structures will mean the difference between
• Major burns life and death, or permanent disability. Maintaining oxy-
• Amputations genation and preventing hypercarbia are critical, espe-
• Two or more proximal long bone fractures cially for patients who have sustained head trauma. In a
• Paralysis practical way, in a nonintubated patient, asking brief
questions will lead to a quick evaluation of the airway and
Data from Mullins RJ, Mann NC: Development of a systematic review of neurologic status. If the patient can talk, the airway
published evidence regarding the efficacy of trauma systems. J Surg
Outcomes 1:45, 1985. is often patent. This assessment has to be repeated
constantly.
The airway is especially critical in the head and/or
maxillofacial trauma patient. The causes of upper airway
disease, age younger than 5 years or older than 55 years, compromise in the trauma patient may be tongue
and cardiac or respiratory disease. position, aspiration of foreign bodies, regurgitation of
stomach contents, or facial, mandibular, tracheal and/or
PRIMARY SURVEY laryngeal fractures, bleeding, a retropharyngeal hema-
toma resulting from cervical spine fractures. or traumatic
Once the trauma victim arrives at the resuscitation room, brain injury.13 Any laceration to the neck is classified
a quick assessment of major injuries, vital signs, and according to the anatomic level and aggressively explored.
mechanism of injury is done to prioritize what needs to Placement of a surgical airway may be necessary if endo-
be treated first. The airway is always the first concern. A tracheal intubation is not possible.
trauma team leader will command the personnel regard- A patent airway must be established while still protect-
ing actions to take. A team member will be ready to write ing the cervical spine. A jaw thrust or chin lift procedure
all the important information regarding the patient who can be used to accomplish this. The jaw thrust maneuver
has just arrived. There are formats specially designed for involves the placement of the fingers of both hands on
this purpose with human body graphics in different the angle of the mandible and the thumbs over the teeth
views, whereby drawings could be made for better docu- or chin. The mandible is then gently pulled forward and
mentation of the injuries. EMS personnel usually will rotated inferiorly. The elbow may be placed on the
describe the information regarding the patient as they surface next to the patient to assist with stability. This
enter the room. procedure is the safest method of jaw manipulation in a
The treatment could be summarized as primary survey, patient with a suspected cervical spine injury. However,
resuscitation of vital functions, a second survey, once the it does necessitate the use of both hands, and assistance
patient has stabilized, and definitive care. The logical is required to remove debris from the airway.
sequence of this process constitutes the ABCDEs of A chin lift procedure may be performed by placing
trauma: the thumb over the incisal edge of the mandibular ante-
Airway maintenance with cervical spine protection rior teeth and wrapping the fingers tightly around the
Breathing and ventilation symphysis of the mandible. The chin is then gently lifted
Circulation with hemorrhage control anteriorly and the mouth opened, if possible. Care
Disability—neurologic status should be taken not to extend the neck while the other
Exposure, environmental control: Undressing the patient hand should be used to clear any debris from the oral
but preventing hypothermia cavity.
During the primary survey, the life-threatening con Tonsillar suction should also be used to clear any
ditions are identified and treated and vital signs are secretions or other accumulations from the pharynx. A
stabilized. Different conditions are frequently treated nasogastric tube or soft suction catheter may be used in
simultaneously. patients without suspected substantial midface fractures
Special consideration must be given to pediatric, preg- or cranial base fractures because these tubes can be inad-
nant, and older patients. In general, the guidelines are vertently passed into the cranial vault. An oral or nasal
the same, but the health care provider should take into airway should be placed to keep the airway patent and
consideration the differences in physiology, metabolism, the tongue elevated off the posterior pharynx. A nasal
response to trauma, amount of fluids, resuscitation tech- airway is better tolerated in an awake patient.
niques, and medication dosage. In the pregnant patient, Any patient with multisystem trauma, altered level of
the condition can be assessed by palpating the abdomen consciousness, or blunt trauma above the clavicle should
or a performing a human chorionic gonadotropin test. be assumed to have a cervical spine injury. Hyperexten-
It is important to mention that in the geriatric popula- sion or hyperflexion of the patient’s neck during airway
tion, comorbidities such as diabetes, cardiovascular establishment should be avoided. Excessive movement
disease, coagulopathies, liver and renal disease, and the can turn a cervical spine injury without neuronal damage
into neuronal deficit or even paralysis. In a multiple present. Extraordinary care must be taken in cases of
trauma patient with an altered level of consciousness, or facial trauma (e.g., nasal, frontal, midface fractures) In
any injury above the clavicle, the cervical spine (C-spine) addition, applying cricoid pressure during the intubation
has to be protected and stabilized. The presence of dis- will help to prevent aspiration.
tracting injuries may deflect the attention to the C-spine; The mnemonic LEMON (Table 4-2) is useful when
usually, a cervical collar is placed until the C-spine could assessing the difficulty for intubation:
be cleared. If during the placement of a definitive airway, • Look externally.
the cervical collar has to be removed, another trauma • Evaluate 3-3-2 rule
team member will hold the head and neck to provide • Mallampati scale
temporary stabilization. The cervical spine can be main- • Obstruction
tained in a neutral position using a backboard, bindings, • Neck mobility
and purpose built head immobilizers. The use of soft or After initial preoxygenation, a direct laryngoscopy is
semirigid collars is discouraged because they only stabi- performed. The tube is inserted in the trachea and the
lize 50% of movement. Cervical spine control should be cuff inflated; once the position of the tube is verified,
maintained in a patient with suspected cervical spine it is secured and connected to a ventilation system. A
injury until it can be ruled out clinically and/or radio- gum elastic bougie can be used in cases of difficult
graphically during the secondary survey. Patients with intubation.
severe head injury and an altered level of consciousness Airway control by rapid-sequence tracheal intubation
because of alcohol or drugs, or with a Glasgow Coma (oral endotracheal tube [OETT]) is performed with
Score (GCS) of 8 or less, usually require the placement in-line stabilization of the cervical spine. Correct place-
of a definitive airway with C-spine protection. ment of the endotracheal tube can be confirmed using
A patient who does not demonstrate purposeful motor the following:
responses or a patient who is combative often requires 1. End-tidal carbon dioxide monitoring device
definitive airway management, with placement of an 2. Observation of the tube passing through the vocal
airway cuffed tube in the trachea and the tube connected cords
to some form of oxygen ventilatory system. All airway 3. Auscultation of the chest
management equipment should always be taped in place. The pediatric patient needs special consideration
regarding instrumentation and knowledge of different
Endotracheal Intubation anatomic features, such as the position of the larynx. In
When intubation is to be performed, two trained indi- addition, obesity and retrognathia are other medical con-
viduals should be involved, one performing the intuba- ditions for which intubation may be more challenging.
tion and the other administering medications such as Several well-defined options for achieving airway
sedatives and muscle-paralyzing drugs, which should be control must be established in the event that OETT
used with caution. In many cases in which intubation is placement is not able to be achieved. These options
performed during the initial assessment, the use of seda- include laryngeal mask airway (LMA), intubating LMA,
tives and muscle blockers are unnecessary. fiberoptic intubation, percutaneous cricothyroidotomy,
Oral or nasal intubation should be performed accord- and surgical cricothyroidotomy (tracheostomy in chil-
ing to the operator’s preference and the injuries that are dren). Tracheal inspection is essential to determine
TABLE 4-2 LEMON Chart
Physical Signs Less Difficult Airway More Difficult Airway

Look externally Normal face and neck Abnormal face shape
No face or neck pathology Sunken cheeks
Edentulous
Buck teeth
Receding mandible
Narrow mouth
Obesity
Face or neck pathology
Evaluate 3-3-2 rule Mouth opening > 3F Mouth opening < 3F
Hyoid-chin distance > 3F Hyoid-chin distance < 3F
Thyroid cartilage to mouth floor distance > 2F Thyroid cartilage to mouth floor distance < 2F
Mallampati scale Class I and II (can see the soft palate, uvula, Class III and IV (can only see the hard palate ± soft
fauces, ± facial pillars) palate ± base of uvula)
Obstruction None Pathology within or surrounding the upper airway (e.g.,
peritonsillar abscess, epiglottis, retropharyngeal
abscess)
Neck mobility Can flex and extend the neck normally Limited range of motion of the neck
whether there is peritracheal crepitus or deviation from Inadequate ventilation may result in hypoxemia,
the midline indicating potential direct airway, intratho- hypercarbia, cyanosis, depressed level of consciousness,
racic pulmonary, or major vascular injury. bradycardia, tachycardia, hypertension, and/or hypoten-
sion. As a general rule, until stability has been ensured,
Surgical Airway one should administer high-flow oxygen by mask to all
When intubation is not possible, such as edema of the patients to abrogate the potential for hypoxemia.
glottis, laryngeal fracture, or profuse hemorrhage, a sur- If the patient is breathing spontaneously and ventila-
gical airway must be established. A cricothyrotomy is pre- tion is adequate, supplemental oxygen can be adminis-
ferred to a tracheotomy because it involves less time and tered by face mask. Assisted ventilation has to be instituted
is associated with less bleeding. if opening of the airway does not result in spontaneous
Needle Cricothyroidotomy. Needle cricothyroidotomy is ventilation. Compromised ventilation could be the result
a temporary airway. The patient can be oxygenated for a of airway obstruction, altered mechanics, or CNS
maximum of 30 to 45 minutes. A needle is inserted into depression.
the cricothyroid membrane. A jet system is then con- The exchange of air does not guarantee adequate
nected, which will provide oxygen until a more definitive ventilation. There are injuries that may impair ventila-
airway can be established. It is not indicated for patients tion, causing an obstructive or mechanical impairment.
with abnormal pulmonary function or chest injury. Fur- For example, a patient with a pneumothorax, flail chest,
thermore, it is not indicated for patients with head or hemothorax may have a chest wall that moves but
trauma caused by CO2 retention. ventilation may still be inadequate. In addition, shallow
Surgical Cricothyroidotomy. Surgical cricothyroidotomy breaths or slow rates may not allow for adequate ventila-
is a surgical incision made on the skin, extending to the tion. Very slow and rapid rates of respiration suggest poor
cricothyroid membrane. A hemostat or scalpel handle ventilation. Older patients with pulmonary dysfunction
may be used to dilate the opening, followed by the inser- fall into a group with an increased risk of developing
tion of a small-caliber tube into the trachea (5 to 7 mm mechanical pulmonary problems.
outer diameter [OD]). This is not recommended for A patient’s respiratory status should be monitored
children because of potential damage to the cricoid constantly. Signs of ventilator deterioration warrant
cartilage. placement of a secured airway via an endotracheal tube
or the initiation of assisted ventilation. At this point, a
Airway Evaluation patient can be artificially ventilated by a bag-valve mask
The airway can be compromised at any time. It could be or a bag attached to an endotracheal tube. Patients who
sudden, progressive, total, or partial. Therefore, paying require assisted positive-pressure ventilation with an
constant attention to the airway will warrant its patency. Ambu-Bag or mechanical ventilator should be closely
The following are signs of airway obstruction: monitored if their chest status has not been completely
1. Observation. Agitation, labored breathing, using evaluated. A simple pneumothorax can be converted
accessory muscles indicates hypoxia; obtundation into a tension pneumothorax when the intrathoracic
indicates accumulation of carbon dioxide or hypercar- pressure increases (Fig. 4-7). In the presence of a pneu-
bia. Cyanosis, a late sign, will indicate inadequate oxy- mothorax, especially a tension pneumothorax, immedi-
genation. The use of pulse oxymetry is an adjunct for ate treatment with a regular chest tube or needle insertion
blood oxygen saturation. is necessary.
2. Listen for abnormal sounds. Stridor can be associated During the primary survey, the chest should be fully
with partial obstruction of the airway. Hoarseness exposed and inspected for any signs of obvious injury.
implies functional laryngeal obstruction. Presence of bruising, flail chest, penetration, and bleed-
3. Palpate the trachea and determine whether it is in the ing should be noted. The chest should be palpated for
midline signs of rib or sternal fractures. Any subcutaneous emphy-
sema should be appreciated. The neck should be evalu-
BREATHING ated for any sign of tracheal deviation and jugular venous
Once a patent airway is verified or established, pulmo- distention. Chest expansion should be equal bilaterally,
nary function should be assessed. Adequate exchange of without intercostal or supraclavicular muscle retractions
gas is required for oxygenation and elimination of carbon during respiration. The breathing rate should be assessed
dioxide. Gas exchange necessitates adequate ventilation. for signs of abnormality, such as tachypnea. Tachypnea
The lungs, chest wall, and diaphragm must all function with shallow respirations is suggestive of chest injury and
adequately to ensure proper ventilation. impeding hypoxia. Distant heart sounds and distention
Breathing evaluation is most readily accomplished by of the neck veins can be suggestive of cardiac tampon-
visual inspection and palpation of thoracic cage move- ade. If any of these conditions is suspected, before or
ment and auscultation of gas entry. The patient is assessed after intubation and initial ventilation, a chest x-ray
for inequalities in chest movement from one side to the would be mandatory.
other, crepitus, and local movement asymmetry, as in Head injuries may result in abnormal breathing pat-
paradoxic thoracic cage movement in flail chest. A terns that could alter normal ventilation. Spinal cord
trained provider should also be evaluating the patient for injuries at the level of the cervical spine may affect
signs of impending respiratory failure, such as uncoordi- normal muscle function and therefore compromise
nated thoracic cage and abdominal wall movement, oxygen demands. Complete cervical transection at the
accessory muscle use, and stridor. C3 and C4 levels will compromise the phrenic nerves,
A B
FIGURE 4-7 A, Simple pneumothorax. B, Tension pneumothorax.
resulting in abdominal breathing and paralysis of the pneumothorax by reducing venous return. Extensive
intercostal muscles. damage to the CNS or spinal cord may result in a neu-
Standard monitors with a capnometer and pulse oxim- rogenic shock. In very unusual situations, septic shock
eter ensure adequate ventilation evaluation. Remember may be present if the treatment of the patient was initi-
that the pulse oximeter does not measure the partial ated several hours after the initial trauma.
pressure of oxygen (Pao2) and, according to the position
of the oxyhemoglobin dissociation curve, the Pao2 could Response to Shock
vary. The use of pulse oximetry alone cannot distinguish The initial circulatory response to hemorrhage is physi-
between oxyhemoglobin and carboxyhemoglobin or ologic compensation. There is a release of endogenous
methemoglobin. This is an important consideration catecholamines and hormones. The catecholamines will
in patients with vasoconstriction and carbon dioxide increase vascular resistance, increasing diastolic blood
poisoning. pressure and reducing pulse pressure—difference
between the maximum and minimum blood pressures
CIRCULATION MANAGEMENT produced during one heartbeat.
In the primary survey, circulation becomes the priority Other vasoactive hormones that are released include
after airway and breathing have been definitively histamine, bradykinin, beta endorphins, and a cascade
managed. Delivery of oxygen to the tissues is dependent of postanoids and cytokines. Vasoconstriction of the skin
on adequate circulation. The main cause of deaths that and extremities help maintain perfusion to the vital
can be prevented is caused by hemorrhage. It is esti- organs of the brain, kidneys, and heart. There will be an
mated that hemorrhage accounts for 30% to 40% of increase in heart rate to maintain cardiac output. Ini-
trauma mortality, with 35% to 65% of deaths occurring tially, blood pressure is not affected, although once com-
in the prehospital period; 50% of deaths secondary to pensatory mechanisms are overcome, it will be affected.
hemorrhage occur within the first 24 hours after the In cases of major fractures of the tibia or humerus,
initial trauma.14 In general, blood volume is 7% of body blood loss could reach up to 1.5 units. In femoral
weight; in children, it is considered to be 8% to 9%. fractures, it could be twice that amount and, in pelvic
Shock in a trauma patient is primarily hypovolemic sec- fractures, blood loss could be significant, presenting
ondary to trauma, although the patient may present with as a retroperitoneal hematoma. Edema, in the case of
cardiogenic, neurogenic, or even septic shock. There are increased endothelium permeability fluid loss, will shift
conditions that will contribute to a shocklike tension from the plasma to the extravascular space.
Poor perfusion will affect aerobic metabolism, with • Level of consciousness: Cerebral perfusion indicates
nutrients and oxygen being deprived, and consequently an adequate circulating volume of blood, although a
result in anaerobic metabolism, with the formation of conscious patient may have a significant amount of
lactic acid. This will ultimately lead to metabolic acido- blood loss.
sis. If this situation continues, the cell membrane will • Pulse: The pulse should be checked in central arteries
lose its integrity and there will be progressive cellular such as the femoral and carotid arteries.
damage. Continuous hypoxia will result in cellular Rapid pulse may indicate blood loss whereas an irregu-
death. Research has shown that the lethal triad of acido- lar pulse may indicate cardiac dysfunction. Different age
sis, hypothermia, and coagulopathy initially cause the categories should be taken into consideration when
first problems in the polytrauma patient, associated with assessing heart rates. For example, young patients with
high mortality.15 normal vagal tone and older patients with pacemakers
The initial damage to soft tissues and organs, and and/or beta blockers will have different responses to
fractures in the trauma patient, represents a major chal- hypovolemia. The heart rate will not increase as expected.
lenge. The local tissue damage resulting from contusions • Respiratory rate: According to the degree of hemor-
or lacerations, hypoxia, and hypotension result in further rhage present, patients may become tachypneic as a
damage from local and systemic responses. These pro- physiologic response to the need for more oxygen to
cesses are activated to preserve immune system integrity be delivered to the tissues.
and stimulate reparative mechanisms. This systemic • Blood pressure: If the blood loss is significant (>30%
inflammation is known as SIRS (systemic inflammatory of blood volume), there will be changes in blood
response syndrome). In addition, the initial inflamma- pressure.
tory response is augmented by a second hit, such as • Skin color: A gray, pale ashen tone may indicate
ischemia and reperfusion injuries and surgical interven- hypovolemia; pink skin is an indication of good
tions or infections (two-hit theory).16 perfusion.
In this chapter, the differences between adults and • Urinary output: Urinary output is considered to be in
children are discussed, followed by a review of circulatory normal limits with approximately 0.5 mL/kg/hr for
compromise and its definitive management. Causes of the adult and 1 mL/kg/hr for children. A decrease of
circulatory compromise include the following: urinary output to less than 30 mL/hr in an adult may
• Respiratory failure, hypoxemia, hypercarbia indicate hypovolemia in the absence of other medical
• Blood loss, internal or external conditions (e.g., renal damage).
• Tension pneumothorax • Acid-base balance: In early hemorrhagic shock, there
• Pericardial tamponade is an initial respiratory alkalosis, followed by metabolic
• Ruptured ventricle (rare) acidosis in severe cases.
• Cardiac contusions In general, children have an extraordinary physiologic
• Acidosis reserve and will not show signs or symptoms of hypovo-
• Burns lemia until there is a severe circulating blood depletion.
• Profound hypothermia A cool patient with tachycardia is considered to be in
Effects of circulatory compromise include the shock, until proven otherwise.
following:
• Decreased or complete loss of consciousness
• Respiratory distress, failure TREATMENT
• Hypovolemia—reduced cardiac output leads to Definitive Hemorrhage Control and Resuscitation
inadequate blood flow to all body organs (hypovo- The first step in hemorrhage control is to find the source
lemic shock) of bleeding. In a penetrating injury with active bleeding,
• Tissue hypoxia, metabolic acidosis, increased respi- the anatomic location of entrance and exit wounds guide
ratory rate the surgical procedure to stop the bleeding. Hemody-
• Ischemic injury to the brain, heart, kidneys, liver, namically unstable patients have to be taken for a quick
and bowel, with cell death and inadequate function radiologic screening to search for possible sources of
of these organs bleeding in the chest, abdomen, or pelvic compartments.
The use of multislice abdominal ultrasound (focused
ASSESSMENT assessment with sonography for trauma [FAST]) can be
The surgeon should be aware of the simultaneous com- performed to find abdominal free fluid. A positive result
pensatory mechanisms in a trauma patient and also the necessitates an emergency laparotomy.14 Advances in
individual situation. In the older patient, for example, resuscitation techniques have reduced the mortality rate,
aging will affect general and specific organ systems that along with the use of interventional radiology for embo-
are predictive of failing health. Medically compromising lization of vessels without the need for immediate surgi-
conditions and the use of different medications are fre- cal intervention.18
quently present in this group and can contribute to high External hemorrhage is managed with pressure and
morbidity and mortality rates with relative minor inju- bandages. Small wounds and scalp lacerations represent
ries.17 According to the ABCs of trauma, once the airway a potential source for blood loss; 300 mL of blood could
is patent and ventilation is reestablished, the hemody- be easily lost in 1 hour if there are several small bleeding
namic status (blood volume and cardiac output) should wounds. During the second survey, it may be necessary
be assessed, as follows to use staples or sutures to control bleeding.
In respect to resuscitation, venous access and fluid use of medications that affect coagulation (e.g., warfarin,
replacement are an important part of prehospital nonsteroidal anti-inflammatory drugs [NSAIDs]). Trans-
advanced life support (ALS) and are carried out based fusion platelets, cryoprecipitates, and fresh-frozen plasma
on clinical judgment.19 At least two large-caliber IV cath- (FFP) are administered accordingly. Biswadev et al
eters should be used. It is important to remember that has shown increased initial survival in association with
the amount of fluid delivered is determined by the diam- higher FFP-to-RBC (red blood cell) ratios in massive
eter of the gauge of the catheter compared inversely with transfusion in cases of higher proportions of blunt inju-
its length, and not by the caliber of the vein where it is ries.22 Patients with brain injuries release thromboplastin
placed. Other IV lines are placed as necessary, according and are prone to coagulation disorders. Close monitor-
to the trauma leader who is directing the treatment of ing is mandatory.
the patient. In children younger than 6 years, the place-
ment of an intraosseous needle should be attempted DISABILITY
before placing a central line. Intraosseous access is also During the acute resuscitation period, a brief assessment
possible in adults. Blood tests are done at this time, of neurologic status should be performed. This assess-
including arterial blood gas (ABG) tests, complete blood ment should include the patient’s posture (e.g., any
count (CBC), and cross-matching. asymmetry, decerebrate or decorticate posturing), pupil
When aggressive resuscitation is necessary, 1 liter of asymmetry, pupillary response to light, and global assess-
warm crystalloid solution (normal saline or lactated ment of patient responsiveness. A recommended system
Ringer’s solution) should be given as a bolus at the begin- is the AVPU method:
ning of the procedure, followed by another liter accord- A—Patient is awake, alert, and appropriate.
ing to vital signs. Giving 20 mL/kg is recommended for V—Patient responds to voice.
pediatric patients. Shock usually is hypovolemic in origin P—Patient responds to pain.
in the trauma patient. Generally, 3 mL of crystalloid are U—Patient is unresponsive.
needed for each milliliter of blood loss. If the patient During the secondary survey, a complementary assess-
does not respond to this therapy, blood transfusion may ment using the GCS should be made and whenever
be required. the patient’s mental status appears to change. A more
Hypothermia should be prevented by protecting the detailed assessment of the patient’s neurologic status is
patient using a warm solution (39° C [102.2° F]) and made during the secondary survey. The assessment
increasing the temperature of the resuscitation room. during the primary survey establishes a baseline; if the
Blood cannot be warmed in a microwave but can be patient’s neurologic condition varies from the primary to
passed through IV fluid warmers. the secondary survey, a change in intracranial status may
After the initial resuscitation, the patient’s response in be present. A decrease in the level of consciousness may
terms of adequate perfusion and oxygenation is assessed indicate decreased cerebral oxygenation or perfusion,
by mental status, urinary output, and vital signs. Improve- which will necessitate a reevaluation of the ABCs.
ments in central venous pressure (CVP) and skin circula- The reactivity of the pupils to light provides a quick
tion are good indicators of adequate therapy. Acid-balance assessment of cerebral function. The pupils should react
is continuously monitored and, in cases of metabolic equally. Changes may indicate cerebral nerve damage,
acidosis, bicarbonate is rarely indicated. optic nerve damage, or changes in ICP. Further changes
in pupil reactivity or levels of consciousness may be
Blood Replacement caused by alterations in ventilation or oxygenation status.
Blood replacement may be necessary, despite the fact The most common causes of coma or depressed levels of
that resuscitation is provided through the administration consciousness are hypoxia, hypercarbia, and hypoperfu-
of crystalloids. The transfusion of blood restores the sion of the brain.23 Depressed levels of consciousness
intravascular oxygen- carrying capacity. When there is no with narrow pinpoint pupils may be seen with opiate
information regarding the patient’s type-specific blood, overdose. In overdose with meperidine hydrochloride
type O packed cells are indicated in case of emergency (Demerol), the pupils may appear normal or dilated.
hemorrhage. Unmatched, type-specific blood is pre- Treatment necessitates the narcotic antagonist naloxone
ferred over type O in life-threatening situations. hydrochloride (Narcan), with 0.4 mg given initially. Care
should be taken to avoid a quick, violent withdrawal
Coagulopathy phase in the opiate abuser, which is accompanied by
Patients who suffer severe trauma may present with a profound distress, nausea, agitation, and muscle cramps.
coagulopathy, which is a complex and multifactorial con- Hypoglycemia and hyperglycemia can cause depressed
dition that includes tissue trauma, shock, hemodilution, levels of consciousness. If a quick blood glucose level
hypothermia, acidemia, and inflammation, with the cannot be obtained because of other injuries, the patient
primary factors being direct trauma in conjunction with can be given an immediate bolus of 25 g of glucose to
shock and hypoperfusion. This process seems to occur manage the more critical hypoglycemia. A benefit of the
immediately after an accident; studies have shown a 24% to glucose load is the attainment of a hyperosmolar status,
36% incidence of early post-traumatic coagulopathy.20,21 which may reduce cerebral edema for a short time.24
Determination of coagulation factors, prothrombin
time (PT), partial thromboplastin time (PTT), and plate- EXPOSURE
let counts are usually ordered within the first hour, espe- Patients should be completely disrobed during the initial
cially with a previous history of coagulation disorders or assessment and the subsequent secondary survey. This
helps ensure the observation and assessment of signifi- function, coordination, and reflexes. Identify any neuro-
cant injuries. At the same time, efforts to prevent signifi- logic asymmetry. Patients with lateralizing signs and those
cant hypothermia using a warm ambient room (82° to with an altered level of consciousness (GCS score < 14)
86° F [28° to 30° C]), overhead heating, and warmed IV should undergo cranial computed tomography (CT)
fluids, should be instituted. The patient’s temperature scanning. Patients with a traumatic brain injury (TBI) are
should be measured on arrival at the emergency particularly susceptible to secondary brain injury from
room and strenuous efforts should be made to avoid hypoperfusion, hypoxia, hypercarbia, hyperglycemia,
significant hypothermia during resuscitation and thera- hyperthermia, and seizure activity.
peutic intervention. Injuries to the head and skull may include lacerations,
abrasions, avulsions, and contusions, fracture of the
SECONDARY ASSESSMENT cranium, cerebral contusions, and shearing injuries.
These can result in intracranial bleeding, hypoxia, and
The secondary assessment is initiated once the primary ischemia, which can lead to secondary brain injury. A
assessment has been completed and management of life- cerebral ischemia may not be caused by a head injury but
threatening conditions has begun. The patient’s vital can result from an arterial hypotension. Cranial injuries
signs and condition should be constantly monitored to can cause an ischemia as a result of elevated ICP and
assess the effects of intervention during the primary pressure on intracranial vessels from an expanding
survey and any life-threatening issue that was undiag- hematoma. Severe volume changes taking place within
nosed during the primary survey. Changes in the patient’s the fixed volume of the skull can lead to herniation of
vital signs, respiratory and cardiovascular function, and the brain from the cranial vault.
neurologic status are expected to occur within the first Cerebral hypoxia is caused by impaired oxygen deliv-
24 hours after the initial trauma.24 A secondary assess- ery to the brain, which can occur from ischemia or from
ment includes a subjective and objective evaluation of reduced oxygen-carrying capacity of the blood. Second-
the trauma patient. ary effects of hypoxia and many forms of ischemia are
The secondary assessment begins with a subjective usually preventable. Approximately 50% of patients with
evaluation. If possible, this should include a brief inter- head injuries have some degree of reversible injury
view with the patient. In the comatose patient, family caused by increased ICP that can be controlled with
members, bystanders, or other victims are a good source aggressive measures. Failure to control an increased ICP
of information for subjective evaluation. A brief health is the most common cause of death in hospital patients
history should be obtained, which includes medications, with head injuries. Hypertension with concomitant bra-
allergies, previous surgeries, and history of the injury dycardia and irregular respirations (Cushing’s triad) can
(e.g., location, duration, time frame, intensity). be a sign of increasing ICP. In contrast, hypotension with
The history should include an assessment based on tachycardia usually indicates hypovolemia from blood
the following protocol. This can be remembered by using loss. Shock is rarely associated with primary neurologic
the AMPLE acronym: A, allergies; M, medications; P, past injury, and therefore a systemic source of blood loss
medical, surgical, and social history; L, last meal; and E, should be investigated. Cushing’s triad is usually present
events leading to injury, scene findings, notable interven- in less than 25% of patients with increased ICP, even in
tions, and recordings en route to the hospital. cases of ICP higher than 30 mm Hg (>15 mm Hg is con-
An objective evaluation should include inspection, sidered abnormal).
palpation, percussion, and auscultation of the patient Head CT scanning is a rapid noninvasive technique
from head to toe. All segments of the body (head and that can accurately assess neurologic injuries and detect
skull, maxillofacial area, neck, chest, abdomen, extremi- mass lesions. It causes no life-threatening risk to the
ties) and neurologic status should be evaluated to provide head-injured patient and establishes a baseline for future
a baseline of the patient’s current condition. Further- studies. In patients with suspected intracranial injury, CT
more, special procedures such as peritoneal lavage, scans can quickly and easily diagnose and localize intra-
radiographic studies, and further blood studies may be cranial hemorrhage, contusions, foreign bodies, and
performed during this evaluative phase. Many institu- skull fractures. Also, a CT scan can demonstrate second-
tions will conduct FAST as part of their primary survey ary effects of trauma, such as edema, ischemia, infarc-
rather than as part of the secondary survey. tion, brain shift, and hydrocephalus. With acutely
traumatized patients, CT scans have an almost 100%
FACE, HEAD, AND SKULL INJURIES accuracy in the diagnosis of intracerebral and extracere-
The next sequential phase in the evaluation of injury and bral hematoma formation. Substantial lesion masses can
instability is the palpation of the entire cranium and face. cause cerebral ischemia by elevation of the ICP or com-
Sutures, staples, or Raney clips may be helpful in control- pression vasculature. Following stabilization of the
ling bleeding from large scalp flaps. Palpate for facial trauma patient, a CT scan should be performed imme-
crepitus and a mobile middle third of the face as a clue diately rather than waiting for clinical signs of an expand-
to potential difficulty in airway control. Hemotympanum ing intracranial hematoma. In patients with a suspected
and the presence of bruising around the eyes (raccoon head injury, the possibility of a lesion mass has been
eyes) and mastoid process (Battle sign) suggest a basal reported in 40% of adults and 25% of children (<18
skull fracture. years). Controversy remains concerning indications for a
Recheck the pupils and repeat GCS scoring. Evaluate head CT scan; however, it should usually be performed
the cranial nerves, peripheral motor and sensory in patients with seizure activity, unconsciousness lasting
longer than a few minutes, abnormal mental status, transport of the patient back to the CT scanner for addi-
abnormal neurologic evaluation, and clinical evidence of tional imaging as a result of failure to extend the initial
skull fracture. The use of CT scans has been suggested CT examination to all structures of the face.
for patients with blunt trauma and those who have expe- As the ICP continues to rise further above normal
rienced any loss of consciousness or mild amnesia, even (15 mm Hg), there is a standard progression of neuro-
with normal neurologic findings.25 logic abnormalities that are seen clinically. In order of
occurrence, these abnormalities include factors affecting
Types of Injuries the following:
Skull Fractures. Skull fractures may present in the 1. Cerebral cortex and altered state of consciousness
cranial vault or the base of the skull. The classic signs of 2. Midbrain, exhibited by dilation and then progres-
a skull base fracture include periorbital ecchymosis sive fixation of the pupils
(raccoon eyes) retroauricular ecchymosis (Battle sign), 3. Pons, resulting in loss of the corneal reflex and
cerebrospinal fluid (CSF) leakage from the nose, and abnormal doll’s eye sign
cranial nerve VII or VIII impairment. Carotid arteries 4. Medulla, demonstrated by apnea and followed by
may be affected. CT scans are mandatory. An arteriogra- hypotension and death
phy should also be performed in a patient with a sus- A careful physical examination of the head should
pected injury to the carotid. include examination of the scalp for lacerations and
Intracranial Lesions. Intracranial lesion can be diffuse foreign bodies. Because of the rich vascular supply of the
or focal. A significant brain injury can occur from a scalp, substantial blood loss can result. Lacerations over-
diffuse brain injury caused by a mild concussion, with lying injury to the cranium or intracranial hemorrhage
only brief periods of apnea, or from more severe diffuse may be present. These wounds can act as portals for the
injuries in which there is a prolonged period of apnea entry of bacteria into the injured area(s), resulting in
or shock. The CT scan may appear initially normal or meningitis or brain abscess. Hematoma formation or
may appear swollen, with loss of the normal gray-white ecchymosis over the mastoid (Battle sign), hemotympa-
appearance. Diffuse axonal injuries may present as mul- num, CSF rhinorrhea or otorrhea, and subscleral hemor-
tiple punctuated hemorrhages through the cerebral rhage all suggest basilar skull fracture. In patients with
hemispheres. These are usually the result of a high- suspected basilar skull fractures, nasogastric tube place-
velocity impact or deceleration. ment should not be performed because the tube can
Hematomas inadvertently be passed into the cranial vault.
Epidural Hematomas. Epidural hematomas result A brief neurologic examination should evaluate the
from the tear of the medial meningeal artery and, occa- level of consciousness, motor and cranial nerve function
sionally, from a venous sinus. The hematoma materializes (suggestive of mass lesions), brainstem findings, and
between the dura and inner table of the skull. The shape trends in neurologic status. A neurologic examination
is biconvex or lenticular. They are relatively uncommon can be complicated by trauma patients under the influ-
and constitute only 0.5% of all brain injuries. ence of drugs and alcohol. A decreased level of con-
Subdural Hematomas. Subdural hematomas develop sciousness should not be solely attributed to alcohol or
from the shearing of small surface or bridging blood drug intoxication until intracranial pathology or injury
vessels of the cerebral cortex. The shape follows more has been ruled out.
along the contour of the brain and are more common As noted, the GCS (see Table 4-1) provides a simple
than epidural hematomas. grading of consciousness and functional capacity of the
Contusion or Intracerebral Hematomas. Contusion or cerebral cortex. This scale is based on three behavioral
intracerebral hematomas occur frequently in the frontal responses—eye opening, best verbal response, and best
and temporal lobes. They may transform into intracere- motor response. This scale can be used in the field and
bral hematomas or the contusion may evolve to such a as a reassessment tool to assess brain function, brain
magnitude that it requires surgical evacuation. damage, and patient progress. Injury to two areas of the
brain, regardless of cause, can produce unconsciousness,
Diagnostic Testing and Evaluation the cerebral cortices bilaterally and the brainstem reticu-
In patients with brain injuries, a CT scan should be lar activating system.27
ordered, if available, within 24 hours of the initial evalu- The assessment of motor function is part of the GCS
ation and a neurosurgery consultation obtained once and provides information about asymmetrical function.
cardiopulmonary stabilization is achieved. Because of the Conscious patients should be asked to move their extrem-
high incidence of cervical spine fractures in patients with ities in response to commands. The inability to follow
head and facial trauma, extreme care should be taken these commands may indicate damage to the spinal cord.
when moving this patient to the CT scanner.26 If there is In the unconscious patient, deep tendon reflex and the
suspicion of spinal trauma, the cervical spine should plantar response can demonstrate the functioning of
remain immobilized before movement of the patient and sensory input and motor output. Any nonpurposeful or
the CT examination should be extended to include visu- abnormal postural movements are of special concern.
alization of the cervical spine. If facial injuries are sus- Abnormal flexor activity (decorticate) involves flexion of
pected, the CT scan should be extended inferiorly to the forearms on the chest, with flexion of the wrists and
allow visualization of the inferior border of the mandible. fingers. Abnormal extensor posturing occurs when the
However, in many cases, evaluation and treatment of arms, hands, and fingers are extended, with the hands
facial injuries are delayed because of the needless abducted. In both situations, the lower extremities are
extended and there is no attempt to localize the point of may precipitate cerebral herniation in the trauma patient
stimulation. Bilateral extensor plantar responses are non- with an elevated ICP. CSF emerging from the nose (rhi-
specific. However, a unilateral Babinski sign suggests cor- norrhea) or ear (otorrhea) is commonly associated with
ticospinal tract damage. The level of consciousness and a basilar skull fracture. Clear or red-tinged fluid that
brainstem function can be assessed through pupillary drains from the nose or ear should be considered to be
function. Eye movements and eye opening can provide CSF. No reliable method exists in the emergency room
information about the degree of injury. The size, shape, for distinguishing CSF from nasal mucus. The use of
and reactivity of the pupil to light provide insight with glucose indicator sticks has been associated with a high
respect to the function of cranial nerves II and III and incidence of false-positive results. A useful aid may be a
midbrain activity. A sluggish but reactive pupil or a ring sign. A drop of blood from the nose or ear is placed
dilated nonreactive (blown) pupil unilaterally indicates on a piece of filter paper. The blood components of the
compression of cranial nerve III by brain herniation in fluid remain in the center and rings of clear fluid may
the unconscious patient. The pupillary light reflex can develop about it, thus producing the ring sign.9 This test
be used to evaluate cranial nerve function and possible often lacks sensitivity and specificity. A positive laboratory
elevated ICP with brain herniation. test for beta-2 transferrin confirms the presence of CSF
With normal pupillary activity, light directed into one in the fluid. With confirmation of a CSF leak, a CT scan
eye produces contraction of pupils in both eyes. The should be performed to determine the presence, loca-
optic nerve (cranial nerve II) carries visual and papillary tion, and extent of fracture. The head of the bed should
fibers. Bilateral optic nerves connect shortly after they be elevated to 90 degrees. If indicated, the fracture
leave the retina to form the optic chiasm. At the optic should be reduced and the leakage should resolve within
chiasm, the nasal fibers cross to join the temporal fibers 7 days. If a CSF leak is persistent, neurosurgical proce-
from the other eye and the visual fibers and terminate in dures may be indicated to repair the dural tear.
the visual cortex of the occipital lobe. The pupillary The performance of a rectal examination is important
fibers are relayed bilaterally to the Edinger-Westphal for patients with head injuries. The presence of rectal
nucleus of the oculomotor nerve (cranial nerve III). sphincter tone suggests intracranial injury only. With the
Cranial nerve III supplies neurologic function to the absence of rectal tone, a coexisting spinal cord injury
sphincter muscle of the iris, causing it to contract. Auto- should be suspected. Coexisting head and spine injuries
nomic innervation also supplies the eyes. The iris is sup- should be suspected until proven otherwise.
plied by sympathetic and parasympathetic fibers. A head injury can be initially classified as mild (GCS,
Stimulation of the sympathetic fibers causes the pupil to 13 to 15), moderate (GCS, 9 to 12), or severe (GCS < 8).
dilate and elevation of the upper eyelid via Muller’s Patients with a head injury and no loss of consciousness,
muscle. If a light is shone into the right eye and the left no amnesia, no palpable fractures, and a GCS score of
eye does not respond, there may be disruption of the 15 can be discharged to a reliable caretaker without brain
right optic nerve or left oculomotor nerve. A light should imaging. However, it is generally recommended to have
then be shone in the left eye. If the left eye does not CT imaging because of the convenience and decreased
respond, disruption of the cranial nerve III should be cost of this imaging modality. Patients with a history of
suspected. Pupillary dilation of one eye may be caused loss of consciousness, amnesia, or a GCS score of 13 to
by brain herniation developing on the ipsilateral side, 14 must undergo immediate head CT. With a negative
with bilateral papillary dilation suggestive of notable mid- finding in the CT examination, the patient can be
brain injury or loss of parasympathetic function. Con- discharged with instructions. Admission to an ICU or
versely, pinpoint pupils after head trauma may indicate neurologic observation unit for continuing care and
drug overdose or loss of sympathetic tone as seen in observation is indicated for a patient presenting with
Horner’s syndrome. focal neurologic abnormalities, a GCS score of less than
The brainstem can be assessed through an evaluation 13, or an intracranial lesion on a head CT. Prophylactic
of the corneal reflex. The corneal reflex involves sensory phenytoin (Dilantin) administration with an IV loading
input from the trigeminal nerve (cranial nerve V). The dose of 18 mg/kg is used by some trained individuals for
oculocephalic maneuver (doll’s eye test) necessitates an control of possible seizure activity.
intact vestibulocochlear nerve (cranial nerve VII) to Benzodiazepines can be used for ongoing seizure
permit head rotation to evaluate reflexive movement of activity. A neurosurgical consultation should always be
the eyes. This maneuver should not be used in patients obtained early in the management of any obvious head
with suspected cervical spine injury. trauma or head injury. Severely headiinjured patients
The oculovestibular response test can be used to eval- (GCS < 8) should undergo rapid sequence intubation to
uate cranial nerves III, IV, VI, and VIII along with brain- protect the airway and achieve better control of ICP. An
stem activity. This test is performed by irrigating the increased ICP can be controlled using various tech-
external auditory canal with cold water. If the reflex is niques, including the following: (1) reverse Trendelen-
intact, there should be full eye movement toward the ear burg’s position; (2) osmotic diuresis (mannitol); (3)
canal lavaged with cold water. If there is no movement, hyperventilation of intubated patient (little reported
disruption of the neural tract of the tympanic membrane benefit and this has fallen out of favor); (4) sedation; (5)
should be suspected. pharmacologic paralysis; and (6) phenobarbital coma
A lumbar puncture should not be performed in (last resort). The judicious use of resuscitative fluids
patients with acute head injuries. Changes in pressure (limited fluid resuscitation) and control of systemic
associated with removal of CSF from the lumbar region hypertension will also help control an elevated ICP.
pneumothorax; the ensuing wound should eventually be

NECK INJURIES closed in the operating room. If, after closure of the
Maintaining cervical spine stabilization when removing wound in the operating room, the lung fails to expand
a rigid cervical immobilization device is imperative. Pen- or poor ventilation persists, the patient should be placed
etrating injuries of the neck may require angiographic, on a ventilator with positive end-expiratory pressure
bronchoscopic, or radiologic examination, depending (PEEP) to allow expansion of the lung. While on the
on the level of injury (i.e., zone I, II, or III). In particular, ventilator with PEEP, the patient should be closely moni-
zone II injuries that violate the platysma may be readily tored with a chest tube in place to prevent the deve
explored. Those injuries that correlate to zone I or III lopment of a tension pneumothorax. The signs of a
benefit from additional investigation because of the dif- tension pneumothorax in patients on ventilators include
ficulty in identifying and controlling injuries in those increased airway resistance, tracheal shift, and dimin-
zones. ished tidal volume.
CHEST INJURIES Closed Pneumothorax

During the entire secondary assessment of the multiple A closed pneumothorax can result from blunt trauma to
injured patient, the primary evaluation of airway, breath- the chest or fracture of a rib with laceration to the lung.
ing, and circulation must be continually monitored for An external communication into the pleural space, such
the detection of new or overlooked findings and/or inju- as through a wound, is not present in the closed pneu-
ries. A pneumothorax, open pneumothorax, hemotho- mothorax. Air from the lungs is allowed to pass through
rax, flail chest, and cardiac tamponade can develop after a lung laceration into the pleural space, equalizing the
primary assessment and must be treated accordingly. negative pleural pressure and subsequently collapsing
Chest injuries are directly responsible for more than 25% the lung. This collapse of the lung results in a ventilation
of the 50,000 to 60,000 fatalities that result annually from perfusion deficit because blood is still circulated to the
MVAs and contribute significantly to at least 25% more collapsed lung but is not oxygenated. Percussion to the
of these fatalities. Therefore, continued monitoring and side of the chest with a pneumothorax elicits hyperreso-
management of chest injuries are essential. nance. Breath sounds on the affected side are usually
distant or absent. Confirmation and evaluation of a
Open Pneumothorax pneumothorax are done via upright chest radiography.
An open pneumothorax occurs when there is a defect in On seriously injured patients, studies have shown that
the chest wall, allowing air to be moved in and out of the 76% of occult pneumothoraces have gone undiagnosed
pleural cavity with each respiration. This condition may when x-rays were interpreted by the trauma team. It is
result when a large defect of the chest is present. imperative to pay attention to clinical predictors in
If the opening is two thirds of the diameter of the patients who are at greater risk. These risks include sub-
trachea, air will enter through this opening, resulting in cutaneous emphysema, pulmonary contusions, rib frac-
ventilatory impairment, hypoxia. and hypercarbia. The tures, and female gender). Occult pneumothoraces are
loss in chest wall integrity allows an equilibrium to prone to develop further complications in patients with
develop between intrathoracic pressure and atmospheric a decreased cardiac pulmonary reserve or in those who
pressure. With each respiration, the involved lung col- need positive-pressure mechanical ventilation.28
lapses on inspiration and slightly expands on expiration, An open pneumothorax with an occlusive dressing
allowing air to be sucked in and out of the chest wall. placed over the wound is transformed into a closed pneu-
Hence, this pathology is referred to as a sucking chest mothorax. Traumatically induced pneumothoraces are
wound. If the chest wall defect (wound) is two thirds of frequently treated with tube thoracostomy (chest tubes).
the size of the diameter of the trachea, air will pass This procedure is used to correct respiratory compro-
through the chest wall defect because it becomes the mise. However, a small pneumothorax may be treated
path of least resistance. As the involved lung collapses, by hospitalization with close observation if the patient
the loss of negative pleural pressure causes the expired is otherwise healthy, symptom-free, does not require
air from the normal lung to pass into the affected lung general anesthetic or mechanical ventilation, and if the
on expiration and back into the normal lung on inspira- size of the pneumothorax is not increasing, as measured
tion. This results in an enlarged functional dead space on serial 24-hour x-rays.29,30 This situation is rarely seen
in the normal lung and loss of the involved lung, thereby with the trauma patient, and a chest tube should be
causing a ventilation perfusion problem. placed in a patient with a pneumothorax and accom
The treatment of this condition involves coverage of panying multiple injuries.
the defect with a sterile occlusive dressing secured at A chest tube is generally placed anteriorly in the
three of the four sides. The unsecured side acts as a second intercostal space midclavicular line or in the
one-way valve, allowing air to escape the pleural cavity on fourth or fifth intercostal space midaxillary line. The
expiration. Taping of all edges could cause accumulation level generally corresponds to the level of the nipple. If
of air within the thoracic cavity and subsequent develop- a patient has large breasts, it is essential to have an assis-
ment of a tension pneumothorax. Vaseline gauze can be tant medialize the breast tissue. The midaxillary site is
used as a temporary occlusive dressing over large defects generally preferred for cosmetic reasons, and it can effec-
during the initial examination. Chest tube placement tively remove fluid and air if the tube is positioned prop-
at a distant site on the affected chest wall should erly (superiorly toward the apex of the lung). The second
be performed to prevent development of a tension intercostal space location is usually reserved for needle
decompression of a suspected tension pneumothorax. A anteriorly in the affected hemithorax through the second
moderately sized tube is most often the choice for this or third intercostal space in the midclavicular line. This
procedure. A size 32 to 40 Fr is acceptable in adults and maneuver can quickly convert a tension pneumothorax
size 26 to 30 Fr in children. If a hemothorax is present, to a pneumothorax, which can then be treated by inser-
a larger tube is generally selected. The region is prepped tion of a chest tube.
and draped and a local anesthetic is generally used. A It is critical that maxillofacial patients with chest wall
skin incision that is approximately 3 cm in length is first injuries be closely monitored during the perioperative
made at one intercostal space below the intended place- period. If a patient has been given positive-pressure ven-
ment of the tube. This is to allow the tube to maintain tilation during an operative procedure, there is a risk of
an increased seal and conform to the profile of the rib a tension pneumothorax. If a patient does have a chest
cage. Subsequently, a gloved finger is used to traverse tube in place, its removal may in part be dictated by the
bluntly through the subcutaneous tissue in a superior timing of the repair of the maxillofacial injuries. Com-
direction to locate the intercostal space intended for munication with the trauma surgeon and anesthetist
tube placement. A curved Kelly clamp is used to separate regarding the timing of maxillofacial repairs is benefi-
the intercostal muscles. A finger is inserted to verify cial. It is important to be vigilant when treating maxil-
entrance into the pleural cavity. The tube is then placed lofacial injuries in a trauma patient who has had a small
superiorly and posteriorly into the pleural cavity and pneumothorax that was not managed with a chest tube
secured to the skin with suture; an occlusive dressing or in a patient who has had a chest tube removed before
placed over the defect around the tube. The next phase surgery. The positive-pressure ventilation delivered by an
of the procedure is connection of the tube to an under- anesthetist can expand the prexisting pneumothorax.
water sealed drainage to remove air or fluid. After final
placement, an upright posteroanterior and lateral chest Hemothorax
radiograph should be taken to confirm the position of A hemothorax is a collection of blood within the pleural
tube, position of the last drainage hole in the tube, and cavity. It occurs most frequently as a result of penetrating
amount of air and fluid remaining in the pleural cavity. injuries. It can also result from any blunt trauma that
Serial daily radiography and physical examination should disrupts the vasculature. Initial blood accumulation
be performed to monitor the progress of air and fluid within the pleural cavity is bleeding that is coming from
removal. If the tube becomes blocked and substantial the lung parenchyma. This process is usually slow in
amounts of air or fluid remain, a new chest tube should nature because of the low pulmonary pressure. A massive
be inserted. hemothorax with rapid accumulation of blood is a result
of injuries of the aortic arch, pulmonary hilum, internal
Tension Pneumothorax mammary arteries, and/or intercostal arteries. A hemo-
The presence of a tension pneumothorax should be con- thorax can notably reduce vital capacity of the lung and
sidered in patients who rapidly become acutely ill and result in hypovolemic shock in the presence of a large
develop severe respiratory distress. Patients who fall into amount of blood in the chest. A hemothorax, usually
this category will exhibit decreased breath sounds, hyper- associated with a pneumothorax, can produce metabolic
resonance on one side of the chest, distended neck veins, and respiratory acidosis via decreased cardiac output and
and deviation of the trachea away from the involved hypoxia, respectively.
side. A tension pneumothorax develops when an injury When evaluating a patient with reduced breath sounds
through the chest wall or from the lung acts as a one-way and dull percussion to one lung field and who also has
valve, allowing air to enter the pleural cavity on inspira- a history of sustaining penetrating or blunt chest trauma,
tion without escape on expiration. This results in a pro- a hemothorax should be suspected. Neck veins can be
gressive increase of intrapleural pressure, causing flat because of severe hypovolemia or distended because
complete collapse of the affected lung. With increasing of the mechanical effect of a chest full of blood.27 The
pressure, the trachea and mediastinum are displaced to loss of a small amount of blood (<400 mL) makes it more
the opposite pleural cavity and impinge on the normal difficult to diagnosis a hemothorax. This is because
lung. Compression on the normal lung causes shunting changes in the patient’s appearance, vital signs, or physi-
of blood flow to nonventilated areas and results in severe cal findings may be minimal. A collection of fluid more
ventilation-perfusion disturbances. The positive intra- than 200 to 300 mL can be observed on good upright
pleural pressure causes compression of the vena cava, chest radiographs, with blunting of the costophrenic
resulting in decreased cardiac output. All these changes angles evident. A supine chest radiograph is considered
develop into a rapid onset of hypoxia, acidosis, and to be less accurate.30
shock.30 Common causes of tension pneumothorax The treatment of a hemothorax includes airway
include mechanical ventilation with PEEP and spontane- control, supported ventilation as required, drainage of
ous pneumothorax with blunt chest trauma in cases in the accumulated blood in the pleural cavity, and restora-
which the parenchyma has failed to seal. Traumatic chest tion of the circulating blood volume. The blood volume
defects have also been occasionally known to cause can be restored by transfusion of fluids, volume expand-
tension pneumothorax.27 ers, blood or blood products via large-bore IV lines.
A tension pneumothorax can rapidly become fatal if Blood can be evacuated from the pleural cavity as out-
not treated quickly. Treatment includes release of intra- lined earlier through insertion of a large chest tube (36
pleural pressure as soon as possible. This can be accom- to 40 Fr) at the fifth or sixth intercostal space at the
plished by inserting a large-bore needle (14 to 16 gauge) midaxillary line. The tube should be directed superiorly
and posteriorly to prevent damage to an elevated dia- movement of the segment and reduced pain associated
phragm. The chest tube is to be connected to an under- with movement. The splinting tends to reduce vital
water seal with continuous suction (20 to 30 cm of water). capacity; however, it increases the ventilation efficiency.
A new chest tube should be inserted in lieu of irrigating This form of treatment is adequate for approximately 30
a tube that becomes clogged or fails to drain. Patients minutes until more definitive treatment can be rendered.
with massive bleeding can have an autotransfusion of the A prolonged period of splinting can produce atelectasis.
evacuated blood until banked blood becomes available.31 Severe injuries can be managed with open reduction and
It is critical to evaluate the amount of fluid being evacu- internal fixation.
ated from the chest tube initially and on an ongoing The second stage of treatment provides prolonged
basis. Surgical exploration via thoracotomy is indicated relief of pain via intercostal nerve blocks. Pain relief from
in patients with persistent hemorrhage. Massive hemo- the fractured segment allows the patient to breathe
thorax can result from the accumulation of more than deeply and cough.
1500 mL of blood or one third of the patient’s blood The final stage of treatment uses a volume-cycled res-
volume in the thoracic cavity. Conditions that exacerbate pirator with endotracheal intubation to provide PEEP
the need for surgical exploration include the following: and intermittent mandatory ventilation (IMV). The
(1) an initial drainage of more than 20 mL/kg of blood; effective internal splinting with the ventilator support
(2) persistent bleeding at a reate of more than 7 mL/ allows for adequate depth of ventilation, improves oxygen
kg/hr; (3) increased appearance of hemothoraces on absorption in the areas of contusion, and decreases atel-
serial chest x-rays; and (4) hypotension despite volume ectasis. If the initial stage of treatment is implemented
replacement. Furthermore, when other sites of blood early, the respiratory support is generally only required
loss have been ruled out or the patient decompensates for 2 to 4 days. If there is a delay until the patient shows
after initial response to resuscitation, exploratory surgery signs of respiratory difficulty, prolonged therapy is gener-
may be indicated.30 In a few cases, presentation to a criti- ally required for up to 14 days.
cal care unit may necessitate an emergency thoracotomy.
This procedure, however, is associated with an increased Cardiac Tamponade
mortality rate. Cardiac tamponade occurs when the pericardium is
filled with blood from the heart, great vessels, or pericar-
Flail Chest dial vessels. This injury is a direct result of blunt or pen-
Flail chest occurs when a disruption of the bony integrity etrating trauma. A small amount of blood is required to
of the chest is present. A flail chest is a result of multiple fill the pericardial sac, causing restriction of cardiac activ-
rib fractures. These fractures present at multiple sites ity and filling. Signs of cardiac tamponade include the
along the rib, creating an unstable fragment of chest classic Beck triad, comprised of venous pressure eleva-
wall. This fragment moves paradoxically during respiration, decrease in arterial pressure, and muffled heart
tion, moving inward with inspiration and outward with tones. Pulseless electrical activity (PEA) is suggestive of
expiration. The mechanical effects of paradoxical move- cardiac tamponade. Diagnosis is established with the use
ment of the fragment and the pain associated with respi- of the echocardiogram, FAST, or pericardial window.
ration may lead to hypoxemia. A fractured rib can also Surgical intervention with rapid evacuation of pericar-
puncture the lung, causing pneumothorax and/or dial fluid is indicated for unstable patients who do not
hemothorax. Often, the problem that occurs with a flail respond to resuscitation measures and are suspected
chest is a contused lung. Initially, the contused lung may of having cardiac tamponade. Pericardiocentesis could
be asymptomatic, but later may interfere with gas be diagnostic and/or therapeutic in cases without an
exchange as fluid moves into the lung and decreases experienced surgeon available, but it would not be
compliance. In many cases, it is the contusion injury to definitive.
the lung in a flail chest that causes most of the hypoxia The secondary assessment of the trauma patient
and morbidity. Mortality rates in patients who sustain includes evaluation of an upright view chest radiograph
severe blunt injury to the chest remain high, at 12% to for the presence of air in the mediastinum or under the
50%.32 diaphragm, a widening of the mediastinum with a shift
A flail chest is apparent on visual inspection in an toward the midline, thoracic injuries and fractures with
unconscious patient. However, in the conscious patient, lung expansion, and the presence of fluid collection. In
the injury may not be as apparent because of splinting most cases, the multisystem-injured trauma patient will
of the chest wall by the patient. Because of the paradoxi- be immobilized on a backboard and a supine film can
cal movement of the chest wall fragment and the ensuing be substituted for an upright one. If suspicion of a chest
pain on respiration, movement of the thorax can be injury exists, a CT scan of the chest should also be
asymmetrical and uncoordinated, resulting in poor ven- obtained. An electrocardiogram (ECG), arterial blood
tilation. The area of the fractures can also be tender to gas analysis, hematocrit, and urinalysis should also be
palpation. obtained. Six potentially lethal injuries that should be
The management of flail chest injuries generally evaluated in the secondary assessment are pulmonary
involves three steps. The first stage involves stabilization contusion, aortic disruption, tracheobronchial disrup-
of the loose segment with an external splint. A sandbag, tion, esophageal disruption, traumatic diaphragmatic
rolled sheet, or IV fluid bag can be taped over the area hernia, and myocardial contusion.27
with paradoxical movement. This splinting of the frac- The treatment for pulmonary contusions with or
tured segment of chest wall allows for reduced without accompanying flail chest is the same. Pulmonary
contusions occur commonly with blunt chest trauma of a nasogastric tube—and becoming hypertensive until
because the capillary damage in the lungs results in inter- an aortic rupture can be ruled out by arteriography.
stitial and intra-alveolar edema and shunting. Pulmonary
contusions and adult respiratory distress syndrome Blunt Cardiac Injury
(ARDS) are the most common potentially lethal chest Blunt cardiac injury resulting from blunt trauma can
injuries seen in the United States. This is because result- cause cardiac chamber rupture, dissection of coronary
ing respiratory failure does not occur instantaneously, arteries, thrombosis, valvular disruption, and/or cardiac
but develops 24 to 72 hours after the initial injury. tamponade. In a conscious patient, this can manifest as
Patients with these injuries often complain of pain and chest discomfort presenting as a rib or sternum fracture
dyspnea. Their blood gas levels tend to deteriorate pro- contusion. Hypotension and dysrhythmias may be
gressively over the initial 48 to 72 hours because of the present. The implementation of FAST is of paramount
increasing edema developing in the alveoli. Chest x-rays importance in the diagnosis during the initial assess-
may demonstrate opacification developing in the involved ment. A two-dimensional echocardiogram will confirm
areas. Treatment for these conditions include adequate the diagnosis. Electrocardiographic changes are variable
ventilation of the lungs, chest physiotherapy, supplemen- and troponins are nonspecific.
tal oxygen, coughing with deep breathing, and nasotra-
cheal suction. If the patient should require ventilator
assistance, spontaneous ventilation with intermediate OTHER POTENTIALLY LIFE-THREATENING INJURIES
mechanical ventilation provides a much better ventilation- Traumatic Esophageal Rupture
perfusion ratio, better hemodynamics, and quicker Traumatic esophageal rupture occurs as a direct result of
weaning than pure assisted ventilation. The use of ste- penetrating trauma and, less frequently, blunt trauma.
roids to reduce inflammation is a controversial issue for This rupture occurs when gastric contents are forced into
these patients. the esophagus from a blow to the abdomen that pro-
duces a tear. Thus, the gastric contents leak into the
Tracheobronchial Tree Injury mediastinum, resulting in mediastinitis or pleural space
Tracheobronchial tree injury ensues when there is injury empyema. Treatment mandates a direct repair with wide
to the trachea or main bronchus. At times, this injury is drainage of the mediastinum and pleural space.
overlooked, resulting in death of the trauma patient. The
typical presentation is a patient with subcutaneous Traumatic Diaphragmatic Injury
emphysema, hemoptysis, or tension pneumothorax. Blunt trauma may result in large tears of the diaphragm,
If a pneumothorax continues to present an air leak, whereas penetrating trauma will produce small tears. It
tracheobronchial tree injury should be suspected and is usually missed in the x-rays. This injury is more common
immediate surgical consultation should be obtained. in the left than the right side. Treatment consists of direct
Intubation in these cases is difficult secondary to distor- repair.
tion of normal anatomy. In this situation, surgical inter-
vention should be immediately performed.
Damage to intrathoracic large arteries or veins via ABDOMINAL AND PELVIC TRAUMA
blunt or penetrating trauma is the most common cause Abdominal trauma and pelvic trauma include diaphragm
of sudden death after an MVA or a fall from a great injuries, duodenal injuries, genitourinary injuries,
height.33 The aortic root and descending aorta at the small bowel injuries, solid organ injuries, and pelvic
origin of the ductus arteriosus and diaphragm are fractures.
common sites of injury.
Complete rupture is fatal unless the surgical interven- Diaphragm Injuries
tion is performed within a few minutes. A small number Blunt tears occur more frequently in the left side in this
of patients, approximately 15% of those with thoracic type of injury. X-ray findings include blurring of the
aortic injuries, reach the hospital alive. It is not uncom- hemidiaphragm or hemithorax. As noted, these injuries
mon for the aortic intima and media to be fractured are often undiagnosed.
circumferentially, with only the adventitia and surround-
ing mediastinal tissue preventing fatal hemorrhage. Duodenal Injuries
Patients with this type of injury may appear clinically Duodenal injuries occur as a result of a direct blow to
stable; however, failure to recognize this vascular injury the abdomen. This trauma is often seen in unrestrained
leads to eventual death. The indicators found on chest drivers in MVAs or in bicycle riders who sustain a frontal
radiographs that are suggestive of thoracic vascular injury collision. X-ray films will show retroperitoneal gas or the
include a widened mediastinum, fractures of the first and gastric aspiration will show blood.
second ribs, obliteration of the aortic knob, deviation of
the trachea to the right, presence of a pleural cap, devia- Genitourinary Injuries
tion of the esophagus to the left, and downward displace- A traumatic impact to the back may result in renal
ment of the left mainstem bronchus. Patients with abdominal injuries. These may present with gross hema-
suspected aortic rupture on clinical or radiographic turia, microscopic hematuria in patients with penetrating
examination should have arteriography performed. It is abdominal wounds, and hypotension. In addition, ante-
imperative that the patient be restricted from excessive rior pelvic fractures are frequently correlated with ure-
coughing or gagging—as can occur with the placement thral injuries.
foreign debris, such as avulsed teeth or dentures. The

Small Bowel Injuries oral cavity and pharynx should be cleared of any debris
Small bowel injuries occur in the process of deceleration, or secretions using a large tonsillar suction. An oral
with tearing at a fixed point. Typically, these patients will airway assists with tongue position; however, care must
show ecchymosis in the lower abdomen resulting from always be taken to prevent manipulation of the neck and
the seat belt (seat belt sign). The presence of a distract- to provide for access to the oral cavity and dentition for
ing lumbar injury should suggest a small bowel injury. reduction and fixation of any fractures requiring some
period of intermaxillary fixation (IMF). Neither the pres-
Solid Organ Injuries ence of midface fractures nor cerebrospinal fluid (CSF)
Injuries to the liver and/or spleen could be present in rhinorrhea is a contraindication to nasal intubation. Nev-
an unstable patient. A laparotomy is indicated in patients ertheless, care should be taken to pass the tube along the
in whom injury to these organs is suspected, with evi- floor of the nose into the pharynx, and the tube should
dence of hemodynamic instability or shock. be visualized before intubation of the trachea.
A thorough physical examination should begin with
Pelvic Fractures an evaluation for soft tissue injury. Lacerations should be
Pelvic fractures are frequently the result of high-impact débrided. Vital structures, such as the facial nerve or
injuries sustained through MVAs (car, pedestrians) or parotid duct, should be carefully examined for signs of
motorcycle accidents associated with extensive blood disruption. Eyelids should be elevated to examine for
loss. Pelvic fractures coincide with peritoneal and retro- neurologic and possible ocular damage. The face should
peritoneal visceral and vascular injuries. Tears to the tho- be examined for asymmetry, discolorations, or swelling
racic aorta may be present. Simple immobilization with suggestive of bony or soft tissue injury. All bony land-
a sheet will decrease the pelvic volume. Rapid transporta- marks should be palpated for signs of crepitus, steps, or
tion to a trauma center is essential. other irregularities. Palpation should include the supra-
orbital, lateral, and infraorbital rims, malar eminences,
SPINE AND SPINAL TRAUMA zygomatic arches, nasal bones, maxilla, and mandible.
Spine and spinal injury should always be suspected in the Any steps or irregularities along the bony margin may be
trauma patient and special care should be implemented suggestive of a fracture. Paresthesia over the area of dis-
when transporting such individuals. These patients tribution of the trigeminal nerve is usually noted with
should be immobilized during transport. The transporta- fractures of the facial skeleton. An oral cavity examina-
tion board is to be removed as soon as possible to mini- tion should include an evaluation of lost teeth, lacera-
mize further damage, but only after injuries to the tions, and alterations in the occlusion. Teeth avulsed
cervical, thoracic, and lumbar spine have been ruled out. at the time of injury must be accounted for because
It is important to recognize the importance of removing the tooth may have been inadvertently aspirated or
the board in a timely manner and avoiding prolonged swallowed.
use. Shock patients have a reduced perfusion pressure. There should be a concomitant examination of the
Patients with spinal injuries and a potential neurologic neck for injury. Subcutaneous air may be visualized if
deficit in the autoregulation of blood pressure, as well as massive injury is present; if subtle, it may only be detected
those with loss of pain sensation, are at greater risk of by palpation. The presence of air in the soft tissue (tissue
developing sores. Ironically, however, these patients are emphysema) may be the result of tracheal damage. Any
more likely to spend more time on boards because of externally expanding edema or hematoma of the neck
complicated treatment plans.34 must be monitored closely. Continued expansion can
During the examination, neurologically intact patients lead to an airway compromise. Carotid pulses should be
who are alert and awake can be asked simple questions assessed bilaterally. Palpation of the thyroid cartilage
that may help expedite care to the target area of the should be performed to ascertain abnormalities in the
injury. The initial evaluation should be followed by lateral contour and midline position of the trachea.
cervical x-rays and chest and pelvic radiography. If a
patient is unconscious, a craniocervical 2-mm-thick CT EXTREMITIES AND FRACTURES
scan should be obtained. If this study is negative, mag- Hypovolemia caused by life-threatening blood loss can
netic resonance imaging (MRI) is the preferred study of be a result of pelvic fractures, fractures of the femur, and
choice for excluding instability.35 multiple fractures of other long bones—the primary site
of which may be difficult to determine. Blood loss of 1
MAXILLOFACIAL INJURIES to 5 liters can occur with closed fractures of the pelvis,
The involvement of a maxillofacial surgeon in the poly- femur fractures can sustain a loss of 1 to 4 liters of blood,
trauma patient is important. Early treatment of facial and arm fractures may induce losses of 0.5 to 1 liter of
injuries, whenever possible, will result in better func- blood from the vasculature. Some extremity injuries are
tional and esthetic outcomes.36 considered life-threatening when accompanied by com-
It is possible for maxillofacial injuries to result in plications associated with massive open fractures with a
airway compromise because of the following: (1) blood jagged dirty wound, bilateral femoral shaft fractures
and secretions; (2) mandibular fracture that allows the (open or closed), vascular injuries, with or without frac-
tongue to fall posteriorly against the posterior wall of the tures, proximal to the knee or elbow, crush injuries of
pharynx; (3) midface injury that causes the maxilla to fall the abdomen and pelvis, major pelvic fractures, and trau-
inferiorly and posteriorly into the nasopharynx; and (4) matic amputations of the arm or leg.27
The physical examination should include inspection of injury.38 Primary rigid fixation allows the patient to get
and palpation of the chest, abdomen, pelvis, and all four out of bed and assume the upright position, thus improv-
extremities. Areas of tenderness, discoloration, swelling, ing pulmonary and musculoskeletal function. Early
and deformity should be assessed and proper radio- mobilization, along with the use of mechanical ventila-
graphs obtained. All peripheral pulses should be exam- tion with PEEP, lowers the incidence of ARDS and remote
ined for evidence of vascular injury. The pulse rates organ failure.39
should be equal; any abnormality of distal pulse rates
suggests a vascular injury and requires additional explo-
ration. Doppler examination of the extremity is useful, INITIAL MANAGEMENT OF THE TRAUMA
but angiography is best for definitively evaluating a sus- PATIENT IN THE INTENSIVE CARE UNIT
pected vascular injury if the diagnosis is in doubt.27
Direct pressure can be used to control hemorrhage Trauma patients who are transferred to the ICU present
and fractures should be splinted as quickly as possible. with multiple challenges. They require immediate, thor-
Splints should include joints about and below the site of ough, and ongoing evaluation guided by but not limited
injury. A prompt orthopedic consultation needs be to the initial report by the emergency care clinician and/
obtained. or the trauma team’s initial evaluation.
Fat embolism syndrome is frequently associated with The concept of tertiary survey was introduced by
major long bone fractures, especially fractures of the Enderson et al. This occurs after the patient has been
femur, in which the patient will be stable for 24 to 48 stabilized. The patient is subsequently reevaluated to
hours and then develop progressive respiratory and CNS confirm the initial diagnosis and to determine whether
deterioration. Concomitant laboratory value changes there are any other injuries missed during the primary
include hypoxemia, thrombocytopenia, fat in the urine, and secondary surveys.40 These patients may be stable on
and a slight drop in the hemoglobin level. Fat enters the arrival, but continue to remain at risk for deterioration
venous sinusoids at the fractured site and becomes because of unrecognized injuries, initial surgical or
lodged in the lung alveoli. Fat embolism syndrome has medical management complications, unknown past
been reported to occur in 30% to 50% of major long medical history, and possible allergic reactions to essen-
bone and pelvic fractures. However, with current trends tial medications.
in the coordinated management of multiple-injured
patients, the incidence of fat embolism syndrome and INITIAL AND ONGOING ASSESSMENT
ARDS has decreased. Pelvic fracture treatment and expe- After receiving the transfer report for an incoming
ditious management of femoral shaft injuries account for trauma patient to the ICU, all members of the respon-
this reduction. The primary treatment is ventilator assis- sible health care team discuss the nature of the injuries,
tance. Steroid and aspirin therapy have been shown to patient’s past medical history (PMH), hemodynamic
be helpful, possibly because of a reduction of platelet status, and nature and timing of the surgical interven-
aggregation. tions performed by the field crew, emergency clinicians,
A better understanding of fluid and electrolyte therapy, or trauma surgeons for damage control.
early aggressive management of hemorrhagic shock, and The ICU team then quickly designs a protocol detail-
prompt surgical treatment are now possible. However, in ing immediate steps and accommodations. In addition,
the interest of acute resuscitation, orthopedic injuries they ascertain whether other specialists need to be
are often overlooked initially and are treated at a later involved and formulate a plan of care. Once the patient
date. When these injuries involve the spine, pelvis, or arrives at the ICU, an immediate and comprehensive
femur they necessitate immobilization of the patient for reassessment is performed in accordance with ATLS
the purpose of traction. In immobilized patients with guidelines.
unstable fractures, there is an increased morbidity caused
by respiratory failure or sepsis with related multiple Airway, Breathing, and Circulation
organ failure. If the severely injured patient with ortho- If the patient has been intubated, the position of the tube
pedic fractures survives the acute phase of treatment, the should be assessed clinically. This is accomplished by
ensuing regimen frequently follows a prolonged course verification of breath sounds bilaterally. Additionally, an
in the ICU. This phase leads to morbidity secondary to x-ray should be taken to ensure placement and rule out
decreased musculoskeletal function characterized by dislodgment during transport.
muscles wasting, stiff joints, and limb length loss. The Appropriate IV and arterial access are mandated to
reduction in musculoskeletal function is attributed to obtain blood gas samples and to accommodate rapid
delays in fracture stabilization and subsequent patient infusion in case of fluid resuscitation. A thorough neu-
immobilization. Studies have shown that early fracture rologic assessment should be conducted, along with
stabilization can significantly lower mortality, decrease documentation of the patient’s GCS score.
musculoskeletal morbidity, and decrease the cardiopul-
monary and metabolic consequences commonly associ- Obtaining Past Medical History
ated with polytrauma patient care.37 Trauma patients transferred to the ICU may be unable
Long bone fractures are a common cause of fat embo- to supply a detailed PMH, perhaps because of altered
lism syndrome and ARDS. Fat embolism syndrome can mental status or because they are intubated and sedated.
be prevented by operative fixation of long bone fractures The availability of family members is also unpredictable.
in patients with multiple injuries within the first few days ICU staff members are frequently confronted with these
situations. A patient’s social history, with possible sub- dations for transfer to the regular floor or the step-
stance abuse, is a vital piece of information in the man- down unit.
agement of withdrawal syndromes. It is estimated that • Follow-up on a secured airway or tracheotomy as
more than 30% of trauma patients present with ongoing needed and as recommended by the surgical team.
drug or alcohol dependence.
The ICU team needs to obtain a PMH for the trauma TYPES OF INTENSIVE CARE UNITS
patient so that they may better predict possible mortality An ICU is a specially staffed and equipped, separate, and
or morbidity outcomes. Studies have corroborated a self-contained area of a hospital dedicated to the man-
direct relationship between the number of underlying agement of patients with life-threatening illnesses, inju-
medical conditions that trauma patients have and the ries, and complications and monitoring of potentially
mortality rate. Furthermore, a rapid recovery following life-threatening conditions. It provides special expertise
surgical intervention can be negatively affected by the and facilities for the support of vital functions and uses
presence of chronic medical problems. the skills of medical, nursing, and other staff experi-
In the ICU, trauma patient status is continuously enced in the management of these problems.
updated and ongoing assessment is of paramount impor- In many units, ICU staffs are required to provide ser-
tance. The possibility of undiagnosed injuries (e.g., intra- vices outside the ICU such as emergency response (e.g.,
cranial hemorrhage, intra-abdominal injuries, iatrogenic rapid response team) and outreach services. Where
complications of procedures) or studies that patients applicable, the hospital must provide adequate resources
underwent during the initial management may require for these activities. Specialized types of ICUs include the
emergency procedures such as chest tube placement, following:
endotracheal intubation, emergency cricothyroidotomy, • Neonatal intensive care unit (NICU)
or tracheotomy. • Special care nursery (SCN)
The ICU team is constantly evaluating the treatment • Pediatric intensive care unit (PICU)
plan: • Psychiatric intensive care unit (PICU)
• The dynamics of reevaluation are accomplished • Coronary care unit(CCU)
through updating current studies, laboratory test • Cardiac surgery intensive care unit (CSICU)
results, and values reflecting the hemodynamic • Cardiovascular intensive care unit (CVICU)
status of the trauma patient. Accordingly, the rec- • Medical intensive care unit (MICU)
ommendations would be implemented to correct • Medical-surgical intensive care unit (MSICU)
and normalize the resulting values, with the goal • Surgical intensive care unit (SICU)
being to optimize the chemical and electrolyte • Overnight intensive recovery (OIR)
balance. • Neurotrauma intensive care unit (NICU)
• The surgical plan prepared by the various surgical • Neurointensive care unit (NICU)
teams involved in the management of the trauma • Burn wound intensive care unit (BWICU)
patient’s injuries should be discussed in terms of • Trauma intensive care unit (TICU)
keeping the NPO status and securing all surgical • Surgical trauma intensive care unit (STICU)
and anesthesia consents from the patient or family. • Trauma-neuro critical care (TNCC)
• The hemodynamic status is updated and any cor- • Respiratory intensive care unit (RICU)
rections needed are confirmed (e.g., fluid resusci- • Geriatric intensive care unit (GICU)
tation, blood or blood product transfusion). • Mobile intensive care unit (MICU)
• Initiation and follow-up of the secured airway or • Postanesthesia care unit (PACU)
tracheotomy are carried out as needed and per
recommendation by the surgical team. MECHANICAL VENTILATION
• Follow-up on studies or procedures ordered or A significant number of patients in the ICU will require
taken by different services is carried out and the some form of mechanical ventilator support. Mechanical
appropriate documentation is made. ventilation refers to the use of life support technology to
• Secure a safe and monitored patient transport for perform the work of breathing for patients who are
different studies or procedures, as required. unable to breathe effectively on their own. Patients
• Follow isolation protocol as recommended by infec- requiring mechanical ventilation include the following:
tious disease guidelines when indicated. 1. Trauma patients who have been intubated to secure
• Follow hospital guidelines in terms of restraints and the airway
one on one observation, as needed. 2. Critically ill patients with advanced and potentially
• Determine the necessary consults with different reversible respiratory failure because of pulmonary or
specialists or services and act on their recommen- nonpulmonary processes
dations in a timely manner. 3. Patients who are only temporarily unable to ventilate
• Carry out intensive maintenance of the IV or arte- adequately on their own following general anesthesia
rial lines, airway circuits, or ventilator, including 4. Patients who have chronic respiratory or neuromuscu-
ongoing blood gas testing, and make the appropri- lar disorders that may prevent them from breathing
ate changes to the existing settings, as needed. effectively without mechanical support.
• Continually assess and update the status of the A maxillofacial trauma patient with panfacial fractures
patient surgically, medically, hemodynamically, and will often be intubated during the perioperative period
neurologically and make appropriate recommen- and would therefore require admission to the SICU.
BOX 4-4 Common Misconceptions Regarding Weaning

BOX 4-3 Criteria for Intubation
from Ventilator Support
CLINICAL • The method of weaning determines the ability to wean.
• Shortened speech • The longer the duration of mechanical ventilation, the more
• Use of accessory muscles difficult to wean.
• Subjective air hunger • Diaphragm weakness is a common cause of failed wean
• Change in mental status attempts.
• Poor inspiratory force • Removal of the endotracheal tube reduces the work of
breathing.
LABORATORY*
• Pao2/Fio2 < 250
Data from Marino PL: The ICU book, ed 2, Philadelphia, 1998, Lippincott
• Paco2 > 50 mm Hg Williams & Wilkins.
• pH < 7.25
• RR > 35 breaths/min
• <−25cm H2O
• V E > 12 liter/min weaned. Regardless of the method used, most weaning
occurs in the same sequence. Initially, the Fio2 is reduced
*Although the decision to intubate should primarily be a clinical decision, to 40% or less and PEEP is reduced to its minimal value.
several laboratory values and pulmonary tests can help guide this
decision.
The rate is then reduced. If the rate is low and PS is
Data from Townsend CM, Mattox B, Evers M, Beauchamp D, editors: added, it should be weaned. During these alterations in
Sabiston textbook of surgery, ed 16, Philadelphia, 2001, WB Saunders. support, the patient is appropriately evaluated for
RR, Respiratory rate; VE , minute ventilation. changes in hemodynamics, oxygenation, and ventilation.
The patient should be awake, alert, and able to protect
his or her airway before extubation. This usually means
that sedation, which is frequently propofol (Diprivan)
Indications delivered by a pump, has been discontinued.
There are many algorithms that have been devised to aid If there is a concern about airway edema, as is common
the clinician when deciding to initiate mechanical venti- with some maxillofacial trauma patients, a cuff test should
lation. The following three rules can aid in the decision be performed. In this test, the patient is removed from
making process: the ventilator, the endotracheal tube cuff is deflated, and
1. The indication for intubation and mechanical ventila- it is verified that the patient can exchange air (inspira-
tion is “thinking of it.” There is often a tendency to tory and expiratory) around the occluded endotracheal
delay this form of therapy in the hope that it will not tube. Hemodynamic and metabolic stability should also
be necessary. It is important to note that elective intu- be verified before extubation. For many facial trauma
bation carries fewer risks to the patient than an emer- patients, it is prudent to have the necessary equipment
gent intubation. ready in case reintubation is required. This could include
2. Intubation is not an act of weakness. Physicians often wire cutters, equipment for a surgical airway, and possibly
believe that they must apologize on morning rounds a fiberoptic endoscope. Some clinicians will temporarily
when they have intubated a patient. However, no one remove a nasal endotracheal tube from the trachea and
should be faulted for securing an airway in a critically leave a portion in the nasopharynx. It will act as a nasal
ill patient. airway during the first several minutes as the clinician
3. Endotracheal tubes are not a disease and ventilators verifies that the patient has good control of the airway.
are not an addiction. Endotracheal tubes and ventila- If the patient maintains the airway, the tube is removed
tor support do not create a need for mechanical ven- completely. If the patient is not protecting the airway
tilation, but cardiopulmonary and neuromuscular despite a cuff test showing good air exchange, then the
diseases do.31 endotracheal tube is at the nasopharynx and can be
Airway protection in the form of endotracheal intuba- advanced into the trachea.
tion is common in many of the patients with whom an Bedside Weaning Parameters. The first step in this
oral and maxillofacial surgeon will be involved. This can phase is to identify which patients are candidates for
be lifesaving in the multisystem trauma patient with max- weaning. Patients should have an adequate blood gas
illofacial injuries. Other criteria for intubation are listed Fio2 of 0.5 or less and PEEP set at 5 cm H2O or less. After
in Box 4-3. this is verified, there are a number of parameters that
should be evaluated (Table 4-3). Although most of these
Weaning values are easily obtained, many have poor predictive
Weaning from mechanical ventilation generally refers to value for individual patients.32
the progressive reduction in mechanical support that is Two of the most predictive parameters include
delivered to a patient. The concept of weaning patients maximal inspiratory pressure and the frequency-to-vol-
from ventilator support has been dominated by numer- ume ratio. The respiratory therapist is frequently asked
ous misconceptions, some of which are listed in Box 4-4. to check weaning parameters in the ICU. These are
No single method of weaning has been proven to be obtained with patients who have had their level of seda-
better than others. Most agree that when a patient is tion weaned so that can cooperate and reduce the respi-
ready to wean from mechanical ventilation, they will be ratory effects of the sedation on their values.
NONRESPIRATORY ISSUES TO MONITOR IN

TABLE 4-3 Bedside Weaning Parameters
THE INTENSIVE CARE UNIT
Parameter Normal Range (Adult) Threshold for Weaning
Pao2/Fio2 >400 200
VASCULAR ACCESS
Tidal volume 5-7 mL/kg 5 mL/kg
Vascular access can essentially be divided into two broad
categories, peripheral and central venous access. Periph-
Respiratory 14-18/min <40/min
eral short-term catheters are safe for giving many IV
rate
medications (e.g., antibiotics), for providing mainte-
Minute 5-7 L/minute <10 L/min nance IV fluids, and for blood sampling for laboratory
ventilation tests. However, numerous fluids and medications (e.g.,
Vital 65-75 mL/kg 10 mL/kg hyperosmolar solutions, resuscitative drugs) cannot be
capacity given through peripheral catheters because of local and
Maximum >−90 cm H2O (female) −25 cm H2O venous irritation. Children who require long-term treat-
inspiratory >−120 cm H2O (male) ment (e.g., antibiotics), emergency medications (e.g.,
pressure inotropes, medications to manage cardiopulmonary
Respiratory <50/min/liter <100/min/liter arrest), chemotherapy, and total parenteral nutrition
rate/tidal (TPN) require central venous access.
volume General indications for central access include admin-
istration or facilitation of the following:
The maximum inspiratory pressure is calculated from • Total parenteral nutrition
the ventilator by having the patient maximally exhale • Chemotherapy
and then inhale maximally against a closed valve. A low • Venous access in chronically ill children who
maximum inspiratory pressure has more value in identi- require repeated venous punctures for blood sam-
fying which patients will fail to wean as opposed to a high pling and medication
maximum inspiratory pressure, which indicates that • Long-term antibiotics (e.g., >3 to 4 weeks)
weaning will be successful. • Emergency access (e.g., to manage cardiopulmo-
The frequency-to-volume ratio attempts to identify nary arrest or trauma)
patients who are breathing rapidly and in a shallow • Critical care monitoring (e.g., of pulmonary wedge
manner. This ratio is calculated by comparing the respi- pressure) and medications (e.g., inotropes)
ratory rate to the tidal volume. A value of less than 50
breaths/min/liter is normal. Patients who fail to wean
often have values greater than 100 breaths/min/liter. GASTROINTESTINAL STRESS
This ratio has a high predictive value for identifying ULCER PROPHYLAXIS
patients who will be able to wean. Physiologic stress associated with illness and hospitaliza-
Methods of Weaning. There are generally two types of tion is known to result in gastrointestinal ulceration,
methods for the withdrawal of ventilator support. One especially among the critically ill. The complication of
involves periods of time during which the patient is this stress-related mucosal disease can be prevented with
breathing spontaneously interspersed with periods of appropriate application of pharmacologic prophylaxis.
ventilator support. This method is often referred to as Gastrointestinal prophylaxis guidelines in the ICU are
T-piece weaning. The other type of weaning uses a important in the prevention of stress gastritis. The inci-
gradual withdrawal of ventilator support using IMV. dence of clinically significant bleeding in critically ill
T-Piece Weaning. As noted, this method of weaning patients is 2% to 15%. However, it is important to under-
has the patient breathing spontaneously for a period of stand the actual indications for prophylaxis.
time. It originally consisted of a piece of equipment that Most experienced clinicians believe that it should be
was shaped like a T that connected to the endotracheal limited to patients at high risk for stress-related mucosal
tube. It allowed inspiration of oxygen and outflow of diseases, which include the following conditions: mechan-
exhaled gases. Currently, most ventilators will allow the ical ventilation longer than 48 hours; coagulopathy;
patient to breath spontaneously without the need for a endoscopic or radiographic diagnosis of peptic ulcer
T-piece. When the spontaneous breathing takes place or gastritis; history of an upper gastrointestinal (GI)
with the ventilator, a minimum amount of pressure bleed less than 6 weeks prior to admission; significant
support is often added to overcome the resistance in the burns (>15% of total body surface area); traumatic brain
ventilator tubing. injury; and large doses of glucocorticoids (e.g., >50 mg
Intermittent Mandatory Ventilation Weaning. As noted, hydrocortisone/day).
IMV provides a set number of machine breaths per The commonly used GI prophylactic medications
minute and allows the patient to breathe spontaneously to prevent stress gastritis include antacids, sucralfate,
between machine breaths. The number of machine histamine-2 receptor antagonists (H2 blockers), and
breaths per minute can then be gradually decreased, proton pump inhibitors (PPIs). Cook et al, in a multi-
allowing the patient to support her or his pulmonary center, randomized, double-blind controlled trial, dem-
function with spontaneous breaths. A minimal amount onstrated that H2 blockers (ranitidine) compared with
of pressure support is usually added for the same reason sucralfate decreased clinically significant bleeding, with
as mentioned for T-piece weaning. no difference in ventilator-associated pneumonia.
VENOUS THROMBOEMBOLISM PROPHYLAXIS ENTERAL NUTRITION

Until the 1990s, venous thromboembolism (VTE) was Enteral nutrition in the trauma patient is recommended
viewed primarily as a complication of hospitalization for to be initiated as early as feasible in recently published
major surgery, or associated with the late stage of termi- practice guidelines. The provision of enteral nutrition
nal illness. However, recent trials in patients hospitalized for the critically ill patient preserves physical barrier gut
with a wide variety of acute medical illnesses have dem- function. The host defense function of the intestine
onstrated a risk of VTE in medical patients comparable reduces the translocation of bacteria from the gut to the
with that seen after major general surgery. In addition, bloodstream and thus decreases the possibility of a sys-
epidemiologic studies have shown that between 25% and temic infectious complication. There is a significant
50% of all clinically recognized symptomatic VTEs occur reduction in mortality when enteral nutrition is provided
in individuals who are neither hospitalized nor recover- within 24 hours.41
ing from a major illness. This expanding understanding
of the population at risk challenges physicians to examine ELECTROLYTE MANAGEMENT
risk factors for VTE carefully to identify high-risk patients Daily monitoring of electrolyte levels is mandatory in the
who could benefit from prophylaxis. ICU setting. Electrolyte imbalances may lead to instabil-
Isolated factors sufficient to prompt physicians to con- ity that could worsen the status of the trauma patient.
sider VTE prophylaxis include major surgery, multiple The electrolytes are usually checked before rounds in
trauma, hip fracture, or lower extremity paralysis caused educational institutions so that replacements could be
by spinal cord injury. Additional risk factors, such as done in a timely fashion. In some cases, electrolyte imbal-
previous VTE, increasing age, cardiac or respiratory ances are related to total body water. The following is a
failure, prolonged immobility, presence of central venous description of the most common situations.
lines, estrogens, and a number of inherited and acquired
hematologic conditions contribute to an increased risk Sodium
for VTE. These predisposing factors are seldom sufficient Hypernatremia. The normal serum sodium concentra-
by themselves to justify the use of prophylaxis. Neverthe- tion is 135 to 145 mEq/liter. Hypernatremia is a result of
less, individual risk factors, or combinations thereof, can a serum sodium level above 145 mEq/liter. This situation
have important implications for the type and duration of occurs in hypotonic fluid loss, defined as an increase in
appropriate prophylaxis and should be carefully reviewed the sodium concentration that occurs when there is a loss
to assess the overall risk of VTE in each patient. of water from a normal serum sodium level, or hyper-
A thrombus in the proximal deep venous system of tonic fluid gain in which there is an increase of the serum
the lower extremities is often silent until a clot is dis- sodium level along with an increase of water (Fig. 4-8).
lodged and sent toward the lungs. A thrombosis below To treat this, the extracellular volume must be deter-
the knee is not a common source of pulmonary mined based on invasive hemodynamic monitoring, if
emboli. The trauma patient carries an increased risk available, or clinical observation. The loss of fluid occurs
for a thromboembolism. Those at the highest risk are with loss of sodium, affecting the total body water. The
patients with a spinal cord injury, fractures of the lower loss of sodium predisposes the patient to hypovolemia
extremities or pelvis, and multisystem involvement. and hypertonicity.
These patients will often have a vascular injury, venous Low Extracellular Volume. All body fluids, with the
stasis, and a generalized hypercoagulable state. exception of small bowel and pancreatic secretions,
Depending on the level of risk, appropriate methods contain sodium. Hypernatremia with low extracellular
of prophylaxis intervention will include sequential volume occurs when there is hypotonic fluid loss—that
compression devices (SCDs), low dosage of heparin is, excessive diuresis and diarrhea. The major concern in
(5000 IU twice daily), low-molecular-weight heparin these cases is to maintain cardiac output by replacing
(enoxaparin, Lovenox; 30 mg SC twice daily) and a low volume. Treatment consists of rapid sodium deficit
dosage of coumadin. When anticoagulation is contrain- replacement and slow water replacement, maintaining
dicated, a nonpharmacologic intervention would be a intravascular volume and avoiding intracellular water
vena cava filter (e.g., Greenfield filter). Most ICUs have shift. This is of particular importance to avoid cerebral
protocols for screening lower extremities with ultra- edema. Once hypovolemia is corrected, the replacement
sound to detect venous thrombosis. Often, a combined of free water has to be accomplished. Free water deficits
venous compression ultrasound and Doppler ultra- have to be replaced slowly so that the sodium level
sound is performed (duplex scan). decreases no faster than 0.5 mEq/liter/hr.
The clinical manifestations of an acute pulmonary Normal Extracellular Volume. This condition occurs
embolism are varied and not very sensitive or specific. when there is a net loss of water as with diabetes insipidus,
The diagnostic tests of value include a ventilation- central or nephrogenic, or a loss of hypotonic fluids in the
perfusion scan, spiral chest CT, and pulmonary angiog- diuresis process. The diagnosis of diabetes insipidus is
raphy. The main treatment is heparinization. It is confirmed when there is failure of the urine osmolarity to
important for the oral and maxillofacial surgeon to main- increase more than 30 mOsm/liter in the first hours of
tain hypervigilance with respect to VTE when a trauma complete fluid restriction. The treatment is replacement
patient has had a prolonged stay in the ICU and is then with isotonic saline in a 1 : 1 ratio. The replacement is
transferred to the oral and maxillofacial surgery service done slowly, over 2 to 3 days, to prevent intracellular over-
to have facial fractures managed. hydration as can occur in cerebral edema.
FIGURE 4-8 Algorithm for diagnosing the

causes of hypernatremia. Na+, Sodium;
NaCl, sodium chloride; NaHCO3, sodium
bicarbonate; TBW, total body water; U,
urinary. (Adapted from American Association
of Critical Care Nursing, Carlson K: AACN
advanced critical care nursing, St. Louis,
2009, WB Saunders, Elsevier.)
In central diabetes insipidus, administration of vaso- Hypotonic Hyponatremia. Hypotonic hyponatremia is

pressin is indicated to prevent further free water losses. an increase of free water in relation to sodium in the
The usual dose is 2 to 5 units of subcutaneous aqueous extracellular fluids. In patients who present with this
vasopressin every 4 to 6 hours. The serum sodium level condition, there will be fluid losses in addition to hypo-
has to be aggressively monitored. tonic fluid replacement. Consequently, there will be a net
High Extracellular Volume. Nonketotic hyperglycemia sodium loss in relation to total free water.
is a generally uncommon voluminous state that occurs The urine sodium level concentration will help deter-
when there is a gain of hypertonic fluids via the admin- mine if the cause for the loss is renal or extrarenal. If the
istration of a hypertonic solution for resuscitation or urine sodium is more than 20 mEq/liter, it is renal; if less
sodium bicarbonate solution for metabolic acidosis. than 20 mEq/liter, it is extrarenal.
Treatment is with diuresis, which will induce sodium loss Renal losses are indicative of adrenal insufficiency and
in the urine. The urine volume loss is replaced with cerebral salt wasting syndrome. Extrarenal losses mani-
hypotonic fluids related to the urine. fest with symptoms of vomiting and diarrhea. Treatment
Hyponatremia. Hyponatremia manifests when serum is implemented with the administration of hypertonic
sodium levels of less than 135 mEq/liter are found in saline 3% in symptomatic patients and isotonic saline in
hospitalized patients with neurologic disorders, those asymptomatic patients
with AIDS and, less commonly, older and postoperative Isovolemic Hyponatremia. Isovolemic hyponatremia
patients. is hyponatremia with a small amount of gained water, as
Pseudohyponatremia. The traditional methods of in inappropriate release of antidiuretic hormone
measuring sodium levels use the aqueous and nonaque- (ADH). This excretion of ADH results in an inappropri-
ous phases of plasma. Sodium is only present in the ate urine concentration and urine osmolality above
aqueous phase of plasma; thus, the amount measured 100 mOsm/kg H2O with hypotonic plasma. Additional
will be lower than the measured level. Elevation of the medical conditions that can produce hyponatremia are
protein or lipid concentration will increase the volume excessive ingestion of water secondary to a psychogenic
of the nonaqueous phase of plasma, so the measured cause (polydipsia) and syndrome of inappropriate ADH
sodium level will be decreased. Pseudohyponatremia (SIADH), which occurs in patients with certain infec-
occurs as a result of this condition. There is, however, a tions and tumors. Treatment is the administration of
specific laboratory test (ion-specific electrode) that is hypertonic saline with furosemide diuresis in symptom-
conducted to measure the plasma sodium concentration atic patients and isotonic saline in asymptomatic
in pseudohyponatremia. patients.
Hypervolemic Hyponatremia. Hypervolemic hypona- replacement. If the potassium levels do not rise as
tremia is a direct result of an excess of sodium and water expected, the magnesium levels should be checked
when the amount of water gain exceeds the sodium gain. Hyperkalemia. Hyperkalemia occurs when the serum
Medical conditions associated with hypervolemic hypo- concentration level increases to more than 5.5 mEq/
natremia include heart failure, renal failure, and hepatic liter. Significant hyperkalemia can be life-threatening,
failure. The presence of sodium in the urine in the clini- with the most dangerous manifestation being slowing of
cal presentation may be misleading in patients for whom the electrical conduction of the heart. Initially, it will
diuretics are used. present as tall T waves in V2 and V3; as hyperkalemia
Treatment for these patient is diuresis induced by progresses, the PR segment lengthens, as well as the QRS
furosemide, with strictly monitored hypertonic saline segment, culminating in ventricular asystole.
levels. Treatment is determined by the extracellular It is important to distinguish hyperkalemia from pseu-
volume and neurologic status of the patient. A rapid cor- dohyperkalemia, in which traumatic hemolysis occurs
rection of the sodium level may lead to central pontine from venipuncture, potassium released from the muscles
myelinolysis, a condition that can lead to permanent distal to a tourniquet, or potassium released from cells
CNS damage or death. The recommended rate of rise in in a clot formation in the specimen. Hence, whenever
sodium plasma should be no more than 0.5 mEq/liter/ there is an asymptomatic patient, the test should be
hr and the final plasma concentration should not exceed repeated. Hyperkalemia could be caused by cellular
130 mEq/liter. The goal of replacement is 130 mEq/ potassium release or impaired renal excretion. A urine
liter. The formula for sodium replacement is as follows: potassium level higher than 30 mEq/liter suggests a tran-
scellular shift, whereas a potassium level lower than
Sodium deficit (mEq) = normal TBW × (130 − current 30 mEq/liter is more consistent with problems caused by
plasma sodium) × ( 32.8 ) impaired renal excretion.
Acidosis is related to hyperkalemia when associated
where TBW is total body water (in liters), 60% of the lean with renal failure and tubular acidosis. Renal failure
body weight in men (in kg) and 50% of the lean body occurs when the glomerular filtration rate falls below
weight in women (in kg). 10 mL/min or total urinary output is less than 1 liter/
day. Drugs associated with the impairment of renal excre-
Potassium tion of potassium by blocking the renin-angiotensin-aldo-
Potassium is the most important intracellular cation of sterone system include angiotensin-converting enzyme
the intracellular fluid. The normal serum potassium con- inhibitors, angiotensin receptor blockers, potassium-
centration is 3.5 to 5.5 mEq/liter. A total body potassium sparing diuretics, NSAIDs, heparin, trimethoprim-
deficit of 200 to 400 mEq will reduce the serum potas- sulfamethoxazole, and pentamidine.
sium by 1 mEq/liter; a potassium excess of 110 to Digitalis toxicity is related to hyperkalemia by the tran-
200 mEq will raise the concentration of serum potassium scellular potassium shift. In addition, rhabdomyolysis
by 1 mEq/liter. and acidosis with impaired renal function and massive
Hypokalemia. Hypokalemia is present when the potas- blood transfusions in shock patients contribute to
sium level falls below 3.5 mEq/liter. Severe hypokalemia hyperkalemia.
serum levels below 2.5 mEq/liter may present with muscle Treatment. This is guided by the level of potassium
weakness. Mild cases are asymptomatic. In 50% of these present.
cases, electrocardiographic changes may be present with 1. Electrocardiographic changes or potassium level more
U waves, flattening or inversion of T waves, and pro- than 7 mEq/liter:
longed T waves. Possible causes include the following: • Calcium gluconate 10%, 10 mL IV over 10 minutes,
1. Transcellular shift: Uptake of beta agonists (minimal repeat every 5 minutes; response lasts 20 to 30
effect), alkalosis, hypothermia, and insulin minutes; do not give bicarbonate after calcium.
2. Potassium depletion: Depletion secondary to renal or • Electrocardiographic changes and circulatory
extrarenal loss compromise—calcium chloride 10%, 10 mL over 3
Renal loss: The main cause of renal loss is diuretics, minutes (contains three times more calcium than
nasogastric tubes, alkalosis, and magnesium deple- calcium gluconate).
tion (impairs potassium absorption). 2. AV block refractory to calcium treatment:
Extrarenal potassium loss: The major cause is • 10 U of regular insulin in 500 mL of 20% dextrose;
diarrhea. infuse in 1 hour (should drop serum potassium by
Treatment. The health care provider must first stop 1 mEq/liter for 1 or 2 hours).
the condition that is causing the potassium shift and then Treatment includes transvenous pacemaker.
replace the potassium. The most common form is potas- 3. Digitalis toxicity:
sium chloride as fluid replacement (1 and 2 mEq/mL) • Magnesium sulfate, 2-g IV bolus; digitalis antibodies
in ampules containing 10 to 40 mEq of potassium; these if necessary (do not use calcium).
solutions are hyperosmotic and have to be diluted. 4. Postacute phase:
Potassium, 20 mEq, is usually added to 100 mL of iso- • Sodium polystyrene (Kayexalate), PO, 30 g in
tonic saline and is infused over a 1-hour period. The 50 mL of 20% sorbitol or rectal dose of 50 g in
maximum dose is 20 mEq/hr and a central line should 200 mL 20% sorbitol as retention enema; oral
be used because of the irritant properties of the solution. route is better tolerated; if renal failure is present,
Oral potassium administration is another form of hemodialysis is indicated.
100 mL of isotonic saline over 10 minutes, followed by

Magnesium an infusion of 1 to 2 mg of elemental calcium/kg/hr for
Magnesium is the second most abundant intracellular 6 to 12 hours.
cation and works as a cofactor for more than 300 enzyme Hypercalcemia. Hypercalcemia is present in cases of
reactions. The normal value for an average adult is 24 g hyperparathyroidism or malignancy; less common condi-
of magnesium. tions are immobilization, thyrotoxicosis, and some drugs
Magnesium deficiency is common in hospitalized (e.g., lithium, thiazide diuretics).
patients. It is frequently affiliated with other electrolyte Clinical manifestations of hypercalcemia include the
abnormalities of calcium and phosphate. Patients may following:
present with arrhythmias, with the most serious being 1. Gastrointestinal: Nausea, vomiting, ileus, constipa-
torsade de pointes. In addition, there are neurologic tion, pancreatitis
manifestations of altered mentation, seizures, tremor, and 2. Renal: Nephrocalcinosis, polyuria
progressive obtundation. Common causes of magnesium 3. Cardiovascular: Hypotension, hypovolemia, short-
deficiency include diuretic therapy, antibiotic therapy, ened QT interval
digitalis, epinephrine, alcoholism, secretory diarrhea, dia- 4. Neurologic: Confusion, altered mental status
betes mellitus, acute myocardial infarction, and the che- Treatment. If the patient is symptomatic or if the
motherapeutic agents cisplatin and cyclosporine, serum calcium level is higher than 14 mg/dL (ionized
Magnesium Replacement Therapy. Oral and parenteral calcium > 3.5 mg/dL), infuse IV fluids (saline) to restore
solutions are available. Parenteral solutions are pre- volume, correct hypovolemia, and induce calcium
ferred. The standard preparation is magnesium sulfate, excretion. This is followed by the administration of furo-
1 to 4 g IV, added to current bag, 100 mL over 2 to 3 semide (40 to 80 mg every 2 hours) to promote calcium
hours. A 50% sulfate solution has to be diluted to 10% elimination. For malignancy, calcitonin will prevent bone
or 20% for IV use because of its osmolality. Saline solu- resorption, with 4 U/kg given every 12 hours. Hydrocor-
tion should be used; calcium in Ringer’s solution will tisone is given in addition to calcitonin in a dosage
counteract magnesium. of 200 mg IV daily, divided in two or three doses.
Magnesium Excess. Magnesium excess presents with Dialysis is used for patients with hypercalcemia and renal
hyporeflexia, weakness, altered consciousness, bradycar- failure.
dia, respiratory failure, nausea and vomiting. AV blocks
with progressive cardiac arrest can occur with the eleva-
tion of serum magnesium levels. Causes: Exogenous Phosphorus
administration, rhabdomyolysis, adrenal insufficiency, Most of the body phosphorus is located in the skeleton
hemolysis, impaired renal function, hyperparathyroid- (85%); the rest is present as free phosphorus (15%). The
ism and lithium intoxication. To treat magnesium excess, normal values are 2.5 to 5.0 mg/dL.
give 10 mL of calcium gluconate 10% over 10 to 20 Hypophosphatemia. Causes include diabetic ketoacido-
minutes in 50 to 100 mL of dextrose 5% in water (D5W), sis, glucose loading, respiratory alkalosis, beta receptor
one ampule D50 with 5 to10 U of regular insulin IV, agonists, sepsis, and phosphate binding agents. Hypo-
furosemide 20 mg IV. phosphatemia may affect aerobic energy production and
present as muscle weakness. This occurs as a result of
impaired myocardial contractibility, reduced cardiac
DIALYSIS output, hemolytic anemia, and depletion of 2,3-
Calcium. Calcium is the most abundant electrolyte in diphosphoglycerate, which deviates the oxyhemoglobin
the body; 99% of the body’s calcium is stored in bones. dissociation curve to the left.
The calcium level in the body 9.0 to 10 mg/dL; the To treat severe hypophosphatemia without adverse
ionized calcium leve is 4.5 to 5.0 mg/dL. effects, with a phosphate level below 1 mg/dL, adminis-
Hypocalcemia. This is caused by magnesium depletion, ter Sodium Phosphate or Potassium Phosphate 0.6 mg/
sepsis, alkalosis, blood transfusions, renal failure, pancre- kg/hr IV. To treat hypophosphatemia with adverse
atitis and drugs such as aminoglycosides, cimetidine, and effects, with a phosphate level below 2 mg/dL, adminis-
heparin. ter Sodium Phosphate or Potassium Phosphate 0.9 mg/
Clinical manifestations of hypocalcemia include the kg/hr. Serum phosphate levels should be checked every
following: 6 hours.
1. Neuromuscular excitability (tetany, hyperreflexia, Hyperphosphatemia. Most cases of hyperphosphatemia
paresthesias, and seizures). Chvostek’s sign is non- are related to renal failure with impaired excretion or
specific and Trousseau’s sign is insensitive. release from widespread cell necrosis (rhabdomyolysis or
2. Cardiovascular manifestations. Hypotension, ven- tumor lysis). Clinical manifestations usually present with
tricular ectopic activity, decreased cardiac output; hypocalcemia and tetany as a consequence.
heart block, and ventricular tachycardia are seen in Treatment of hyperphosphatemia includes the
more severe hypocalcemia. following:
Treatment of hypocalcemia consists of identifying 1. Calcium acetate tablets (PhosLo) will raise the
and treating the cause first. For symptomatic hypocalce- serum calcium and lower serum phosphorus levels.
mia, infusion of calcium in a central vein is preferred. 2. Promote phosphorus binding in the GI tract with
However, with a peripheral vein, calcium gluconate is sucralfate or aluminum-containing acids.
administered; 200 mg of calcium is given as a bolus in 3. GI dialysis should be initiated.
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Effect of early operative stabilization of fractures. J Trauma 25:375,
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CHAPTER
Emergency Airway Management in the
5 Traumatized Patient
Alisha Moreno
| Jacob G. Calcei
| Michael P. Powers
OUTLINE
Systematic Approach to Airway Management Endotracheal Intubation
Initial Assessment: Recognition of Airway Obstruction and Adjuncts to Intubation
Breathing Surgical Airway
Airway Maneuvers and Adjuncts Pediatric Considerations
Bag-Valve-Mask Ventilation Anatomy
Adjuncts to Intubation Tips for Specific Intubation Procedures on Children
T
raumatic injuries to the head, neck, and maxillo- patient to facilitate a complete physical examination.5
facial structures can easily compromise an indi- This chapter focuses on the first two steps.
vidual’s ability to get oxygen to their lungs. If
oxygen is unable to reach the lungs and diffuse through
alveolar walls to be picked up by red blood cells, a number
of adverse consequences occur, ranging from loss of con- SYSTEMATIC APPROACH TO
sciousness to organ failure and eventual death. It is only AIRWAY MANAGEMENT
a matter of seconds to minutes before an individual loses
consciousness in the absence of oxygen. As a result, suc- The approach to airway management in the patient who
cessful trauma intervention consists of the ability to has suffered from trauma is as follows:
establish and maintain a patent airway, including proper 1. Initial assessment: Recognize airway obstruction.
ventilation, while avoiding aspiration. 2. Perform airway maneuvers, clear the airway, and repo-
Airway-related medical interventions have been docu- sition the patient
mented for centuries. The Bible contains references to 3. Use artificial airways, and perform bag-valve-mask
airway interventions dating back as far as 850 bc.1,2 More ventilation
recently, in 2007, the National Confidential Enquiry into 4. Perform endotracheal intubation.
Patient Outcome and Death published a report regard- 5. Create a surgical airway if unable to intubate.
ing trauma care in the United Kingdom. The study found Recognizing a patient in clear respiratory distress
that although 19.8% of patients presented noisy or requires little to no clinical medical experience. On the
blocked airways, the failed intubation rate for prehospi- other hand, it takes a greater degree of clinical experi-
tal intubations was 12%.3 Another study, from 2010, ence and knowledge to identify at risk patients prior to
focused on the airway management of combat-injured the onset of an airway problem. When possible, it is advis-
patients in Operation Iraqi Freedom. Although the effec- able to intervene before a major crisis occurs by anticipat-
tiveness of body armor has improved, the head and neck ing problems and taking action early. The stepwise
regions are often unprotected and susceptible to serious approach should be used as a general guideline and not
injury. The high-velocity, penetrating trauma associated as a rigid set of rules that cannot be modified. For
with war only adds to the difficulty of securing a patent example, there are times when an emergency cricothy-
airway in these patients. Of the 196 patients in the study, rotomy is indicated, before attempting earlier, futile
68% of them had potentially lifesaving airways placed.4 efforts.
This high percentage reinforces the priority of the airway
and the role of a head and neck or airway specialist in
times of trauma. INITIAL ASSESSMENT: RECOGNITION OF AIRWAY
Despite recent major medical advancements, the basic OBSTRUCTION AND BREATHING
priorities and principles of airway management remain The primary goal of the initial assessment is to determine
the same. The American College of Surgeons Advanced if the injuries sustained have compromised the airway
Trauma Life Support (ATLS) ABCDE mnemonic is and/or breathing in the patient (Figs. 5-1 and 5-2). A
as follows: A, airway maintenance with cervical spine failure to recognize the need for an airway or the inabil-
protection; B, breathing and ventilation; C, circulation ity to establish an airway can lead to death.6 Injuries that
with hemorrhage control; D, disability, the neurologic result from direct airway trauma are dynamic and require
status of the patient; and E, exposing or undressing the frequent reexamination (Tables 5-1 and 5-2). A standard
77
FIGURE 5-1 Airway anatomy. (From Chapleau W, Pons

P: Emergency medical technician, St. Louis, 2007,
Mosby/JEMS.)
TABLE 5-1 Causes of Airway Injury Specifically Related

to Maxillofacial Trauma
Unstable facial fractures Hemorrhage
Soft tissue swelling and edema Displacement of
larynx and trachea
Smoke inhalation Airway burns
Hematoma Head injury, reduced
consciousness
Aspiration caused by fractured teeth,
bone fragments, vomitus, blood,
debris, foreign body obstruction
Adapted from references 7, 8, and 9. FIGURE 5-2 Airway damaged by burns.
TABLE 5-2 Signs of Airway Compromise
Direct Indirect Developing

Dyspnea Tracheal deviation or other anatomic Nonsuperficial neck or face burns (see Fig. 5-2)
abnormality of larynx or trachea
Stridor Painful swallowing Severe bleeding in oropharynx or nasopharynx
Signs of bruising on neck because of Trismus Hematoma in neck or lower face
underlying laryngotracheal injury
Drooling Subcutaneous air in neck or upper chest
Hoarseness or other voice alterations
Sense of shortness of breath, despite adequate
oxygen saturation
Adapted from references 8 and 10.
Emergency Airway Management in the Traumatized Patient CHAPTER 5 79
“look, listen, and feel” approach is often used to identify M: Mallampati score. This assessment serves as a predic-
breathing difficulties. tor for difficult intubation. By estimating the space for
Look. Patients with a compromised airway tend to sit oral intubation, in addition to determining the mouth
upright because they do not tolerate the supine position opening and the size of the tongue, the Mallampati
well. A look of panic or terror may accompany obvious score gives clinicians another tool for assessing poten-
breathing irregularities such as gasping, retraction, tially difficult airways. There are four classes:
heaving, quick but shallow breaths, and large gulping • Class I: Clear visibility of tonsillar pillars, uvula, soft
breaths. Anxiety or agitation may be a sign of hypoxia and palate, and fauces
the patient should be treated as such until proven other- • Class II: Tongue obscures view of tonsillar pillars
wise. Obtundation, on the other hand, may be a sign of but soft palate, uvula, and fauces are visible
hypercapnia and the patient’s quality of air movement • Class III: Only soft palate and base of uvula visible
should be examined. The oropharynx should be inspected • Class IV: No soft palate visibility9,15
using a light source and tongue blade to evaluate injuries Classes I and II on the Mallampati spectrum should
and to clear the airway of blood, emesis, secretions, loose result in an easy laryngoscopy. Difficulty should be
teeth, bone fragments, or foreign bodies.6,11-13 expected with class III; the most extreme cases of difficult
Listen. A quick test of airway patency is to have the airways are class IV (Fig. 5-5).
patient describe the injury. If they are able to speak In cases of severe trauma or unconsciousness, when
clearly and coherently, in full and nonlabored sentences, the patient is unable to assist in the Mallampati assess-
the patient is unlikely to require immediate airway assis- ment, the clinician should use a laryngoscope blade or
tance. Chest sounds should be noted to determine the tongue blade and attempt to open the mouth and
quality of air flow. It should be assumed that an unre- examine the tongue-to-oropharynx ratio. If this test
sponsive patient has a compromised airway until proven shows a large tongue to oropharynx ratio, a difficult
otherwise. Obstruction of the airway causes noisy breath- laryngoscopy should be anticipated.9,15
ing such as stridor, gurgling, or wheezing. Foreign body O: Obstruction, obesity. An upper airway obstruction can
upper airway obstruction, secretions in the airway, soft block access to the airway and make it difficult to view
tissue damage, and respiratory tract irritation are all the glottis. In obese patients, the extra tissue layers in
potential causes of an obstructed airway.10,11,14 the upper airway make direct laryngoscopy more
Feel. It is of importance to feel for facial fractures, soft challenging.
tissue swelling, subcutaneous air in the neck, laryngeal N: Neck mobility. Because maxillofacial trauma patients
tenderness, and dental injuries during the primary assess- are assumed to have a cervical spine injury until oth-
ment. Additionally, all blunt trauma patients should be erwise cleared, the patient may not be able to main-
assumed to have a cervical spine injury until examina- tain the proper positioning for an intubation. If
tions show otherwise. In the absence of imaging studies, possible, patients are put in the sniffing position prior
a trauma patient can be cleared of a cervical spine injury to intubation. In cases of cervical spine immobiliza-
if they exhibit the following6,11: tion during intubation, the view of the glottis is limited.
• Neurologically intact Neck mobility is also limited in patients with severe
• Not under the influence of drugs rheumatoid arthritis and ankylosing spondylitis.
• Free of tenderness in posterior midline of cervical Beyond the LEMON test, other potentially difficult
spine situations include airway burns, notable facial trauma
• Free of distracting, painful injuries. with bleeding and swelling of the soft tissues, and patients
In cases in which the patient is neurologically unsta- with previously difficult intubations. Securing an airway
ble, the cervical spine must be immobilized until in trauma patients is vital and clinicians must anticipate
further examinations can clear the patient of such an these potentially complex scenarios before they occur to
injury.12 increase the chances of maintaining a successful airway.9,15
Assessing for Potentially Difficult Laryngoscopy AIRWAY MANEUVERS AND ADJUNCTS
The clinician must be able to quickly determine the poten- Basic Maneuvers
tial for a difficult airway in each patient before choosing Once it has been determined that an airway is obstructed
the best intubation method (Fig. 5-3). The inability to because of maxillofacial trauma, basic airway maneuvers
recognize general characteristics associated with a diffi- are used (Fig. 5-6). The most basic airway maneuvers are
cult airway can lead to a failed airway. The mnemonic the chin lift and jaw thrust. In the case of an unconscious
LEMON describes a series of physical evaluations that patient, these simple techniques may be enough to
assist in determining the difficulty of the airway9,15: restore the airway if the obstruction was caused by the
L: Look externally. What is the general impression of the tongue or relaxed upper airway muscles. Severe fractures
airway? Is there any unusual anatomy or facial trauma of the mandible can also cause the tongue to become
that should be considered? displaced posteriorly, leading to an obstructed airway.6,16,17
E: Evaluate (3-3-2 rule). Take note of the following mea- In a patient who has not been cleared of a cervical
surements: mouth opening, mandible size, and dis- spine injury, these maneuvers must be done without sig-
tance between the mentum and hyoid bond. If these nificant neck extension. The chin lift (Fig. 5-7) is per-
measurements are not represented in the 3-3-2 rela- formed to open up the hypopharynx. It is done with two
tionship (Box 5-1), the possibility for a difficult laryn- fingers under the point of the chin and jaw while the
goscopy remains (Fig. 5-4). soft tissue is lifted forward. The jaw thrust (Fig. 5-8) is
Auditory tube
Nasal cavities (eustachian tube)
Pharyngeal tonsil
(adenoids)
Oral cavity
Nasopharynx
Tongue
Lingual tonsil Palatine tonsil
Oropharynx
Laryngopharynx
Epiglottis
Larynx
Vocal cords Esophagus
Trachea
Thyroid
Epiglottis
False
vocal cord
Glottis
True
vocal cord
Thyroid cartilage
(Adam’s apple) C
Epiglottis
Trachea
Glottis
Inner lining
of trachea
FIGURE 5-3 Anatomy for direct laryngoscopy.
(From Herlihy B, Maebius N: The human body in
health and illness, Philadelphia, 2000, Saunders.) B D
BOX 5-1 3-3-2 Rule for Difficult Airway Assessment: LEMON Test
3—A normal* patient can open the mouth wide enough for three of his or her own fingers to fit between the incisors. This eases
airway access and facilitates the insertion of the laryngoscope and the view of the glottis.
3—A normal* patient can place three of his or her own fingers between the mentum and the neck-mandible junction near the hyoid
bone. This is an estimation of the volume of the submandibular space.
2—A normal* patient can place two fingers in the space between the superior notch of the thyroid cartilage and the neck-mandible
junction near the hyoid bone, also called the superior laryngeal notch. This identifies the location of the larynx in relation to the
base of the tongue. The positioning of the larynx is important in difficult airway assessment.
*A normal patient in this case signifies a person for whom a difficult laryngoscope is not expected.
Adapted from references 9 and 15.
A B
FIGURE 5-4 3-3-2 rule. A, Three fingers are placed along the floor of the mouth beginning at the mentum. B, Two fingers are placed in
the superior laryngeal notch.
Mallampati Classification
Class 1 Class 2 Class 3 Class 4
Class 1; soft palate, fauces, uvula, pillars

Class 2; soft palate, fauces, portion of uvula
Class 3; soft palate, base of uvula
Class 4; hard palate only FIGURE 5-5 Mallampati classifications.
Yes + potential C-spine injury:

No:
Chin lift and jaw thrust
Insert OPA
Avoid extention of head and neck
Yes + cleared of C-spine injury: Suction + assess Maintain temporary airway

Is the patient’s
Chin lift, jaw thrust and head tilt gag reflex: Active until more definitive airway
airway obstructed?
can be performed gag reflex? can be placed
No:
Yes:
Supply oxygen and
Insert NPA
regularly reassess
FIGURE 5-6 Basic maneuvers of initial airway management for maxillofacial trauma.
FIGURE 5-7 Chin lift, head tilt. (From Monahan F, Sands J, Neighbors M, et al: Phipps’ medical-surgical nursing, ed 8, St. Louis, 2007,
Mosby.)
performed with the physician behind the patient. The

knuckles of the index fingers are placed behind the
angle of the mandible on each side, and the physician’s
thumbs apply pressure on the cheek bones at the same
time that the jaw thrust lifts and displaces the mandible
forward. The jaw thrust without head extension is espe-
cially important in cases of suspected spinal injury.6,10,16,18
The chin lift and head tilt (see Fig. 5-7) can be per-
formed if the patient has been cleared of a cervical spine
injury. These can be done by grasping the mandible and
lifting up while rotating the occiput caudad.6
The suctioning of debris such as broken teeth or
bones, other foreign objects, or secretions should be
completed once the basic maneuvers have been per-
A formed. This is done carefully to avoid gagging a con-
scious patient, which could lead to vomiting and a more
serious situation. 10
Adjuncts
Oropharyngeal (Fig. 5-9) and nasopharyngeal airway
devices (Fig. 5-10) can be effective in temporarily main-
taining the airway in a patient, but these adjuncts are
not considered definitive airway management. Rather,
these devices are used until the patient is ready for
intubation.6,11
The oropharyngeal airway (OPA) should be used in a
patient who lacks an active gag reflex. In adult patients,
the size of the OPA is measured so that it reaches from
the mouth angle to the ear lobe. When placed in the
mouth, the OPA (Fig. 5-11; see Fig. 5-9) is inserted upside
B down and turned 180 degrees once it reaches the level
of the uvula (Table 5-3). This technique helps the device
FIGURE 5-8 Jaw thrust. (From Malamed SF: Medical emergencies to push the tongue down anteriorly and away from the
in the dental office, ed 6, St. Louis, 2007, Mosby.) posterior pharyngeal wall. It should be emphasized that
TABLE 5-3 Technique for Placement of

Oropharyngeal Airway
Step Instructions
1 Use suction to clear mouth of secretions and
assess gag reflex; if no gag reflex present, then
continue.
2 Select OPA size; OPA should be measured so that
it stretches from the corner of the mouth to the
angle of the mandible.
3 Insert device upside down so that it curves
upward.
4 Rotate OPA into proper position so that tongue is
FIGURE 5-9 Oropharyngeal airway. (From Malamed SF: Medical pulled forward and away from pharynx.
emergencies in the dental office, ed 6, St. Louis, 2007, Mosby.) Adapted from references 6, 10, and 11 and American Heart Association:
ACLS advanced cardiovascular life support provider manual: Professional.
Chicago, 2011, American Heart Association.
TABLE 5-4 Technique for Placement of

Nasopharyngeal Airway
Step Instructions
1 Select NPA size.
2 Prepare NPA by applying lubricant with local
anesthetic.
3 Gently insert device while passing it along the
nasopharynx; slightly rotate NPA during
insertion if met with light resistance.
Adapted from references 10 and 11 and American Heart Association:
ACLS advanced cardiovascular life support provider manual: Professional.
Chicago, 2011, American Heart Association.
FIGURE 5-10 Nasopharyngeal airway. (From Stoy W, Platt T, the most critical part of the assessment is the presence
Lejeune D: Mosby’s EMT—basic textbook, ed 2, St. Louis, 2007, or absence of the gag reflex. If the reflex can be stimu-
Mosby.) lated, do not use the oropharyngeal airway.6,10,11,16
An alternative to the oropharyngeal airway is the naso-
pharyngeal airway (NPA). The NPA provides a passage
of airflow between the nares and pharynx and can be
used in patients who are conscious or semiconscious,
with an intact gag reflex (Table 5-4). The device is
prepped with lubricant, ideally one that contains a local
anesthetic agent, before it is placed in the larger nasal
passage. The length of the NPA should approximate the
distance between the end of the patient’s nose and the
ear lobe (Fig. 5-12). If there is slight resistance during
the insertion of the device, it should be rotated slightly
to allow it to pass down behind the tongue and into the
oropharynx. If there is stiff resistance during device
insertion, a smaller NPA should be selected to fit the
patient’s nasal passage better. Because of its small size, it
is not uncommon for the NPA to become obstructed.
Consequently, the airway should be regularly reevaluated
until an airway is definitively established.10,11,16
BAG-VALVE-MASK VENTILATION
If other basic maneuvers and adjuncts are unsuccessful
FIGURE 5-11 Insertion of oropharyngeal airway (OPA). (From in maintaining a patent airway, bag-valve-mask (BVM)
Marshak AB: Emergency life support. In Wilkins RL, Stoller JK, ventilation is performed to achieve oxygenation and
Scanlan CL, editors: Egan’s fundamentals of respiratory care, ed ventilation for the patient.19 Bag-mask devices are the
8, St. Louis, 2003.) most common method of providing positive-pressure
FIGURE 5-14 Two-hand technique for BVM ventilation. (From

FIGURE 5-12 Inserted nasopharyngeal airway (NPA). (From
Thomsen T, Setnik G, editors: Procedures consult—emergency
McSwain N: The basic EMT: Comprehensive prehospital care, ed
medicine module, St. Louis, 2008, Elsevier.)
2, St. Louis, 2003, Mosby.)
partner, or as part of a three-person team. The preferred
method for BVM ventilation requires two people, and is
known as the two-hand or two-provider technique (Fig.
5-14). The patient is positioned so that the ear is in line
with the sternal notch.22 An OPA or NPA should already
be in place and the mask size should be chosen. A cor-
rectly sized mask fits just below the eyes, does not extend
past the chin, and completely covers the nose and
mouth.21 This allows the mask to create a good seal and
provide more effective ventilation. With two providers
present, one is responsible for delivering the bag ventila-
tions. According to the 2011 Advanced Cardiac Life
Support (ACLS) guidelines, this should be done at an
approximately 600-mL tidal volume to produce chest rise
over 1 second.16 Gastric inflation is one major risk of
BVM ventilation, but the established tidal volume of
600 mL minimizes this risk.23 The second provider should
FIGURE 5-13 Bag-valve-mask. (Courtesy Sedation Resource, Lone secure the mask on the patient’s face by creating a C
Oak, Texas.) shape with the thumb and index finger of each hand and
gently pressing down on the mask. By using the remain-
ing fingers to lift up on the mandible, the second pro-
ventilation16 (Fig. 5-13). The importance of this skill vider can simultaneously perform the chin lift and hold
cannot be understated. If done correctly, it can serve as the mask in place while the first provider delivers bag
a definitive airway in many cases. When comparing the ventilations. In rare cases in which a third provider is
survival rates of trauma patients who had prehospital available, they should supply cricoid pressure to avoid
endotracheal intubations to those who had BVM ventila- excess air in the esophagus and stomach while remaining
tions, it was found that there was no survival advantage aware of the potential for airway obstruction because of
to endotracheal intubations when the severity of their the cricoid pressure.11,21
injuries were taken into account.20 An alternative method for the two-hand technique
Basic airway adjuncts and maneuvers are often per- (Fig. 5-15) uses different hand positioning for the pro-
formed in conjunction with BVM ventilation to assist in vider responsible for securing the mask. Both thumbs
the maintenance of the airway. This includes the use of face away from the provider and run parallel to each
oropharyngeal and nasopharyngeal airways, along with other as the thenar eminences hold the mask against
the jaw thrust, chin lift, and head tilt techniques. The the patient’s face and the remaining fingers lift the
equipment needed for proper BVM ventilation includes mandible.19
the bag-valve device, masks of different sizes, oxygen When only one provider is available, the one-hand E-C
source, oxygen connector tubing, pulse oximeter, suction technique is used (Figs. 5-16 and 5-17). The thumb and
and vacuum power source, OPAs or NPAs, and water- index finger of the nondominant hand form a C shape
based lubricant.21 over the mask and apply pressure. The remaining fingers
There are three main techniques for BVM ventilation. lift up the mandible to perform the jaw thrust, creating
Ideally, three individuals should be assigned to this task. the E shape.19
Because this is not always feasible, it is imperative that The mnemonic MOANS is used to identify potential
providers are adept at completing this alone, with one difficulties with BVM ventilation (Box 5-2). It is not
FIGURE 5-15 Alternate two-hand technique for BVM ventilation.

(From Thomsen T, Setnik G, editors: Procedures consult—
emergency medicine module, St. Louis, 2008, Elsevier.)
FIGURE 5-17 One-hand E-C technique (top view). (From Malamed

SF: Sedation: A guide to patient management, ed 5, St. Louis,
2010, Mosby.)
BOX 5-2 MOANS Test for Difficult

Bag-Valve-Mask Ventilations
M: Mask seal—facial hair, abnormal facial anatomy, and
excessive bleeding or vomiting may lead to an ineffective
mask seal. A water-soluble lubricant can be used for
patients with facial hair to improve the seal.
O: Obstruction or obesity—an upper airway obstruction or a
BMI > 26 can lead to difficulty with BVM ventilation.
A: Age—patients older than 55 years, although not an exact
FIGURE 5-16 One-hand EC technique for BVM ventilation. (From age cutoff, tend to have less elasticity of the tissues and
Malamed SF: Sedation: A guide to patient management, ed 5, St. therefore are at higher risk for difficult BVM ventilation.
Louis, 2010, Mosby.) N: No teeth—teeth provide a natural framework for the mask
to rest against. If a patient wears dentures, they should be
left in during BVM ventilation to increase the chances for
success.
uncommon for providers to hyperventilate patients
S: Stiffness—this may be a sign of asthma, chronic obstruc-
during BVM ventilation and extra care should be taken
tive pulmonary disease (COPD), or pulmonary edema.
to avoid this whenever possible. The American Heart
Association cautions that the negative impacts of hyper- Adapted from references 9 and 15.
ventilation include increased intrathoracic pressure,
reduced venous return, diminished cardiac output, and
decreased coronary and cerebral perfusion.24 whether or not to place a definitive airway to avoid the
challenges of securing a crash airway.14
ENDOTRACHEAL INTUBATION There are four major questions outlining the decision
According to various studies, between 9% and 28% of to perform an intubation14:
trauma patients undergo tracheal intubation.25 Although 1. Is there a failure of airway maintenance or protec-
the exact percentage may be debatable, the failure to tion? A loss of airway reflexes, pooling secretions
secure a definitive airway in a trauma patient is undoubt- signifying the inability to swallow, and tolerance of
edly a major cause of preventable death.3 the placement of nasopharyngeal airway or oropha-
ryngeal airways indicate a patient’s inability to
Indications maintain and protect their airway.
A definitive airway consists of a cuffed tube that is secured 2. Is there a failure of oxygenation? This is illustrated
in the trachea.26 Table 5-5 provides a list of indications by clinical symptoms of cyanosis, obtundation, rest-
that a definitive airway should be promptly secured. Pro- lessness or agitation, and by low oxygen saturation
viders should err on the side of caution when deciding as measured by a pulse oximeter. A lack of oxygen
TABLE 5-5 Indications for Definitively Secured Airway Miller straight

blade
Apnea Glasgow Coma Scale score < 9
Sustained seizure activity Unstable midface trauma, Epiglottis
Vocal cords
maxillofacial fractures
Airway injury or obstruction Cardiac arrest
Persistent hypoxia (Spo2 < High aspiration risk, blood, Trachea
90%) vomit
Inability to obtain adequate Shock; systolic BP < 80 mm Hg
seal with facemask;
insufficient ventilation
Anticipation of impending Hypoventilation
airway compromise
Inability to maintain patent Severe hypoxemia
airway via other techniques A
Combative patient
Adapted from references 11, 12, 26, and 27.
Macintosh blade
can cause irreversible damage to human tissues in
only minutes.
Vallecula Vocal cords
3. Is there a failure of ventilation? This can be observed Epiglottis
through the patient’s mental status and observing
the patient’s respirations. The inability to release Trachea
carbon dioxide from the body adequately leads to
altered mental status and respiratory acidosis.
4. Is there an anticipated need for intubation? It is
absolutely imperative that providers assess the likely
progression of symptoms and anticipate impending
airway compromise whenever possible.14
Contraindications B
Because of the importance of securing an airway, there
FIGURE 5-18 The epiglottis (A) and vallecula (B) are important
are few contraindications to intubation.28 The only major landmarks when performing direct laryngoscopy. (From Stoy W,
contraindication to intubation is the ability to maintain Platt T, Lejeune D: Mosby’s EMT—basic textbook, ed 2,
a patent airway in a less invasive manner.11 If it is possible St. Louis, 2007, Mosby.)
to maintain a patent airway through basic adjuncts and
maneuvers, advanced airway measures should be avoided.
Possible cervical spine injury is not a contraindication for as needed. Overinflation (>30 mm Hg) of the cuff can
intubation; however, immobilization of the cervical spine cause mucosal necrosis and should be avoided.6
should be maintained throughout the procedure in cases The average man will tolerate an endotracheal tube
in which the patient’s spine has not been cleared of with an internal diameter of 7.5, 8.0, or 8.5 Fr. The
injury.28 There are several contraindications to specific average woman, however, requires a slightly smaller tube
types of intubation (see later). of 7.0 or 7.5 Fr in most cases. Tubes that are met with
resistance at the vocal cords should be substituted for a
Types of Endotracheal Tubes smaller one to prevent tracheal damage.6
Endotracheal tubes have many shapes and sizes. The dif-
ferences in shapes may vary slightly and should be Direct Laryngoscopy
selected based on the specific type of intubation. In A direct laryngoscopy is a procedure that uses a short
general, endotracheal tubes have the following charac- rigid instrument to deflect the tongue and jaw, allowing
teristics: two open ends, a 15-mm adapter for a bag-valve for a view of the larynx and the placement of a tube
or ventilator device, measurements on the side, a large within the trachea.30 The epiglottis and vallecula are
distal port and small side port to reduce chances for important anatomic landmarks to identify before per-
occlusion, and a low-pressure, high-volume cuff.11 The forming a laryngoscopy (Fig. 5-18; see Fig. 5-3). The
cuff is in place to secure a seal with the patient’s trachea, epiglottis, found at the base of the tongue, covers
helping minimize leakage during positive pressure venti- the underlying glottis; the vallecula is a cleft between the
lation. Additionally, the cuff centers the tube to avoid tongue and epiglottis.31
damaging any surrounding mucosa.29 The cuff can be To move forward with the procedure, it is important
safely inflated to 10 mL initially but this can be adjusted to have the proper equipment available and easily
morbidity in emergent situations or with cardiopulmo-

nary instability.31
If the patient has not been cleared of a cervical
spine injury, the spine must remain immobilized
throughout the procedure. The front of the neck collar
is often removed to improve the clinician’s view, but an
assistant must stabilize the neck manually. The inability
to position the patient may create a more difficult
laryngoscopy.11
In situations in which the patient is cleared of a cervi-
cal spine injury, he or she is placed in a supine position,
with an elevated head (5 to 7 cm) and flexion of the
neck, to align the pharyngeal and laryngeal axes. The
patient’s head is extended at the atlanto-occipital joint
so that the oral axis is in line with the other two31,34
(Fig. 5-20).
Technique of Direct Laryngoscopy: Cleared Cervical Spine.
The STOP MAID mnemonic device can be used as a
reminder about the steps and tools of intubations31:
S: Suction
T: Tools (e.g., blade, handle.)
O: Oxygen
FIGURE 5-19 Laryngoscope blades. The most common P: Positioning
laryngoscope blades are the Miller and Macintosh blades. A, M: Monitors (electrocardiogram [ECG], O2, CO2, blood
Miller no. 2. B, Miller no. 3. C, Macintosh no. 3. D, Macintosh no. pressure [BP])
4. (From Spiro S, Albert R, Jett J: Clinical respiratory medicine, ed A: Assessment, airway devices, assistant
3, St. Louis, 2009, Mosby.) I: IV access
D: Drugs
Direct laryngoscopy begins immediately after the initial
assessment is made. The assistant positions the patient’s
accessible. All equipment should be checked to avoid the body and opens her or his mouth while the clinician
use of any damaged parts. The necessary equipment grabs the laryngoscope in the left hand. The right hand
includes the following31: should be free to suction, manipulate the larynx, and
• Laryngoscope handle with various blades (Fig. 5-19) insert the endotracheal tube.34 The curved blade is then
• Endotracheal tubes of various sizes positioned along the right side of the tongue, displacing
• Stylet the tongue out of sight and to the left. This allows the
• Introducer epiglottis to come into view so that it can be lifted to
• Oropharyngeal and nasopharyngeal airways expose the glottis.32 The tongue and epiglottis are ele-
• Rescue airway devices—laryngeal mask airway, vated as the clinician pulls the left hand up and away
Combitube while keeping the elbow in close to the body. When the
• Monitors—blood pressure, heart, pulse oximeter, epiglottis is identified, the curved blade is advanced until
end-tidal carbon dioxide it reaches the vallecula.11 At this time, the endotracheal
• Esophageal detector tube is inserted, its placement is confirmed, and the tube
• Tape is secured in place.31 The straight blade is advanced in a
A laryngoscope blade has a light source attached and similar manner, but it can be advanced deeper into the
can be curved (Macintosh) or straight (Miller).11 If the hypopharynx and may be obscured by the tongue. A
straight blade is used, it should be inserted under the paraglossal technique can be performed with the straight
epiglottis so that the glottis becomes exposed. Alterna- blade to displace the tongue properly and create a better
tively, the curved blade should be placed into the val- view. For this technique, the blade is inserted between
lecula.32 The Macintosh blade tends to provide a better the tongue and lower right molars and advanced between
view in adult trauma cases.6 the tongue and tonsillar pillar until the epiglottis can be
Positioning. The positioning of the patient is critical seen. At this point, the tongue is displaced laterally and
during direct laryngoscopy. In a recent study, 10% of the anteriorly.
3400 emergent intubations performed were classified as
difficult because they required multiple attempts.33 Confirming Tube Placement
Proper positioning gives the clinician the best chance of Proper endotracheal tube (ETT) placement can be con-
success on the initial attempt. Experienced clinicians firmed clinically by visualization of the tube passing
should expect to be successful on the first attempt in through the vocal cords, observation and auscultation of
most cases. However, in difficult airways, multiple the chest, and condensation in the ETT from exhala-
attempts may be required before the intubation is com- tion.35 In many cases, this is not possible or there may be
pleted. Multiple intubation attempts should be avoided, false results, so other methods must be used. The gold
when possible, because they are associated with increased standard for verifying proper ETT placement is
FIGURE 5-20 Positioning during laryngoscopy with cleared C-spine. (From Spiro S, Albert R, Jett J: Clinical respiratory medicine, ed 3, St.
Louis, 2009, Mosby.)
capnometry, which measures exhaled CO2 from the tube. for the confirmation of proper ETT placement.37 Ulti-
When the ETT is positioned in the trachea, the carbon mately, confirmation of proper ETT placement should
dioxide levels should not drop significantly over time. If be done using a number of methods to be sure of the
positioned in the esophagus, however, these levels will results.
drop continuously to near zero. False-positives can occur
if the patient has recently ingested a carbonated bever- Nasotracheal Intubation
age, causing carbon dioxide levels in the stomach to be In most cases of maxillofacial trauma, nasotracheal intu-
higher than normal.11An esophageal detection device bation is contraindicated because of the potential risk of
can also be used to verify the position of the ETT, brain injury. Fractures of the basilar skull and cribriform
although this device is not 100% accurate.36 plate are especially susceptible to this type of injury.39
Capnometry and esophageal detection devices provide Clinicians should also avoid this procedure with pediatric
information immediately, enabling the clinician to patients, and those showing signs of traumatic brain inju-
perform another intubation if the tube is placed into the ries or rising intracranial pressure.11 On the other hand,
esophagus by mistake.37 The use of an ETT introducer if difficulty is anticipated with other airway techniques,
also helps confirm proper placement of the ETT, because and if the clinician is experienced with this method,
the rings of the trachea can be felt as the introducer tip nasotracheal intubation should be considered. When a
is advanced. The introducer tip will also stop abruptly conscious patient needs airway intervention, nasotra-
once it reaches the bronchus. If the ETT is in the esopha- cheal intubation may be preferred because of the patient’s
gus instead, the tracheal rings will not be felt, and there active gag reflex. This technique places less pressure on
will be no abrupt stopping point.38 A chest x-ray provides the tongue and therefore leads to less gagging.32
a view of the depth of ETT placement, but is unable Properly sized nasotracheal tubes are 0.5 to 1.0 sizes
to differentiate between the esophagus and trachea.34 smaller than oral tubes. Other necessary materials
The ideal depth is 5 ± 2 cm above the tracheal carina35 include a topical vasoconstrictor anesthetic and fiberop-
(Fig. 5-21). tic bronchoscope, which is placed through the nasotra-
Although all these methods are acceptable, it is impor- cheal tube. The patient is put in the sniffing position with
tant to note that a physical examination is not sufficient immobilization measures taken in case of cervical spine
6. Placement
7. Postintubation Care
Preparation. All necessary personnel, equipment, and
medication should be ready on arrival of the patient. The
equipment should be inspected for integrity prior to
being used.
Preoxygenation. The patient is placed on 100% oxygen
through a rebreather mask for 3-5 minutes to create an
oxygen reservoir in the lungs prior to paralysis. This
helps KEEP the patient’s blood oxygen saturation from
dropping to dangerous levels (<90%) during the intuba-
tion procedure. If the patient does not respond to the
rebreather mask, a bag-valve mask device can be used
instead.40,41
Premedication and Induction. When time permits, it is
optimal to administer premedication to the trauma
patient prior to induction and intubation. These agents,
given approximately 3 minutes before induction, have
the ability to mitigate the physiologic responses associ-
ated with intubation.40 The mnemonic device LOAD is
used to identify the premedication step of RSI42:
L: Lidocaine
FIGURE 5-21 Endotracheal tube positioning. (From Bogdonoff DL: O: Opioids (typically fentanyl)
Airway considerations in the management of patients requiring A: Atropine
long-term endotracheal intubation. Anesth Analg 74:276, 1992.) D: Defasciculating agent (vecuronium, rocuronium)
Table 5-6 details the four components of premedica-
tion. Induction begins a few minutes after the premedi-
injury. The tube should be warm and lubricated before cation agents are administered. The induction agents
it is advanced into the larger naris along the nasal floor. have a sedative effect and are given prior to the paralytic
To minimize potential damage to the Kiesselbach plexus, agent. The five most common induction agents will be
the bevel of the tube should face the septum.34 The tube discussed, but only one should be given during RSI. The
is advanced past the vocal cords and eventually down into induction agent is selected based on patient-specific
the larynx on inspiration, where a cough indicates proper characteristics.42
placement. Slow and steady insertion of the broncho- Induction Agents
scope and nasotracheal tube, along with slight rotation Etomidate. In the case of maxillofacial trauma, etomi-
when needed, should be sufficient to overcome slight date is the most commonly used induction agent. This
resistance. As with other methods of intubation, if the hypnotic agent has a very short half-life (≈5 minutes)
tube is met with stiff resistance, the tube should not and is hemodynamically neutral. The proper dosage is
be forced any further. The procedure should then be 0.3 mg/kg IV for children and adults.43 However, because
attempted through the other side or a smaller sized tube of its short half-life, administration of etomidate is typi-
may be required. cally followed by another sedative agent, such as propofol
The ideal depth of placement for a nasotracheal tube or midazolam.6 The major drawback of etomidate is that
is 28 cm for men and 26 cm for women, as measured at it can cause adrenal suppression. It should not be used
the nares. As with orotracheal intubation, proper tube in patients suffering from septic shock.
placement should be confirmed. Vocal cord sounds of Ketamine. A dissociative anesthetic agent, ketamine is
any type signify a failed attempt at nasotracheal intuba- unique because of its amnestic effects in addition to its
tion, which may be modified by repositioning or rotating sedative and analgesic properties. It stimulates the car-
the tube.34 diovascular system and relaxes smooth muscle, making it
especially useful for patients suffering from hypotension
Rapid-Sequence Intubation or bronchospasms.11 The proper dosage is 1 to 2 mg/kg
The standard of care for securing an emergency airway IV or 3 to 4 mg/kg IM.6 The major drawback of ketamine
in semiconscious or conscious patients is rapid-sequence is increased intracranial pressure (ICP); therefore, it
intubation (RSI).38 The success rate of this procedure by should not be used in patients with traumatic brain
properly trained individuals is greater than 97%, accord- injury.42
ing to various studies.11 RSI uses sedation and paralysis Propofol. This hypnotic agent is a lipid-soluble, alkyl
to facilitate intubation and minimize potential risks. The phenol derivative, which causes sedation and amnesia.
steps of RSI are known as the seven Ps6: Propofol has a short half-life, reduces ICP, and has an
1. Preparation antiepileptic effect, making it a desirable induction
2. Preoxygenation agent. However, it is also a myocardial depressant and
3. Premedication and induction is associated with significant hypotension. The proper
4. Paralytic dosage is 1 to 2 mg/kg IV bolus for children and
5. Pressure (cricoid) adults.40
TABLE 5-6 Premedication for Rapid-Sequence Intubation
Drugs Dosage Effects Cautions

Lidocaine 1.5 mg/kg IV Suppresses airway reactivity; reduces intracranial Hypotension
pressure; reduces hypertensive response
Fentanyl 2-8 µg/kg IV Sedative and analgesic effects; reduces Patients with severe shock
intracranial pressure; hemodynamically Hypotension
nonreactive
Atropine 0.02 mg/kg IV, children Treats bradycardia and asystole; reduces Only for use in children up to age
0.5-1.0 mg, adults secretions 5 years
Or Adults with Bradycardia
Rocuronium 0.08-1.2 mg/kg Counteracts increase in ICP caused by High doses may result in paralytic
(10% of paralytic dosage) succinylcholine; prevents fasciculations effect (>0.06 mg/kg)
Adapted from references 40 and 41 and from Muskat PC: Emergency airway management in the traumatized patient. In Fonseca RJ, Turvey TA, Marciani
RD, editors: Oral and maxillofacial surgery, ed 2, St. Louis, 2008, WB Saunders, pp 25–34.
Midazolam. This benzodiazepine causes sedation and

amnesia, but also has antiepileptic properties. The BOX 5-3 Contraindications to Succinylcholine
proper dosage is 0.1 mg/kg IV, but it is typically under-
dosed as a precaution for its major drawback, hypoten- • Personal or family history of malignant hyperthermia
sion.40 The speed of onset varies by patient, but tends to • Denervation of muscles because of neuromuscular disease
be slower than etomidate. • Muscular dystrophy
Sodium Thiopental. An fast-acting barbiturate, sodium • Stroke (>72 hr old)
thiopental is known for causing deep amnesia and seda- • Rhabdomyolysis
tion, although it lacks analgesic characteristics. It is espe- • Burn (>72 hr old)
cially helpful for patients suffering from traumatic brain • Significant hyperkalemia
injuries because of its cerebroprotective properties.11
Drawbacks of sodium thiopental include inhibition of Adapted from references 40, 42, and 44.
the sympathetic central nervous system (CNS) response,
lack of availability, and hypotension. The proper dosage rocuronium. Similar to succinylcholine, rocuronium is
is 3 to 5 mg/kg IV in adults and 5 to 8 mg/kg IV in fast-acting and creates ideal intubation conditions, but its
children.41 paralytic effects last significantly longer. Although other
Paralytic Agents. To achieve optimal intubation condi- alternatives such as vecuronium and pancuronium exist,
tions, a paralytic agent is administered after the induc- rocuronium is the best alternative to succinylcholine.42
tion agent. Although the induction agent is a sedative The proper dosage is 1 mg/kg IV.
with analgesic and amnestic effects, the paralytic agent Cricoid Pressure. The literature exploring cricoid pres-
causes the relaxation of skeletal muscle. Through this sure and its role in RSI is inconclusive. Some sources
relaxation of the facial muscles, the clinician gets a better include it as a necessary step, whereas others point to a
view during laryngoscopy, which facilitates an easier intu- lack of definitive support and consider it optional.40
bation and reduces the chance of complications.42,44 When proper technique is not used, cricoid pressure can
Paralytics are known as neuromuscular blocking obscure the view of the glottis, impede passage of the
agents (NMBAs) and are classified in two distinct groups: ETT, and prevent adequate ventilation.38 On the other
1. Depolarizing—act on motor end-plate to activate hand, if it is done correctly, it can facilitate intubation
acetylcholine receptors and reduce potential complications.
2. Nondepolarizing—act on motor end-plate to Cricoid pressure (Sellick maneuver) is performed fol-
inhibit acetylcholine receptors lowing induction and is maintained until the ETT is
Succinylcholine. This depolarizing NMBA is the most properly placed.38 One assistant performs the Sellick
commonly used paralytic. It is fast-acting, in less than 1 maneuver by using the thumb and middle or index
minute, and has a short half-life. The use of paralytics finger to apply pressure to the cricoid cartilage. It is
leads to an apneic patient, emphasizing that they should performed after the anterior portion of the cervical
only be used under the administration of appropriately collar is removed while another assistant maintains cervi-
trained clinicians. The proper dosage is 1.5 to 2 mg/kg cal spine immobilization. There are three reasons to
IV.11 There are some major contraindications to the use apply cricoid pressure6:
of succinylcholine in RSI (Box 5-3). In the presence of 1. To avoid insufflation of the esophagus and stomach
any contraindications, the use of succinylcholine should during BVM ventilation, which reduces the risk of
be avoided. vomiting and passive regurgitation. If active vomit-
Rocuronium. When succinylcholine is contraindicated, ing occurs at any time, cricoid pressure should
a nondepolarizing NMBA is used instead. The most be immediately released to prevent a ruptured
common nondepolarizing NMBA used in RSI is esophagus.
2. To prevent passive regurgitation after induction Further treatment can be administered at this time,
and sedation agents are administered. because a patent airway has been secured.
3. To manipulate the larynx for optimal vocal cord
visualization and to improve the view of the glottis ADJUNCTS TO INTUBATION
through use of the BURP method (backward- When difficult laryngoscopy is expected, adjuncts to intu-
upward-rightward pressure). bation are used to facilitate easier placement of the
If the Sellick maneuver (Fig. 5-22) is performed, the ETT.31 The tracheal tube introducer, or gum elastic
assistant should be careful to avoid the common error of bougie (Fig. 5-24), is inexpensive and easy to use. This
applying pressure to the thyroid cartilage. plastic wand acts as a guide for the endotracheal tube. It
Placement of the Endotracheal Tube. The next step in is placed through the vocal cords during direct laryngos-
RSI is the placement of the ETT. This step is addressed copy. The insertion of the bougie is easier than place-
earlier in the chapter, where direct laryngoscopy is dis- ment of the ETT because of its smaller diameter.39
cussed in more detail. Introducer. Although it is contraindicated in the pres-
Postintubation Care and Management. Immediately after ence of maxillofacial trauma because of its blind inser-
placement of the ETT is confirmed, the tube should tion, the lighted stylet (Fig. 5-25) is another useful
be secured in place with tape (Fig. 5-23). If the Sellick adjunct to intubation. Unlike the bougie, the lighted
maneuver was performed, cricoid pressure can be stylet takes significant practice before mastery. Once mas-
stopped at this time. The cervical collar is put back in tered, the stylet has a high success rate.11 The advantage
place if it was taken apart at any stage of RSI. A chest of the lighted stylet is that it does not require direct
x-ray is obtained to verify proper ETT placement.38 laryngoscopy. The ETT fits over the stylet, which has a
bent, illuminated distal end. When properly positioned
in the trachea, the stylet illuminates the skin of the neck
just above the thyroid notch. If it is placed in the esopha-
gus, the light will not be visible.32
Rescue Airway Devices. The laryngeal mask airway
(LMA) consists of a curved tube and inflatable cuff. This
rescue device is used as a noninvasive way to provide
ventilation. Another version of this device, called the
LMA Fastrach, allows passage of an ETT blindly through
the cuff and into the trachea. The LMA Fastrach can
accommodate a no. 3 or 4 ETT for women and a no. 4
or 5 ETT for men.6
The LMA is easy to use and has few potential complica-
tions. Using the thumb and index finger, the LMA is
lubricated, placed into the mouth, and pressed against
the hard palate. The LMA follows the curvature of the
FIGURE 5-22 Sellick maneuver. The cricoid cartilage is identified by
palpation below the thyroid cartilage. Firm pressure is placed on
this structure to occlude the esophagus. Pressure is maintained
until after intubation; airway control is documented by auscultation
of the lung fields and end-tidal CO2. (From Spiro S, Albert R, Jett
J: Clinical respiratory medicine, ed 3, St. Louis, 2009, Mosby.)
FIGURE 5-23 Secure the ETT with tape. (From Perry A, Potter P:
Clinical nursing skills and techniques, ed 7, St. Louis, 2006, FIGURE 5-24 The tracheal tube introducer. (From Buck C:
Mosby.) Step-by-step medical coding St. Louis, 2009, WB Saunders.)
tongue to the back of the mouth and is advanced into so the Combitube can only be used on adults taller than
the oropharynx with the index finger. The device is then 5 feet. The Combitube consists of two cuffs; the larger,
pushed even further down the hypopharynx before the pharyngeal cuff seals the oronasopharynx and the distal
index finger is removed.32 Once in its final position, the cuff seals at the trachea or esophagus (Fig. 5-27). The
LMA cuff should be inflated to between 20 and 30-mL proximal cuff is sealed first, followed by the distal cuff.11
of air and secured in place6 (Fig. 5-26). It is important to The side holes on the tube aid in ventilation. Similar to
note that according to ATLS guidelines, the LMA is not the LMA, the Combitube is not considered a definitively
a secure airway device and does not protect the patient secure airway and is performed as a precursor to place-
against aspiration.11 ment of an ETT or tracheostomy.
The esophageal-tracheal Combitube (Kendall-
Sheridan, Argyle, NY) is another rescue airway device Alternative Intubation Techniques
that is used as a backup for failed intubation. It is a Fiberoptic-Assisted Intubation. This instrument is used
double-lumen tube that is usually reserved for emergent for difficult intubations, but may not be available in all
situations because of the potential for esophageal injury.39 emergency departments. Spontaneous breathing in the
The presence of supraglottic obstruction is an indication patient is an indication to try this method.10 A conscious
for use of this device; the Combitube is unique because patient can assist in the procedure by sticking out the
of its ability to provide ventilation from placement in the tongue to keep it out of the way. The fiberoptic scope is
esophagus or trachea.32 Limited device sizes are available, placed within the ETT before it is advanced into the
trachea.
Retrograde Intubation. A previous study has shown that
patients with maxillofacial fractures are successfully
managed at the trauma site during the first attempt at
retrograde intubation.10 This technique involves passing
a guidewire through a needle inserted into the larynx
and delivering that wire through the mouth or nose
to guide the endotracheal tube. Topical anesthesia is
applied to the oropharynx as lidocaine is injected at the
cricothyroid membrane and into the larynx. The guide-
wire is passed into the needle, back through the larynx,
and up into the oropharynx. Forceps are used to retrieve
the guidewire in the mouth. Finally, the ETT follows the
path of the guidewire into the trachea.32
Awake Laryngoscopy. If there is a risk of both aspira-
tion and a difficult airway, an awake laryngoscopy may be
performed. Some slight sedation is used to facilitate
patient cooperation by reducing their protective reflexes.
The necessary effect for successful laryngoscopy is
produced by 30 mg/kg of midazolam in addition to
1.5 mcg/kg of fentanyl .32 A topical anesthetic may also
aid in the facilitation of this procedure. Patients at risk
for an expanding hematoma would be candidates for an
FIGURE 5-25 The lighted stylet. (From Cote C, Lerman J, Todres awake laryngoscopy. Because the patient remains con-
ID: A practice of anesthesia for infants and children, ed 4, St. scious, it is important that the clinician explain the steps
Louis, 2009, Saunders.) of the procedure.
FIGURE 5-26 Insertion and proper placement of the laryngeal mask airway (LMA). A, Insertion of LMA. B, Proper location of LMA
(deflated). C, Properly placed and inflated LMA. (From Rothrock J: Alexander’s care of the patient in surgery, ed 13, St. Louis, 2007,
Mosby.)
breath. After removal of the tube, the mouth is suctioned

Extubation again and supplemental oxygen is administered. Imme-
Before the endotracheal tube is removed, the patient’s diately after extubation, the patient is monitored for
respiratory sufficiency is observed. If the inspiratory changes in vital signs. Positive-pressure ventilation may
capacity of the patient is measured at 15 mL/kg or be used as a method to prevent laryngospasms and respi-
greater, and the patient is able to protect his or her own ratory failure after extubation.45
airway, the clinician can continue with extubation.34
During this process, the patient is in an upright position Complications of Endotracheal Intubation
and the ETT and oral cavity are suctioned. The tube is The use of proper intubation techniques certainly mini-
removed in one smooth motion on exhalation of a deep mizes the number of complications. Complications may
arise from three distinct stages of the process—during
direct laryngoscopy and endotracheal intubation, while
the tube is in place, and postextubation.11 Table 5-7 orga-
nizes these complications by stage.
SURGICAL AIRWAY
Establishing a surgical airway can be a last resort in
response to failed intubation attempts for a critical
patient with a compromised airway. When intubation
fails, although the Combitube and laryngeal mask airway
have been used with positive outcomes, surgically estab-
lishing the airway remains the gold standard. In some
cases, a surgical airway is indicated prior to less invasive
techniques. Typically, these situations consist of extreme
facial trauma or a completely compromised airway,
because serious brain damage can occur in a short period
of time if the airway remains obstructed. When dealing
with a compromised airway, delaying treatment can result
in irreversible consequences. Therefore, avoiding delay
in establishing a patent airway is as important, if not
more so, than choosing which method or device to use
in the setting of a patient with a compromised airway.46
The three accepted methods of obtaining surgical
FIGURE 5-27 Esophageal-tracheal Combitube. The distal tube and airways in adults are needle cricothyrotomy and transla-
cuff can be placed into either the esophagus or trachea. The ryngeal jet ventilation, cricothyrotomy, and tracheos-
operator must quickly determine where the tip of the device is tomy. In an emergency situation, cricothyrotomy has
located to ventilate the correct airway tube. (From Roberts J, been shown to be faster and have lower morbidity and
Hedges J: Clinical procedures in emergency medicine, ed 5, mortality rates than tracheostomy, and is therefore indi-
St. Louis, 2010, Saunders.) cated over tracheostomy. Additionally, cricothyrotomy
TABLE 5-7 Complications of Intubation
During Laryngoscopy, Endotracheal Intubation While ETT is in Place After Extubation

Mucosal trauma Laryngeal edema Swallowing impairment
Dislocation of mandible Cuff leakage Infection
Dental trauma Tracheal mucosal damage Sinusitis
Esophageal Intubation Infection Laryngeal ulceration
Soft tissue perforation Obstruction of ETT Paralysis of vocal cords
Spinal cord injury caused by hyperextension Aspiration Pharyngitis, laryngitis, tracheitis
Induced vomiting Laryngeal granulomas Tracheal stenosis
Bronchial intubation Tube displacement Tracheoesophageal fistula
Vocal cord damage Vocal cord damage
Unable to intubate
Epiglottis fracture
Hemorrhage of airway
Hypertension, tachycardia, bradycardia, dysrhythmias
Adapted from references 11, 31, 34, and 37 and from Muskat PC: Emergency airway management in the traumatized patient. In Fonseca RJ, Turvey
TA, Marciani RD, editors: Oral and maxillofacial surgery, ed 2, St. Louis, 2008, WB Saunders, pp 25–34.
should be avoided in infants and approached cautiously [ID], 2.8 to1.5 mm) or a 6-Fr transtracheal catheter (ID,
in children younger than 10 to 12 years because of the 2mm) for adequate oxygenation and enough ventilation
small anatomy of the cricoid cartilage and the associated to delay acidosis. Infants and small children typically
high complication rates.47-49 require 16- to 18-gauge catheters. Needleless safety cath-
eters should be avoided because of their inability to
Needle Cricothyrotomy and Translaryngeal connect to a syringe.57
Jet Ventilation
History. In 1967, Sanders first described the percuta-
neous placement of a tracheal needle with jet ventilation. Superior
Spoerel et al and Klain and Smith (1977) described the thyroid
technique and indication for the procedure.50-52 artery
Indications. Endotracheal intubation is contraindi-
cated in certain situations, including severe hemorrhag-
ing of the airway, edema, and some facial fractures or
dislocations. In such cases, a needle cricothyrotomy
(Figs. 5-28 and 5-29) is a quick and useful technique that
provides oxygen on a short-term basis.53 This should only
be used temporarily until a definitive airway can be
secured.54,55 Extended use of this intervention will lead
to severely elevated CO2 levels, resulting in worsened
respiratory acidosis.56 Needle cricothyrotomy is quickly
performed and may oxygenate the patient for up to 45 Level of
minutes while the physician establishes a more stable vocal folds
airway.57 Needle cricothyrotomy and translaryngeal jet
ventilation are indicated over cricothyrotomy in pediat-
ric settings because of the smaller cricothyroid mem-
Cricothyroid
brane and narrow airway in children.47,49,58 artery
Technique. Needle cricothyrotomy consists of the
insertion of a catheter through the cricothyroid mem-
brane (see Figs. 5-28 and 5-29). The use of appropriate
equipment increases the efficacy of translaryngeal jet Cricothyroid
ventilation. There are catheter devices made specifically membrane
for this procedure, such as the emergency transtracheal
airway catheter (Cook, Bloomington, Ind). The major
benefit of using these specific devices is that they tend to
kink less frequently than standard angiocatheters, which FIGURE 5-28 Cricothyrotomy anatomy. (From Thurnher D,
may be used if the specific needle cricothyrotomy cath- Moukarbel RV, Novak CB, Gullane PJ: The glottis and subglottis:
eters are not available. Most adults require a 12- to An otolaryngologist’s perspective. Thorac Surg Clin 17:549,
16-gauge standard angiocatheter (internal diameter 2007.)
FIGURE 5-29 Needle cricothyrotomy. (From Custalow

CB: Color atlas of emergency department procedures,
Philadelphia, 2005, Elsevier Saunders.)
After identifying the relevant anatomic landmarks, the are barotrauma, subcutaneous emphysema, and pneu-
trachea is stabilized by the thumb and middle finger of mothorax. By securing the catheter in place for the dura-
the nondominant hand while the index finger locates the tion of the procedure, the risk of these complications can
cricothyroid membrane. The skin is anesthetized with be minimized. Subcutaneous emphysema is often the
1% lidocaine or a similar local anesthetic. A 10-mL result of a kinked catheter or multiple puncture sites.
syringe filled with 5-mL of saline is attached to the cath- The use of a specific needle cricothyrotomy catheter
eter and the needle is directed caudally at the inferior (kink-resistant) helps decrease the chance of subcutane-
aspect of the cricothyroid membrane. Ideally, the needle ous emphysema during or after the procedure. This com-
enters the skin at a 30- to 45-degree angle to the horizon- plication may be unavoidable if there is leakage at the
tal and avoids injury to the surrounding vessels. In cases original puncture site or if there is significant catheter
of severe laryngeal trauma, it may be necessary to use a movement during ventilation causing subcutaneous air
more distal tracheal puncture.11 Negative pressure is and swelling.11
applied to the syringe on insertion of the needle and Measures should be taken to avoid exceedingly high
continues throughout advancement of the catheter. pressures by adjusting the airflow, depending on the
The entrance of air bubbles into the syringe confirms apparatus used.66 Complete upper airway obstruction is
proper tracheal placement and the catheter is advanced a contraindication to needle cricothyrotomy. It can lead
until the hub reaches the level of the skin. Once the to an inability to expel gas from the trachea and may
catheter has been advanced, the needle and syringe are cause additional air leakage at the puncture site, as well
withdrawn.57,59,60 as increased pressure overall. Preventive measures
Because of the importance of proper placement, the should be taken to avoid excessive insufflation of oxygen,
syringe is reattached and aspirated to verify that the cath- minimizing the risk of pneumothorax.67 Some of the
eter remains in place after the removal of the needle. An less common complications of needle cricothyrotomy
oxygen source is connected to the catheter and oxygen and translaryngeal jet ventilation include infection,
is delivered at 50 psi, with a flow rate of 15 liters/min. damage to surrounding tissues and structures, and
Although some devices are specifically made for this pro- bleeding.57
cedure, there are numerous variations of a moonlighter’s Percutaneous Cricothyrotomy. Percutaneous cricothy-
device, used to connect the oxygen source to the catheter rotomy differs slightly from the traditional needle crico-
for translaryngeal jet ventilation. One simple variation thyrotomy. Many commercially made kits come with
includes oxygen tubing, a 3-mm endotracheal tube all the necessary equipment to perform the procedure
adapter, and a tracheal suction catheter vent.11 Ventila- including needles, catheters, syringes, no. 15 scalpel
tions occur through the port on the suction device at a blade, airway catheters of varying sizes, dilators, airway
ratio of 1-second insufflation for every 4 to 5 seconds of devices, flexible guidewire, and tracheal ties. It is impor-
exhalation. Although the ratio of 1 : 4 or 1 : 5 provides tant to note that some of these kits come with cuffed
sufficient oxygenation in many cases, it does not provide devices and others do not. Those kits containing uncuffed
adequate ventilation over time.60 devices do not provide definitive airway management.
Throughout the ventilation process, the catheter is The Melker emergency transcricothyrotomy catheter kit
manually secured in place until a definitive airway can (Cook) and the Pertrach kit (Pulmodyne, Indianapolis)
be maintained.57 It is important to note that because both contain cuffed devices.60
needle cricothyrotomy and translaryngeal jet ventilation The procedure for the percutaneous cricothyrotomy
only provide temporary airway control, a direct laryngos- begins just as the traditional needle cricothyrotomy does,
copy may be performed at any time. The air bubbles with the identification of anatomic landmarks, stabiliza-
within the trachea because of the translaryngeal jet vention of the trachea with the nondominant hand, and
tilation may serve as a helpful guide for laryngoscopy.11 insertion of the needle into the cricothyroid membrane.
The traditional method of direct puncture (Quick- If necessary, a no. 15 blade scalpel can be used to make
trach, VBM Medical, Sulz am Neckar, Germany), despite the initial cut, followed by placement of the catheter over
being a faster intervention, may involve more complica- the needle with the attached syringe. Negative pressure
tions than the wire-guided tube placement technique is kept on the syringe until proper placement is con-
(Melker set, Cook).61 Additionally, a combined cannula- firmed by the presence of air bubbles. The needle and
over-needle and wire-guided technique has been pro- syringe are removed and the Seldinger technique, or
posed.62 A recent study using a swine model has revealed placement of a guidewire through the catheter and into
the potential benefit of using an esophageal detector the trachea, is then used. The catheter is removed and
device to ensure proper IV catheter placement in needle extra care is taken to grasp the guidewire firmly so that
cricothyrotomies.63 Newer, more flexible techniques have it is not released into the airway. The dilator and airway
also been reported in the literature, including the use of device are placed over the guidewire and gently advanced
an apparatus constructed using IV line tubing that has into the trachea. Use of the dilator makes the opening
been executed successfully in emergency situations in larger for the catheter and device, leading to better
adult patients.64,65 Alternatively, the retrograde technique ventilation.60
of intubation can be attempted using the translaryngeal Despite their advantages on paper, some studies have
catheter, which can be carefully withdrawn and redi- suggested a higher complication rate and increased
rected rostrally while still in the trachea.11 placement times for percutaneous cricothyrotomy with
Complications. The most common complications of the kits when compared with the traditional surgical
needle cricothyrotomy and translaryngeal jet ventilation cricothyrotomy.68-79 The results of these studies have indi-
cated that there is no substitute for experience of tech-

nique and proper use of equipment. TABLE 5-8 Cricothyrotomy
Cricothyrotomy Indications Contraindications
History. The history of cricothyrotomy (also known as Maxillofacial trauma— Age < 11 yr
cricothyroidotomy) is complicated and somewhat obstructed airway
uncertain because of the numerous terms used to Oropharyngeal obstruction— Crushed larynx—may result in
describe this procedure. The similarities of tracheos- edema, infection, allergic tracheal separation because
tomy, tracheotomy, laryngotomy, high tracheostomy, reaction, heat injuries, foreign of direct trauma
and coniotomy make it difficult to differentiate between body, lesions, failed
the histories of each procedure in cases in which the intubation
medical literature did not specify the important ana- Unsuccessful tracheal Preexisting laryngeal or
tomic landmarks used. The first published descriptions intubation caused by tracheal pathology
of laryngotomy and cricothyrotomy occurred in the congenital malformations,
seventh century by Paul of Aegina and French surgeon hemorrhaging, vomiting,
Vicq d’ Azyr, respectively.80-82 The European diphtheria laryngospasms
epidemic in 1833 gave rise to the popularity of the high
Adapted from reference 11.
tracheostomy, although Bretonneau and Trosseau origi-
nally described the procedure as an incision through
the cricoid cartilage.80,81
In 1909, Chevalier Jackson first described the surgical
techniques of the cricothyrotomy, even though he also cricothyrotomy with translaryngeal jet ventilation is the
referred to the procedure as a high tracheostomy. In the preferred surgical airway method for children.5,49
early 1920s, Jackson had 200 patients develop tracheal Surgical Anatomy and Procedures. The cricothyroid
stenosis after the original procedure. When reviewed in space and its relevant anatomic landmarks can be identi-
further detail, it was found that 158 of the patients actu- fied visually and are palpable from the normal surface
ally had a high tracheostomy done, whereas the remain- anatomy. Inferior to the mandible, the hyoid bone is
ing 32 patients had true cricothyrotomies. In the located at the midline of the anterior neck and lies supe-
aftermath of these complications, Jackson decided that rior to the laryngeal prominence (Adam’s apple). The
cricothyrotomies were unsafe and should no longer be laryngeal prominence is located at the superior edge of
taught as a form of surgical airway management.11,83 the thyroid cartilage, which is 2 to 3 cm above the cricoid
In 1976, Brantigan and Grow published their findings cartilage.89 It is most clearly seen in thin men, and is less
of a study that included cricothyrotomy data from 655 likely to be visible or palpable in women, children, or
patients. Their results illustrated a low complication rate obese patients.90,91 The widest portion of the cricoid car-
of 6.1%, in addition to no cases of subglottic stenosis.52 tilage is found posteriorly.83 The cricothyroid membrane
In the years since they published their paper, numerous is found in the space just below the thyroid cartilage but
studies have supported their findings and provided vali- above the cricoid cartilage, and is also enclosed by the
dation that the cricothyrotomy is a safe and effective lateral cricothyroideus muscles on each side. This is the
emergency surgical airway method.54,56,68-70,84 The role of most important anatomic landmark because it is the loca-
the cricothyrotomy in elective airway management, tion of the cricothyrotomy. Typically, the cricothyroid
however, remains controversial.71-74,85 membrane measures between 2.7 and 3.2 cm wide and
Indications and Contraindications. Cricothyrotomy between 0.5 and 1.2 cm high (see Fig. 5-28).
(Table 5-8) is indicated in cases in which orotracheal and Depending on the patient and case specific circum-
nasotracheal intubation are unsuccessful. If a patient is stances, the procedure can be done under local or
unable to get oxygen through simple methods and also general anesthesia. The head and neck should be slightly
cannot be intubated, an airway device such as the LMA extended, unless a cervical spine injury is suspected or
may be used until the proper equipment and personnel has not been ruled out. When working on a conscious
are in place to perform a cricothyrotomy.86 In an emer- patient, a local anesthetic (1% lidocaine) is administered
gency medicine study that reviewed the most common to the skin and subcutaneous tissues after the anterior
conditions requiring cricothyrotomies, facial fractures neck is prepped with an antiseptic solution. The position-
were responsible for 32% of the cricothyrotomies per- ing of the surgeon is a key element in obtaining a suc-
formed and blood or emesis in the airway were respon- cessful surgical airway. A right-handed surgeon performs
sible for another 32%.87 Oral and maxillofacial trauma is the procedure by standing on the patient’s right side and
one of the most important indications for cricothyrot- a left-handed surgeon stands on the patient’s left side.83
omy.11 Trismus, which may occur during cardiac arrest, Using the same technique as in the needle cricothyrot-
is another indication for cricothyrotomy to maintain oxy- omy, the thumb and middle finger of the nondominant
genation and ventilation.88 Contraindications include hand are used to immobilize the larynx while the index
complete or partial transection of the airway, significant finger locates the cricothyroid membrane. Stabilization
injury to the cricoid cartilage, and a severely fractured of the larynx should be maintained at all times during
larynx.83 In young children, cricothyrotomy is contrain- the procedure.11
dicated because of the size of the cricothyroid membrane A 2-cm horizontal incision is made through the skin
and narrowing of the pediatric airway. As a result, needle and subcutaneous tissue. (There is some debate among
experts about the benefits of a 3- to 5-cm vertical midline 1. Palpate and identify the cricothyroid membrane.
incision. These benefits include easy extension of the 2. Using the no. 20 scalpel, make a 1- to 2-cm horizon-
incision if the initial cut is too high or too low, as well as tal incision through the skin, subcutaneous tissue,
the ability to avoid the vascular structures located along and cricothyroid membrane.
the lateral aspect of the structure.)* 3. Place the tracheal hook (before removing the
Regardless of the type of incision, care should be scalpel) and direct it inferiorly to provide caudal
taken to avoid damaging the surrounding vessels by traction.
making the incision just superior to the cricoid cartilage. 4. Insert the tracheostomy tube.83,103
The incision is carried down through the cricothyroid Based on the fewer number of steps used, the RFST is
membrane without going through the posterior wall of typically quicker than the traditional method, as con-
the airway, and is directed caudally to avoid the vocal firmed by a cadaver study.104 Although previous cadaver
cords. The nondominant index finger is used to hold the studies explored the potential increase in complications
incision open and to minimize the bleeding. A Trousseau for using the rapid technique, other clinical studies have
dilator or a large hemostat is inserted to spread the inci- suggested a higher complication rate associated with the
sion vertically. This increased opening in the cricothy- traditional technique based on retrospective data.105,106
roid membrane eases placement of the tracheal hook.95-97 For patients who have well-defined anatomic landmarks
In some cases, the scalpel may remain in the incision with little fat or inflammation, the RFST of cricothyrot-
until the tracheal hook is in place and can be used to omy is likely to be successful. However, in patients with
retract the thyroid cartilage superiorly and anteriorly. less obvious anatomic landmarks or significant swelling,
The cephalad traction on the thyroid cartilage against the traditional technique should be followed.11
the dilator stabilizes the airway and allows the surgeon to Similar to the rapid four-step technique is the recently
release the grasp of the larynx with their nondominant developed bougie-assisted cricothyrotomy technique.107
hand. A properly sized tracheostomy tube (no. 6 Shiley The major difference is the insertion of a bougie and
for average men, no. 4 for average women) is inserted endotracheal tube instead of a Shiley tracheostomy tube.
into the opening and advanced into the trachea. An ETT In animal studies, the bougie-assisted cricothyrotomy
can be placed if a tracheostomy tube is not immediately technique was demonstrated as a faster technique with
available.98,99 The efficacy of certain ballpoint pen tubes similar complication rates compared with the standard
to serve in place of a tracheostomy tube in emergency cricothyrotomy technique.108
out of hospital situations has been documented.100 When the patient is confined to a small area, the
The dilator and tracheal hook are carefully removed limited space may make an intervention difficult. A study
to avoid causing any damage. The obturator is then analyzing the execution of emergency cricothyrotomy in
removed before the inner cannula is inserted and the confined spaces has revealed that the medical residents
cuff or balloon of the tracheostomy tube is inflated. The preferred a particular kit, the Quicktrach kit (VBM
tube is attached to a bag-valve device or a mechanical Medical). The Quicktrach kit was placed correctly in the
ventilator and is secured with umbilical tape that is tied airway and had the fastest placement time because of the
around the neck before ventilation begins.60,83 Because quality and simplicity of the kit when compared with the
of the potential for the development of subcutaneous multipart Melker kit (Cook).109
emphysema and pneumomediastinum, especially during Complications. Complications of cricothyrotomy vary
mechanically supported respirations, the skin is not greatly depending on clinical circumstances—most
sutured as a method for securing the tube in place.11 notably, whether the procedure was elective or emergent.
Additional bleeding from the insertion site is not uncom- Typically, emergency cricothyrotomy has a higher
mon, and gentle pressure is applied to stop it. After the complication rate than elective cricothyrotomy. This is
cricothyrotomy is complete, a chest x-ray should be expected because patients who undergo emergency cri-
obtained to verify proper positioning of the tube and to cothyrotomy are often critically ill, have difficult airways,
exclude pneumothorax.99,101 and need to be oxygenated immediately. The higher
An analysis of different cricothyrotomy devices (cuffed: complication rate is acceptable in emergent cases because
Quicktrach II [VBM Medical], Portex cricothyroidotomy of the importance of securing an airway. Studies have
kit [Smiths Medical, Dublin, Ohio], Melker cuffed shown complication rates of up to 8% for cricothyrot-
cannula [Cook]; uncuffed: Airfree (VBM Medical), omy, although for emergency procedures, the rate is
4.0-mm ID Quicktrach, 6.0-mm ID Melker, 13-gauge between 28% and 32%.92,110,111 In these emergent cases,
Ravussin cannula [VBM Medical]) has demonstrated the poor outcomes are usually because of the original trauma
superiority of cuffed devices during controlled, manual, and not directly attributed to the cricothyrotomy. Another
and spontaneous ventilation.102 study, conducted in 2001, suggested a low rate of minor
The traditional cricothyrotomy procedures have been long-term complications.112 Complications from a crico-
described, but a simplified four-step technique can also thyrotomy can be divided into two groups, perioperative
be used. The only equipment needed for the rapid four- and postoperative.
step technique (RFST) is a no. 20 scalpel, hook, and Perioperative Complications. The most common peri-
tracheostomy tube. The procedural steps are as follows: operative complications include hemorrhage, improper
placement of the tube, and prolonged execution time.
Bleeding during the procedure is not usually severe, and
can be controlled by ligation, cautery, or packing with
*References 11,60,83,86,91-94. gauze. Clamping should be avoided, if possible, to protect
the surrounding structures. By correctly positioning the Galen, Antyllus, and Aretaeus wrote about the elective
patient, using adequate light and suction, selecting the tracheostomy during the second century ad.90,119-122
proper instruments, and placing the tube under direct Prior to the nineteenth century, the tracheostomy
visualization, the potential for complications caused by (laryngotomy or bronchotomy) was not often performed
improper tube placement can be minimized. This com- because of the belief that it was a dangerous and futile
plication occurred in 1.3% of elective cricothyrotomies procedure. The techniques of tracheostomy were first
and in 36% of emergent cricothyrotomies.11,98,99,113 described by Hieronymus Fabricius in 1617 and Habicot
Although an uncomplicated cricothyrotomy can be per- in 1620. Although Heister introduced the term tracheot-
formed in as few as 30 seconds, 3 minutes is the accept- omy in the early 1700s, Negus did not introduce the term
able standard of time for the procedure. Some of the tracheostomy until 1938; tracheostomy became an accept-
more severe complications are associated with longer able surgical technique in 1833 in response to the find-
procedure times and the airway should therefore be ings of Bretonneau and Trousseau.90,119-122 They found
secured as quickly and efficiently as possible.110 that tracheostomy was successful in treating the airway
Less common perioperative complications include obstruction of children suffering from diphtheria or
injury or laceration to the thyroid or cricoid cartilage, croup. From there, Chevalier Jackson increased the
injury to the esophagus or laryngeal nerve, pneumome- depth of understanding procedural techniques and
diastinum, perforation of the posterior trachea, and sub- complications through papers published in 1909 and
cutaneous emphysema.11,83 1921.123,124 As a more detailed understanding of trache-
Postoperative Complications. Postoperative complica- ostomy evolved, indications for its use increased.
tions of cricothyrotomy include hemorrhage, infection, Because of the safety, speed, and relative ease of RSI
aspiration, tube occlusion, paralysis of the vocal cords, by properly trained individuals, in addition to the choice
persistent stoma, dysphonia and hoarseness, and subglot- of needle or open cricothyrotomy as the preferred
tic stenosis. Infection is a rare complication of cricothy- surgical intervention when an emergency surgical
rotomy. In the report by Brantigan and Grow in the airway is indicated, tracheostomy has been relegated
1970s, only 3 of 655 patients studied experienced post- to limited use in emergency situations.47,125,126 However,
operative infections.92 Voice changes, including dyspho- a recent study by Bobek et al has revealed the use,
nia, hoarseness, and changes in pitch or volume, are safety, and efficacy of tracheotomies in elective, urgent,
some of the more common postoperative complications and emergent situations as an acceptable alternative
of cricothyrotomy. Some studies have shown that the rate to cricothyrotomy.127
of this complication is approximately 40%.110,112,114,115 In Indications and Contraindications. In general, the best
most cases, the voice changes correct themselves over results from tracheostomy occur when it is carefully per-
time, although a follow-up surgery to remove granulomas formed in the operating room. Tracheostomy in the con-
may be performed, if necessary, to correct any serious trolled environment of the operating room has been
complications.11 The most severe complication of crico- shown to have a complication rate of less than 3%.128 It
thyrotomy is subglottic stenosis, which is experienced is also important to note that early tracheostomy
by from 1.2% to 2.6% of patients according to various placement—within the first week of mechanical
studies. When compared with the subglottic stenosis ventilation—in the patient with an anticipated mechani-
complication rates of other surgical airway methods, cal ventilation time of longer than 10 days results in
such as tracheostomy (18% to 20%) or even long-term significantly less nosocomial pneumonia, decreases time
endotracheal intubation, these rates are extremely on mechanical ventilation, and shortens ICU stay.129-131
low.91,111,116,117 Postoperative stenosis caused by cricothy- However, studies focused on the timing of tracheostomy
rotomy is typically found at the cuff site or just inferior placement in relation to ICU survival rates have pro-
to the vocal cords. This condition can be treated with duced varying results.132-134 Hospitalized critically ill
steroids, chronic cannulation, dilation, surgical removal patients who received a tracheostomy had a lower mortal-
of granulation tissue, or tracheal resection. ity rate (13.7%) than those who did not (26.4%).135
Proper postoperative care, including the monitoring Needle or open cricothyrotomy remains the surgical pro-
of cuff pressure, is crucial for the prevention of second- cedure of choice in most emergency settings because it
ary complications. These complications may include tends to be less difficult and time-consuming and has
hemorrhage, tracheomalacia, and cellulitis.11 lower complication rates. However, in some rare situa-
Few deaths have been identified as a result of compli- tions, an emergency tracheostomy is the recommended
cations from cricothyrotomy. Of those published cases, or only course of action.111,114,118,136
the causes of death ranged from loss of airway during Blunt neck trauma, including laryngotracheal trauma,
surgery, to the inadvertent tube removal and inability to is the one condition for which a tracheostomy is the
reinsert due to tube occlusion, and asystole during tube undisputed method of establishing the airway. Although
change.98,99,110,118 this particular type of trauma is rare, usually occurring
in high-speed accidents when the anterior neck strikes a
Tracheostomy cord or rope, people who experience it are almost cer-
History. The tracheostomy is one of the oldest docu- tainly found in some form of respiratory distress.137 Dis-
mented surgical procedures, dating as far back as 2000 tortion of the larynx makes anatomic identification and
bc, when it was described in the Rig Veda, a sacred Hindu proper tube placement difficult in a cricothyrotomy.126,138
text. Information on the procedure was also found in Blunt neck trauma can also lead to fractures of the
Egyptian documents written more than 3500 years ago. thyroid or cricoid cartilage, vessel damage, or fracture of
the hyoid bone. These injuries may prevent access to

the cricothyroid membrane, making cricothyrotomy
difficult.
If endotracheal intubation or cricothyrotomy is per-
formed in the presence of a tracheal transection, there
is a chance that the trachea may retract into the medias-
tinum. To avoid this, a tracheostomy is indicated in the
presence of tracheal transection.139 Other indications for
tracheostomy include upper airway obstruction, need for
prolonged mechanical ventilation, complex facial frac-
tures, large or expanding neck hematomas, edema, deep
space neck infections, and lacerations to the floor of the
mouth.137,140 Attempts to establish an airway by cricothy-
rotomy through a hematoma could result in exsanguina-
tion. As a result, the airway must be accessed lower in the Thyroid cartilage
trachea, indicating tracheostomy.141 Because of improved
intubation techniques and use of the fiberoptic laryngo- Larynx
scope and bronchoscope, it has become less common to
use upper airway obstruction as an indication for Esophagus
tracheostomy.11
It should be reinforced that tracheostomy is contrain- Tracheostomy tube
dicated if an airway can be secured by any other method.
If endotracheal intubation fails or cannot be performed,
cricothyrotomy is the preferred surgical airway. The dif-
ficulty level, amount of time needed, and potential com-
plications are greater for tracheostomy than for other
FIGURE 5-30 Tracheostomy. (From Black JM, Hawks JH, Keene
definitive airways, emphasizing that this is the method of
AM: Medical-surgical nursing: Clinical management for positive
last resort.11
outcomes, ed 6, Philadelphia, 2001, WB Saunders.)
Surgical Anatomy and Procedures. To gain access to the
trachea, a thorough knowledge of neck anatomy is
needed to avoid unnecessary complications. Figures 5-30
and 5-31 (also see Figs. 5-3 and 5-28) present a variety of
neck anatomy illustrations. The hyoid bone attaches to
the base of the skull, tongue, and mandible by muscles. Internal carotid artery
It is the most stable portion of the airway and can be a
useful anatomic landmark throughout the procedure.137 External carotid artery
The thyroid cartilage is palpable superficially and supe- Carotid sinus
riorly. The cricothyroid membrane and cricoid cartilage External jugular vein
are identified inferior to the thyroid cartilage. Proceed- Hyoid bone
Common carotid artery
ing inferiorly, the tracheal rings are palpable initially, but Thyroid cartilage
palpation becomes increasingly difficult as the trachea Internal jugular vein
Cricoid cartilage
descends into the chest. The suprasternal or jugular Left subclavian artery
Thyroid gland
notch is the visible dip located where the neck and chest Left subclavian vein
come together. Once the trachea reaches this level, it is Trachea
1 to 1.5 cm deeper than the cricoid cartilage, emphasiz-
ing the technical expertise required to perform a trache-
ostomy safely.142 FIGURE 5-31 Neck vasculature. (From Seidel HM, Ball JW, Dains
The superficial layers are made up of skin and subcu- JE, et al: Mosby’s guide to physical examination, ed 6, St. Louis,
taneous tissue, followed by the investing fascia, which 2006, Mosby.)
above the sternum divides into two layers attached to the
anterior and posterior sternum, forming the suprasternal
space of Burns. Loose connective tissue and fat fill this beneath the infrahyoid fascia and muscles. The anterior
space, which also contains the anterior jugular veins and portion of the pretracheal fascia is thin; however, it is
their anastomosis—the jugular venous arch. Sometimes, thicker laterally as it blends with the carotid sheath. Pos-
the anterior jugular veins come together to form the teriorly, the fibroelastic wall of the trachea lies against
median jugular vein. The infrahyoid muscles and their the esophagus.11,143,144 The thyroid gland, which has a rich
fascia, found laterally to the midline, form the posterior blood supply, is difficult to avoid during tracheostomy
wall of the space of Burns. The infrahyoid muscles do because of its location directly anterior to the second,
not cross the midline, resulting in the formation of a third, and fourth tracheal rings.137 The complex neck
linea alba at the midline.11,143,144 vasculature is illustrated in Figure 5-31. Although the
The pretracheal fascia, which overlies the trachea with major blood vessels do not typically cross the midline of
its palpable rings, and the thyroid isthmus are located the neck, many of the major vessels anastomose anterior
to the thyroid gland. This plexus of veins includes the the superficial layer of the deep cervical fascia is
infrahyoid veins, which empty into the brachiocephalic identified.143,145,144
vein, the infrathyroid artery from the thyrocervical trunk, As the space of Burns is entered bluntly, the inferior
and the thyroid ima artery. The brachiocephalic and left thyroid veins are identified, clamped, and tied before
common carotid arteries are in the same layer inferiorly. cutting them to minimize bleeding. The infrahyoid
Although these arteries are not usually exposed in adults, fascia, which overlies the sternohyoid muscles, is bluntly
they can be exposed in children because their hearts and dissected through its linea alba. By vertically retracting
great vessels sit at a higher level.145 Ultrasound guidance the midline tissue away from the trachea, injury to major
may prove to be beneficial for the localization of anterior vessels, nerves, and glandular tissue can be avoided.
neck anatomy, especially the vasculature, in surgical Retraction and dissection now expose the pretracheal
tracheostomies.146 fascia and thyroid isthmus. The second through fourth
In preparation for the procedure, the skin incision tracheal rings are located underneath these structures.
should be marked while the patient’s head is in a normal Because of the richly vascular nature of this region, blunt
position. Marking the incision spot before extension of dissection is done to prevent significant hemorrhaging.
the neck should ensure that the incision is located in the The thyroid gland is retracted out of the field, exposing
proper tracheal opening. This also prevents skin irrita- the tracheal rings. If the thyroid isthmus cannot be
tion, skin tension against the tube, and dislodging of the retracted out of the field, it must be transected, which
tracheostomy tube. Unless contraindicated because of can be done by cutting the suspensory ligament. On each
potential cervical spine injury, a rolled towel is placed side of the midline, clamps are used and the isthmus is
under the patient’s neck and shoulders. Full extension cut and oversewn. At this point, the tracheal rings should
of the neck fixes the airway in position and enlarges the now be visible. The trachea has an external diameter of
surgical field.137,142 1.5 to 2.0 cm in the adult and 3 to 4 mm in the newborn.
Depending on the particular circumstances regarding It is composed of 16 to 20 hyaline cartilage rings and a
each individual patient, general or local anesthesia may fibroelastic tissue connects it posteriorly. The dissection
be necessary to establish the airway by tracheostomy. If a should be clear, making it easy to identify the cricoid
patient is hypoxic, uncooperative, or difficult to restrain, cartilage and the first four tracheal rings (see Fig.
a sedative medication may be indicated. The sedative of 5-30).11,137
choice is typically one that leaves the gag reflex intact, Although there are various techniques for surgical
preserves spontaneous respirations, and does not have entrance into the trachea, two principles must be fol-
extensive hemodynamic consequences. If a patient is lowed no matter which technique is used. First, the
conscious and cooperative, the procedure can be done cricoid cartilage and first tracheal ring must not be cut
under local anesthesia. The equipment should be or injured. Second, the incision into the trachea must
checked to ensure that all needed parts are available, stop at or above the fourth tracheal ring.11
properly sized, and working effectively. The average man A tracheostomy hook is placed just below the first
requires a no. 7 or 8 Shiley tracheal tube; the average tracheal ring. This acts to immobilize and elevate the
woman requires a no. 5 or 6 Shiley tracheal tube.137 trachea. The tracheal incision can be made by the follow-
Appropriately sized tracheostomy tubes are selected to ing techniques—U, inverted U, T flap, and cruciform. In
occupy from two thirds to three quarters of the tracheal emergent situations, a vertical midline incision between
lumen diameter.11 the second and fourth tracheal rings is recommended.
The neck is prepped with an antiseptic solution and a In nonemergent situations, the inverted U offers some
local anesthetic, such as 1% lidocaine, is injected into the distinct advantages; it prevents the cannula from being
incision site. Additionally, 2 mL of the local anesthetic is inserted anterior to the trachea, the patient can breathe
inserted into the cricothyroid membrane and injected more easily through the stoma if the cannula is lost in
into the trachea. This blunts the cough reflex. The airway the first few days, and changing of the cannula is facili-
should be stabilized with the nondominant hand, similar tated.148,149 A traction suture of 2-0 silk is placed through
to the procedure for the other surgical airways. Both the flap tip and inferior margin of the skin and is tied.
vertical and horizontal incisions can provide adequate This secures the position of the flap tip forward and
access to the airway. In an emergency tracheostomy, the down. Traction on the suture helps position the trachea
vertical incision maintains midline dissection and reduces and stoma anteriorly, leading to better visualization and
the potential for anatomic damage when the direction of access. The inverted U incision is made through the
the incision is changed.126 The 3- or 4-cm vertical incision second and third tracheal rings. Once the incision is
is made through the skin, subcutaneous tissue, and pla- made, a Trousseau dilator or Kelly hemostat is inserted
tysma muscle. It begins just below the cricoid cartilage and spread vertically. The tracheal lumen and an ETT, if
and extends to the suprasternal or supraclavicular notch. present, should be visible. The tracheostomy tube should
An incision that follows these landmarks will result in be inserted under direct vision once the Trousseau
proper placement over the second through fourth tra- dilator is in place. While the tracheostomy tube is
cheal rings.137,142,147 inserted, the ETT, if present, is carefully and slowly with-
In an elective tracheostomy, the horizontal incision is drawn to expose the tracheal lumen. The cuff and tip of
preferred for better cosmetic results. A 4- to 5-cm hori- the tube are advanced into position, just inferior to the
zontal incision is made approximately 2 cm below the vocal cords.11,137
cricoid cartilage. Like the vertical incision, it is carried Proper tube location and fit should be assessed and
through subcutaneous tissue and platysma muscle until the patient’s chest should be monitored for movement.
The cuff is then inflated and the skin can be left open artery. Other potential sources of hemorrhage are the
or loosely sutured. If the skin is sutured too tightly, sub- thyroid gland isthmus if it is improperly clamped, cut, or
cutaneous emphysema may result from not allowing air oversewn and the carotid sheath, found lateral to the
to escape during forced expiration or continuous positive- trachea, which contains the common carotid artery,
pressure ventilation.11 vagus nerve, and jugular veins. This location makes it
Once it has been determined that the tube is in the susceptible to injury by the scalpel if it is not properly
right location, a tracheostomy gauze dressing should be controlled, especially in infants.11 Approximately 5% of
placed under the tracheostomy tube phalanges and tracheostomy cases result in some form of hemorrhage.
around the cannula. The tube should be secured with It is important to recognize and treat hemorrhaging as
cloth tape tied around the patient’s neck to prevent inad- soon as it is discovered to avoid the more serious compli-
vertent extubation. Typically, a chest x-ray is obtained to cations associated with major bleeds or exsanguinations.
verify tube placement and to check for pneumothorax, If delayed hemorrhage presents itself during the postop-
a complication of special concern in the pediatric popu- erative period, it may be a sign of a major bleed.161,162
lation.101,141,150 In one 2012 study, however, Tobler et al Visible pulsation of the placed tracheostomy tube also
argued that there may be no benefit to obtaining a chest signifies a potential great vessel bleed.
x-ray unless clinically indicated.151 Regarding postoperative hemorrhages, most occur in
Complications. Although it was once a commonly used the first 2 to 4 weeks after the procedure. By the end of
surgical procedure, the historical results of complica- the third postoperative week, almost 72% of hemor-
tions caused by tracheostomy are not favorable. In fact, rhages that will develop have already occurred. In some
the literature has identified only 28 successful proce- rare cases, hemorrhage can occur months after the pro-
dures performed before 1825.152 Throughout the years, cedure in patients with long-existing tracheostomies and
advances in surgical technique, instrumentation, postop- a thoracic surgery consult is indicated.163
erative care, and surgical training have moved tracheos- Cases that involve a tracheostomy placed below the
tomy into the realm of an acceptable, predictable surgical third or fourth tracheal ring could lead to excessive cuff
procedure, especially in a controlled environment.11 or tube tip pressure. This can cause erosion of the trachea
Although recent advances have improved the postopera- or major vessels in the neck and mediastinum. Break-
tive outcomes of this procedure, complications following down of tissue barriers because of infection or inflamma-
tracheostomy still occur. Reports of the morbidity rate of tion can contribute to an environment in which a
tracheostomies range from 6% to 58%. Emergent proce- catastrophic bleed can occur. The innominate artery is
dures tend to have higher morbidity rates.137 located superior to the manubrium; formation of a tra-
Overall, the incidence of complications from trache- cheoinnominate artery fistula and subsequent hemor-
ostomy ranges from 2.7% to 48%.73,111 Rogers has rhage is a rare but serious complication.164 Jones et al163
reported rates of 9.6% and Chew and Cantrell have have conducted a review of 9415 tracheostomies and a
reported rates of 15.8% in larger sample sizes.153,154 One tracheoinnominate artery fistula occurred with an inci-
factor that greatly affects the morbidity incidence and dence of 0.6%. A surgically repaired fistula has a survival
severity of tracheostomy is the duration of tube place- rate of approximately 25%. However, if the fistula is not
ment. An increase in duration from 7 to 30 days causes operated on, there is almost a 100% mortality rate.154
an increase from 20% to 50%.155 Obesity is another factor Procedural interventions for tracheoinnominate artery
that increases the chances of tracheostomy complica- fistula include endovascular stenting and endovascular
tions.156 One study, which reviewed the frequency of com- embolization of the innominate artery.165,166
plications related to tracheostomy placement and If a major bleed occurs, overinflation of the tracheos-
management in morbidly obese (body mass index [BMI] tomy tube can tamponade the vessel until surgical control
> 40 kg/m2) patients to be 25% compared with non- can be achieved. This maneuver has been found to be
obese patients, at 14%.157 In general, the complications effective approximately 85% of the time. In cases in
for tracheostomy are similar to those associated with cri- which the originally placed tube was noncuffed, it must
cothyrotomy. Hemorrhage, pneumothorax, subcutane- be replaced with an ETT or cuffed tracheostomy tube. If
ous emphysema, pneumomediastinum, hypoxia through cuff pressure fails to slow the bleeding, digital comp
false passage, obstruction, and extubation are periopera- ression of the artery against the sternum should be
tive complications common to both procedures. Compli- attempted.163,167,168
cations specific to tracheostomy include recurrent Infection is the second most common complication of
laryngeal nerve injury, tracheoesophageal fistula, and tracheostomy. Potential postoperative infection includes
death. Postoperative complications caused by tracheos- surgical site infection, tracheitis, mediastinitis, and pneu-
tomy are also similar to those associated with cricothy- monia.137 Stomal infection can be caused by contami-
rotomy and include hypoxia, infection, hemorrhage, nants from the skin, nasopharynx, and oral cavity.
tracheal stenosis, tracheal erosion, tracheomalacia, and Mediastinitis is a more severe and devastating complica-
unsatisfactory cosmesis.11 tion; it occurs because the infection of the stoma travels
Of the perioperative complications listed, acute hem- into the chest. The pathogens most commonly isolated
orrhage is the most common complication because of from tracheostomy infections are Pseudomonas aeruginosa,
the rich vasculature of the neck, specifically the trache- Staphylococcus aureus, hemolytic streptococci, and
ostomy site.158,141,159,160 The vessels in this area include the Candida.154,155,159
anterior jugular veins and their midline anastomoses, Tracheal stenosis is one of the most common delayed
inferior thyroid plexus of veins, and superior thyroid complications of tracheostomy. Results about the rate of
occurrence for this complication vary greatly. Although Postoperative Care. The importance of proper after-
one study reported a 98% chance of stenosis, another care for tracheostomy patients should not be under-
study, which reviewed autopsy reports, showed a much stated. In the days and weeks following the procedure,
lower incidence rate of 65%.137,152,169 Stenosis is not con- numerous complications can potentially arise. Some of
sidered clinically significant until the normal adult those complications may be avoided with proper care.
trachea is compromised between 25% and 50%. System- Tracheal cannula occlusion caused by hemorrhage or
atic stenosis occurred in 2% to 20% of tracheostomy mucous secretions can lead to serious complications.
cases.160,170 With the help of clinical investigations and Regular monitoring and proper suctioning can reduce
experimental studies, the causes of stenosis have been the chances of this postoperative complication. “Trach
documented. One potential cause of the complication is care,” which describes the specific techniques for proper
cuff pressure that exceeds the mucosal capillary perfu- tube care, consists of tube aspirations and frequent suc-
sion pressure (≈30 mm Hg). This causes an interruption tioning in the days and weeks after surgery. If blood,
in the mucosal blood supply, leading to tissue death, mucus, or other secretions build up in the airway and
ulceration, resultant granulation tissue formation, and cause occlusion of the tube, the patient will lose the
scarring.11 Currently, the highest acceptable cuff pressure ability to breathe. If this is not immediately recognized,
is 20 to 30 mm Hg.171-173 Another possible contributing the consequences can be fatal.
factor to stenosis is the location of the incision. Cartilage To aspirate the tracheostomy tube effectively, it is rec-
loses its ability to regenerate after it becomes infected or ommended that that patient’s lungs be filled with 100%
is damaged because of ischemia, resulting in granuloma oxygen for 2 or 3 minutes before suctioning occurs; then
formation, tracheomalacia, or stenosis. 5 mL of sterile saline is injected into the tracheal tube,
The occurrence of pneumothorax after tracheostomy immediately followed by 2- to 3-second suctioning inter-
is higher than after cricothyrotomy; it may occur in as vals. The steps should be repeated as long as notable
many as 5% of adult tracheostomies.152 Infants, children, secretions are removed from the airway. Trach care is
and those with chronic obstructive pulmonary disease completed once every hour for the first 48 hours. The
also have an increased chance of pneumothorax compli- following 2 days, it should be completed once every 2
cations after tracheostomy. The risk is as high as 17% for hours. After the first 4 days, it should be completed every
children and infants because their pleural domes are 4 hours.11
higher in the neck.174 Furthermore, the loose connective In addition to cleaning the original tracheostomy tube,
tissue in children allows for air tracing, which can lead it is recommended that the tube be changed as needed.
to pneumomediastinum and rupture of the pleura.175 There is no exact time frame for when tubes should be
Aspiration is a serious postoperative tracheostomy changed, but guidelines vary, from 5 days to 1 week to 7
complication that is especially important in patients to 14 days after the original tube placement.11,180,181 Tube
older than 70 years. Younger patients are more likely to changes are often indicated by clinical circumstances such
have a successful swallow post-tracheostomy.176 as patient discomfort, improper tube positioning, patient-
Recurrent, bilateral laryngeal nerve injury may cause ventilator asynchrony, cuff leak, tube fracture, need for a
severe dyspnea because of collapse of the vocal cords different tube type, or bronchoscopy.
and may be noticed only when attempts at decannula- Other important aspects of postoperative tracheos-
tion are unsuccessful. Permanent tracheal cannulation tomy care include keeping the surgical wound clean and
may be necessary in the presence of paralysis. If the dry by frequently changing the sterile gauze dressings
damage is only affecting a single nerve, it may result in and maintaining proper cuff pressure (≈20 mm Hg).
hoarseness and dyspnea on exertion, or the patient may When a tracheostomy tube is in place, the patient is
be completely asymptomatic. Through proper mainte- unable to humidify inspired air because the nasopharynx
nance of the midline dissection and careful use of blunt is bypassed in the respiration process. As a result, 40%
dissection techniques, with adequate light and proper humidified air should be administered during postopera-
instrumentation, the risk of laryngeal nerve damage can tive care to prevent drying of mucosal tissues and to aid
be limited.144 in secretion removal. If humidified air is not provided in
Because of the difficulty of emergency tracheostomy, sufficient amounts, secretions become more viscous from
technical errors are not uncommon and complications the effects of dehydration.11
can occur. Mortality rates from tracheostomy are reported Coughing, deep breathing, and pulmonary toilet are
in the range of 2.5% to 10%, with higher rates in chil- all encouraged in conscious patients. The presence of a
dren and infants.169,177 It is imperative that when review- weak cough, or an inability to cough, predisposes the
ing the statistics on complications and mortality rates patient to aspiration, leading to serious complications. As
after tracheostomy, it is understood that the patients noted, tracheostomy leads to a decrease in the amount
undergoing these procedures are critically ill or have of humidified air present, which leads to decreased
experienced incredible trauma. It is highly likely that ciliary function. This makes the cough mechanism even
some of the complications are directly related to the more important.125,142
underlying condition, and not actually because of the
placement of the surgical airway.11 The most common Percutaneous Tracheostomy
fatal complications (listed in descending frequency) are The need for a more efficient and safe tracheostomy
hemorrhage, displaced tube, infection, obstruction, aspi- technique led to the development of the percutaneous
ration, and tracheal erosion, with resultant stenosis or tracheostomy. Although not indicated for emergency
fistula.153,178,179 airway management, it should be mentioned as a method
of elective airway management because of its increas- scarring is another relative contraindication to the pro-
ing popularity in ICU settings.182 The technique was cedure, along with obesity, short neck anatomy, infection
originally developed based on Seldinger’s description of of the soft tissues, tracheomalacia, and cervical spine
arterial catheterization in 1953.183 Shortly after, a needle- instability. Surgical tracheostomy may be indicated over
guided trocar was described by Shelden et al for access PDT in some of these cases.180,190
into the trachea.184 Many variations of the technique have A 2011 study by Jackson et al has demonstrated the
since been developed. Most of the techniques incorpo- potential benefit of using bronchoscopic guidance for
rate slight changes to the procedure originally described percutaneous tracheostomy in elected cases of patients
by Ciaglia et al in 1985. This percutaneous dilational with difficult anatomy.191 The use of ultrasound guidance
tracheostomy, based on the Seldinger technique, uses in percutaneous tracheostomy to ensure proper tube
sequentially sized dilators prior to placement of the tra- placement and avoidance of vascular structures has been
cheostomy tube.185 There are numerous commercial kits shown to increase the accuracy and safety of this inter-
available; most are based on the Ciaglia technique. vention.192,193 Similar to open tracheostomy, the forma-
There are many similarities between the percutaneous tion of tracheoinnominate artery fistulas and subsequent
dilational tracheostomy (PDT) and the emergency per- life-threatening hemorrhage following percutaneous tra-
cutaneous cricothyrotomy. The first procedural step of cheostomy have been documented.164 The results from
the PDT is to make a horizontal incision (≈2 cm long) at one study reported that critically ill patients undergoing
the level of the second tracheal ring. This is followed by PDT have a high short-term mortality, with 11% of
blunt vertical dissection. At this point, the five major patients dying within the first 2 weeks postprocedure.194
steps of percutaneous cricothyrotomy are similarly In general, advocates of the percutaneous tracheos-
followed: tomy believe that it is quicker because it can be per-
1. A needle with a saline-filled syringe attached is formed at the bedside, safer as it omits the transportation
inserted into the trachea. The presence of air bubbles to and from the operating room, and more cost-effective
in the syringe confirms proper tracheal placement. because there is no operating room, equipment, anes-
2. The syringe is removed and the guidewire is intro- thesiologist, or surgeon fees charged to the patient.
duced through a cannula into the trachea. The Based on this information, it is not surprising that per-
needle is also removed. cutaneous tracheostomy is more widely used than surgi-
3. Dilators that increase sequentially in size are intro- cal tracheostomy.179 Critics of PDT believe that financial
duced into the surgical site over the guidewire. cost should not be a deciding factor and that the bene-
Each dilator should be lubricated to ease entry into fits of proper lighting, equipment, and qualified person-
the stoma. nel outweigh the monetary difference between the
4. The dilators are removed and the tracheostomy procedures.11
tube is lubricated and placed. Until surgeons have obtained sufficient experience
5. Proper positioning and airway control are performing this procedure, Powell et al have recom-
confirmed. mended guidelines to maximize the chance for success.195
Although many of these steps are consistent from As with all the surgical airways, it is imperative that the
technique to technique, some variations include the use surgeon be familiar with the relevant anatomy so that
of a flexible bronchoscope or type of skin incisions.11 major complications can be avoided. Because the rate of
Some advantages to the PDT over surgical tracheos- complications for PDT fluctuates greatly depending on
tomy are as follows: the procedure is less time-consuming, the method chosen and expertise of the surgeon, it is
it may have a lower complication rate (depending on important that this procedure only be done under the
the specific method and expertise of the person per- supervision of experienced personnel.
forming the procedure), and there is increased flexibil-
ity as to when it can be performed.182,186 It has also been PEDIATRIC CONSIDERATIONS
reported that the PDT technique reduces patient cost.187
The results of a 2006 study confirmed a reduction in Treatment of the pediatric airway in the presence of
complications regarding wound infections for PDT maxillofacial trauma is similar to that of the adult airway.
patients.180 Other studies have been inconclusive about There are however, a few important differences that need
some of the potential PDT advantages. Rosenbower to be addressed. Pediatric trauma patients are especially
et al,188 in 1998, had comparable complication rates, but susceptible to cervical spine injury and these precautions
found the percutaneous method to be more cost- should be taken seriously. Clinicians should maintain
effective at their institution.11 In 1999, Dulguerov et al proper immobilization at all times, until the child has
found that although surgical tracheostomy had a higher been cleared of a cervical injury.196
postoperative complication rate, PDT led to higher rate
of perioperative complications.189 A multi-institutional ANATOMY
analysis of 1,175 tracheostomies has revealed a signifi- The anatomy of children varies slightly from that of
cantly higher rate (6.6%) of postoperative bleeding in adults. In general, their airways are smaller and tend to
percutaneous tracheostomies than open tracheostomies become obstructed more easily. Foreign bodies, secre-
(1.9%).160 tions, or even edema can cause an obstructed airway.197
Percutaneous dilational tracheostomy should not be Furthermore, the tongue and tonsils of a child are large
performed in patients younger than 15 years. Neck dis- in relation to the rest of the oral cavity. Because of their
tortion caused by hematoma, tumor, thyromegaly, or relatively large size, they have a tendency to get in the
way during airway interventions.198 The larynx is located 2. Historical resuscitation cover illustrations. JAMA 227(Suppl):834,
higher and more anteriorly in children than in adults. 1974
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CHAPTER
Management of Nonpenetrating
6 Chest Trauma
Kimberly Pingel
| Deepak Kademani
OUTLINE
History of Chest Trauma Rib Fractures
Motor Vehicle Accidents and Thoracic Injuries Diagnosis
General Management of Blunt Chest Trauma Treatment
Pulmonary Dysfunction First Rib Fractures
Extrathoracic Injuries Flail Chest
Process for Treating Chest Wall Injuries Pathophysiology
Arterial Blood Gas Diagnosis
Radiographic Examination Treatment
Advanced Trauma Life Support Fractured Sternum
Pneumothorax Cervical Tracheal Disruption
Closed or Noncommunicating Pneumothorax Tracheobronchial Injuries
Tension Pneumothorax Esophageal Injuries
Simple Pneumothorax Penetrating Neck Trauma
Open Pneumothorax Diaphragmatic Injuries
Hemothorax Rupture of the Aorta
Diagnosis Injuries of the Descending Thoracic Aorta
Management Diagnosis
Hemopneumothorax Treatment
Pulmonary Contusion Myocardial Contusion
Treatment Treatment
HISTORY OF CHEST TRAUMA MOTOR VEHICLE ACCIDENTS AND

THORACIC INJURIES
Trauma is the leading cause of morbidity and mortality
in Americans younger than 45 years and the third highest The number of motor vehicles on the roads worldwide
overall cause of death in the United States.1 Thoracic has increased steadily since World War II and, with the
trauma can cause significant mortality, because 25% of increase in high-speed motor vehicle travel, there has
traumatic deaths are secondary to thoracic injuries.2 The been a correlated increase in the number of motor
written history of chest trauma can be traced back to vehicle accidents (MVAs). MVAs are leading cause of
1600 bc in Egypt; 48 cases of trauma were reported, and death for people age 5 to 34 years in the United States.3
four of these involving the chest were described. One Each year, more than 6 million people are injured in
detailed flail chest, which at that time was deemed hope- MVAs. Of those, 45% to 50% have thoracic injuries and
less. In 400 bc, Hippocrates described wrapping of chest approximately 150,000 of these victims die. A total of
with linen to stabilize fractures for 20-40 days. This prac- 25% of these 150,000 deaths are caused entirely by tho-
tice continued until the twentieth century. In 1773, racic injuries and in another 50% of victims, injuries of
William Bromfield performed the first thoracentesis for the thorax are a major contributing factor to mortality4-6
traumatic pneumothorax and described tension The male-to-female ratio is 6.5 : 1. Also, nonfatal chest
pneumothorax. injuries, such as rib fractures and pneumothorax or
Over the last 100 years, most of what we have learned hemothorax, are frequently seen in victims of MVAs.
about chest trauma was taken from wartime. During MVAs are the most common cause of blunt chest trauma,
WWI, 37% of deaths were related to chest injuries.2 In accounting for 70% to 80% of blunt thoracic injuries.
WWII, 34% of deaths were related to chest injuries. The costs of crash-related deaths and injuries among
However, the overall mortality from WWI to WWII drivers and passengers in 2003 totaled $70 billion dollars.
decreased from 24% to 8%. Advances in antimicrobials, The mortality rate from isolated blunt chest trauma
anatomy, and physiology have helped improved morbid- 25 years ago approached 50%. Fortunately, improve-
ity and mortality associated with chest trauma. ments in prehospital care and the development of rapid
109
Respiratory decompensation Intubation or tracheostomy Thoracotomy for Operative

Hypoxia Mechanical ventilation associated severe stabilization
Hypercarbia Analgesia cardiothoracic injury
PO2/FiO2 200 Fixed thoracic impaction
Shock
Surgery for concomitant injury
History and physical Multiple rib fractures Wean from ventilation Unable to wean
examination Flail chest ABG parameters due to gross
Mechanism Ventilation parameters instability
Site
Symptoms
Chest wall exam
Past medical history
Blunt chest Resuscitation No respiratory distress Admission

Discharge
wall trauma Airway Normal ABG Aggressive pulmonary
O2 Normotensive physiotherapy
IV fluids No severe associated Analgesia
Associated injury injuries Incentive spirometry
survey Suctioning
Nasogastric tube Bronchodilators
Mucolytics
Mobilization
Laboratory Associated injuries Admission Gross displacement

HCT Sternal fracture Abnormal EKG Cardiac monitor Uncontrolled pain
ABG Echocardiogram
CXR Analgesics
EKG
Isolated Discharge Operative

Not displaced Analgesics Stabilization
Normal EKG
FIGURE 6-1 Chest wall trauma algorithm. (Adapted from Mattox KL, Feliciano DV, Moore EE, editors: Trauma, ed 4, New York, 2000,
McGraw-Hill.)
transport systems have lowered the mortality rate to less GENERAL MANAGEMENT OF BLUNT
than 10%. Less than 10% of the patients suffering blunt CHEST TRAUMA
chest trauma require a thoracotomy. Prevention of closed
chest injuries associated with MVAs has been the focus of The most common injury associated with blunt chest
improved highway construction and design, as well as trauma is rib fracture, which occurs in 56% of patients
vehicular safety features and innovations such as air bag reported in a study of chest trauma victims, followed by
systems, safety belts with shoulder harnesses, antilock pneumothorax in 40% of patients evaluated, pulmonary
brakes, use of energy-absorbing materials, and improved contusion (35%), flail chest (13%), and injury to the
design. Enforcing the use of safety belts and impaired heart and major vessels in 5% of cases.9 Initial manage-
driver legislation have also decreased the severity of ment of patients with blunt chest trauma should focus
MVAs and associated injuries.7 It is hoped that once the on performance of the ABCs of trauma care,10 including
patient reaches the hospital, the prompt recognition of establishment of a patent airway, initiation or support of
chest injuries, coupled with an improved understanding adequate ventilation, and treatment of shock (Fig. 6-1).
of their pathophysiology and management, will further Treatment of severe chest wall injury must focus on
reduce the number of deaths caused by nonpenetrating the identification and care of specific injuries after estab-
thoracic trauma.8 lishing adequate ventilation and oxygenation. Chest
Management of Nonpenetrating Chest Trauma CHAPTER 6 111
not recognized early, death frequently results. Those

BOX 6-1 Injuries Associated with Nonpenetrating caring for patients who have sustained blunt trauma to
Chest Trauma the chest must not be deceived by initial clinical stability
Cardiovascular and must always be alert for the likelihood of later dete-
• Myocardial concussion rioration. Some patients with life-threatening injuries
• Myocardial contusion may appear clinically well on arrival to the emergency
• Cardiac rupture room.
• Air embolus
• Traumatic aortic injury PULMONARY DYSFUNCTION
• Aortic fistula Most of the pulmonary dysfunction associated with non-
• Great vessel injury penetrating chest trauma is secondary to the underlying
• Traumatic asphyxia pulmonary contusion or lung injury rather than disrup-
Pulmonary tion of chest wall expansion and respiratory mechanics
• Tracheal tear caused by fractured ribs and/or sternum, pain, or muscle
• Bronchial tear splinting.17-19 Compression of the chest wall by heavy
• Pneumothorax objects (e.g., automobiles, rocks, with a trapped victim)
• Pneumomediastinum emphysema prevents respiration and may result in significant increase
• Subcutaneous emphysema in pressure within the veins of the upper thorax and
• Hemothorax
traumatic asphyxia. Frequent observation of any patient
• Lung laceration
with blunt chest injury is as important as the initial evalu-
• Pulmonary contusion
ation to detect progressive changes in function. A pneu-
• Acute respiratory distress syndrome
Chest Wall
mothorax may develop several hours after an injury and
• Rib fractures a small hemothorax may continue to increase in size over
• Flail chest a period of several hours. A flail segment not apparent
• Sternum fractures on an initial examination may become obvious from 1 to
10 days after an injury.11,20
Diaphragm
• Diaphragmatic rupture EXTRATHORACIC INJURIES
• Esophageal injuries Patients with thoracic injuries frequently sustain multiple
extrathoracic injuries. The physician’s attention must not
be diverted from thoracic injuries by obvious extratho-
trauma can cause mortality from airway obstruction, tra- racic trauma, such as abdominal, maxillofacial, or central
cheobronchial injuries, pulmonary secretions, hemor- nervous system (CNS) injuries. Associated injuries occur
rhage, loss of oxygenation, ventilation, exsanguination, in 66% to 80% of patients with chest trauma and usually
or cardiac failure. Blunt forces inflicted on the chest wall involve the head, abdomen, pelvis, and extremities.21
will cause injury by three mechanisms—rapid decelera-
tion, direct impact, and compression.11 Rapid decelera- PROCESS FOR TREATING CHEST WALL INJURIES
tion is usually associated with MVAs and falls from heights. After any immediate life-threatening emergencies have
It is important to recognize that serious intrathoracic been treated, the physician should undertake a careful
injury can occur without obvious external chest injuries history, if possible, and should methodically examine all
or rib fractures. The degree of injury to the chest wall is systems of the injured patient. Knowledge of the patient’s
usually not indicative of the severity of the injury to the past medical history, allergies, and medications may
internal tissue and/or organs. The possibility of injury to influence subsequent therapy. Clues to likely injuries may
the heart, lungs, vessels, and other tissue should be taken be gained from knowledge of the circumstances under
into account (Box 6-1). Deceleration produces traction which the injuries occurred. The chest wall should be
on the great vessels and trachea, with disruption and inspected for wounds, lacerations, contusions, abrasions,
tears near points of anatomic fixation, such as the liga- or other evidence of trauma and splinting, paradoxical
mentum arteriosum with the aorta and the carina with movement of the chest wall with breathing caused by rib
the trachea.9 or sternum fractures. The neck should be evaluated for
When the chest wall is exposed to a significant enough distention of the veins or tracheal deviation. The physi-
force that can fracture ribs, the semirigid chest wall of cian should listen to the lung fields and heart for the
older adults absorbs energy that would otherwise be presence, absence, or alteration of breath or cardiac
transmitted to the lung parenchyma and great vessels. sounds, and heart murmurs or bruits that may be indica-
However, the flexible chest wall of the younger patient tive of a developing cardiac, lung, or vessel injury. A
transmits essentially all the kinetic energy to the thoracic nasogastric tube should be placed, unless contraindi-
contents. Thus, the absence of rib fractures does not cated because of injury, to prevent acute gastric dilation,
exclude the possibility of life-threatening injuries because which can exacerbate respiratory compromise in injured
injuries to the lung parenchyma, cardiac contusion, or patients.11
pneumothorax are possible without external signs.
Almost 50% of all patients with traumatic aortic injury12-14 ARTERIAL BLOOD GAS
and up to one third of patients with myocardial contu- Arterial blood gas (ABG) determinations are a means
sion15,16 have no external signs of trauma. If the injury is of indirect measurement and serial assessment of the
TABLE 6-1 Indications for Respiratory Support TABLE 6-2 Arterial Blood Gas
Function Value Condition pH PaCO2 HCO3

MECHANICS Respiratory acidosis Decreased Increased Normal
Respiratory rate (breaths/min) >35 Respiratory alkalosis Increased Decreased Normal
Vital capacity (mL/kg body <15 Metabolic acidosis Decreased Normal Decreased
weight) Metabolic alkalosis Increased Normal Increased
FEV1 (mL/kg body weight) <10
Inspiratory force (cm H2O) <−25 Parameter Definition Normal Range
OXYGENATION pH Measurement of acidity or 7.35-7.45
PaO2 (mm Hg) <60 (supplemented with O2) alkalinity based on the
AaDO2 (mm Hg) >450 (on 100% O2) hydrogen (H+) ions present
PaO2 Partial pressure of oxygen 80-100 mm Hg
VENTILATION that is dissolved in arterial
PaCO2 (mm Hg) >55 blood
Vd/Vt >0.60
SaO2 Arterial oxygen saturation 95%-100%
AaDO2, Alveolar-arterial difference in partial pressure of oxygen; FEV1, PaCO2 Partial pressure of carbon 35-45mm Hg
forced expiratory volume in 1 second; Vd, volume of dead air space; Vt,
dioxide in arterial blood
tidal volume.
HCO3 Amount of bicarbonate in 22-26 mEq/liter
the bloodstream
functional impairment associated with pulmonary injury. Base excess Indicates the amount of −2 to +2 mEq/liter
All patients with suspected flail chest or pulmonary con- excess or insufficient level
tusion should be observed, including taking serial blood of bicarbonate in the
gas measurements. Often, the first sign of impending system
respiratory failure will be marked hypoxia (Table 6-1).
The ratio of arterial oxygen tension to the fraction of
inspired oxygen (PaO2/FiO2 ratio) yields an estimate of
the extent of an intrapulmonary shunt and may be used clinically apparent. It is also important to obtain baseline
as a parameter indicating the need for mechanical ven- radiographs during the initial examination of the patient
tilation in patients with pulmonary contusion and flail to evaluate the patient’s clinical progress or changes in
chest.22 Serial ABG determinations, compared with base- clinical signs and symptoms further. Chest films should
line data obtained while the patient breathes room air, be delayed only if obvious therapeutic measures are
may be useful in predicting trends in respiratory function immediately required, such as for significant bleeding,
(Table 6-2). Using a fractional concentration of inspired shock, and airway and/or ventilatory problems.
oxygen (FiO2) of 0.21 permits consistent serial compari- Chest computed tomography (CT) has proven to be
sons and gives a more accurate estimation of the severity of great use in distinguishing chest wall injury from
of the respiratory impairment. Patients should be fol- parenchymal or mediastinal injury. Also, by CT scanning,
lowed initially with ABG determinations every 4 hours for more injuries are detected and consequently treated.
48 hours to detect subtle changes that might prompt Therefore, every patient who has sustained severe tho-
modification of treatment. Noninvasive measurement of racic trauma and is hemodynamically stable should get a
oxygen saturation by pulse oximetry can be used as an CT scan of the chest on admission to a hospital.23-26
indicator of the degree of functional pulmonary injury
and response to treatment. ADVANCED TRAUMA LIFE SUPPORT
Appropriate patient management of nonpenetrating
RADIOGRAPHIC EXAMINATION chest wall trauma involves the correction of alterations
Radiographic examination using standard supine chest of gas exchange and ventilation and support of respira-
radiographs, with inspiratory and expiratory views and a tory function. Blunt thoracic injuries may quickly develop
lateral projection, should be obtained early in the exami- into life-threatening circumstances. Consequently, each
nation of patients with nonpenetrating chest wall trauma patient should be assessed according to Advanced
to evaluate the sternum, spine, ribs, heart, lungs, and Trauma Life Support (ATLS) principles, including estab-
other structures of the neck, thorax, and abdomen for lishment of a patent airway with cervical spine support
the presence of a pneumothorax, hemothorax, widened until cleared, initiation or support of adequate breathing
mediastinum, subcutaneous air, pulmonary contusion, and ventilation, and treatment of shock. Lives can be
ruptured diaphragm, and other abnormal findings (see saved if each patient is assessed according to ATLS prin-
Box 6-1). It is important to obtain quality chest x-rays ciples. Initial assessment with the ABCDE algorithm—
quickly in the initial management of patients with blunt airway, breathing, circulation, disability, and exposure—is
chest trauma, even when the patient has serious associ- followed by a thorough secondary survey. At all times,
ated injuries, such as head trauma or compound frac- lifesaving interventions should be made when identified,
tures, because there may be developing life-threatening followed by reevaluation and stabilization, and finally
injuries that have not been previously detected or transfer to a definitive care hospital.
FIGURE 6-2 A, A pneumothorax develops

from damage to the chest wall or laceration
of the lung pleura, with a resulting loss of
negative intrapleural pressure. A
A pneumothorax may be graded as small
(<15%), moderate (15% to 60%), or large
(>60%). Usually, only patients with moderate
or large pneumothoraces are symptomatic.
B, C, With an open wound in the chest wall,
air can be often heard moving in and out of
the wound during respiration, known as a
sucking chest wound. An open
pneumothorax may be converted to a simple
pneumothorax with the use of an occlusive
dressing over the chest wall wound. Care
must be taken not to create a trapdoor
effect that does not allow the air from the
pleural cavity to escape and create a tension
pneumothorax. (From Marx JA, Hockberger
B C RS, Walls RM: Rosen’s emergency medicine,
ed 7, St. Louis, 2010, Mosby.)
PNEUMOTHORAX
The thoracic cavity is normally filled by the expanded
lung. A potential space exists between visceral and pari-
etal pleura, blood, or air in the space is pathologic. If
there is air present in the pleural space, one of two events
has occurred: (1) communication between alveolar
spaces and pleura; or (2) direct or indirect communica-
tion between the atmosphere and pleural space.27 Pneu-
mothorax is a common complication of penetrating
chest trauma caused by a defect in the chest wall that
allows air to be moved in and out of the pleural cavity
with each respiration or a sudden increase in intra
thoracic pressure (Fig. 6-2). An equilibrium develops
between the intrathoracic pressure and atmospheric
pressure, which affects the ability of the lung to remain FIGURE 6-3 A wound in the lung from a fractured rib allows
inflated. The involved lung collapses on inspiration and inspired air to escape into the pleural cavity in a patient with a
slightly expands on expiration. This causes the air to be closed pneumothorax injury. The involved lung collapses on
drawn out of the wound in the chest wall with an open inspiration (as outlined by the arrows) and slightly expands on
pneumothorax or from a wound in the lung from a frac- expiration, causing the air to be drawn out of the wound in the
tured rib. Inspired air escapes into the pleural cavity in lung.
a closed pneumothorax injury (Fig. 6-3). Pneumothorax
is usually unilateral; however, it may be bilateral in 10%
to 15% of cases.8 Most of these injuries are associated parenchyma caused by a fractured rib and compression
with MVAs, but blast injuries, falls, direct blows to the of the chest against a closed glottis that ruptures the
chest, or automobile-pedestrian collisions may also be alveoli.28
associated with a pneumothorax. Pneumothoraces are
categorized as open or closed and are further defined as CLOSED OR NONCOMMUNICATING PNEUMOTHORAX
simple or complicated. A simple pneumothorax is air in A closed pneumothorax, the most common type, usually
the pleural space that does not communicate with the results from a rib fracture, causing a parenchymal lacera-
atmosphere or distort the mediastinum. The two possible tion (Fig. 6-4). It may also occur without an accompany-
mechanisms include laceration of the pleura or lung ing rib fracture. In general, this type of pneumothorax
FIGURE 6-4 A closed pneumothorax, the most common type of

injury to the lung, is demonstrated in the right lung (arrow) on this
expiratory chest radiograph. (From Rosen P, Doris PE, Barkin RM,
et al, editors: Diagnostic radiology in emergency medicine, St. FIGURE 6-5 A tension pneumothorax resulting from trauma. This
Louis, 1992, Mosby.) upright chest radiograph demonstrates the shift of the
mediastinum, with compression of the opposite lung and resultant
tends to be self-limited because the resultant pulmonary hypoxia.
collapse usually seals the air leak (simple pneumotho-
rax). However, if a large parenchymal disruption exists, insertion of a large angiocatheter (14 to 16 gauge) in the
air from the damaged lung continuously is allowed to midclavicular line in the second intercostal space. This
enter the pleural cavity. Because the air cannot escape quickly converts the tension pneumothorax into a pneu-
from the pleural cavity, it tends to accumulate under mothorax, which can then be treated with a thoracos-
pressure, producing a tension pneumothorax. Air from tomy in the anterior axillary line at the level of the nipple
the lung to the pleural space equalizes the pressure and placement of a chest tube. If the clinical diagnosis
within the chest cavity and the lung collapses. A of a tension pneumothorax is missed clinically, the chest
ventilation-perfusion deficit occurs because the blood radiograph will demonstrate a large collection of air in
circulated to the affected lung is not oxygenated. With a the involved hemithorax, with a shift of the mediastinum
pneumothorax, percussion of the chest shows hyperreso- toward the unaffected side. The lung on the involved side
nance and breath sounds are usually distant or absent. need not be completely collapsed.
Positive pressure ventilation is the major cause of
TENSION PNEUMOTHORAX tension pneumothorax; however, a tension pneumotho-
A tension pneumothorax that develops as a result of rax may be associated with invasive medical procedures
trauma exists when the tissues surrounding the opening such as central line placement. The development of a
into the pleural cavity act as a valve, allowing air to enter tension pneumothorax occasionally occurs with sponta-
the pleural cavity but not to escape (Fig. 6-5). This results neous breathing, but is more likely in patients who
in a shift of the mediastinum, with compression of the undergo bag-valve-mask or mechanical ventilation.
opposite lung and resultant hypoxia. The positive intra- Positive-pressure ventilation may also convert a simple
pleural pressure produces compression of the vena cava, pneumothorax to a tension pneumothorax. As the intra-
thereby interfering with diastolic filling of the heart and pleural pressure increases, the mediastinum shifts and
resulting in low cardiac output. the venous return to the superior vena cava is impaired.
Patients with tension pneumothoraces are acutely ill Tension pneumothorax causes hypotension, increases
and in respiratory distress with chest pain. They are rest- the central venous pressure, decreases cardiac output,
less, agitated, dyspneic, and at times cyanotic. On physical and ultimately produces cardiovascular collapse.29,30
examination, the patients are hypotensive, tachycardiac,
and tachypneic. Breath sounds are absent and percussion SIMPLE PNEUMOTHORAX
is hyperresonant over the involved hemithorax. The cervi- Simple pneumothoraces are usually classified according
cal trachea is displaced to the side opposite the pneumo- to the volume of the hemithorax occupied by air or the
thorax, and distended neck veins may be present. degree of pulmonary collapse. A pneumothorax that
Tension pneumothorax is life-threatening and demands occupies 15% or less of the pleural cavity is classified as a
immediate treatment following a clinical diagnosis based small pneumothorax. One that occupies between 15%
on the above-mentioned signs and symptoms. If and 60% of the pleural cavity is classified as moderate, and
untreated, tension pneumothorax quickly results in one that occupies more than 60% is classified as
death. If a developing tension pneumothorax is sus- large. Usually, only patients with moderate or large
pected, the positive intrapleural pressure should be pneumothoraces are symptomatic. However, in patients
released as soon as possible, and not delayed for radio- with significant underlying parenchymal disease, a small
graphic confirmation. The pressure can be released with pneumothorax may compromise pulmonary function
sufficiently to cause symptoms and require immediate chest tube. Only rarely, in asymptomatic patients who are
treatment. otherwise healthy and have no associated injury, should
The most frequent symptoms in patients with pneu- a pneumothorax be treated with observation. If observa-
mothoraces are chest pain and shortness of breath. On tion is chosen as a method of treatment, a repeat chest
physical examination, the breath sounds are distant or film should be obtained 6 to 8 hours after admission and
entirely absent over the involved hemithorax. In an daily thereafter until complete reexpansion of the lung
attempt to decompress the thoracic cavity, air frequently occurs. If the patient is breathing spontaneously, supple-
escapes into the subcutaneous tissues, resulting in subcu- mental oxygen should be delivered by a face mask. The
taneous emphysema. Approximately 25% of patients exchange of air does not guarantee adequate ventilation.
with pneumothorax have associated injuries of the chest The chest wall of a patient with a pneumothorax, flail
wall. chest, or hemothorax may move but not ventilate effec-
tively. Also, shallow breaths with minimal tidal volumes
Diagnosis do not ventilate the lungs effectively. The patient should
The diagnosis of a simple pneumothorax is suggested by at least be monitored by pulse oximetry. If the patient
the history and clinical findings and is confirmed by the requires mechanical ventilation, operative intervention
chest radiograph. The chest radiograph should be for other injuries, or transportation to another hospital,
obtained at the earliest possible moment, but it should a chest tube must be placed in the patient to prevent
not take precedence over emergency treatment if the development of a tension pneumothorax.
clinical condition suggests that a pneumothorax is The indications for closed tube thoracostomy
present. (Fig. 6-6) include the following: (1) pneumothorax of
moderate to large size; (2) presence of respiratory symp-
Treatment toms regardless of the size of the pneumothorax; (3)
Most pneumothoraces associated with trauma require increase in size of the pneumothorax that initially was
only simple treatment, with thoracostomy drainage with treated conservatively; (4) recurrence of pneumothorax
Parietal pleura
Vessels and
nerves
Y
X
Adequate skin
incision here
A B
FIGURE 6-6 Closed tube thoracostomy. A, Place a moderate-sized chest tube (32 to 40 Fr in adults or 26 to 30 Fr in children) either
anteriorly in the fourth or fifth intercostal space midaxillary line (X) or in the second intercostal space, midclavicular (Y). The midaxillary line
is generally preferred for cosmetic reasons; if the tube is positioned properly, superiorly toward the apex of the lung, it can effectively
remove both fluid and air. B, Make a skin incision of approximately 3 cm in length through the skin along the fifth intercostal space. Use
a Kelly clamp to create a pocket along the anterior and superior aspect of the rib to avoid the neurovascular bundle, which runs inferior
and slightly medial to the rib. Continued
Intercostal muscles
Parietal pleura
Middle strip
Torn of torn tapes
tape
Kelly forceps Torn

tape
Tape secures
anchoring tape
C D
FIGURE 6-6, cont’d C, With a gloved finger, tunnel transversely through the subcutaneous tissue to the inferior margin of the fourth rib.
Separate the intercostal muscles with a large Kelley clamp and insert the chest tube superiorly and posteriorly into the pleural cavity.
D, Secure the tube to the skin with sutures, and use an occlusive dressing to cover the defect around the tube. A wide piece of tape is
longitudinally split into three pieces; the two outside pieces are placed on the skin on either side of the tube, and the center strip is
wrapped around the chest tube. A similar piece of tape can be secured to the tube at a 90-degree angle to the first piece. The tape is
secured to the skin with an anchoring piece of tape. The tube is then connected to an underwater sealed drain to remove the air or fluid.
Upright posteroanterior and lateral chest radiographs should be taken to confirm the position of the chest tube, the position of the last
drainage hole on the tube, and the position and amount of air or fluid remaining in the pleural cavity.
after the initial chest tube was removed; (5) any pneu- emphysema, which is usually extensive and involves both
mothorax in a patient who requires ventilatory support; hemithoraces, cervical region, head, and anterior abdom-
(6) any pneumothorax in a patient who is undergoing inal wall.
general anesthetic; (7) associated hemothorax; (8) bilat- If the wound in the chest wall is approximately two
eral pneumothoraces; and (9) tension pneumothorax.31 thirds the diameter of the trachea, air will pass through
the chest wall defect preferentially to the trachea. With
OPEN PNEUMOTHORAX the collapse of the involved lung and loss of negative
An open pneumothorax, or sucking chest wound, that pleural pressure, the expired air from the normal lung
results from blunt chest trauma is associated with a large passes to the involved lung instead of out of the trachea,
defect in the chest wall, and atmospheric air has direct and the expired air returns to the normal lung on inspi-
access to the pleural cavity through the wound. Because ration. Eventually, a large functional dead space develops
of the loss of chest wall integrity, equilibrium develops in the normal lung and, combined with loss of the
between the intrathoracic pressure and atmospheric involved lung, may develop into a severe ventilation-
pressure. Complete expansion of the lung is impossible, perfusion problem.
because continued communication with the atmosphere Sucking chest wounds demand immediate surgical
is always present. The patient will have signs and symp- treatment. Patients may require intubation and ventila-
toms of respiratory distress. During respiration, a sucking tory support. The wound should be covered with a sterile
sound is often heard. The involved lung collapses on occlusive dressing secured on three sides of the dressing
inspiration and slightly expands on expiration, causing to the chest. The unsecured side of the dressing acts as
air to be sucked in and out of the wound. This is referred a one-way valve, allowing air to escape the pleural cavity
to as a sucking chest wound. Also present is subcutaneous on expiration. Secure taping of all edges of the dressing
FIGURE 6-7 A, A tension pneumothorax develops

as air enters into the pleural cavity on inspiration
but cannot be removed during expiration. B, As
the air builds in the pleural cavity, a progressive
increase in intrapleural air pressure develops. The
injury in the chest wall or trachea acts like a
one-way valve and the increasing intrapleural
pressure results in a shift of the trachea and
mediastinal structures away from the injury. (From
Marx JA, Hockberger RS, Walls RM: Rosen’s
emergency medicine, ed 7, St. Louis, 2010,
Mosby.)
results in an accumulation of air within the thoracic

cavity and a subsequent tension pneumothorax. Occlu-
sive dressings such as petrolatum gauze may be used as
a temporary measure during initial examination or over
large defects. A chest tube must be placed in a distant
site on the affected chest wall to prevent development of
a tension pneumothorax, and the wound must eventually
be closed in the operating room. If the lung does not
expand after closure of the defect or if signs of poor
ventilation persist, the patient should be placed on a
ventilator with positive end-expiratory pressure (PEEP)
to expand the lung. The patient should be carefully mon-
itored and have a chest tube in place to prevent the
development of a tension pneumothorax caused by a
tear in one of the bronchi or in the lung parenchyma FIGURE 6-8 Hemothorax. The collection of blood in the inferior
(Fig. 6-7). Signs of a tension pneumothorax in patients aspect of the pleural cavity blocks visualization of the diaphragm,
on ventilators include increased airway resistance and ribs, and other structures in the upright chest film.
diminished tidal volume.
HEMOTHORAX
no physical findings of intrapleural fluid may be present.
Hemothorax, a common sequela of blunt chest trauma, With larger losses (>1000 mL), the findings of internal
is usually unilateral; however, bilateral hemothoraces hemorrhage may be present—pallor, restlessness, tachy-
may occur in 10% to 20% of victims of blunt chest trauma cardia, and hypotension. The patient may complain of
(Fig. 6-8). The source of bleeding may be the lung, heart, dyspnea or of a peculiar tightness in the chest. On the
great vessels or their branches, intercostal artery or vein, chest radiograph, the pleural fluid is best visualized with
mediastinal veins, or vessels of the diaphragm and chest the patient in the upright position.
wall. Bleeding from the lung results if the lung is torn
from a fractured rib driven inward toward the lung. A MANAGEMENT
large amount of blood may be present without significant The greatest problem with hemothorax is obtaining
respiratory compromise and may be apparent only on proper drainage. Although the initial hemothorax can
the chest radiograph. More often, a large hemothorax be treated with thoracentesis, adequate drainage is of the
under pressure can interfere with ventilation by causing utmost importance, necessitating placement of large-
a mediastinal shift, collapse of the lung, and resultant bore (32 or 36 Fr) thoracostomy tubes. Tube thoracos-
hypoxia. The shifting of the mediastinum further aggra- tomy allows constant monitoring of continued blood loss
vates venous return and ventilation. This combination of and continued drainage for better reexpansion of the
hypovolemia and hypoxia can be lethal unless appreci- lung. Only 10% of patients require a thoracotomy (Box
ated and corrected in a timely fashion. 6-2) for hemothorax from blunt trauma. Inadequate
drainage (residual clot occupying more than one third
DIAGNOSIS of the thorax), sepsis, multiloculation, and hemodynamic
If less than 400 mL of blood is lost, there may be little or or respiratory compromise are appropriate indications
no change in the patient’s appearance or vital signs and for operation. Improperly drained hemothoraces result
BOX 6-2 Radiographic Clues Suggestive of Thoracic

Vascular Injury
Widening (>8 cm) of the upper mediastinum
Loss of aortic knob contour
Left apical pleural hematoma
Fractured sternum
Fractured first rib
Massive left hemothorax
Depression of the left mainstem bronchus more than 140
degrees
Calcium layering in the aortic knob (double-shadow sign)
Loss of aortopulmonary window on lateral chest film
Deviation of the trachea to the right
Deviation of the nasogastric tube in the esophagus away from
the midline
Blurring of aortic contour
FIGURE 6-9 A pulmonary contusion, damage to the lung
parenchyma that results in hemorrhage and edema without
accompanying pulmonary laceration.
in a fibrothorax, restrictive lung disease, and possible

respiratory compromise. Restoration of the circulating
blood volume should be attempted with transfusion of without accompanying pulmonary laceration (Fig. 6-9).
fluids, volume expanders, and blood or blood products It is a common finding in patients who have sustained
through large-bore IV lines. blunt chest trauma. A chest radiograph may expose signs
A persistent hemorrhage requires surgical explora- of a pulmonary contusion, but a multislice CT scan
tion. In a few cases, emergency thoracotomy in the emer- provides better visualization of the extent of the contu-
gency room may be necessary for control of blood loss. sion.32 The incidence of pulmonary contusion in victims
However, mortality from this procedure is very high. of nonpenetrating chest trauma varies between 30% and
The indications for thoracotomy for hemothorax are 75%.33 Although often mild and frequently masked by
the following: other more dramatic injuries, such as flail chest, pneu-
1. Drainage of 1500 mL of blood on placement of a mothorax, and hemothorax, pulmonary contusion
chest tube deserves special consideration. It is now well recognized
2. More than 300 mL/hr for 3 hours that when undiagnosed and consequently untreated, pul-
3. More than 150 mL/hr for 3 hours in older or com- monary contusion is frequently progressive and may be
promised patients fatal because of respiratory insufficiency. Pulmonary con-
4. Lack of lung reexpansion tusion has played a major role in 25% of deaths resulting
5. Bleeding with hemodynamic instability from chest injuries sustained in MVAs.
6. Increasing hemothorax on chest radiographs Most victims of MVAs sustain a pulmonary contusion
despite tube thoracostomy when the chest strikes the steering wheel during decel-
eration. The precise pathogenesis of pulmonary injury in
HEMOPNEUMOTHORAX these patients is unknown, but most believe it is analo-
gous to the mechanism thought to operate in a blast
A hemothorax is usually associated with a pneumothorax injury—a forceful high-pressure wave that compresses
secondary to the injury of the lung, chest wall, and associ- the thoracic cavity. The force is also transmitted to the
ated vasculature. With a developing hemopneumotho- lung by virtue of its continuity with the tissue of the chest
rax, the loss of blood causes hypotension, decreased wall. The increase in intrathoracic pressure compresses
cardiac output, and metabolic acidosis, which when com- the lung by diminishing the size of the thorax and results
bined with ventilatory compromise results in hypoxia in parenchymal hemorrhage and edema. When the force
and respiratory acidosis. Patients with hemopneumotho- of compression is removed, decompression occurs and
rax, as identified by an air-fluid level on the chest radio- the distorted thorax springs back, creating an instant of
graph, should have two chest tubes inserted, one through negative intrathoracic pressure that leads to additional
the fifth or sixth intercostal space at the midaxillary line injury in the areas ruptured during compression. Among
and the other through the second or third intercostal the factors that influence the severity of lesions produced
space at the midclavicular line. The patient should be are the amount of padding of the chest wall and flexibil-
evaluated and treated as discussed in the earlier sections ity of the chest. If the ribs are sufficiently elastic, severe
on pneumothorax and hemothorax. compression of the lung can occur without a break in the
costal cartilage. Some of the most severe pulmonary con-
PULMONARY CONTUSION tusions occur in patients who exhibit neither rib frac-
tures nor discontinuity of the chest cage.
Pulmonary contusion is defined as damage to the lung Pulmonary contusion is frequently associated with
parenchyma that results in hemorrhage and edema, multiple injuries and is often subject to incidental
Pulmonary contusion
Increased respiratory work
Hypoxia Decreased respiratory Chest wall

Impaired ability Retained
and movements injury
to cough secretions
acidosis
Decreased cardiac output
Myocardial contusion
FIGURE 6-10 Pathophysiology of untreated pulmonary contusion.
resuscitative measures, such as administration of large oxygen dissociation (shifting the curve to the left
volumes of fluid, which are directed at other injuries. reduces the ability of hemoglobin to release oxygen).
The rapid administration of large volumes of noncolloi- It is imperative that nutritional support be ade-
dal fluid has been shown in experimental and clinical quate in these patients. Impairment of host defenses
studies to have an adverse effect on the already damaged secondary to malnutrition may result in bacterial
lung. Figure 6-10 examines the pathophysiology of an translocation from the gut and multiple organ system
untreated pulmonary contusion. failure from sepsis.
The course of pulmonary contusion is determined by
TREATMENT the severity of the initial injury. In patients with mild
It should be emphasized that the keys to successful man- pulmonary contusion who do not require ventilatory
agement in patients with pulmonary contusions are as support, the course of the illness is characterized by rapid
follows: resolution within 72 hours. In patients who require ven-
1. Early and vigorous therapy (the first 24 hours of treat- tilatory support, gradual improvement occurs, with
ment are the most important) weaning from the ventilator in 12 to 14 days. In any
2. Restoration and maintenance of oxygenation patient with a pulmonary contusion and delayed improve-
3. Intense pulmonary hygiene, including intratracheal ment, one should suspect superimposed processes, such
suction and physical therapy as pneumonia, fat embolism, and pulmonary embolism.
The following steps should be taken in the treatment Despite optimal therapy, approximately 15% of patients
of pulmonary contusion: with pulmonary contusion die of progressive respiratory
1. A percutaneous radial artery catheter should be insufficiency.
inserted for frequent ABG determinations.
2. Crystalloid solution should be administered based RIB FRACTURES
on hemodynamic measurements.
3. A nasogastric tube should be inserted for gastric Rib fractures are a common injury that can affect 350,000
decompression and nutritional support. people each year. Rib fractures lead to respiratory com-
4. Adequate pain relief should be achieved with small plications prolonged hospitalizations, pain, disability,
frequent doses of narcotics, epidural catheter, or nosocomial pneumonia, and increased morbidity.12 The
intercostal nerve blocks. incidence and location of rib fractures appear to be
5. When appropriate, broad-spectrum antibiotics related to the age of the patient. Fractures of the ribs are
should be started for documented infection. more common in adults than in children because the
6. Indications for ventilatory support by means of resilient chest wall of the child can absorb more of an
endotracheal intubation are listed in Figure 6-1. impact without fracture. In contrast, the ribs of older
The lowest FiO2 possible should be used to maintain adults are brittle and can be broken by even minor
a PO2 of 60 mm Hg. Positive end-expiratory pres- stresses, including those associated with coughing. Rib
sure should be used if a PO2 of at least 60 mm Hg or fractures usually occur at the posterior angle, the weakest
an FiO2 of 60% cannot be obtained. The hematocrit point in the rib structurally, and the area that tends to
should be kept at a level greater than 30% to opti- be under the most pressure during impact. Rib fractures
mize mixed venous oxygen and oxygen use. associated with blunt trauma occur most commonly
7. The pH should be maintained at a level higher than because of chest compression and most often involve the
7.35, because an alkaline pH allows for greater fourth through ninth ribs laterally, because these are
more exposed. The compression type of fracture usually compared with patients younger than 65 with more than
results in an outward break, in contrast to the fractures five rib fractures. Similarly, patients with poor cardiovas-
resulting from direct trauma. One should be suspicious cular reserve or underlying chronic lung disease should
for abdominal injuries if the tenth to twelfth ribs are be hospitalized, because the additional insult of the rib
broken. fracture may result in pulmonary or cardiac decompensa-
The number of rib fractures, degree of displacement tion. Narcotics should be given immediately to control
of the rib fragments, and injury to the underlying lung pain and should be repeated as often as necessary. Epi-
are dependent on the force and direction of the impact dural anesthesia or an intercostal nerve block may be
and the area of its distribution. Rib fractures can be beneficial and should include two segments above and
complete or incomplete, or have varying degrees of two segments below the fractured site. With adequate
overlap. If a fracture is displaced more than 1 to 2 cm, analgesia and physiotherapy, the patient should be able
the likelihood of healing is diminished.12 If the injuring to cough and breathe deeply, and thus bronchial
force is applied over a wide area, especially in the antero- secretions can be effectively expelled, which limits atel-
posterior projection, the ribs buckle outward and break ectasis and prevents pneumonia. Older methods of
at the midshaft position, without injuring the underlying adhesive chest strapping limit respiratory excursion and
pulmonary parenchyma. A direct force applied over a result in further decompensation of respiratory status.
small area tends to push the rib fragments inward and Consequently, the use of chest strapping should be
can cause lacerations of the pleura, pulmonary paren- condemned.
chyma, and intercostal vessels, producing hemothorax,
pneumothorax, or both. FIRST RIB FRACTURES
One of the most significant complications associated At one time, first rib fractures were thought to be of
with rib fractures, especially in patients with preexisting significant consequence, because the first rib lies low in
chronic lung disease, is pneumonia and possibly respira- the neck as a short, broad, and relatively thick structure
tory failure. Rib fractures are invariably accompanied by requiring extreme force to be fractured. Interestingly,
pain that results in splinting, reducing effective deep the mechanism of injury is important, rather than the
breathing and ventilation, and causing alveolar collapse, actual first rib fracture itself. Usually, in these cases,
secretion accumulation, and atelectasis. As atelectasis major chest, abdominal, and cardiac injuries are rela-
develops, a vicious cycle is set up that leads to hypoven- tively infrequent; however, a high incidence of serious
tilation and further collapse. Hypoventilation can result maxillofacial and neurologic injuries has been noted.
in pulmonary infection from retained secretions. There- Associated injuries of the subclavian, carotid arteries, and
fore, it is important to supply supportive care and ade- brachial plexus have been reported in 5% to 15% of
quate pain control so that deep breathing, coughing, and patients with first rib fractures.33 The following are indi-
clearing of secretions can be continued. cations for an arteriography in patients with first rib
fractures:
DIAGNOSIS 1. Absent or decreased upper extremity pulses
The physician can arrive at the diagnosis of rib fractures 2. Evidence of brachial plexus injury
by noting the history of trauma and by eliciting pain on 3. Marked displacement of fragments, especially poste-
palpation. The presence of fractures is confirmed by rior displacement
chest radiograph. Because anterior or lateral rib frac- 4. Altered serial chest radiographs
tures may not have been seen on an anteroposterior 5. Subclavian groove fracture seen anteriorly
chest radiograph, it is necessary to obtain left anterior No specific therapy exists for first rib fractures. The
and right anterior oblique views as well, so that all regions only significance of these fractures is that they alert the
of the ribs may be seen. It may be important to obtain physician to the possibility of associated intrathoracic
serial x-rays in all patients with rib fractures, because and extrathoracic injuries, particularly maxillofacial and
delayed pneumothorax or hemothorax can develop after neurologic injuries.
the initial injury, along with atelectasis or pneumonia
from hypoventilation.
TREATMENT FLAIL CHEST

When pneumothorax or hemothorax complicates rib Flail chest may result when each of three or more con-
fractures, these are treated promptly before the treat- tiguous ribs is fractured at two points (Fig. 6-11). Flail
ment of the rib fractures. Usually, tube thoracostomy chest may also be generated by anterior dislocation of
drainage is needed on the appropriate side. Treatment the costochondral junction coupled with a lateral or pos-
of rib fractures is dependent on the severity of the injury, terior fracture. Multiple fractures in several ribs result in
age of the patient, extent of preexisting lung disease, and a damaged segment of chest wall that no longer main-
pain threshold of the patient. In older patients, a rib tains its bony continuity with the remainder of the chest
fracture is a serious injury; these patients should be and becomes flail. Because the flail portion of the chest
hospitalized regardless of the initial appearance to evalu- wall is subject to changes in intrathoracic pressure, it
ate possible underlying injury and monitor for subse- begins to move independently of and paradoxically to
quent hypoventilation. An older patient’s mortality risk the intact portion of the chest wall. A flail segment may
increases with the number of fractured ribs. Patients occur anteriorly, laterally, or posteriorly on the chest. In
older than 65 years have a twofold increase in mortality a flail chest injury, the unstable segment of the normally
FIGURE 6-11 A, Flail chest occurs when three or more adjacent ribs are fractured in at least two locations, resulting in a freely moving
segment of chest wall during respirations. The chest wall moves paradoxically during inspiration and expiration because of the flail
segment. B, On inspiration, the flail segment sinks inward as the chest wall expands, impairing the ability to produce negative intrapleural
pressure. The heart and other contents of the mediastinum shift toward the noninjured side. C, During expiration, the flail segment is
pushed outward, the chest wall cannot efficiently force air from the lungs, and air may shift uselessly from lung to lung. (From Black JM,
Hawks JA: Medical-surgical nursing, ed 8, St. Louis, 2009, Saunders.)
rigid chest wall moves separately in the opposite direc- intrapleural pressure enhances this inward motion. A
tion from the rest of the thoracic cage as the patient reverse relationship develops on expiration in that the
attempts to inhale and exhale. The lateral type of flail intrathoracic pressure exceeds atmospheric pressure and
chest is the most common. The anterior type of flail the flail segment is pushed outward as the remainder of
results when the ribs become separated at the costochon- the thorax contracts normally. Thus, the loss of the struc-
dral junction, with or without an associated fracture of tural integrity of the thoracic cage does not permit gen-
the sternum. The posterior type of flail occurs when the eration of sufficient negative intrapleural pressure and
posterior ribs are fractured. In this case, paradoxical respiratory work increases in an attempt to overcome this
motion is minimal because of the support provided by abnormality.
the scapula and associated musculature. The associated pulmonary parenchymal injury pro-
The underlying problem with a flail chest is not so duces additional physiologic derangement. As a result of
much that of chest wall deformity as the underlying the lung damage (contusion and atelectasis), lung com-
parenchymal injury. A significant amount of force is pliance is notably reduced, airway resistance is increased,
required to cause multiple rib fractures, and this force is pulmonary diffusion is decreased, and the ventilation-
transferred internally to the underlying lung. During perfusion ratio is altered. These changes lead to an even
inspiration, the flail segment moves inward and during further increase in respiratory work.
expiration the flail segment is pushed outward. Other
significant injuries, intrathoracic and extrathoracic, are DIAGNOSIS
associated with a flail chest. The incidence of pulmonary The diagnosis of flail chest injury is usually made by
contusion with a flail chest is almost 70%.34,35 In these physical examination with careful inspection of the
patients, hemothorax is seen in 50% and pneumothorax unclothed patient. Observation of chest wall excursion
in 30%. More than 20% of patients have significant demonstrates paradoxical respiration of the involved
abdominal injuries, neurologic injuries, or both. chest segment. Excursions of the chest wall are best
observed while the physician stands by the patient’s side
PATHOPHYSIOLOGY and puts his or her hand on the injured hemithorax.
The physiologic alterations that occur with flail chest Paradoxical motion can be accentuated by having the
result not only from the disruption in chest wall mechan- patient taking a deep breath or cough. The chest radio-
ics but also from the associated pulmonary injury. As a graph is of limited value in establishing the presence of
consequence of the chest wall injury, the bellows action paradoxical respiration, but is useful in demonstrating
is reduced in the chest wall. During inspiration, the intact chest wall fractures, pulmonary contusion, atelectasis,
portion of the rib cage expands, drawing air into the hemothorax, or pneumothorax. Although flail chests are
lungs. However, the flail portion does not expand, usually readily identifiable clinically, a specific search
because it is no longer in continuity with the normally should be made for double fractures of three or more
expanded portion. Atmospheric pressure is exerted on adjacent ribs, a rib fracture associated with sternal frac-
the unstable segment, forcing it inward. The negative ture, or a costochondral separation.
BOX 6-3 Indications for Treatment of Flail Chest with BOX 6-4 Elements of Treatment of Flail Chest without
Mechanical Ventilation Mechanical Ventilation
Respiratory failure manifested by one or more of the following Supplemental oxygen administration
criteria: Humidification of inspired air
• Clinical signs of progressive fatigue Active physical therapy
• Respiratory rate > 35 breaths/min or <8 breaths /min Incentive spirometry
• PaO2 < 60 mm Hg at FiO2 > 0.5 Nutritional support
• PaCO2 > 55 mm Hg at FiO2 >0.5 Oscillating or rotating bed
• PaO2 /FiO2 ratio < 200 Analgesia
• Vital capacity < 15 mL/kg Nonsteroidal anti-inflammatory drugs (NSAIDS)
• FEV < 10 mL/kg Parenteral narcotic administration
• Inspiratory force > −2cm H2O Patient-controlled analgesic devices
• Alveolar-arterial oxygen gradient (AaDO2 [in mm Hg] at FiO2 Continuous epidural analgesic
1.0) > 450 Intermittent positive-pressure breathing
• Shunt fraction (Qs/Qt) > 0.2 Upper airway and endobronchial suctioning
• Dead space tidal volume ratio (Vds/Vt) > 0.6 Early stabilization of long bone fractures
• Clinical evidence of severe shock Continuous reassessment
• Associated severe head injury with lack of airway control or Physical examination
need to ventilate Serial chest x-rays
• Severe associated injury requiring surgery Serial arterial blood gas determinations
• Airway obstruction Oximetric monitoring
Serial spirometric testing
FEV, Forced expiratory volume in 1 second. Surveillance for pulmonary morbidity
Scheduled outpatient follow-up
Arterial blood gas measurements are of value in esti- morbidity and mortality than patients who require
mating the severity of the patient’s condition, even in the intubation.17-19,22 Tracheostomy is not routinely indicated
absence of obvious symptoms. These measurements may because many patients with flail chest injury require only
provide crucial information if the patient’s clinical course brief periods of ventilatory support. Tracheostomy should
deteriorates and can be used as the basis for instituting be considered in patients who have significant craniofa-
ventilatory support. Most patients with a flail chest have cial, maxillary, and mandibular injury—especially with an
a low partial pressure of oxygen (PO2) while breathing unstable airway or evidence of upper airway obstruction—
room air. A normal or elevated pH in association with an and in those intubated patients in whom ventilatory
elevated partial pressure of carbon dioxide (PCO2) indi- support is expected to exceed 7 to 10 days.37
cates the presence of severe parenchymal injury. Patients with unilateral paradoxical motion, a small
volume of chest wall paradox, mild to moderate pulmo-
TREATMENT nary contusion, and an arterial partial pressure of oxygen
The treatment of flail chest depends on the underlying (PaO2) greater than 60 mm Hg while breathing room air
parenchymal injury. It includes aggressive pulmonary (or >80 mm Hg while breathing supplemental oxygen),
physiotherapy, effective analgesia, selective use of endo- or with a tidal volume greater than 10 to 15 mL/kg of
tracheal intubation, and close observation for alterations body weight, can be treated without mechanical ventila-
in clinical signs and symptoms. The flail segment disrupts tion. The treatment regimen is the same as that discussed
the mechanics of breathing, prevents lung inflation, and for pulmonary contusion. Patients undergoing therapy
produces significant ventilatory compromise and hypoxia. in this manner should be observed carefully and have
The underlying pulmonary contusion, not the mechani- frequent ABG measurements. If signs of ventilatory
cal disruption of the chest wall, causes the respiratory insufficiency develop, endotracheal intubation must be
insufficiency. Specific indications for endotracheal intu- carried out promptly and mechanical ventilation
bation depend on objective evidence of respiratory instituted.
failure (Box 6-3), such as measurements of ABG levels, Adjunctive treatment for flail chest and pulmonary
respiratory rates, intrapulmonary shunting, and pulmo- contusion has historically included diuretics, fluid restric-
nary mechanics. Indications for intubation include a PO2 tion, steroids, and prophylactic antibiotics. However,
less than 60 mm Hg while the patient breathes room air there has been limited evidence that these measures
or less than 80 mm Hg while the patient breathes supple- enhance outcome or prevent pulmonary morbidity, and
mental oxygen, a tidal volume (VT) less than 10 mL/kg they are not routinely recommended.*
of body weight, hypercapnia (PCO2 > 55 mm Hg), respi- Effective pain management and aggressive chest phys-
ratory rate greater than 35 breaths/min, or the inability iotherapy, including suctioning, incentive spirometry,
to clear secretions and protect the airway.36 Not all
patients with flail chest injury require intubation (Box
6-4). Patients without respiratory impairment do not
require ventilatory assistance and tend to have lower *References 11, 27, 29, 30.
Costovertebral
dislocation
(any level)
Costochondral Traumatization of
separation pleura and of lung
(pneumothorax,
lung contusion,
Sternal subcutaneous
fracture emphysema)
Multiple rib Oblique rib

fractures fracture
(flail chest) Tear of
blood vessels
(hemothorax)
Compounded by
missile (may be Transverse
deflected) or by rib fracture
puncture wound
Overriding
Costosternal rib fracture
separation
Chondral
fracture
Injury to heart
or to great vessels
FIGURE 6-12 Blunt chest trauma can cause fractures of several components of the thoracic cage, including the ribs, clavicle, sternum
and, importantly, result in significant damage and complications to the heart, lungs, and other structures of the thoracic cavity.
humidification of air, and patient mobility, are useful and severity of the underlying parenchymal injury, and
important to enhance outcome and minimize morbidity. number of associated injuries.9,19 In Symbas’ series,38 a
Coughing is difficult and extremely painful for patients flail chest combined with pulmonary contusion was asso-
with flail chest because it is difficult for the patient to ciated with a 40% mortality rate. The mortality rate for
generate a cough with several fractured ribs. The explo- patients younger than 30 years or for those whose sole
sive force of the cough is limited secondarily to the para- injury is a flail chest is less than 3%. However, the mortal-
doxical movement of the chest wall. Because these ity rate approaches 40% in patients with head injuries
patients are limited in their ability to cough, bronchial and 60% in patients older than 60 years.
secretions cannot be effectively removed by the patients
and secretions may accumulate, with possible atelectasis
and pneumonitis. Current treatment relies on supportive FRACTURED STERNUM
measures; however, fixation of the fractured rib segments
has been advocated to restore chest wall mechanics. Two Blunt chest trauma associated with steering wheel inju-
small studies have conducted randomized trials suggest- ries is common (Fig. 6-12). However, fractures of the
ing that flail chest would benefit from open reduction sternum are relatively rare, occurring in only 5% of all
and internal fixation.12 They have found decreases in the victims of blunt trauma. These fractures are seen primar-
number of days a person is in the intensive care unit ily in older patients, rather than in children and young
(ICU) and on the ventilator. adults, because of the acquired inelasticity of the chest
The patient must be provided with adequate means of wall. Almost all fractures occur in a transverse plane and
pain control. Chest wall injuries can be painful, limiting most occur in the body of the sternum, near its junction
the patient’s ability to endure aggressive chest physio- with the manubrium. Fractures of the xiphoid process
therapy. Pain management techniques include nerve rarely occur because of its protected position between
blocks of the intercostal nerves, intrapleural local anes- the flare of the costal margins bilaterally. The diagnosis
thetics administered via the chest tube, nonsteroidal anti- is confirmed by visualization of the fracture site on a
inflammatory drugs (NSAIDs), narcotic and synthetic lateral or oblique chest radiograph or a radiograph of
opioids, epidural and/or systemic analgesics, continuous the sternum. A significant force is usually necessary to
and patient-demand local anesthetic or narcotic infusion produce a sternal fracture; thus, associated injuries are
systems, and other means of local or systemic pain common. It is therefore important to evaluate all patients
management. with sternal fractures for associated cardiac injuries or
The mortality rate from flail chest varies from 15% to other intrathoracic trauma. Injuries associated with a
89%, with death directly related to the age of the patient, fractured sternum include the following:
1. Myocardial contusion the emergency room. In such cases, surgical cricothyroid-

2. Pulmonary contusion otomy might be an option.
3. Flail chest Bronchoscopy is an important additive to ensure
4. Pneumothorax appropriate tracheal placement. Associated injuries to
5. Hemothorax the cervical spine, esophagus, and great vessels of the
6. Hemopericardium neck must be avoided, especially if a developing cervical
7. Pericardial laceration hematoma is present. As soon as the patient’s airway is
8. Ruptured bronchus established and stabilized, the tracheal disruption should
9. Cardiac rupture diminish. Prior to removal of the tracheostomy tube, the
10. Ruptured thoracic aorta functional status of the vocal cords and presence or
11. Abdominal visceral injuries absence of a previously unrecognized laryngeal fracture
12. Spinal injuries should be determined.
Most sternal fractures are nondisplaced and treatment
is directed only toward pain relief. Analgesics usually TRACHEOBRONCHIAL INJURIES
control significant sternal pain but, if they are not suffi-
cient, they can be supplemented with anesthetic injec- Tracheobronchial injuries are relatively rare but can be
tion into the fracture site. Although sternal fractures a devastating consequence of blunt chest trauma if
rarely require any surgical intervention, open reduction unrecognized or improperly treated. Prior to reaching
and stabilization should be carried out in all patients the emergency department, 75% of patients die.39 They
with severely displaced fractures, especially in those represent 1% to 3% of all thoracic injuries associated
who exhibit paradoxical motion, because nonunion is with blunt chest trauma and are frequently associated
common. These repairs should be delayed until the with other major thoracic injuries, such as cardiac, great
other associated injuries have been evaluated and treated vessel, or esophageal injuries. Blunt trauma that causes
because the mortality associated with sternal fractures is tracheobronchial injury has a high incidence of associ-
directly attributed to the associated injuries and not to ated injuries, and one third to one half have concomitant
the fracture itself. facial trauma. Although every level of the tracheobron-
chial tree can be involved, more than 80% of the injuries
CERVICAL TRACHEAL DISRUPTION are within 2.5 cm of the carina. Most injuries are to the
intrathoracic trachea or right mainstem bronchus. Cervi-
Cervical tracheal injuries are caused by direct trauma to cal tracheal injuries represent 4% of injuries, left bron-
the cervical area. Rupture of the cervical trachea may chus injuries 17%, distal tracheal injuries 22%, and right
occur without any external evidence of trauma. There bronchus injuries 27%.
are a number of symptoms of cervical tracheal disrup- The mechanisms of injury causing tracheobronchial
tion, including subcutaneous emphysema, inspiratory injuries include forceful compression of the trachea and
stridor, hoarseness, hemoptysis, dyspnea, coughing, thoracic cage, increased airway pressure, rapid decelera-
localized pain or tenderness, and cyanosis. The most tion injuries with shear forces at the point of relative fixa-
common early sign of cervical tracheal disruption is sub- tion of the trachea ( i.e., carina), and direct injuries.
cutaneous emphysema, which develops rapidly and In patients with tracheal or major bronchial disrup-
spreads extensively over the chest and anterior aspect of tion, two clinical patterns exist, depending on the rela-
the neck (Box 6-5). Pneumothorax, a common complica- tionship between the disrupted airway and pleural
tion, is usually mild and responds promptly to chest tube space. Patients who have a free communication between
insertion. Disruption of the cervical trachea must always the site of disruption and pleural cavity will have a large
be considered in any victim of blunt chest trauma who pneumothorax. Insertion of a chest tube results in con-
manifests respiratory distress in association with exten- tinuous bubbling of air and failure of the lung to reex-
sive subcutaneous emphysema. If rupture of the cervical pand with suction. The usual signs and symptoms in this
trachea is suspected, an initial attempt at intubation is group of patients include hemoptysis, dyspnea, and
warranted, with a flexible scope. If intubation is not pos- extensive subcutaneous emphysema. In patients in
sible, a tracheostomy below the level of the injury will be whom there is no communication between the site of
necessary. Performing an acute tracheostomy can be a disruption and pleural cavity, usually little or no pneu-
time-consuming and difficult procedure when done in mothorax exists.
Chest and cervical spine plain films can be most useful
in showing disruption of the tracheobronchial tree.
Bronchoscopy is the single definitive diagnostic study,
BOX 6-5 Causes of Subcutaneous Emphysema direct or fiberoptic.39 Securing the airway is the highest
priority for tracheal bronchial injuries. Flexible broncho-
• Perforation of trachea, bronchial tree, esophagus scope may facilitate intubation or oral intubation with
• Lung injury cervical spine stabilization. The necessity of a tracheot-
• Injury to face tracking inferiorly through fascial spaces omy can be up to 4%. A cricothyroidectomy is not as
• Injury to retroperitoneal space that tract through diaphrag- useful because the injury is usually distal.
matic hiatus If a pneumothorax is present, suction will reexpand
• Introduced from outside as a result of penetrating injury the lung. However, the surrounding granulation tissue
gradually obstructs the site of transection and delayed
atelectasis occurs. Nonoperative therapy is recommended

only for those patients with partial tears, complete reex- TABLE 6-3 Contents of Neck
pansion of the lung, and no prolonged air leak. All other
patients with transection of the tracheobronchial tree Zone 1 Zone 2 Zone 3
should undergo repair to avoid disastrous complications, Clavicle to inferior Inferior border of Angle of mandible
such as bronchiectasis or obstruction with secondary cricoid cartilage cricoid cartilage to to skull base
infection and lung destruction after they have been ini- angle of mandible
tially stabilized. If the injury is proximal, a low cervical Great vessels of Great vessels, Cranial cavity,
collar approach can be used. The injury should be neck, aortic arch, aerodigestive great vessels,
repaired with interrupted sutures. The operator should subclavian vessels, tract, cervical cervical spine,
be sure to examine the esophagus at the same time. If trachea, esophagus spine larynx, pharynx
the injury is more distal (intrathoracic), a sternotomy or
Adapted from Kesser BW, Chance E, Kleiner D, et al: Contemporary
thoracotomy approach may be indicated. Any devitalized management of penetrating neck trauma. Am Surg 75:1, 2009.
or necrotic tissue should be débrided. Most injuries can
be closed primarily and the injured area is resected;
primary repair of up to 50% of the trachea can be closed
primarily with the use of neck flexion. A guardian suture tracheostomy, with as little manipulation of the neck as
can be placed, which helps connect the chin to the possible, protecting from cervical injuries. After initial
sternum and prevent disruption of the repair. primary and secondary surveys have been conducted, the
patient can be definitively managed. The neck is divided
ESOPHAGEAL INJURIES into three zones to help communication among surgeons
and help plan treatment of possible injuries associated
Blunt injury to the esophagus is extremely rare because with injury to each zone (Table 6-3)16:
of the tremendous force required to cause injury and its Zone 1: Sternal notch or clavicles to inferior border of
position in the posterior mediastinum. Lack of tethering cricoid cartilage. Structures in zone 1 include the
of the esophagus helps protect the esophagus from great vessels of the neck, aortic arch, subclavian vessels,
tearing or disruption during deceleration injuries, unlike trachea, and esophagus.
the aorta.40 The diagnosis is frequently made late in the Zone 2: Inferior border cricoid cartilage to angle of man-
patient’s course of treatment. Signs and symptoms of dible. Structures in zone 2 include the great vessels,
esophageal injury include acute dysphasia, or the inabil- aerodigestive tract, and cervical spine.
ity to swallow saliva; 92% of patients have dysphasia and Zone 3: Structures in zone 3 include the angle of man-
60% have neck tenderness. A total of 90% of these inju- dible to the skull base, cranial cavity, great vessels,
ries are intrathoracic, occurring just above the level of cervical spine, larynx, and pharynx.
the gastroesophageal junction. Of blunt esophageal Accessing zone 1 and 3 is difficult. Previously, injuries
injury victims, 19% have cervical emphysema. If sus- to zone 2 that penetrated the platysma were mandated
pected, a biplane esophagogram, esophagoscopy, or to be explored surgically.16 Because of a high incidence
both should confirm the diagnosis. Esophageal injuries of negative neck explorations, surgical exploration is no
are diagnosed by lateral radiographs of the cervical or longer mandatory. Also, a negative neck rate as high as
upper thorax. An examination of the radiograph for 75% had been seen. Current recommendations include
emphysema in the mediastinum can indicate esophageal surgical intervention in the unstable patient (e.g., hemo-
perforation. If the patient’s signs or symptoms lead to a dynamic instability, airway, shock, hematoma, active brisk
strong suspicion, a Gastrografin swallow study or open bleeding, air sucking in or out of the wound). The ABCs
exploration in the acute setting or sepsis is the gold stan- are performed first. Stable patients can now benefit from
dard evaluation. An increase in the inflammatory a comprehensive workup, including CT with and without
response because of esophageal injuries such as leuko- angiography. Immediate interventions for the unstable
cyte increase with a left shift, low PO2, or acidosis can be patient should include DL, bronchoscopy, and/or esoph-
seen. Most of these injuries can be repaired coupled with agoscopy. The common carotid artery is the most
wide mediastinal drainage to prevent empyema from common injury in zone 2. Patients who remain hemody-
developing. Tracheoesophageal fistula can be a long- namically stable must receive routine physical examina-
term consequence. The patient should be kept NPO, tions to monitor for changes in vital signs and
have a nasogastric tube placed, and be given IV symptoms.
antibiotics.
DIAPHRAGMATIC INJURIES
PENETRATING NECK TRAUMA
Traumatic disruption of the diaphragm is an infrequent
Vascular injury is the serious consequence of penetrating occurrence in victims of nonpenetrating trauma. It is
neck trauma. Signs and symptoms of neck injury include detected in only approximately 3% of patients who
impending airway compromise of garbled or loss of survive MVAs and in 4% to 7% of immediate fatalities.
speech, hoarseness or dysphonia, persistent bleeding Left-sided diaphragmatic hernias occur in 95% of these
from oropharynx, and respiratory distress.16 A secure patients; the remaining patients having right-sided
airway is the highest priority in penetrating neck injuries hernias (Fig. 6-13). A force of great magnitude is needed
by endotracheal intubation, cricothyrotomy, or to disrupt the diaphragm; therefore, associated
displacement of the heart and mediastinal structures.

The diagnosis of traumatic disruption of the diaphragm
should be suspected in any patient who has sustained
blunt trauma to the chest and in whom the previously
described clinical and radiographic findings are present.
Note that the treatment of every form of traumatic dis-
ruption of the diaphragm is surgical. The mortality rate
for traumatic disruption is dependent on the severity of
associated injuries and degree of cardiorespiratory dis-
tress that results from herniated abdominal contents.
RUPTURE OF THE AORTA

An estimated 800 deaths annually are caused by aortic
disruption.37 Aortic injury is the second most common
cause of death in blunt trauma next to brain injury. The
cause of aortic injury is mostly MVAs and falls, with MVAs
resulting in 80% of injuries. In 1990, only 9% of aortic
ruptures survived at the scene. For drivers and front seat
passengers, the steering wheel deformity on arrival to the
FIGURE 6-13 Diaphragmatic rupture, with massive herniation of
emergency department is an independent predictor of
intraabdominal contents into the chest. This herniation results in
compression of the lung and displacement of the mediastinum to
serious thoracic injury . Classification of aortic injuries
the contralateral side, followed by marked respiratory distress,
are in six groups: intimal hemorrhage, intimal hemor-
cyanosis, and hypotension. The characteristic radiographic rhage with laceration, medial laceration, complete lac-
findings are elevation of the left hemidiaphragm, presence of an eration, false aneurysm formation, and periaortic
air-fluid level above the diaphragm, and displacement of the heart hemorrhage. Patients who arrive alive usually have an
and mediastinal structures. incomplete, noncircumferential lesion to the media or
intima. The tunica adventitia and mediastinal pleura
then prevent rupture. A patient with a suspected thoracic
vascular injury should be evaluated immediately by a
thoracic surgeon. Of those who have sustained a trau-
matic rupture of the aorta, 10% to 20% reach the hospi-
tal alive because the aortic blood is contained temporarily
by the adventitial or mediastinal pleura, forming a pseu-
doaneurysm. Left untreated, approximately 25% of
patients will die within the first 24 hours, with 5% of the
remaining patients dying each day during the next 2
weeks. Approximately 6% of the original group will
survive to develop chronic injuries, leading to a rate of
late rupture of 2%/year. To prevent this catastrophic
outcome, it is imperative that the diagnosis be estab-
lished quickly and appropriate therapy be instituted.
Traumatic rupture of the thoracic aorta is caused by
the following mechanisms:
1. Deceleration with or without chest compression,
most commonly encountered in motor vehicle col-
FIGURE 6-14 Diaphragmatic rupture. lisions or in falls from great heights
2. Compression or crushing injuries of the chest; inju-
ries frequently sustained when a person is run over
by a car or kicked in the chest by a large animal
intra-abdominal injuries are common, such as spleen, The more frequent sites of rupture of the thoracic
kidney, or liver lacerations and intestinal perforations. aorta are as follows:
Those with small diaphragmatic tears are usually asymp- 1. Descending aorta (aortic isthmus) immediately
tomatic. Those with large diaphragmatic tears usually distal to the origin of the left subclavian artery
have symptoms as a consequence of massive herniation (55%)
of the intra-abdominal contents into the chest (Fig. 2. Ascending aorta, proximal to the origin of the
6-14). This herniation results in compression of the lung innominate artery (19%)
and displacement of the mediastinum to the contralat- 3. Innominate artery origin (4%)
eral side, followed by marked respiratory distress, cyano- Other sites of involvement include the left subclavian
sis, and hypotension. The characteristic radiographic artery origin, midportion of the descending aorta, and
findings are elevation of the left hemidiaphragm, pres- distal descending aorta at the diaphragmatic hiatus
ence of an air-fluid level above the diaphragm, and (20%).
ment of a trachea-widened mediastinum. A contrast

INJURIES OF THE DESCENDING CT is now an effective diagnostic screening tool for trau-
THORACIC AORTA matic aortic injury; CT now approaches 100% specificity
and sensitivity and is more cost-effective.37
The classic site of blunt aortic injury is the descending Angiography is not recommended if mediastinal wid-
aorta at the isthmus, resulting in 36% to 54% of injuries. ening is present but the aortic contour is clearly defined
They can also occur at the ascending aorta proximal to and the nasogastric tube is not displaced. Angiography
the origin of the brachiocephalic, aortic arch, and distal is recommended if mediastinal widening is present and
descending or abdominal aorta.12,37,41,42 The high index the aortic contour is abnormal or obscured, or the naso-
of suspicion that vascular trauma has occurred in the gastric tube is displaced.43
setting of sudden deceleration remains the most impor- Aortography remains the gold standard for the diag-
tant factor in establishing the diagnosis of aortic injury. nosis of acute rupture of the aorta (Fig. 6-15). It has been
Despite the severe nature of the injury, one third of found to be a highly sensitive and specific method of
patients have no external evidence of thoracic trauma at detecting aortic injuries. Additional advantages are that
the time of the initial physical examination. The clinical it can be performed safely and quickly in critically injured
findings may be deceptively meager, but may include the patients, it can be performed wherever the patient is
following: acute onset of upper extremity hypertension, being evaluated, and no nephrotoxic agents need be
particularly suggestive if associated with excessive blood administered. Despite the severity of their injuries, trans-
loss; presence of a harsh systolic murmur heard over the esophageal echocardiography can be carried out in
precordium or posterior interscapular area; and a differ- victims of blunt chest trauma. It is important to remem-
ence in blood pressure between the upper and lower ber that a negative transesophageal study does not
extremities. These findings, alone or in combination, exclude the presence of a ruptured aorta and should be
occur in one third of patients with aortic rupture. Signs followed by aortography in patients with an unexplained
and symptoms of aortic rupture are dyspnea, chest pain, mediastinal hematoma. Aortography should be per-
and back pain. On the physical examination, shock, formed on any patient who has sustained a high-speed
steering wheel deformity, cardiac murmurs, hoarseness, deceleration injury or blunt trauma, who has clinical
palpable fractures of the sternum, or clavicles, and first findings suggesting aortic rupture, and who exhibits
rib should provoke suspicion of a thoracic vascular injury. changes in serial chest radiographs. The following sum-
marizes the indications for aortography in victims of
DIAGNOSIS blunt chest trauma:
Although the chest x-ray may be normal in patients with 1. History of deceleration injury
traumatic rupture of the aorta, standard chest radiogra- 2. Any chest radiographic finding listed in Box 7-6
phy continues to be an invaluable aid in diagnosing 3. Massive hemothorax
aortic rupture. Radiographic findings are suggestive, but 4. Pulse deficits
not diagnostic, of significant intrathoracic vascular injury 5. Upper extremity hypertension
(Box 6-6). A supine chest radiograph can detect or rule 6. Systolic murmur
out pneumothorax, hemothorax, and fractures. It has a 7. Unexplained hypotension
negative predictive value of 95% to 98%. A chest radio-
graph can show sternal fractures, clavicle fractures, first TREATMENT
rib fractures, obliteration of the aortic knob, depression Immediate repair of aortic injuries is recommended, but
of the left mainstem bronchus, loss of paravertebral surgery still has a mortality rate of 30%. Preexisting
pleural stripe, apical pleural cap, and lateral displace- cardiac disease increases mortality. Patients can be placed
into two categories; hemodynamically stable patients can
be afforded more preoperative time and workup and the
mortality rate can approach 25%. In the unstable group,
mortality increases to 90%. The likelihood of lethal sec-
ondary rupture of a false aneurysm mandates immediate
BOX 6-6 Indications for Thoracotomy* surgical repair as soon as the diagnosis is established and
the site of rupture is localized. Aortography should always
• Acute hemodynamic deterioration with cardiac arrest precede thoracotomy and repair unless contraindicated
• Cardiac tamponade by rapid deterioration of the patient’s condition. In
• Vascular injury at site thoracic outlet or great vessels patients with aortic rupture, associated injuries such as
• Massive air leak from chest tube rib fractures, flail chest, hemopneumothorax, extremity
• Tracheal or bronchial injury
fractures, head injuries, and abdominal injuries occur
• Esophageal injury
more than 75% of the time. When combined injuries are
• Retained hemothorax
• Traumatic diaphragmatic hernia
present, the treatment of specific lesions must be priori-
• Traumatic cardiac valvular or aneurysmal lesions
tized. In patients with stable hemodynamics at the time
• Traumatic pseudoaneurysms or aortic disruption of diagnosis, priority is given to repair of the aortic
• Tracheoesophageal fistula rupture. Abdominal injuries should be treated first in
patients who have unstable hemodynamics but do not
*Indications are based on physical findings, radiographic and echocardio- have hemothorax or an expanding mediastinal hema-
graphic imaging and, most importantly, the clinical course of the patient. toma. Patients who are hemodynamically unstable and
FIGURE 6-15 Aortograph used to diagnosis acute rupture of the aorta.
have an expanding mediastinal hematoma or hemotho-

rax should undergo aortic repair, with subsequent
abdominal evaluation. As noted earlier, of those who
have sustained a traumatic rupture of the aorta, 10% to
20% reach the hospital alive because the adventitial or
mediastinal pleura temporarily contains the aortic blood
(Fig. 6-16). Patients should be managed with an antihy-
pertensive regimen to decrease the risk of rupture. A
systolic blood pressure of less than 100 mm Hg or mean
arterial pressure (MAP) less than 80 mm Hg and heart
rate (HR) less than 100 beats/min should be maintained.
The use of beta blockers or vasodilators can help achieve
these parameters. Repair with an interpositional graft is
the treatment of choice.44
Innominate artery avulsion occasionally results from
deceleration or crush injuries and, like aortic rupture, is FIGURE 6-16 Example of an aortograph that shows a traumatic
frequently difficult to diagnose. Signs of distal ischemia rupture of the aorta, where the aortic blood is contained
are uncommon and diminution of radial or brachial temporarily by the adventitial or mediastinal pleura.
pulses is present in only 50% of patients. Chest radio-
graphic findings are comparable with those seen with MYOCARDIAL CONTUSION
descending aortic rupture, and aortography is necessary
to establish the diagnosis. Treatment is immediate surgi- The exact incidence of myocardial contusion is difficult
cal repair because of the threat of exsanguination from to determine because myocardial contusions are almost
secondary rupture of the pseudoaneurysm. always well tolerated and because the clinical signs are
transient and difficult to recognize, may vary widely in Cardiac dysrhythmias are another frequent finding
severity, and may occur without external evidence of stemming from myocardial contusion. A great variety of
chest injury. It is estimated that myocardial contusion dysrhythmias and conduction disturbances have been
occurs in 30% of blunt trauma cases.45 The most frequent reported. These include atrial fibrillation or flutter,
cause of contusion is a steering wheel injury from sudden supraventricular tachycardia, ventricular tachycardia,
automobile deceleration. However, mechanisms of injury ventricular fibrillation, asystole, right and left bundle
include direct pericardial impact, chest compression, branch block, sinoatrial block, and complete heart
increase in intrathoracic pressure, high-speed decelera- block. Approximately 80% of dysrhythmias requiring
tion, or a combination of these. This injury has also been treatment are demonstrable on the admission
reported to occur from blows to the chest, falls from a electrocardiogram.
great height, and upper abdominal trauma. Serum cardiac troponins—troponin I and troponin
Commotio cordis is a phenomenon caused by T—are highly specific to myocardial injury. They are not
sudden cardiac death resulting from a modest blow to found in skeletal muscles and are released into the cir-
the chest (e.g., softball) during the vulnerable phase of culation only after loss of membrane integrity. Both tro-
repolarization (just prior to the T wave) that leads to ponin I and troponin T are important in diagnosing
ventricular fibrillation and asystole. Only 13% of people cardiac injury. Moreover, a normal concentration of
survive.45 cardiac troponin I or T is an indicator of the absence of
Myocardial contusion is often well tolerated; most myocardial injury.
patients will never suffer any symptoms and recover fully. To diagnose a myocardial contusion, the ideal moment
Nevertheless, in some patients, life-threatening symp- of blood sampling has not been determined. However, if
toms, such as ventricular arrhythmias and cardiac failure, troponin I and T concentrations are within reference
will occur. Therefore, it is important to screen all patients ranges on admission, a second measurement after 4 to 6
with blunt thoracic trauma to identify those at risk for hours is necessary to exclude myocardial injury. Increased
complications. There is a spectrum of myocardial inju- troponin I or T levels may persist for 4 to 6 days and can
ries, ranging from myocardial stunning without myocyte be used to evaluate patients days after the injury.
damage to transmural necrosis and hemorrhage.45 Echocardiography has been helpful in identifying
Symptoms can be a troponin rise to ventricular rupture. structural abnormalities and pericardial effusions in
They may be synonymous with those of a myocardial patients who develop low cardiac output after blunt
infarction. trauma. A screening strategy is used to identify patients
Myocardial contusion has a wide spectrum of symp- at risk for cardiac complications in relation to the severity
toms. In patients with severe myocardial contusion, the of associated injuries. The diagnosis of myocardial contu-
diagnosis is not hard to determine. These patients will sion remains difficult. Sybrandy et al46 have suggested a
have hemodynamic instability. However, the symptoms screening strategy for detecting patients at risk for cardiac
might be caused by other factors in multitrauma patients. complications in relation to the severity of associated
The diagnosis is more difficult in patients without clinical injuries (Fig. 6-17).
evidence of myocardial contusion. The patient may com-
plain of chest pain or palpitations. These complaints are
often attributed to chest wall contusion or fractures. TREATMENT
Although most patients with myocardial contusion have Most patients with a cardiac contusion have a good
chest wall lesions, the absence of the lesions does not prognosis, and those who die usually do so as a result of
exclude the presence of myocardial contusion. other injuries. The treatment for myocardial contusion
In recent years, many studies have been done to find is primarily supportive. Pharmacologic with inotropes
a diagnostic tool to identify patients with a myocardial or temporary transvenous cardiac pacing if third-degree
contusion and those at risk to develop complications. atrioventricular (AV) block or high-degree AV block.
Myocardial contusion cannot be diagnosed with a single The patient should be followed for up to 1 month.
test. Electrocardiography may help establish the diagno- However, a decrease in cardiac output may develop in
sis of myocardial contusion in patients with thoracic as many as 20% of patients with cardiac contusion.
injuries, regardless of the presence or absence of symp- Therefore, and because of the potential electrical insta-
toms. The incidence of electrocardiographic evidence bility of the damaged area, general anesthetics should
of cardiac injury after blunt chest trauma varies from be avoided whenever possible in the period immedi-
18% to 38%. Although the electrocardiographic changes ately following injury. If an operation is deemed neces-
are frequently present when the patient arrives in the sary, the risk must be assumed. Procedures that are not
emergency department (or shortly thereafter), they may urgent should be delayed until there is electrocardio-
not appear until 24 to 72 hours later. Thus, serial elec- graphic evidence of complete healing or stabilization of
trocardiograms should always be obtained at 24-hour the myocardial damage, a process that usually takes
intervals. The most frequent electrocardiographic find- from 2 to 6 weeks.
ings are ST-segment and T wave changes similar to those Intraoperative monitoring of the central venous pres-
observed in myocardial ischemia and infarction. These sure or the pulmonary capillary wedge pressure with a
electrocardiographic changes are usually reversible, but Swan-Ganz catheter is of great value in these patients,
they may be observed for as long as 1 month following because hypotension may be caused by low cardiac
injury. output rather than hypovolemia.
Hemodynamically unstable Hemodynamically stable Mildly injured or

multi trauma patients multi trauma patients asymptomatic patients
Sternal fracture Raised troponin Normal troponin

and associated I/T or ECG I/T Normal
injuries abnormalities ECG
Serial ECGs and troponin Follow up ECG

Admit to ICU for I/T determinations within 24 hours
cardiac observation
and monitoring
In-hospital cardiac Significant

observation and monitoring changes
Deterioration of clinical
status
TTE/TOE
FIGURE 6-17 Screening strategy algorithm for detecting patients at risk for cardiac complications in relation to the severity of associated
injuries. ICU, Intensive care unit; TOE, transesophageal echocardiography; TTE, transthoracic echocardiography. (Adapted from Sybrandy
KC, Cramer MJ, Burgersdijk C: Diagnosing cardiac confusion: old wisdom and new insights. Heart 89:485, 2003.)
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CHAPTER
7 Recognition and Management of Shock

Derrick Flint
| Janice S. Lee
OUTLINE
Cellular Changes Obstructive Shock
Systemic Response Distributive Shock
Major Categories of Shock Treatment Principles
Hypovolemic Shock
Cardiogenic Shock
S
hock occurs when the cardiovascular system fails to Without an adequate supply of oxygen, mitochondria
perfuse vital organs. There are numerous clinical switch to anaerobic respiration, yielding only two ATP
events that cause shock, such as severe hemorrhage, molecules and lactate per glucose molecule. Lactate
trauma, burns, sepsis, anaphylaxis, myocardial infarction, lowers the tissue pH and is released into the systemic
and pulmonary embolism. Despite the cause, shock is system, becoming a useful marker for tissue hypoxia and
defined and ultimately diagnosed by the clinical evidence acidosis. Not only is lactate toxic to cells, but a lack
of inadequate tissue oxygenation and cellular death. of ATP generation leads to free radical formation
Once cell death occurs, inflammation, free radical for- and damage to vital cell functions, most notably ATP-
mation and edema can exacerbate hypoperfusion, creat- dependent ion channels that maintain normal mem-
ing a viscous cycle of irreversible tissue damage that brane potentials. When ATP-dependent Na+, K+, and Ca2+
causes further cardiovascular collapse, despite aggressive transport are disrupted, cellular membranes lose their
treatment. Therefore, it is essential that shock be recog- electrical gradient, leading to intracellular bleb forma-
nized and treated early to prevent end-organ failure and tion, cellular edema, and cell lysis. The tipping point for
death of the patient. irreversible cell damage is not entirely understood but is
Treatment of shock varies depending on the type of thought to be a result of uncontrolled release of intracel-
shock. There are four major categories of shock— lular Ca2+ stores. Intracellular bleb formation and
hypovolemic shock (hemorrhagic versus nonhemor- mitochondrial swelling are signs of irreversible cellular
rhagic), cardiogenic shock, obstructive shock, and dysfunction that leads to cell lysis. When intracellular
distributive shock (septic, anaphylactic and neurogenic).1 enzymes and cellular material are released into the sur-
Each category of shock may present with variable clinical rounding tissue and circulation, further inflammation,
signs and symptoms and requires different treatments. edema, and tissue damage occur.2,3
For example, aggressive volume replacement would be Endothelium normally produces nitric oxide but
appropriate in a patient who is in hypovolemic shock, but when damaged by inflammation, nitric oxide synthase is
may be detrimental in a patient with cardiogenic shock. overexpressed, producing toxic levels of nitric oxide and
Therefore, one must not only recognize shock but also other oxygen-derived free radicals that are formed when
be able to categorize it and implement the appropriate tissue are reperfused with oxygen. This reperfusion
treatment based on the available clinical data. This injury creates free radicals and further activation of
chapter will give an overview of the cellular and systemic inflammatory mediators, notably interleukin-8 (IL-8),
response to shock and then focus on its recognition, IL-1, and tumor necrosis factor (TNF). The combination
categorization, and current treatment philosophies. of ATP depletion, tissue edema, pH changes, free radical
formation, and inflammatory mediator formation leads
CELLULAR CHANGES to a complex vicious cycle of cell death and irreversible
organ damage.3
Organ hypoperfusion creates a hypoxic environment
that initiates cellular changes resulting in shock. At the SYSTEMIC RESPONSE
cellular level, shock occurs when the delivery of oxygen
is inadequate for cells to metabolize glucose for energy Different organ cells have extremely varying cellular
needed to run the cellular machinery. Cells depend on oxygen demands. Two of the most metabolically active
oxygen to carry out aerobic respiration via the mitochon- and oxygen-demanding tissues are the heart and brain.
dria. Mitochondria are the power plants of cells that This is clearly evident in the systemic response to hypo-
supply 36 adenosine triphosphate (ATP) molecules perfusion. During shock, the cardiovascular system
through the oxidation of each molecule of glucose. diverts blood flow from less vital structures to maintain
132
Recognition and Management of Shock CHAPTER 7 133
adequate perfusion to the heart and brain at the expense Afterload is the pressure or resistance to the forward
of tissues such as skin, skeletal muscle, gastrointestinal movement of blood being pumped from the heart. As
(GI) tract, and kidneys. This diversion is made possible the heart contracts, it must overcome the forward pres-
by differences in local and distant regulatory mecha- sure to propel blood through the circulatory system.
nisms. For example, the heart and brain at rest already Myocardial contractility is the force of the pump. A more
exhibit a high sympathetic vascular tone and thus tightly forceful contraction allows for a greater percentage of
autoregulate perfusion through local metabolites. In blood entering the heart to be ejected into the arterial
contrast, splanchnic blood flow is normally in excess of system. The ratio of blood entering and leaving the heart
metabolic demand and its vasculature is influenced is represented by the ejection fraction (EF); EF = SV/
much more by increases or decreases in sympathetic EDV, which is normally 55% to 80% (mean, 67%). An
tone. During prolonged shock, sympathetic-mediated EF of less than 55% indicates depressed myocardial
vasoconstriction in the splanchnic vasculature leads to contractility.
ischemia and necrosis, but the brain and cardiac blood When mean arterial pressure falls below 60 mm Hg,
flow are preserved because of metabolic autoregulation. tissue perfusion is compromised and shock ensues.
Cardiac output (CO) is the amount of blood pumped Hypotension and hypoxia are sensed by chemoreceptors
from each ventricle each minute. It can be represented and baroreceptors, resulting in reduced vagal tone and
by the following equation: the release of catecholamines (norepinephrine and epi-
nephrine) by the neuroendocrine system. This causes an
CO = stroke volume (SV ) × heart rate (HR ) increase in heart rate, cardiac contractility, vascular tone,
and total peripheral resistance to maintain blood flow
or to vital organs. It is the constriction of arterioles that
decreases blood flow to the peripheral organs and
CO = volume of blood pumped by the heartbeat × increases the total peripheral resistance. Blood flow to
beats/min the brain and heart are less affected by distant autonomic
regulation and rely more on local control mechanisms,
It is continuously regulated to meet tissue perfusion such as oxygen tension and metabolic byproducts. This
demands. For example, during strenuous exercise, CO allows for preservation of blood flow, despite significant
will increase from 5.8 to 15 liters/min to meet the reductions in cardiac output. In contrast, splanchnic
requirements of exercising skeletal muscle. CO is depen- blood flow is normally in excess of metabolic demands
dent on three variables: and is controlled more by circulating catecholamines. In
1. Preload times of shock, these organs can experience severe arte-
2. Afterload riolar constriction and early ischemia.
3. Myocardial contractility Vasoconstriction is vital for maintaining adequate per-
Preload is the amount of blood that returns to the fusion and diverting blood flow in times of shock but,
heart prior to contraction, the end-diastolic volume without volume replacement, prolonged vasoconstric-
(EDV). Increasing preload is often referred to as priming tion will lead to ischemia. The body can increase volume
the pump. More blood returning to the ventricles prior through mobilizing extravascular fluid into the circula-
to systolic contraction not only increases the amount of tion and by decreasing renal excretion.
blood ejected per heartbeat, but also increases the force Renin is released because of increased sympathetic
of cardiac contractility as indicated by the Frank-Starling stimulation and a decrease in blood flow sensed by the
law of the heart. The result is an increase in the stroke juxtaglomerular apparatus in the kidneys. Renin stimu-
volume and cardiac output. lates the formation of angiotensin I, which is converted
Preload is determined by the pressure difference to angiotensin II in the lungs. Angiotensin II is a potent
between the central venous system (great veins of the vasoconstrictor. It also stimulates the release of aldoste-
thorax and abdomen) and peripheral venous system. rone by the adrenal cortex and vasopressin, also known
Combined, the venous system holds 60% to 70% of the as antidiuretic hormone (ADH), by the posterior pitu-
circulating blood volume; most of this is stored in the itary. Aldosterone expands the intravascular volume by
peripheral venous pool of organs such as the skin, skel- increasing Na+ retention in the distal convoluted tubules
etal muscle, and splenic system. Veins are compliant and collecting ducts, and vasopressin retains water by
because of their thin walls, allowing them to collapse or increasing aquaporin channels in the collecting ducts.
distend with small changes in pressure. This compliance Overall, this causes a reduction in urinary output that
enables the venous system to act as a reservoir of circulat- can be measured to follow fluid status and resuscitation
ing blood volume, most of which is in the peripheral efforts. Generally, renal output of less than 0.5 mL/kg/hr
veins and does not contribute to the central venous pres- in adults and 1 mL/kg/hr in children signifies renal
sure. During hypovolemia, volume loss is reflected in a hypoperfusion.
loss in this venous reservoir as blood moves from the Not only does reducing the renal excretion of Na+ and
periphery into the central circulation. Also, an increase water increase the intravascular volume, but the body is
in circulating catecholamines—norepinephrine and able to regulate changes in transcapillary fluid move-
epinephrine—causes further venous constriction. This ment to improve intravascular volume. This occurs with
venous compliance allows a net shift of blood from the increases in capillary oncotic pressure and a decrease in
peripheral venous pool to the central venous system, thus hydrostatic pressure. When arterioles constrict, blood
maintaining adequate blood return to the ventricles. flow and hydrostatic pressure through capillary beds is
TABLE 7-1 Signs of Shock by Category
Signs Cardiogenic Hypovolemic Obstructive Neurogenic Septic

Blood pressure ↓ ↓ ↓ ↓ ↓
Jugular vein Distended Nondistended Distended Nondistended Nondistended
Urine output ↓ ↓ ↓ ↓ ↓
Peripheral ↓ ↓ ↓ Normal to ↑ ↑
temperature
Cardiac index ↓ ↓ ↓ Variable ↑
CVP ↑ ↓ ↑ ↓ ↓
PAWP ↑ ↓ ↑ ↓ ↓
SVR ↑ ↓ ↑ ↓ ↓
greatly reduced, causing a net shift of fluid into the vas-

cular space. Also, larger molecules are unable to cross BOX 7-1 Classification of Hypovolemic Shock
capillary fenestrations creating an oncotic pressure that
drives extravascular fluid into capillaries. This oncotic
pressure is magnified when catecholamines stimulate gly- HEMORRHAGIC
cogenolysis and gluconeogenesis, causing an increase in Trauma
Gastrointestinal bleeding
the blood glucose concentration. These compensatory
mechanisms are limited, and definitive treatment must NONHEMORRHAGIC
be initiated quickly and will vary depending on the type External fluid loss
and severity of shock.4 Diarrhea
Vomiting
MAJOR CATEGORIES OF SHOCK Polyurea
Fluid redistribution
These are shown in Table 7-1. Burns
Anaphylaxis
HYPOVOLEMIC SHOCK
The most commonly observed form of shock, hypovole-
mic shock, results from a rapid loss of intravascular
volume; this can be further subdivided into hemorrhagic Class II hemorrhage is a blood volume loss between
and nonhemorrhagic types (Box 7-1). Trauma and/or GI 15% and 30%. Clinical symptoms include tachycardia,
bleeding are the most common sources of hemorrhagic tachypnea, and a decrease in pulse pressure. These
shock, and exsanguination is responsible for 80% of patients are normally stabilized and usually respond to
deaths in the operating room and almost 50% of deaths expansion of the intravascular volume with crystalloids,
in the first 24 hours after injury.5 Retroperitoneal accu- but some patients may require blood transfusion.1
mulation is always a diagnostic challenge and the pres- Patients with class II blood loss can usually sustain normal
ence or amount of blood loss is frequently underestimated. pressures while supine but may be orthostatically
Nonhemorrhagic shock results from increased noncom- dependent.6
pensated fluid loss (e.g., dehydration, vomiting, diar- Class III hemorrhage is a blood volume loss between
rhea, polyuria, fluid redistribution), as seen in burns and 30% and 40%. These patients will have obvious signs of
anaphylaxis. inadequate perfusion, including significant tachycardia
Hemorrhage decreases intravascular volume. The and tachypnea, and are in need of blood products. In
average blood volume in a 70-kg person is approximately class III blood loss, patients are at great risk if resuscita-
5 liters (0.07 × weight in kilograms). The physiologic tion with restoration of intravascular volume is not
response is directly proportional to the volume of blood performed.
that is lost and can be classified by the percentage exsan- Class IV hemorrhage is a blood volume loss of more
guinated. Class I hemorrhage is a blood volume loss up than 40% and is an imminent life-threatening situation.
to 15%. In uncomplicated situations, there are minimal Symptoms include a significant depression in systolic
clinical signs. Patients with class I hemorrhage normally blood pressure and a very narrow pulse pressure. Urinary
compensate by baroreceptor-mediated reflex vasocon- output is negligible and mental status is depressed.1
striction, with a concurrent increased level of catechol- These patients exhibit an impaired level of consciousness
amines from baroreceptor stimulation and increased and will experience a precipitous death if intravascular
renin levels from the juxtaglomerular system. Intravascu- volume is not quickly restored (Table 7-2).
lar volume is regenerated by osmotic shifts from the Tachycardia by itself should never be considered a
extravascular fluid and through fluid absorption from pathognomonic sign in hypovolemic patients, because
the GI tract. Vascular resistance increases secondary to it is not a reliable indicator of the presence or severity
the vasoconstriction. of shock.6 Many hypovolemic patients will initially
TABLE 7-2 Pediatric Signs and Symptoms of Hemorrhagic Shock
System Class I Class II Class III Class IV

CV
Heart rate Normal or slow inc. + ++ +++
Blood pressure Normal Normal or slow −− −−−
Pulse Normal ↓ peripheral Thready peripheral Thready central
Respiratory Normal + ++ +++
CNS Normal/anxious Confused Lethargic Coma
Skin Warm Cool Cool, pallor Cold, cyanosis
Capillary refill Delayed Prolonged
Renal Normal Oliguria, ↑ SG Oliguria, ↑ BUN Anuria
BUN, blood urea nitrogen; CV, cardiovascular; CNS, central nervous system; SG, specific gravity.
Modified from ACS: ATLS course, ed 4, Chicago, 1992, ACS
have symptoms of bradycardia. Also, older patients and

patients on long-term beta blocker may not be able to BOX 7-2 Causes of Cardiogenic Shock
increase their heart rate appropriately. Conversely,
patients who are in pain and have minimal blood may be Extensive left ventricular damage
tachycardic.7 Papillary muscle rupture
Aneurysm of the left ventricular wall
CARDIOGENIC SHOCK Ventricular septal defect
Cardiogenic shock is an impairment of the cardiac pump Aortic stenosis
to maintain cardiac output despite the presence of ade- Cardiac arrhythmias
quate intravascular volume and tone. It can be caused by
intrinsic damage or a conduction disorder resulting in
peripheral hypoperfusion, cyanosis, oliguria, and altered
central nervous system function. On physical examina- myocardial infarction (MI) secondary to medications
tion, patients in cardiogenic shock can appear ashen and such as nitrates, or from hemorrhage caused by antico-
cyanotic, with evidence of confusion or agitation from agulant or thrombolytic drugs. The physiologic response
decreased cerebral perfusion. Extremities vasoconstrict can cause a worsening of cardiogenic shock because of
and become cool and clammy to the touch. Pulses are the perceived reduction in volume and perfusion by the
usually rapid and faint and arrhythmias are common. body, stimulating vasoconstriction and salt and water
The pulse pressure is narrowed and there are generally retention through the renin-angiotensin system. This
distant or muffled heart sounds on auscultation. Also, response increases afterload and worsens fluid overload,
summation gallops may be auscultated because of third causing pulmonary edema. Patients at greatest risk for
and fourth heart sounds. Systolic hypotension of less cardiogenic shock are those with diabetes, older patients,
than 90 mm Hg or a decrease in systolic blood pressure history of prior MI, female gender, peripheral vascular
from baseline by more than 30 mm Hg is usually noted. disease, angina, and EF less than 35%.
Other hemodynamic manifestations are elevated left
ventricular filling pressures greater than 15 mm Hg and OBSTRUCTIVE SHOCK
a reduction in cardiac index (cardiac output divided Obstructive shock occurs as a result of an extracardiac
by the body surface area) to less than approximately blockage of the cardiopulmonary system. The most
2.2 liters/min/m2. common cause of obstructive shock is massive pulmonary
There are many causes of cardiogenic shock (Box embolism. Pulmonary emboli generate circulatory shock
7-2). The classic presentation is heart failure caused by by obstruction of the pulmonary vessels, causing a selec-
extensive left ventricular damage—that is, ischemia to tive right ventricular ischemia, which leads to an increase
40% or more of the left ventricle during a massive infarc- in right cardiac afterload.9 Ensuing hypoxemia, coronary
tion. Most patients with cardiogenic shock (≈75%) have hypoperfusion, and systemic acidosis have a catastrophic
left ventricular failure, with right heart failure occurring effect on cardiac function, which eventually results in
in only 3% of patients.8 A differential diagnosis of cardio- biventricular dysfunction and cardiac failure.10 Other less
genic shock should also consider the mechanical effects common causes of obstructive shock are tumors, pericar-
of papillary muscle rupture, aneurysm of the left ven- dial tamponade, pericarditis, tension pneumothorax,
tricular wall, ventricular septal defect, and aortic stenosis, and primary pulmonary hypertension.
which account for the other 12% of cases. Cardiac
arrhythmias, such as atrial fibrillation with a rapid ven- DISTRIBUTIVE SHOCK
tricular response or ventricular tachycardia, also may Distributive shock is caused by profound circulatory
contribute to hypotensive shock. Shock can also occur in venodilation that results in severe abnormal fluid
patients under treatment for a presumptive diagnosis of redistribution. The most common causes of distributive
shock are sepsis, anaphylaxis, and central neurogenic injury, which results in a venodilatory spasm. In spinal
hypotension. cord lesions rostral to T1, cardiac vagal influences domi-
nate and bradycardia is present. This venodilation causes
Septic Shock a decrease in preload. Blood pressure is initially main-
Septic shock is hypotension caused by a generalized acti- tained by expanding intravascular volume. Poor perfu-
vation of the immune system by a suspected or culture- sion may result in a larger ischemia in the damaged area.
proven infection. It can be produced by infection with For this reason, α1-adrenergic specific therapy should be
any microbe, although gram-negative aerobic bacteria initiated for peripheral vasoconstriction and correction
are most often implicated. Lipopolysaccharide (LPS), a of hypotension.
component of the gram-negative cell wall, has been
found to be the primary causative agent of septic shock. TREATMENT PRINCIPLES
LPS consists of a fatty acid lipid A core and a poly
saccharide coat. Similar proteins have been isolated in Once shock is recognized, treatment to restore adequate
gram-positive bacterial walls and exotoxins (i.e., perfusion should be instituted without delay (Fig. 7-1).
Staphylococcus-induced toxic shock), and fungus. LPS In the trauma patient, lifesaving measures should first
binds in combination with circulatory blood proteins to be directed according to Advanced Cardiovascular Life
CD14 molecules on leukocytes, endothelial cells, and Support (ACLS) and Advanced Trauma Life Support
other cell types. The mononuclear phagocytes respond (ATLS) protocols by assessing and management of the
to LPS by producing TNF, which in turn induces IL-1 ABCDEs (see Chapter 5). In a hemorrhaging patient,
synthesis. TNF and IL-1 both act on endothelial cells to management of obvious massive bleeding is put before
produce other cytokines, such as IL-6 and IL-8. Increas- airway management, especially in the prehospital or bat-
ing concentrations of LPS induce nitric oxide and tlefield setting. Bleeding can usually be controlled by
platelet-activating factor that can produce profound direct pressure, a tourniquet around extremities, or a
vasodilation. IL-1 also increases the temperature set pneumatic antishock garment (PASG) if bleeding is from
point in the hypothalamus, increasing core body pelvic and lower extremity fractures. If massive hemor-
temperature. rhaging in not stopped soon, patients will exsanguinate
Hypovolemia, cardiovascular depression, and systemic and die before an airway can be secured. Most often,
inflammation must all be managed during the resuscita- trauma response is a team approach, with multiple areas
tive efforts of a patient in sepsis. Increased venous capaci- of treatment being orchestrated together. Patients in
tance and an absolute hypovolemia secondary to capillary shock should have an established airway with supplemen-
leakage lead to a relative loss of fluid into the extravas- tal oxygen to maintain oxygen saturation above 95%.
cular tissue. Peripheral vasodilation of vessels to the skin Breathing in shock can be rapid and shallow, a response
and skeletal muscle shunts blood away from the central that uses negative intrathoracic pressure to act as a
circulatory system, causing a decrease in perfusion to the central venous pump to increase venous return and
brain, heart, bowel, liver, and kidney. preload.
Mortality rates from septic shock exceed 50% and Vascular access should be attained with two large-bore
have two different presentations. The first type of IVs (16-gauge or larger) to allow for rapid transfusion.
mortality is the short course. Short-course patients die Poiseuille’s law (Fig. 7-2) demonstrates that flow rate is
within hours of the onset of sepsis because of over proportional to the radius of the capillary by the fourth
whelming refractory vasodilation. The second type has power. Central lines are inadequate for rapid transfusion
a longer lingering course, which has symptoms of a clini- because of the flow rate being inversely proportional to
cal pattern of severe hypotension, lactic acidosis, and the length. Infusion pumps or an inflated blood pressure
vasoconstriction. cuff around the solution can speed infusion by increas-
ing the pressure difference. Fluid warmers are used to
Anaphylactic Shock prevent coagulopathy caused by hypothermia and
Anaphylactic shock is the result of vasodilation secondary increase viscosity. Vascular access can be challenging
to a massive histamine release from an immunoglobulin because of vein collapse. Therefore, other measures such
E (IgE)–mediated systemic response to an allergen. Car- as an intraosseous or venous cutdown may be employed.
diovascular collapse occurs as a result of vasodilation Once vascular access is obtained, patients may receive
capillary leakage, leading to intravascular volume deple- a fluid challenge of 1 to 2 liters of an isotonic solution
tion.11 Treatment goals are to slow or reverse this patho- (lactated Ringer’s or normal saline solution). The
physiologic process. Epinephrine and diphenhydramine patient’s response to this challenge is carefully moni-
hydrochloride should be administered during anaphy tored for signs of improvement. In trauma patients,
lactic shock. All patients should receive supplemental hypovolemic shock caused by hemorrhage is the rule
oxygen, isotonic fluid infusion, and continuous cardiac unless there is an obvious cause for cardiogenic
monitoring. A large volume of crystalloid fluid may be shock, such as isolated trauma above the torso. If shock
necessary to reverse the vasodilatory hypotension that is persists following primary fluid therapy, the exact cause
associated with anaphylaxis. (i.e., hypovolemic versus cardiogenic shock) must be
ascertained.1
Central Neurogenic Hypotension Differentiating shock and determining the patient’s
Central neurogenic hypotension occurs transiently from fluid status rapidly is sometimes difficult. Central hemo-
vagus-induced venodilation or secondary to spinal cord dynamic monitoring can be performed with ultrasonog-

Critically III/Injured Patient
Primary Survey
ACLS/ATLS
Hemodynamically Stable Secondary Survey and Management
Initial Fluid Resuscitation
Recognition of Shock Adult: 2 L NS or RL
red: 20 mL/kg NS or RL
Hemodynamically Unstable
VS, CVP
Etiology
Injury/Conduction Cardiogenic Distributive Obstructive Hypovolemic
Cardiothoracic Surgery Electropharmacologic Therapy
Estimation of Blood Loss
Central Neurogenic Evaluate Need for Blood Products

Hypotension Sepsis Anaphylaxis
Spinal Cord Injury
Trauma
Chest
Tension Pul Pul Cardiac Chest Tube

Neoplasm
Pneumo Embolism Hypertension Tam
Nonhemorrhagic Hemorrhagic Thoracotomy
Abdomen
Fluid Administration
Ultrasound
Treatment of Underlying Cause/Symptoms

DPL
Laparotomy
Pelvic
Recognition and Management of Shock CHAPTER 7
PASG?
FIGURE 7-1 Diagnostic and management algorithm for shock.

137
raphy or catheters (Fig. 7-3) in the pulmonary artery from tension pneumothorax, which also presents with
to provide end points during fluid resuscitation. The distended neck veins, but tension pneumothorax pres-
pulmonary artery wedge pressure (PAWP) and central ents with absent breath sounds and hyperresonance to
venous pressure (CVP) are interpreted as indices of the percussion. These findings may be difficult to ascertained
end-diastolic pressure in the left and right ventricles. in a noisy trauma bay. If a tension pneumothorax is sus-
When PAWP and CVP pressures are less than 6 mm Hg pected and the patient is unstable, treatment should not
(normal, 4 to 12 and 6 to 12 mm Hg, respectively), most be delayed to obtain a chest radiograph. Immediate chest
patients in shock will benefit from fluid infusions tube placement or needle decompression with a large-
administered as repeated boluses equivalent to 1% to bore angiocatheter below the second rib in the midcla-
2% of body weight. Care must be exercised, because vicular line is a temporizing measure until a chest tube
distributive shock patients can manifest severely decreased can be placed. In severe intrathoracic hemorrhage, tho-
arterial pressure despite exponential increases in their racotomy should be performed emergently. In multisys-
cardiac output.12 tem trauma, if abdominal hemorrhage is suspected, a
Recent technologic advances and training in ultraso- diagnostic peritoneal lavage or abdominal ultrasound
nography allow for more rapid and less invasive assess- should be performed, depending on operator prefer-
ment of cardiac function and volume status in critical ences and equipment available.
settings compared with pulmonary arterial catheters. In the setting of volume loss, expanding the intravas-
Table 7-3 compares the advantages of each. Transesopha- cular volume is critical for maintaining cardiac output.
geal echocardiography (TEE) is more invasive (compli- However, what, when, and how much to give is a contro-
cation rate of 0.5%) than noninvasive transthoracic versial topic. As mentioned, a trial of 1 to 2 liters of IV
echocardiography (TTE). However, TEE is rarely indi- crystalloid may help assess the amount of blood loss
cated in an acute setting unless TTE is nondiagnostic. based on the patient’s response and may be the only
Both can yield valuable information, such as left ventricu- volume expander rapidly available in the field. However,
lar filling, EF, CO, diastolic dysfunction, valvular abnor- studies have shown that patients with class III or IV hem-
malities, and vena cava distensibility (inferior vena cava orrhage will need blood replacement; giving IV crystal-
[SVC] TEE and inferior vena cava [IVC] TTE).13 loid transfusions may further increase inflammation
In trauma, a FAST examination (focused assessment and tissue edema and decrease coagulation, leading to
with sonography in trauma) is a rapid way to locate bleed- worsening shock and increased mortality rates.14 One
ing in the pericardial, pleural, or intraperitoneal space. alternative is hypertonic saline (HTS). HTS reduces the
Patients with cardiac tamponade exhibit Beck’s triad of transfusion volume needed and can modulate or decrease
decreased arterial pressure, muffled heart sounds, and the inflammatory response associated with crystalloid
distended neck veins. Tamponade can be distinguished infusions. However, the ability of HTS to improve survival
outcomes is inconclusive in trauma resuscitation.15
Unlike crystalloids, giving blood will increase the
∆P × r 4 oxygen-carrying capacity and provide clotting factor.
Fα
η×L Unfortunately, component therapy is currently the best
F (flow) = ∆P (pressure) multiplied by r (radius)4 divided by blood treatment available to reverse massive blood loss. Blood
viscosity multiplied by L (vessel length). products are taken from donors, separated into various
FIGURE 7-2 Poiseuille’s law demonstrates that flow rate is components, and then stored for up to 40 days for packed
proportional to cannula radius by the fourth power. red blood cells (PRBCs), 30 days for fresh-frozen plasma
RA RV PA PCWP
FIGURE 7-3 Central hemodynamic monitoring catheter placement for central venous pressure and pulmonary wedge pressure. (From
Lederman RJ, Winshall JS: Tarascon internal medicine and critical care, ed 2, 2000, Tarascon Press.)
(FFP), and 5 days for platelets. All products have a shelf establishing predetermined blood component replace-
life and, over time, they slowly lose efficacy. Preservatives ment ratios (plasma-to-platelets-to-PRBCs). Fortunately,
in stored blood and the length of time blood is stored less than 5% of civilian trauma patients will require
may have direct effects on calcium and potassium levels, massive transfusion (10 or more units of PRBCs in the
respectively. The affinity of hemoglobin for oxygen may first 24 hours). However, this 5% account for 75% of the
increase if levels of 2,3-diphosphoglycerate decrease. In blood utilization in busy urban trauma centers.5
the situation of massive transfusion, adjuvant therapy to Although not yet adopted in the current ATLS protocol,
correct coagulopathy and electrolyte imbalance is often research and trends in trauma resuscitation are provid-
required (Table 7-4).16 Depending on institutional trans- ing evidence to support hypotensive resuscitation—
fusion protocols and blood bank availability, older blood target mean arterial pressure (MAP) of 50 mm Hg rather
products closer to expiration are generally given first. than 65 mm Hg—until active bleeding stops. A pros
Multicenter randomized clinical trials are underway to pective, randomized controlled trial of 90 patients by
determine whether shelf life affects blood component Morrison et al has demonstrated that hypotensive resu
efficacy,17 but cohort and observational studies have indi- scitation can decrease postoperative coagulopathy and
cated a possible detrimental clinical effect associated lower the risk of early postoperative death while reducing
with the transfusion of stored red blood cells.18,19 the amount of blood product transfusions and overall IV
Recent data from multicenter trials and the wars in fluid administration.20,21 Other adjuvants that can limit
Iraq and Afghanistan have shown a benefit in replicating transfusion amounts and coagulopathy associated with
what is lost—whole blood. PRBCs alone lack clotting trauma are the use of autotransfusion devices (e.g., cell
factors and, by giving more platelets and plasma upfront saver) and recombinant factor VIIa.5
with PRBCs, one can limit further bleeding and improve The treatment of cardiogenic or obstructive shock is
survival. Also, blood replacement by major trauma management of the underlying cause. In tension pneu-
centers is more effective if they have a massive transfu- mothorax, immediate treatment by needle decompres-
sion protocol (MTP) in place. This includes limiting sion or chest tube placement is essential. In myocardial
crystalloid infusion, reducing time for infusion, and contusion, proper pharmacologic support should be
initiated to restore hemodynamic stability. Patients with
cardiogenic shock secondary to arrhythmia are managed
TABLE 7-3 Advantages of Echocardiography and using ACLS protocols. Patients with pericardial tampon-
Pulmonary Arterial Catheters ade should have a pericardiocentesis. If shock persists,
Advantages of Echocardiography Advantages of PAC
thoracotomy should be initiated for definitive manage-
ment. In cardiogenic shock (i.e., failure secondary to
Cardiac chamber volumes Pressures
MI), right-sided heart catheterization is helpful for diag-
LV ejection fraction SVO2 nosis and treatment followed by emergent placement
LV diastolic function Continuous monitoring of an intra-aortic balloon pump or left ventricular assist
Pericardial space assessment PAOP device (LVAD).22 Revascularization with mergent per
Valvular dysfunction CO measures cutaneous transluminal coronary angioplasty (PTCA)
Noninvasive CO measures Not operator-dependent or coronary artery bypass grafting (CABG) appears to
provide early and longer term survival in eligible
CO, Cardiac output; LV, left ventricle; PAC, pulmonary artery catherter; patients.23
PAOP, pulmonary artery occlusion pressure; SVo2, mixed venous oxygen
saturation. From Salem R, Valle F, Rusca M, et al: Hemodynamic monitor-
Dopamine, dobutamine, and epinephrine are inotro-
ing by echocardiography in the ICU: the role of the new echo techniques. pic drugs that in clinical trials have proven to be benefi-
Curr Opin Crit Care 14:561, 2008. cial for the hemodynamic support of patients in septic
TABLE 7-4 Blood Products
Product Indications Dose

Packed red blood Class III heme 1 unit increases hematocrit by 3%
cells (PRBCs) Class IV heme
Hgb < 10
Platelets Thrombocytopenia Platelets less than 50,000 1 platelet concentration increases platelet count by
5,000-10,000
Fresh-frozen plasma Deficiency of factor concentration PT/PTT 10-15 mL/kg increases to 30% of normal plasma
> 1.5 normal factor concentrations reversal of warfarin therapy for
which 5-8 mL/kg
Cryoprecipitate Hemophilia A, von Willebrand disease, factor 1 unit /10 kg raises plasma fibrinogen concentration
XIII deficiency, microvascular bleeding in by ≈50 mg/dL
transfused patients with fibrinogen concentration
< 80-100 mg/dL
PT, Prothrombin time; PTT, partial thromboplastin time.
shock.24 Dopamine effects are dose-dependent. At low to cells for oxidative metabolism. Through numerous
dosages (1 to 10 µg/kg/min), dopamine is an agonist for compensatory mechanisms, the body attempts to pre-
β1-adrenergic receptors, which increase myocardial serve CO and maintain blood flow to vital organs such
contractility and renal blood flow. At dosages higher as the heart and brain. However, as shock progresses, a
than 10 µg/kg/min, α1-adrenergic receptors become positive feedback of cell death, acidosis, inflammation,
increasingly occupied, resulting in vasoconstriction. and coagulopathy will further worsen tissue perfusion
Dobutamine is predominantly a β1-adrenergic receptor and ultimately become irreversible and fatal. Treatment
agonist, with less stimulation of β2-adrenergic receptors. should be initiated first to stabilize the patient; then
Adverse myocardial effects of dobutamine include heart clinical examination, diagnostic tests, and continuous
rates more than 130 beats/min, ischemic changes on monitoring are necessary to help identify the underlying
electrocardiography, and tachyarrhythmias. Care must cause. Ultimately, the definitive treatment can be
be exercised because dobutamine can also stimulate established.
β2-adrenergic receptors, which may further vasodilate
patients with vascular tone already decreased by inflam-
matory mediators. Epinephrine provides a combination ACKNOWLEDGMENT
of α1- and α2-adrenergic effects, and also stimulates β1-
and β2-adrenergic receptors, increasing systemic vascular The authors wish to thanks Drs. Robert S. Glickman,
resistance (SVR) and CO simultaneously. Vasiliki Karlis, and Michael D. Turner for their previous
In the management of septic shock, antibiotics play contribution to this chapter.
an essential role, although consideration to the large
amount of LPS that is released during cell death must be
accounted for. The release of LPS can cause a severe REFERENCES
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3. Kristensen SR: Mechanisms of cell damage and enzyme release.
associated with a decline in mean arterial pressure below Dan Med Bull 41:423, 1994.
60 mm Hg and critical organ dysfunction.25 Phenyleph- 4. Mohrman DE, Heller LJ: Cardiovascular physiology, ed 4, New York,
rine and norepinephrine are effective agents in the treat- 1997, McGraw Hill.
ment of distributive shock by constricting vessels in the 5. Nunez TC, Cotton BA: Transfusion therapy in hemorrhagic shock.
skin and skeletal muscle. Curr Opin Crit Care 15:536, 2009.
6. Schadt JC, Ludbrook J: Hemodynamic and neurohumoral
Phenylephrine is a nonselective α-adrenergic agent responses to acute hypovolemia in conscious mammals. Am J Physiol
that causes vasoconstriction but does not have direct 260:H305, 1991.
cardiac stimulatory effects. Phenylephrine is useful in 7. Luna GK, Eddy AC, Copass M: The sensitivity of vital signs in iden-
the specific case of septic shock in patients at high risk tifying major thoracoabdominal hemorrhage. Am J Surg 157:512,
1989.
for cardiac arrhythmias. Norepinephrine has combined 8. Hochman JS, Boland J, Sleeper LA, et al: Current spectrum of
alpha and beta effects, and extensive use of this drug in cardiogenic shock and effect of early revascularization on mortality.
patients with septic shock has been well documented.26 Results of an International Registry. SHOCK Registry Investigators.
The refractory vasodilation of septic shock can be Circulation 91:873-881, 1995.
reversed by norepinephrine, which rescues the under- 9. Goldhaber SZ, Visani L, De Rosa M: Acute pulmonary embolism:
Clinical outcomes in the International Cooperative Pulmonary
perfused renal circulation and restores renal function in Embolism Registry (ICOPER). Lancet 353:1386, 1999.
patients with septic shock.27 10. Moore CL, Rose GA, Tayal VS, et al: Determination of left ventricu-
Because accumulation of lactic acid occurs during lar function by emergency physician echocardiography of hypoten-
shock, metabolic and/or respiratory acidosis must be sive patients. Acad Emerg Med 9:186, 2002.
11. Fawcett WJ, Shephard JN, Soni NC, Barnes PK: Oxygen transport
recognized and managed. Lactic acidosis is defined as a and haemodynamic changes during an anaphylactoid reaction.
lactate concentration of 0.5 mmol/liter and a pH of 7.35. Anaesth Intensive Care 22:300, 1994.
Bicarbonate therapy has been advocated for the treat- 12. Bunnell E, Parrillo JE: Cardiac dysfunction during septic shock.
ment of metabolic acidosis, but there is lack of clinical Clin Chest Med 17:237, 1996.
evidence that it improves oxygenation, tissue perfusion, 13. Salem R, Valle F, Rusca M, Mebazza A: Hemodynamic monitoring
by echocardiography in the ICU: The role of the new echo tech-
or overall survival, and its use in patients with lactic aci- niques. Curr Opin Crit Care 14:561, 2008.
dosis is not advocated.28 Respiratory acidosis is managed 14. Haut ER, Kalish BT, Cotton BA, et al: Prehospital intravenous
by ventilation and is based on the presence of physical fluid administration is associated with higher mortality in trauma
signs and depth of acidosis. Pco2 is measured to calculate patients: A National Trauma Data Bank analysis. Ann Surg 253:371,
2011.
the relationship between carbon dioxide production and 15. Bulger EM, Jurkovich GJ, Nathens AB, et al: Hypertonic resuscita-
elimination. Respiratory rates are then adjusted to regu- tion of hypovolemic shock after blunt truama: A randomized con-
late Pco2 levels. trolled trial. Arch Surg 143:139, 2008.
16. Faringer PD, Mullins RJ, Johnson RL, Trunkey DD: Blood compo-
SUMMARY nent supplementation during massive transfusion of AS-1 red cells
in trauma patients. J Trauma 34:481, 1993.
17. Lacroix J, Herbert P, Fergusson D, et al: The Age of Blood Evalu-
Regardless of the category, severity, or multiple causative ation (ABLE) randomized controlled trial: Study design. Transfus
factors, shock is the result of inadequate oxygen delivery Med Rev 25:197, 2011.
18. Edgren G, Kamper-Jørgensen M, Eloranta S, et al: Duration of red 23. Califf RM, Bengtson JR: Current concepts: Cardiogenic shock.
blood cell storage and survival of transfused patients (CME). Trans- N Engl J Med 330:1724, 1994.
fusion 50:1185, 2010. 24. Rudis MI, Basha MA, Zarowitz BJ: Is it time to reposition vasopres-
19. Tinmouth A, Fergusson D, Yee IC, et al: Clinical consequences of sors and inotropes in sepsis? Crit Care Med 24:525, 1996.
red cell storage in the critically ill. Transfusion 46:2014, 2006. 25. Parrillo JE: Pathogenic mechanisms of septic shock. N Engl J Med
20. Morrison CA, Carrick MM, Norman MA, et al: Hypotensive resus- 328:1473, 1993.
citation strategy reduces transfusion requirements and severe post- 26. Marik PE, Mohedin M: The contrasting effects of dopamine and
operative coagulopathy in trauma patients with hemorrhagic norepinephrine on systemic and splanchnic oxygen utilization in
shock: Preliminary results of a randomized controlled trial. hyperdynamic sepsis. JAMA 272:1354, 1994.
J Trauma 70:652, 2011. 27. Redl-Wenzl EM, Armbruster C, Edelmann G, et al: The effects of
21. Sapsford W: Should the ‘C’ in ‘ABCDE’ be altered to reflect the norepinephrine on hemodynamics and renal function in severe
trend towards hypotensive resuscitation? Scand J Surg 97:4, 2008. septic shock states. Intensive Care Med 19:151, 1993.
22. Sarkar K, Kini AS: Percutaneous left ventricular support devices. 28. Forsythe SM, Schmidt GA: Sodium bicarbonate for the treatment
Cardiol Clin 28:169, 2010. of lactic acidosis. Chest 117:260, 2000.
CHAPTER
8 Neurologic Evaluation and Management

Michael Gladwell
| Ivan J. Sosa
| Kevin Arce
OUTLINE
Initial Assessment Vascular Injury
Resuscitation: Initial Trauma Management Superior Orbital Fissure Syndrome
History Skull Fractures
Evaluation Epidural Hematoma
Mental Status Subdural Hematoma
Cranial Nerve Examination Diffuse Axonal Injury
Grading the Severity of Injury Cerebral Contusions
Anatomic Signs Cervical Spine Injury
Functional Signs Occipital Condyle Fractures
Mayo Head Injury Classification System for Traumatic Brain Atlanto-Occipital Dislocation
Injury Atlas Fractures
Diagnostic Studies in Head Injury Axis Fractures
Management of Head Injury Lower Cervical Spine Fractures
A
ccording to the Centers for Disease Control and INITIAL ASSESSMENT
Prevention (CDC), one unintentional injury kills
more people between the ages of 1 and 44 years RESUSCITATION: INITIAL TRAUMA MANAGEMENT
than any other disease or illness. More than 180,000 The initial evaluation of a person who is injured critically
deaths occur from injury each year, with one person from multiple traumas is a challenging task, for which
dying every 3 minutes. It also leads to more than $406 every minute can make the difference between life and
billion annually in medical costs and lost productivity. In death. Over the past 50 years, assessment of trauma
the United States, approximately 1.7 million traumatic patients has evolved because of an improved understand-
brain injures (TBIs) occur each year. Of these, 1,365,000 ing of the distribution of mortality and the mechanisms
(80.7%) were emergency department (ED) visits, 275,000 that contribute to morbidity and mortality in trauma.
(16.3%) were hospitalizations, and 52,000 (3.0%) were Mortality can be grouped into immediate, early, and late
deaths. deaths. Immediate deaths are caused by a fatal disruption
A good neurologic examination, in combination with of the great vessels, heart, and lungs or a major disrup-
a thoughtful battery of tests, will invariably achieve the tion of body cavities. Early deaths may occur at any time,
correct diagnosis. It is vital for the surgeon to become from minutes to hours after the injury. These patients
equally comfortable with the rapid assessment of the frequently arrive at a hospital before death and succumb
trauma patient and the potential for neurologic involve- because of cardiovascular and/or pulmonary collapse.
ment. Once initial stabilization of the patient has This leads to failed oxygenation of the vital organs,
been achieved, management of the neurologic injury is massive central nervous system injury, or both. The
determined by specific causative conditions. Rapid rec- mechanisms of failed tissue oxygenation include inade-
ognition of potentially reversible causes (e.g., basilar quate ventilation, impaired oxygenation, circulatory
artery occlusion [BAO], nonconvulsive status epilepticus, collapse, and insufficient end-organ perfusion. Massive
herniation), followed by the appropriate emergency con- central nervous system trauma leads to inadequate
sultations, can often prevent or reduce morbidity and ventilation and/or disruption of brainstem regulatory
mortality.1-3 centers. Injuries that cause early trauma mortality occur
This chapter is intended as a practical, rational, and in predictable patterns based on the mechanism of
efficient approach to the diagnosis and management of injury, the patient’s age, gender, and body habitus, or
the maxillofacial trauma patient with neurologic involve- environmental conditions. Late trauma mortality peaks
ment. Detailed discussions of neuroanatomy and the from days to weeks after injury and is primarily caused
cranial nerves are available elsewhere and have been by sepsis and multiple organ failure. Organized systems
omitted from this chapter. for trauma care are focused on the salvage of a patient
142
Neurologic Evaluation and Management CHAPTER 8 143
TABLE 8-1 Neurologic Examination
Parameter Description or Function Cranial Nerve Injury Associated Deficit

Mental status Level of consciousness
Glasgow Coma Scale
Simplified motor scale
AVPU
ACDU
Sensation Touch, vibratory, proprioception, pain
Cranial nerves CN I: Olfactory—sense of smell Anosmia
CN II: Optic—visual fields and acuity Visual field deficit; blindness
CN III: Oculomotor—eyelid elevation, pupil Pupillary abnormalities, diplopia, ptosis
reaction to light
CN IV: Trochlear—extraocular movement, Diplopia secondary to superior oblique muscle paralysis
superior oblique muscle
CN V: Trigeminal—muscles of mastication and Facial numbness, loss of corneal reflex, weakness of
face sensation muscles of mastication
CN VI: Abducens—extraocular movement Diplopia secondary to lateral rectus muscle paralysis
(lateral rectus muscle) (inability to abduct the eye)
CN VII: Facial nerve—muscles of facial Paralysis of muscles of facial expression
expression
CN VIII: Acoustic—hearing and balance Vestibular dysfunction, hearing loss
CN IX and X: Glossopharyngeal and vagus—gag Loss of gag reflex, dysphagia; vocal cord paralysis,
reflex, swallowing, vocal cord mobility tachycardia
CN XI: Spinal accessory—movement of Paralysis of trapezius and sternocleidomastoid muscle,
trapezius and sternocleidomastoid muscles shoulder dysfunction
CN XII: Hypoglossal—movement of tongue Tongue deviation toward side of injury, tongue atrophy
Motor system Muscle tone and strength
Cerebellar function Fine motor and gait
Reflexes Deep tendon reflexes, Babinski sign
from early trauma mortality, whereas critical care is during transport or on arrival at the hospital. The sec-
designed to avert late trauma mortality. ondary survey consists of a head to toe systematic assess-
Surgeons’ recognition of these patterns of injury have ment of the abdominal, pelvic and thoracic areas,
led to the development of the Advanced Trauma Life complete inspection of the body surface to find all inju-
Support (ATLS) approach by the American College of ries, and a neurologic examination (Table 8-1). It also
Surgeons. ATLS is the standard of care for trauma includes a complete history and physical examination,
patients; it is built around a standardized protocol for including the reassessment of all vital signs. Each region
patient evaluation. This protocol ensures that the most of the body must be fully examined. The purpose of the
immediate life-threatening conditions are actively identi- secondary survey is to identify all injuries so that they may
fied and addressed in the order of their risk potential. be treated. A missed injury is one that is not found during
The objectives of the initial evaluation of the trauma the initial assessment (e.g., as a patient is brought into a
patient are as follows: (1) to stabilize the trauma patient; hospital’s ED), but rather manifests at a later point in
(2) to identify life-threatening injuries and to initiate time. Radiographs and further imaging indicated by
adequate supportive therapy; and (3) to organize defini- examination are obtained. If at any time during the sec-
tive therapy or transfer to a facility that provides defini- ondary survey the patient deteriorates, another primary
tive therapy efficiently and rapidly.4-7 survey is carried out because a potential life threat may
The first and key part of the assessment of patients is be present. The person should be removed from the
the primary survey, in which life-threatening problems hard spine board and placed on a firm mattress as
are identified and resuscitation efforts are also begun. A soon as reasonably feasible because the spine board can
simple mnemonic, ABCDE, is used as a memory aid for rapidly cause skin breakdown and pain whereas a firm
the order in which problems should be addressed: mattress provides equivalent stability for potential spinal
A, airway maintenance with cervical spine protection fractures.6
B, breathing and ventilation
C, circulation with hemorrhage control HISTORY
D, disability (neurologic evaluation) More than 3 million facial injuries occur in the United
E, exposure and environmental control States each year. Maxillofacial injuries are commonly
On completion of the primary survey, resuscitation encountered in emergency and trauma settings, with
efforts are well established, the vital signs are normaliz- most of them being secondary to assaults and motor
ing, and the secondary survey is begun. This may occur vehicle accidents (MVAs). Information about the causes
of facial fractures depends on the country and location

of the trauma center; therefore, reported statistics vary TABLE 8-2 Terms Describing Altered Mental Status
widely. More than 50% of patients with these injuries
have multisystem trauma requiring coordinated manage- Term Definition
ment among ED physicians, trauma surgeons, maxillofa- Coma State of total unresponsiveness
cial trauma surgeons, and other medical and surgical Stupor State of severely impaired arousal with some
specialists as required for the best outcome for each unresponsiveness to vigorous stimuli
patient.8,9
Obtundation Decreased arousal state with some
Trauma to the maxillofacial anatomy mandates special
responsiveness to touch or voice
attention. The maxillofacial region is a complex area that
controls specialized functions, including seeing, hearing, Lethargy Decreased arousal state maintained
(somnolence) spontaneously or with light stimulation
smelling, breathing, eating, and talking. Also, the vital
structures in the head and neck region are intimately Confusion State of impaired attention but adequate
associated. It is also of great importance to remember arousal
that the psychological impact of disfigurement can be Delirium Acute state of confusion with periods of
devastating. The associated head injures and damage to agitation and sometimes hypervigilance,
the neurologic system are important to identify early in active irritability, and hallucinations; typically,
a patient who has sustained facial trauma. It is imperative alternating periods during which the level of
that the maxillofacial surgeon be scrupulous during the arousal is depressed
initial history taking and physical examination of the Dementia Insidious onset of progressive and
patient to avoid any ill-intended oversight of an injury. irreversible decline in intellectual function;
Once the initial stabilization has been performed, a patients may experience also superimposed
detailed history and complete physical examination are delirium, normal arousability, alertness
essential.10,11 If the patient is unable to give an accurate
history, witnesses to the injury must be questioned. Essen-
tials of the history that must be ascertained through ques-
tioning include the following:
1. Was there a witnessed loss of consciousness follow- suggest a psychiatric illness.12 A depressed level of con-
ing the injury? How much time was involved? sciousness represents failure of global brain function
2. Was there a lucid interval immediately after (Table 8-2).13
the injury? And, did this precede a loss of An immediate assessment of the patient’s level of con-
consciousness? sciousness should be made in the trauma patient, because
3. Has there been a change or deterioration in the a decrease could represent an emergent condition. A
patient’s mental status? patient with a normal level of consciousness is one who
4. Did the patient have any seizures or syncopal events is awake, alert, and aware.14 Quick assessment tools such
following the injury? Was there tonic deviation of as the Glasgow Coma Scale (GCS), AVPU, ACDU, and
the eyes toward one particular side? Simplified Motor Score (SMS; Table 8-3) can be used to
5. Was there associated spinal column trauma? Did rule out conditions that warrant immediate neurosurgi-
the patient complain of tenderness along the spine? cal intervention but are not a substitute for a formal
After the history is taken, a detailed general physical neuropsychiatric evaluation when it has been determined
examination is essential. A rapid neurologic assessment that it is indicated. It is also important to know the
can be made within minutes, thereby facilitating defini- patient’s baseline functional status, any history of altered
tive diagnosis and treatment. behavior, current medications, medical comorbidities,
prior psychiatric history, and any relevant circumstances
that preceded the trauma event. The assistance of family
EVALUATION members to obtain this pertinent history might be neces-
sary in the trauma patient secondary to the presence of
MENTAL STATUS an artificial airway, sedation, or altered level of conscious-
Mental status alterations involve changes in alertness, ness. An assessment of orientation, attention, memory,
cognition, and behavior. When referring to an individu- and executive function forms the foundation of the com-
al’s alertness, one is indicating a person’s ability to inter- prehensive cognitive mental status examination.15
act with his or her environment. Cognition is how one The GCS score is the most commonly used tool for
processes and integrates information and behavior refers the assessment of altered levels of consciousness. It also
to how we react to the environment. An altered mental guides therapeutic and diagnostic decision making and
status could be caused by a traumatic injury, a manifesta- allows estimation of prognosis in TBIs.16 It was developed
tion of a primary neurologic condition, an acute systemic in 1974 to improve communication among health care
process, or a metabolic imbalance. During the clinical providers caring for patients with brain injuries. The
examination, it is important to distinguish among current 15-point scale was published in 1976,17 with the
memory problems, disorders of thought, and an altered modification of the best motor response as having six
arousal or level of consciousness. The presence of levels and the division of flexion into two categories.
memory problems or disorientation is indicative of a Its three components assess the function of the
medical or neurologic illness, whereas thought disorders cerebral cortex and the upper brainstem but do not
information about the patient’s neurologic status. The

TABLE 8-3 Neurologic Scales for Assessment of Level of best eye opening, best verbal response, and best motor
Consciousness response are reported using one of two schemes, EVM
Scale Score or EMV. The former is recommended, because it follows
a logical clinical evaluation; the patient is asked to open
SIMPLIFIED MOTOR SCALE
the eyes and a verbal response is prompted, followed by
Obeys commands 2 a motor response.22
Localizes pain 1 AVPU is an acronym used in ATLS. AVPU scores
Withdrawal to pain or less response 0 roughly correlate to a GCS score of 15, 13, 8, and 6
respectively.23 As with the GCS, the AVPU system does not
AVPU
differentiate causes of altered mental status. The ACDU
Alert A mnemonic was devised in Sweden. In a study comparing
Responds to verbal stimuli V it to AVPU and the GCS scale in neurosurgical patients,
Responds to painful stimuli P ACDU scores roughly correlated to a GCS score of 15,
Unresponsiveness to all stimuli U 13, 10, and 6.24 This study also found that the AVPU scale
was not as effective for detecting early changes in level
ACDU
of consciousness and that the ACDU was easier to use, in
Alert A particular in patients with small decreased level of con-
Confused C sciousness. As such, it could be considered for use as a
Drowsy D screening tool for ward patients.
Unresponsive U The SMS was developed from the motor component
of the GCS because it was thought that the individual
GLASGOW COMA SCALE parts of the GCS score were as predictive of outcome as
Eye Opening the GCS score as a whole. The motor component alone
Spontaneous 4 of the GCS appears to be as sensitive as the GCS total
To voice 3 score when predicting the severity of head injury in
trauma patients and their risk of dying.25,26 The SMS scale
To pain 2
is as follows: obeys commands (2), localizes pain (1), and
None 1 withdrawal to pain or less response (0). The three-point
Verbal Response SMS demonstrates almost identical discriminatory value
Oriented, normal conversation 5 when compared with the six-point motor component of
Confused conversation 4
the GCS, emphasizing the importance of the 4 and 6
range in the GCS in predicting the need for intubation,
Words but not coherent 3
neurosurgical intervention, and outcomes in TBI.27,28
Incomprehensible sounds 2 Furthermore, it has been found to have better interrater
None 1 reliability than GCS, AVPU, and ACDU in patients pre-
Motor Response senting to the ED with an altered level of consciousness
Obeys commands 6 of traumatic or nontraumatic cause.29
Localizes to pain 5
CRANIAL NERVE EXAMINATION
Withdraws to pain 4
Cranial nerve injury is an important component of neu-
Abnormal flexion (decorticate posture) 3 rotrauma, which may not be readily apparent in the
Abnormal extension (decerebrate posture) 2 emergency room to which the patient is brought after
None 1 having sustained a maxillofacial injury. The incidence of
cranial nerve injury in craniocerebral trauma varies
between 5% and 23%.30 The initial evaluation includes a
assess cognition or differentiate delirium from dementia. detailed history and physical and neurologic evaluation,
Sedation and endotracheal intubation can affect its in which sensory and cortical function and hemodynamic
predictive value of the severity of the brain injury, need status are assessed. It is also important to evaluate the
for neurosurgical intervention, and long-term outcome. ocular movements, pupils, facial symmetry, and laryngeal
The GCS was originally established for in-hospital use; function. This will help determine the functional integ-
however, it has been demonstrated that there is a correla- rity of the cranial nerves. A detailed evaluation of each
tion between field GCS scores and patient outcome and individual cranial nerve is a time-consuming and elabo-
the need for neurosurgical intervention.18 Reporting rate exercise, even in a conscious patient, and is not
each GCS component in conjunction with the total score feasible in a comatose patient. Injury to the cranial nerves
provides a better estimate of prognosis, because up to can occur by shearing forces, rapid acceleration or decel-
38 combinations with 13 different sum scores are eration, injury to the skull base, and penetrating cranio-
possible.19-21 There is variation in scoring according to cerebral injuries.
providers and institutions, which can lead to unnecessary
referrals and neurosurgical interventions.22 The neuro- Olfactory Nerve
logic assessment should be repeated multiple times, with Head injury is the most common cause of injury to the
each interval documented to obtain reliable clinical olfactory nerve31,32 and the olfactory nerve is the most
common cranial nerve damaged in head injury.33 Diag- Right Left

nosis of post-traumatic anosmia may not be of importance
in immediate management. However, it may assume medi-
colegal importance for the patient in the future. Olfaction
is impaired because of injury to the olfactory nerve fila-
ments at the cribriform plate or because of injury to the
olfactory bulb or olfactory tracts. The olfactory nerve fila-
ments can get torn by fractures involving the cribriform
plate of the ethmoid bone. Frontal or occipital blows can
shear off the olfactory filaments through a shearing or
stretching mechanism of the nerve fibers and any frac-
tures in the area can lacerate the filaments. Olfaction can
also be impaired by edema, hematoma, or ischemia.
Closed head injury can produce impairment of olfac-
tory recognition despite preserved olfactory detection,
secondary to injury to the orbitofrontal and temporal
lobes.34 Olfactory nerves and tracts can also be injured
iatrogenically during surgical interventions involving the
anterior skull base. Olfactory nerve damage is suspected
in the presence of nasal bleed, periorbital ecchymosis,
proptosis, and cerebrospinal fluid (CSF) rhinorrhea in the
setting of craniocerebral injury. Clinically, patients often
complain of an altered taste sensation.35 In TBI with olfac-
tory nerve dysfunction, almost 40% recover their olfac-
tion. Most of these patients recover it within 3 months, and
may continue up to 2 years.36 In injuries in which there is FIGURE 8-1 Left eye relative afferent pupillary defect (Marcus-Gunn
severe disruption, spontaneous reconnection of the nerve pupil). When light stimulates the right eye (unaffected eye), both
pupils constrict equally and simultaneously. The right pupil has
fibers is not possible, making anosmia permanent.37
intact direct reflex and the left pupil constricts because of an
Optic Nerve and Chiasm intact consensual reflex. When the light is shined to the left eye,
pupils might dilate momentarily because neither eye is stimulated.
The optic nerve is approximately 4.5 to 5.0 cm in length, When the light stimulates the left eye, the pupil will continue to be
of which the intraorbital segment is the longest and the dilated because of an afferent defect and the right eye will not
intraocular segment is the shortest. The intracanalicular have a consensual reflex. (By permission of Mayo Foundation for
portion (contained within the bony optic canal of the Medical Education and Research. All rights reserved.)
sphenoid bone) measures approximately 5 to 7 mm and
is relatively immobile because of the fusion of the dural
sheath of the nerve to the periosteum. The intracranial potentials in the management of optic nerve injury.44
segment measures approximately 9 to 10 mm and joins They performed studies following different protocols,
with the opposite optic nerve to form the optic chiasm. and showed spontaneous visual recovery in 51% to 57%
Optic nerve injury secondary to trauma has been cases with conservative management.
described as a rare injury,38 with only a few series reported The treatment used is as follows:
in the literature.39-41 Loss of vision is the chief complaint 1. All patients are given large doses of dexamethasone
of a conscious patient with an optic nerve injury. A history (initial dose, 0.75 mg/kg, followed by 0.33 mg/kg
of loss of consciousness is elicited in almost 90% of every 6 hours for the next 24 hours)45 Steroids
cases of optic nerve damage40 and the presence of an are beneficial by reducing cellular edema, a
associated epistaxis (Maurer’s triad—head injury, epi- membrane-stabilizing action, and reducing circula-
staxis caused by traumatic pseudoaneurysm of the inter- tory spasm. Studies have shown various recovery
nal carotid artery, uniocular blindness) should alert the rates, from 30% to 100%, after nonoperative
clinician to the possibility of an accompanying optic treatment.46,47
nerve injury.42,43 Diagnosis of optic nerve injury is difficult 2. No patient is operated within 3 weeks. The visual
in patients with severe head injury with altered senso- evoked potential (VEP) test is given every week.
rium. An afferent pupillary defect (Marcus-Gunn pupil) 3. In cases of visual recovery or in patients with no
is seen in an isolated optic nerve injury; bright light perception of light, no surgery is carried out.
shone on the normal side elicits a consensual reflex on 4. In patients with partial recovery that becomes static,
the affected side, whereas light shone on the injured side optic nerve decompression can be carried out.
elicits relative pupillary dilatation (Fig. 8-1). Optic nerve 5. In patients in whom identifiable bony fragments
atrophy sets in approximately 4 to 6 weeks after an injury and hematomas are present, optic nerve decom-
has taken place. pression is carried out immediately.48
Operative versus nonoperative management of an Chiasmal injury is rare, seen in only 0.3% of all cases
optic nerve injury is controversial. Mahapatra and Bhatia of head injury.49 It is often associated with a severe
were the first to carry out a protocol based on a prospec- acceleration-deceleration strain; therefore, it is likely that
tive study and established the role of visual evoked the low incidence of chiasmal injury is related to the low
Right Left
Oculomotor Nerve Compression
Dilated, nonreactive (fixed) pupil due to
either cerebral edema or uncal herniation at
the ipsilateral side of the dilated pupil.
Bilateral Diencephalic Damage

Small, reactive pupils indicative of bilateral,
sympathetic pathway injury at the thalamus and
hypothalamus. This can be present in metabolic
coma.
Horner’s Syndrome
Small, reactive pupil (miosis) at the affected side
with lid ptosis. Patient will also exhibit anhidrosis
on the forehead on the same side. It can be
caused by trauma to the neck, carotid artery
dissection, or a lesion at the lateral medulla or
ventrolateral cervical spinal cord.
Pontine Damage
Small, nonreactive pupils. This can be due to
pontine damage due to ischemia or
hemorrhage. Bilateral pinpoint pupils could
also be representative of opiate overdose.
Bilateral Dilated Unreactive Pupils

Pupils are dilated and fixed secondary to severe
anoxia and indicative of severe brain injury and
imminent death.
FIGURE 8-2 Abnormal pupillary responses during ocular examination. (By permission of Mayo Foundation for Medical Education and
Research. All rights reserved.)
overall survival from this severe type of head injury. Midbrain hematoma in the tectal region can present with
Severe frontal impact can cause fracture in the sella and oculomotor palsy, which often results from compression
clinoid regions. There may be multiple facial fractures, of the nerve at the tentorial hiatus by the uncus during
causing separation of the optic foramina and splitting of transtentorial herniation. Avulsion or stretching of the
the chiasm.50 Skull base fracture can also extend to the nerve at the mesencephalopontine junction can also
sella and clinoids, causing direct injury to the chiasm. result in an isolated oculomotor palsy.54 Frequently, ocu-
During clinical examination, bitemporal field defects are lomotor palsy occurs in conjunction with other ocular
noted and, in the case of associated optic nerve injury, motor nerves contained in the cavernous sinus in the
there will be a visual loss in the involved eye. Funduscopic case of skull base fracture. Injury at the superior orbital
examination also reveals pallor of the optic disc on the fissure, orbit, or maxillofacial injury can result in injury
nasal side. Other cranial nerves may be involved in a to the superior or inferior divisions of the nerve. The
chiasmal injury and the management of this type of oculomotor nerve can also be injured in its course in the
injury is restricted to relieving the compressive bony frag- brainstem by a shearing injury.
ment or a hematoma. In the setting of a head injury, unilateral mydriasis
(Hutchinson’s pupil) assumes ominous importance as
Oculomotor Nerve being representative of an ipsilateral, supratentorial,
Head trauma accounts for 8% to 16% of all oculomotor expanding hematoma. Invariably, this is accompanied by
palsies,51,52 which is seen in 2.9% of all head injuries, concurrent alteration in sensorium. Mydriasis may also
including patients with multiple cranial nerve involve- be accompanied by ptosis and extraocular muscle weak-
ment.53 Of all the cranial nerves, oculomotor palsy ness. An avulsion or stretch oculomotor nerve injury is
in a patient with head injury imparts a sense of urgency suggested by the rapid recovery of consciousness in an
in imaging and management because of the possibility otherwise complete motor palsy present in the clinical
of an expanding intracranial hematoma (Fig. 8-2). examination.55 This injury may be relatively mild.56 In a
patient with proptosis, time should be allowed for the Lateral rectus palsy may recover completely or incom-
swelling to regress before ocular movements can be pletely. Diplopia may be corrected by prisms or by botu-
assessed appropriately. Detection of ocular pulsations linum therapy for antagonism of the medial rectus to
and bruit over the eyeball makes the diagnosis of a caroti- achieve binocular vision. Ocular muscle surgery is offered
cocavernous fistula obvious. in cases of persistence of lateral rectus palsy after 6 to 12
Ocular motility should be assessed after improvement months.
in the level of consciousness and resolution of periorbital
swelling. Palsy caused by a compressive lesion is likely to Trigeminal Nerve
resolve on removal of the lesion, whereas injury to the Branches of the trigeminal nerve are often injured
fascicles is likely to give rise to an aberrant regeneration, during severe maxillofacial and skull base injury, because
in which axons terminate in inappropriate structures. these nerves exit the various foramina from the skull.
Such a regeneration can result in elevation of the optotic The supraorbital and infraorbital nerves are injured in
eyelid on adduction and a pupil that is poorly reactive to trauma to the forehead, orbit, or maxilla. The inferior
light but constricts with adduction.57 Management of dental branch and the mandibular division (V3) of the
unresolved oculomotor palsy is difficult; extraocular trigeminal nerve can be injured in fractures of the
muscle surgery can achieve binocular vision in the mandible. Skull base injury with injury to the cavernous
primary position and reading positions. sinus region can result in ocular motor dysfunction,
with sensory impairment over the ophthalmic division
Trochlear Nerve (V1). Closed or penetrating injuries can cause injury to
The incidence of trochlear nerve injury is 2.14% in the trigeminal ganglion.63 Skull fractures involving the
head injuries.53 It is often accompanied by injury to middle fossa can extend into the foramen ovale and
other ocular motor nerves. When the trochlear nerve is foramen rotundum and damage the exiting nerves.
injured in isolation, this tends to occur at its subarach- Sensation along the cutaneous distribution of the
noid course. A sudden deceleration impact or blow to involved nerve is affected (Fig. 8-3). Hyperpathia can
the head may cause the brain to move back and the occur along the distribution of the affected nerve and
brainstem to impact against the tentorium, resulting in patients should be evaluated for corneal anesthesia,
a trochlear nerve injury. The presence of bilateral troch- because the eye requires sensation to be protected against
lear nerve injury is always caused by trauma.58,59 exposure keratitis and corneal ulceration. Patients who
Diagnosis of trochlear nerve injury is generally made develop a hyperalgesia can be treated with carbamaze-
in a conscious and cooperative patient. The patient com- pine or gabapentin. Alternatively, in intractable cases,
plains of diplopia with a perceived slant in the environ- the involved root can be sectioned or radiofrequency
ment, which is compensated by adopting a characteristic ablation of the ganglion can be done to relieve pain.
head tilt (Bielschowsky’s head tilt), with the head being
tilted away from the affected eye. Clinical examination Petrous Fractures
reveals hypertropia (visual axis higher in the affected The temporal bone itself is composed of five parts—the
eye) that worsens on lateral gaze. Bilateral trochlear palsy squamous, petrous, mastoid, and tympanic portions, as
is diagnosed by the presence of alternating hyperdevia- well as the styloid process (Fig. 8-4). The squamous
tion (upward deviation of one eye) in various positions portion is smooth and convex; the temporalis muscle
of upward gaze. In the presence of concomitant oculo- attaches to this region. The zygomatic arch projects
motor nerve palsy, trochlear nerve palsy can be suspected forward from the inferior part of the squamous portion,
in the absence of intorsion of the eye. Spontaneous giving rise to the articular tubercle just anterior to the
recovery occurs in 65% of patients with a unilateral glenoid fossa. The fossa is bounded posteriorly by the
trochlear nerve palsy.60 The use of an eye patch or prisms tympanic portion of the temporal bone and the bony
pasted onto spectacles can be useful for achieving bin- external auditory canal. The pyramid-shaped petrous
ocular single vision. In case of incomplete recovery after
12 months, corrective ocular muscle surgery can be
carried out.
V1
Abducens Nerve Greater occipital
nerve (C2)
Head injury accounts for almost 3% to 15% of abducens
Lesser occipital
palsies.52 Its long intradural course, with passage over the nerve (C2, C3)
petrous ridge, its relative fixed course under the petro- V2
clinoid ligament, and its location in the cavernous sinus Great auricular
C3
makes it vulnerable to stretch or tear.61 Hyperextension nerve (C2, C3) V3

C4
trauma to the cervical spine can also lead to an abducens
nerve palsy, which is typically accompanied by lower C5 Anterior cutaneous
cranial nerve palsies.62 nerve of the neck (C2, C3)
A conscious patient typically complains of diplopia Supraclavicular
nerves (C2)
on distant fixation; examination of ocular movements
reveals convergence of the visual axes and lateral rectus FIGURE 8-3 Cutaneous sensory distribution of the head and neck.
palsy. In an unconscious patient, the eyeball can be seen (By permission of Mayo Foundation for Medical Education and
adducted, with no abduction on oculocephalic response. Research. All rights reserved.)
Temporal Bone longitudinal fractures account for about 80% of cases,

Squamous part
Lateral View with the remaining 20% being transverse fractures.
Groove for middle Longitudinal fractures are most frequently caused by a
temporal artery lateral blow to the skull in the parietal region. Transverse
fractures are more commonly caused by an intense blow
Mandibular External acoustic to the occipital region or by a direct frontal injury. The
fossa meatus latter are more frequently serious or fatal. A fracture with
Zygomatic significant comminution or fracture lines running in
process both the longitudinal and transverse directions is termed
Articular a mixed fracture. Because studies have suggested that the
tubercle © MAYO traditional classification system may not predict the pres-
2006
Mastoid process
ence of sequelae, such as facial nerve injury or CSF leak,
alternatives to the traditional classification scheme have
Styloid process been developed. One alternative scheme that has dem-
FIGURE 8-4 Lateral view of the temporal bone. (By permission of onstrated better correlation classifies fractures based on
Mayo Foundation for Medical Education and Research. All rights whether they are otic capsule–sparing or otic capsule–
reserved.) violating. Others have suggested that fracture classifica-
tions should include more specifics regarding fracture
Temporal Bone location because of the difficulty in describing many frac-
Skull Base: Superior View
tures as longitudinal or transverse, or should describe
fractures in a manner that correlates with the optimal
surgical approach to repair the facial nerve.64
Facial Nerve
Internal carotid artery Trauma is the second most common cause of facial paraly-
Greater petrosal nerve sis after Bell’s palsy.65 During a deceleration head injury,
Fracture
the facial nerve is injured at the geniculate ganglion,
where it is tethered by the greater superficial petrosal
Right labyrinth nerve. The shearing force results in an intraneural contu-
External auditory canal sion, edema, and hemorrhage. Transection can also occur
Facial nerve in severe head injury cases. The presence of a fracture of
Vestibular nerve the otic capsule indicates severe trauma, and the facial
Cochlear nerve
Glossopharyngeal nerve nerve damage is generally complete in such cases.66 Facial
nerve palsy can be seen in 45% to 50% of patients with
Vagus nerve
Sigmoid sinus
a gunshot wound to the face.67 A missile fragment enters
from the lateral or inferior aspect of the temporal bone
© MAYO and, as it lodges in the bone, it dissipates its energy,
2006
damaging the facial nerve. The facial nerve is commonly
injured at its vertical segment as it exits the cranium at
the stylomastoid foramen.68 Immediate paralysis carries
FIGURE 8-5 Superior view of the temporal bone. (By permission of a worse prognosis and is caused by transection of the
Mayo Foundation for Medical Education and Research. All rights
nerve or another form of severe neural trauma. Delayed
reserved.)
paralysis, longer than 24 hours, is caused by nerve edema
and swelling of the nerve within its sheath or epineurium;
portion of the temporal bone is wedged between the this carries a better prognosis. Delayed paralysis can also
sphenoid and occipital bones at the base of the skull. be caused by external compression by an expanding
There are many important structures that pass through hematoma or edema of the loose fibrous tissue and peri-
it, including the carotid canal, internal jugular vein, and osteum between the nerve and bony canal.69
facial nerve (Fig. 8-5). An injury to the facial and vestibu- Generally, facial asymmetry is clinically obvious in a
locochlear nerves is common after head injury and a conscious patient. In an unconscious patient, there could
temporal bone fracture is a frequent accompaniment to be incomplete eye closure, with associated Bell’s phe-
this injury. As such, it would be pertinent to review briefly nomenon. Bleeding from the ear, CSF otorrhea, the
this type of fracture here.64 Battle sign, and hearing impairment are other features
There are generally two types of temporal bone frac- that should alert the physician to the possibility of a facial
ture patterns described and their reported incidence is nerve injury. Detailed evaluation of the secretomotor and
variable. Studies citing the radiographic incidence of each taste sensations can be done when the patient is con-
fracture type span a time period during which advances scious and cooperative. The site of injury can be ascer-
in imaging technology have led to much more detailed tained by Schirmer’s test, submandibular salivary flow,
radiographic images, and thus to differences in the fre- stapedial reflex, and electrogustometry testing. However,
quency of each radiographic diagnosis. Some fractures are in contemporary practice, high-resolution computed
not purely of a single type, but rather are a combination tomography (CT) and electrical testing studies can delin-
of longitudinal and transverse. As a general rule, classic eate the site of the injury.
Management of traumatic facial palsy continues to be dizziness may persist, which may require treatment with
controversial, with no consensus about the indications labyrinthine sedatives.
and timing of surgical intervention. Turner has reported
on the natural history of immediate and delayed trau- Glossopharyngeal, Vagus, and Accessory Nerves
matic facial paralysis, with satisfactory return of facial The three lower cranial nerves are injured together
function in 82% of cases of delayed facial palsy. Patients because of their close proximity with one another in the
with immediate paralysis had good recovery in 53% of jugular foramen. These nerves, after exiting the brain-
cases. An incomplete recovery may be functionally stem, enter the jugular foramen and a fracture of this
acceptable in some patients. Patients should be reassured region can lead to injury of the three nerves. This type
and watchful waiting initiated. of injury is uncommon because of the infrequent injury
In patients with a facial nerve paralysis, care is taken pattern of the posterior skull base in comparison to that
to avoid exposure keratitis and dryness of the cornea at of the anterior and middle skull base. More often, the
the affected site. Earlier recommendations of waiting for nerves are injured in their extracranial course because
3 weeks have now become obsolete for patients requiring of stab wounds, gunshot injuries, or stretch from high
surgical intervention, with findings of experimental falls. Occipital condyle fracture can also lead to injury to
studies advocating early surgery when appropriate. the ninth and tenth nerves.72
Decompression of the facial nerve improves recovery if Injury to the ninth, tenth, and eleventh nerves is
performed within 48 hours; slitting of the epineurium underestimated, because it may not be readily apparent
does not seem to confer any benefit.70 Presence or in the setting of head injury. A patient might experience
absence of anacusis determines the approach to be taken dysphonia, dysphagia, depressed gag reflex, and/or ipsi-
for decompression of the facial nerve. In anacusis, the lateral palatal palsy with paralysis of the trapezius and
translabyrinthine approach is used because it allows sternocleidomastoid muscles (Vernet syndrome). Indi-
excellent access to the entire intratemporal segment of rect or direct laryngoscopy would help confirm ipsilat-
the nerve. In the presence of hearing, a combined trans- eral vocal cord palsy. This is accompanied by loss of
mastoid middle fossa approach is used, which permits sensation over the posterior third of the tongue, soft
access to the perigeniculate and vertical segments of the palate, uvula, and larynx. A lesion outside the skull is
nerve.70 Results of facial nerve grafting appear to favor likely to affect the cervical sympathetic, and the clinical
early repair over delayed grafting. Anatomically intact picture includes Horner’s syndrome.
facial nerve has a higher potential for recovery. However, Prognosis is generally favorable in cases unaccompa-
there may be unpleasant sequelae of recovery in the form nied by skull base fracture. These patients may require
of dysacusis, ageusia, epiphora, and gustatory lacrima- nasogastric feeding if swallowing is impaired and causing
tion. Late sequelae can be in the form of facial contrac- aspiration. Once swallowing is reestablished, oral feeding
tures, tics, spasm, and synkinesis. Recovery from facial can be resumed. If the risk of aspiration persists,
palsy is graded according to the House-Brackmann these patients will require alternative long-term enteral
grading system. feeding to maintain hydration and nutritional intake.
Detailed evaluation by a speech or swallowing patholo-
Vestibulocochlear Nerve gist will be required for assistance in long-term care and
Following head injury, hearing loss can occur because management.
of damage to the vestibulocochlear nerve. Transverse
fractures of the petrous bone can damage the anterior Hypoglossal Nerve
portion of the vestibule and cochlea. These organs can The hypoglossal nerve is one of the least injured nerves
also suffer a concussion. An injury can occur with damage in traumatic head injuries. Fractures of the occipital
to the central auditory pathways in the brainstem. Pres- condyle can damage the hypoglossal nerve as it passes
sure waves generated by a blow to the head can damage medial to the condyle. Hypoglossal palsy can occur late,
the hair cells in the cochlea and cause high-frequency after a minor head trauma and condylar injury.73,74 More
hearing loss and tinnitus.71 In addition to fracture of the often, the hypoglossal nerve is injured in the course of
bony otic capsule, the nerve can also be damaged at the surgery on the neck while operating on the submandibu-
internal acoustic meatus. lar gland and on C2-C3 cervical disc procedures.
In a patient with an altered sensorium, ear bleeding, Patients with a hypoglossal nerve injury can experi-
CSF otorrhea, and the Battle sign should arouse the sus- ence speech alteration and also have difficulty in moving
picion of an eighth nerve injury. In a conscious patient, the food bolus in the mouth. Clinical examination will
a thorough medical history should include information reveal that tongue movement is absent on the side of
about the presence of vertigo, nausea, tinnitus, and injury, with deviation of the protruded tongue to the
impaired hearing. Otoscopic examination might reveal injured side. Recovery is expected in mild injury cases.
hemotympanum or the presence of CSF in the middle
ear. Facial palsy often is associated with this injury. Con- Motor System
ductive deafness generally has a useful recovery and is The motor system can be divided into the following:
amenable to surgical intervention. However, sensorineu- (1) the peripheral apparatus, which consists of the
ral deafness has a poor recovery, especially if the hearing anterior horn cell and its peripheral axon, the neuro-
loss has been complete. Tinnitus is usually self-limiting muscular junction, and muscle; (2) the more complex
and requires no more treatment other than reassurance. central apparatus, which includes the descending tracts
However, labyrinthine symptoms of vertigo, nausea, and involved in control; and (3) the systems involved in
initiating and regulating movement, the basal ganglia the extremities in space, size and shape of objects, tactile
and cerebellum. sensations of written patterns on the skin, and tactile
Dysfunction in individual components of the motor localization and tactile discrimination on the same side
system results in fairly specific abnormalities that can be or both sides of the body. Position sensation is tested with
evaluated at the bedside. Although multiple components the patient’s eyes closed. The examiner moves various
may be involved, particularly with diseases of the central joints, being sure to hold the body part so that the patient
nervous system, isolated involvement of the various com- does not recognize movement simply from the direction
ponents commonly occurs. Examination for motor dys- in which the patient may feel the pressure from the
function includes assessment of strength, muscle tone, examiner’s hand. Stereognosis is tested by placing some
muscle bulk, coordination, abnormal movements, and familiar object in the patient’s hand while his or her eyes
various reflexes. Many of these are best detected through are closed and asking the patient to identify the object.
simple but careful observation. However, a few maneu- Inability to recognize the size or shape is referred to as
vers aid in the detection of abnormality. astereognosis. Agraphesthesia is the inability to recog-
The power of the individual muscle groups is mea- nize letters or numbers written on the patient’s skin.
sured on a scale from 0 to 5: These abilities are impaired in lesions of the right pari-
• Grade 0—no motor activity etal region.
• Grade 1—palpable muscle contraction; no joint Check the deep tendon reflexes using impulses from
motion a reflex hammer to stretch the muscle and tendon. The
• Grade 2—complete range of motion with gravity limbs should be in a relaxed and symmetrical position,
eliminated because these factors can influence reflex amplitude. As
• Grade 3—complete range of motion against gravity; in muscle strength testing, it is important to compare
no resistance each reflex immediately with its contralateral counter-
• Grade 4—complete range of motion against gravity part so that any asymmetries can be detected. If you
with some resistance cannot elicit a reflex, you can sometimes do so by certain
• Grade 5—complete range of motion against gravity reinforcement procedures. For example, have the patient
with full resistance gently contract the muscle being tested by raising the
The respective muscle groups are referenced in terms limb very slightly, or have him or her concentrate on
of fractions of five (e.g., four fifths or strength as four forcefully contracting a different muscle group just at the
out of five. moment when the reflex is tested. When reflexes are very
When it is possible to assess the patient’s gait, impor- brisk, clonus is sometimes seen. This is a repetitive vibra-
tant information is provided regarding the extent of tory contraction of the muscle that occurs in response to
injury. Gait is tested by having the patient walk normally muscle and tendon stretch. Deep tendon reflexes are
and in tandem. In the latter, the patient is asked to walk often rated according to the following scale:
with one foot immediately in front of the other (i.e., heel • 0, absent reflex
to toe). A tendency to sway or fall to one side indicates • 1+, trace, or seen only with reinforcement
ataxia, suggesting an ipsilateral cerebellar dysfunction. • 2+, normal
Atonia and asthenia can occur in other lesions of the • 3+, brisk
nervous system and are not specific to the cerebellum; • 4+, nonsustained clonus (repetitive vibratory
their testing is described elsewhere. movements)
Loss of ability to perform finger to nose, heel to shin, • 5+, sustained clonus
and rapid alternating movements points to cerebellar Deep tendon reflexes are normal if they are 1+, 2+, or
disease. Hemispheric lesions usually lateralize ipsilater- 3+ unless they are asymmetrical or there is a dramatic
ally, whereas midline (vermian) lesions tend to manifest difference between the arms and legs. Reflexes rated as
with bilateral dysfunction. 0, 4+, or 5+ are usually considered abnormal.
In addition to clonus, other signs of hyperreflexia
Sensory System include spreading of reflexes to other muscles not
Light touch, pain, heat, cold, and vibration provide an directly being tested and crossed adduction of the oppo-
evaluation of the peripheral nerves and their central site leg when the medial aspect of the knee is tapped.
pathways to the thalamus. Light touch is tested by touch-
ing the skin with a wisp touch, using a piece of cotton or
tissue. Pain is tested using a sharp instrument such as a GRADING THE SEVERITY OF INJURY
pin. Temperature can be tested by touching the patient’s
skin with test tubes, one with warm water and the other Neurologic injury can be characterized anatomically or
with cold water. A comparison between both sides functionally.
provides a reference point with the unaffected side.
Vibration is tested with a tuning fork, preferably at a ANATOMIC SIGNS
frequency of 128 Hz. Again, compare this on both sides Plum and Posner have described coma anatomically,
and assess those findings with the same body part of the using respirations, pupils, eye movements, and motor
examiner. examination to localize lesions and to further describe
The cortical sensory system includes the somatosen- the rostrocaudal progression of brainstem herniation.75
sory cortex and its central connections. This system Tests for oculocephalic (doll’s eyes) and oculovestibular
enables the detection of the position and movement of (cold caloric) responses can yield valuable information.
Both tests assess the integrity of the brainstem. With an ing TBI (dura penetrated), subarachnoid hemor-
intact brainstem, the eyes should remain fixed straight rhage, brainstem injury
ahead while the head is forcefully turned to one side or
the other (doll’s eyes). Injection of cold water into one Category B
ear causes conjugate movement of both eyes ipsilaterally If none of the criteria in category A apply, classify as
(toward the irrigated ear) in a patient with an intact mild (probable) TBI if one or more of the following
brainstem (cold caloric). criteria apply:
Cheyne-Stokes respirations are characterized by 1. Loss of consciousness of momentary to less than 30
periods of hyperventilation separated by periods of minutes
apnea. In apneustic breathing, the victim has gasping 2. Post-traumatic anterograde amnesia of momentary to
and irregular respirations, which are separated by long less than 24 hours
periods of apnea. Decorticate posturing implies the 3. Depressed, basilar or linear skull fracture (dura
destruction of cortical input to the red nucleus of the intact)
midbrain (rubrospinal tract); it is characterized by arms
adducted and flexed, with the wrists and fingers flexed Category C
on the chest. The legs may be internally rotated and If none of the criteria in category A or B apply, classify
stiffly extended, with plantar flexion of the foot. Decer- as symptomatic (possible) TBI if one or more of the fol-
ebrate posturing reflects the absence of cortical input lowing symptoms are present: blurred vision; confusion
further caudally, resulting in the arms adducted and (mental state changes); dazed; dizziness; focal neuro-
extended, with the wrists pronated and the fingers flexed. logic symptoms; headache; nausea.81
The legs may be internally rotated and stiffly extended
with plantar flexion of the feet. DIAGNOSTIC STUDIES IN HEAD INJURY
FUNCTIONAL SIGNS CT is the imaging modality of choice for acute head-
Jennett and Teasdale76 have described GCS in an injured patients. It is used during the initial screening of
attempt to characterize the severity of injury and possi- head trauma patients because of its ease, availability, and
ble outcome.76-80 The scale uses three parameters—eye diagnostic value.82-84 The radiographic evaluation of the
opening, best motor response, and best verbal response. trauma patient with suspected intracranial injuries
The postresuscitation GCS is generally considered more allows the identification of life-threatening injuries that
reliable in providing an initial assessment of injury require immediate intervention; the findings can also be
severity. Although not consistently defined, this score correlated with those of the neurologic examination to
generally refers to the best GCS obtained within the help guide treatment and prognosis.85 The use of CT
first 6 to 8 hours of injury following nonsurgical resusci- scanning is of increasing value in the severely injured
tation. In severe head injury, the scale usually reads patient, in whom the need for intubation, ventilation,
between 3 and 8, in moderate head injury, it is between and sedation limits the clinical examination and assess-
9 and 13, and in mild head injury, it is between 14 ment of the injury severity.
and 15. In a retrospective review of trauma patients admitted
Coma is defined as the inability to obey commands, at a large trauma center, almost 50% of patients required
utter words, and open the eyes. No single score within head CT as part of their initial evaluation.86 Of these,
the range of 3 to 15 points forms a cutoff point for coma. 12.4% of patients were also diagnosed with a facial frac-
However, 90% of all patients with a score of 8 or less, and ture, demonstrating the value of CT in the overall survey
none of those with a score of 9 or more, are found to be of the polytrauma patient. When considering whether a
in coma according to the preceding definition. There- facial CT should also be ordered at the time of obtaining
fore, a GCS score of 8 or less has become the generally a head CT, the presence of a lip laceration, intraoral
accepted definition of coma. laceration, periorbital contusion, subconjunctival hem-
orrhage, and nasal laceration were found to have a high
MAYO HEAD INJURY CLASSIFICATION SYSTEM FOR correlation with the presence of facial fractures.87
In patients with severe injuries, CT scans are typically
TRAUMATIC BRAIN INJURY used to assess for internal injuries involving the head and
Category A neck, chest, and abdomen. Determining which stable,
If one or more of the following criteria apply, classify the alert trauma patient requires spinal imaging can be
injury as moderate to severe (definite) TBI: challenging. The history, mechanism of injury, physical
1. Death caused by this TBI examination, and clinical decision rules aid in determin-
2. Loss of consciousness of 30 minutes or longer ing which patients need spinal imaging and which type
3. Post-traumatic anterograde amnesia of 24 hours or is to be used. The clinical decision rules for spinal and
longer head imaging help limit the amount of unnecessary CT
4. Worst GCS full score in the first 24 hours less than 13, scans, provide for better use of resources, and limit the
unless invalidated on review (e.g., attributable to amount of radiation exposure while not missing life-
intoxication, sedation, systemic shock) threatening injuries. The clinical decision rules available
5. One or more of the following present: intracerebral include the Canadian Computed Tomography Head
hematoma, subdural hematoma, epidural hematoma, Rule (CCHR), the New Orleans Criteria (NOC), and the
cerebral contusion, hemorrhagic contusion, penetrat- NEXUS Low-Risk Criteria (NLC)88-90 (Box 8-1).
BOX 8-1 Clinical Decision Rules for Obtaining Cervical Spine or Head Radiographs in Trauma Patients
NEW ORLEANS CRITERIA In patients with none of the high-risk characteristics listed,
CT is required for patients with a minor head injury with any one assessment for any low-risk factor that allows for safe assess-
of the following findings (these criteria apply only to patients ment of neck range of motion is then done:
who also have a GCS score of 15): • Simple rear end MVA
• Headache • Sitting position in ED
• Vomiting • Ambulatory at any time
• Age ≥ 60 yr • Delayed onset of neck pain
• Drug or alcohol intoxication • Absence of midline cervical spine tenderness
• Persistent anterograde amnesia (deficits in short-term Patients who do not exhibit any of the low-risk factors are
memory) not suitable for range-of-motion-testing; therefore, radio-
• Visible trauma above the clavicle graphs must be obtained. When range of motion can be
• Seizure tested, radiographs are indicated in patients who are not able
to rotate their neck actively 45 degrees left and right.
NATIONAL EMERGENCY X-RADIOGRAPHY UTILIZATION STUDY
(NEXUS): LOW-RISK CRITERIA CANADIAN COMPUTED TOMOGRAPHY HEAD RULE
Cervical spine radiography is indicated for trauma patients High Risk for Neurosurgical Intervention
unless they satisfy all five criteria: • Glasgow Coma Scale score < 15 at 2 hr after injury
• No posterior midline cervical spine tenderness • Suspected open or depressed skull fracture
• No evidence of intoxication • Any sign of basal skull fracture (hemotympanum, raccoon
• Normal level of alertness eyes, otorrhea or rhinorrhea, Battle sign)
• No focal neurologic deficits • Two or more episodes of vomiting
• No painful distracting injuries • Age ≥ 65 yr
CANADIAN C-SPINE RULE Medium Risk for Brain Injury Detection by CT
Radiography is indicated for patients in whom a C-spine injury • Amnesia before impact ≥ 30 min
is a concern when any of the following is present: • Dangerous mechanism (struck by a motor vehicle, ejected
• Age ≥ 65 yr from a motor vehicle, or fall from an elevation of 3 feet or
• Dangerous mechanism of injury (fall from 3 ft or five stairs, more or five stairs
axial load to the head, MVA at high speed, ejection from a The rule is not applicable if the patient did not experience a
vehicle) trauma, has a GCS score lower than 13, is <16 yr of age, and
• Paresthesias in the extremities is anticoagulated or has an open skull fracture.
In the NLC decision instrument, no spine radiographs for surgical intervention and the presence of a foreign
are necessary as long as the patient satisfies all of the object and can help predict complications that can arise
following five criteria: (1) no midline cervical tender- from the surgical intervention. Neuroimaging findings
ness; (2) no focal neurologic deficit; (3) normal alert- with prognostic implications include the following:
ness; (4) no intoxication; and (5) no painful distracting (1) entry and exit sites; (2) missile track; (3) presence of
injury.88 In the NOC, a trauma patient should undergo intracranial fragments; (4) presence of intracranial air;
CT scanning if any one of the following findings is (5) transventricular injury; (6) midline shift; (7) mass
present: headache, vomiting, age older than 60 years, lesion; and (8) basal cistern effacement. Intracranial
drug or alcohol intoxication, deficits in short-term injury from missiles depends on the size and velocity of
memory, physical evidence of trauma above the clavicles, the foreign object. The injury can be caused by direct
and seizure.90 The CCHR is designed for patients older laceration, shock wave transmission, and cavitation.91
than 16 years with a GCS score between 13 and 15 and The prediction of outcome in patients with severe
loss of consciousness but no neurologic deficit, seizure, head injuries allows for proper therapeutic interventions
or anticoagulant therapy. Patients with minor head inju- to be instituted, allocation of required resources, and
ries are categorized into two levels of risk, medium and planning for adequate rehabilitation. Important inde-
high. A patient with any one of the five high-risk factors pendent prognostic factors in regard to outcomes of TBI
or one with two medium-risk factors should have CT are age, GCS motor score, pupil response, presence of
because of the high risk of requiring neurosurgical inter- traumatic subarachnoid hemorrhage (SAH), and CT
vention or having a clinically important lesion diagnosed findings.92 The Marshall CT classification groups patients
on CT.89 into six categories according to CT findings and helps
Traumatic intracranial injuries can be classified into estimate the risk of neurologic deterioration that would
penetrating and nonpenetrating. In the penetrating warrant early surgical intervention (Table 8-4). It uses the
type, a foreign object or a fracture fragment penetrates status of the mesencephalic cisterns, degree of midline
the intracranial compartment. Nonpenetrating trauma shift, and presence or absence of local lesions to catego-
occurs by contact with an object or an acceleration- rize patients. There is a strong correlation between the
deceleration or rotational motion injury. In penetrating Marshall CT classification and mortality and frequency
injuries, the use of CT scans helps determine the need of elevated intracranial pressure (ICP),91,93 with early
compromise. Brain trauma can also lead to dysfunction

TABLE 8-4 Marshall Computed Tomography of the blood-brain barrier (BBB), which in turn con
Classification of Traumatic Brain Injury tributes to the progression of cerebral edema. This cere-
Category Definition bral edema is classified as vasogenic or cytotoxic. In
Diffuse injury vasogenic edema, there is increased permeability of the
I No visible intracranial pathology BBB because of osmotically active molecules, such as
evident on CT scan plasma proteins, that lead to their accumulation in the
II Cisterns present with midline shift of interstitial fluid. Cytotoxic edema is caused by cellular
0-5 mm and/or lesion densities accumulation of osmotically active molecules secondary
present; no high- or mixed-density to changes in cell metabolism and malfunction of
lesion > 25 mL; may include bone membrane-associated pumps and ion transporters. Cel-
fragments lular edema then leads to an increase in tissue pressure
III (swelling) Cisterns compressed or absent with and elevation of the ICP. TBI also causes an increase in
midline shift 0-5 mm; no high- or proinflammatory cytokine production in the brain paren-
mixed-density lesion > 25 mL
IV (shift) Midline shift > 5 mm; no high- or
chyma, which leads to acute and delayed neuronal death
mixed-density lesion > 25 mL
and interference with growth factors.
Hypotension and hypoxia are major causes of second-
Mass lesion
Evacuated (V) Any lesion surgically evacuated
ary brain injury.94,95 The brain requires a continuous
Nonevacuated (VI) High- or mixed-density lesion supply of oxygen and glucose to remain functional and,
> 25 mL; not surgically evacuated unlike other organs, does not have high energy reserves.
It makes up only 2% of the body weight but receives 15%
to 20% of the total cardiac output. Cerebral autoregula-
tion is the mechanism that maintains cerebral blood flow
death being correlated with the presence of midline shift (CBF) across a wide range of cerebral perfusion pres-
greater than 5 mm on initial CT scan and a high-density sures (CPPs), which is the difference between mean arte-
or mixed lesion larger than 25 mL in volume.91 The rial pressure (MAP) and ICP.96 Normal values for CPP
Marshall CT classification is easy to use but it has its limi- range from 70 to 100 mm Hg; however, CBF remains
tations, because it depends on the arbitrary assessment relatively constant; even when the CPP is between 40 and
of the volume of mass lesions, does not take traumatic 140 mm Hg97 because of cerebral autoregulation. This
SAH into consideration, and two of the categories (V and autoregulation is achieved by the constant modulation of
VI) are based on a retrospective review of whether or not cerebral vascular resistance, in which the cerebral arter-
a surgical intervention was performed.91 ies respond to a fall in CPP by dilating and maintaining
relatively constant perfusion to the brain. Although the
MANAGEMENT OF HEAD INJURY optimal level for CPP after brain injury is debated, a
CPP below 50 mm Hg is associated with brain tissue isch-
The pathophysiology of traumatic brain injury is complex. emia and failure of cerebral autoregulation. When this
A TBI could be the result of direct or indirect traumatic happens, CBF and oxygen delivery cannot sustain normal
forces. Rotational, acceleration, or deceleration inertial aerobic metabolism and compensatory brain mecha-
forces during a fall or MVA can lead to superficial or nisms reach their physiologic limits. Therefore, a low
deep brain lesions. After a patient survives the initial CPP, which can be caused by low MAP, high ICP, or a
direct trauma, morbidity and mortality are mostly depen- combination of these changes, carries a significant risk
dent on the severity of the secondary biomechanical pro- for cerebral ischemia. Increases in ICP may be caused by
cesses. A cascade of molecular and functional changes mass lesions, cerebral edema, increased CSF production,
takes place after an injury, with some of these changes and obstructive hydrocephalus. Arterial hypotension may
being beneficial but many being harmful. Within the be caused by acute blood loss, fever, or decreased cardiac
rigid skull, the relationship between intracranial volume output. The elevation of ICP is associated with poor out-
and ICP becomes very important. Brain tissue edema, comes in TBI.98,99 ICP is normally maintained in adult
hemorrhage, and hematomas lead to an increase in cere- humans at approximately 7 to 15 mm Hg,100 with sus-
bral volume, which in turn causes an increase in ICP. tained increases in ICP above 20 mm Hg harmful to the
During primary brain injury, direct mechanical forces brain because of lower CPP and tissue ischemia.
lead to cell damage and axonal dysfunction. This direct
damage is manifested as focal or diffuse lesions. Focal VASCULAR INJURY
brain injuries include cerebral contusions, subarachnoid Blunt cerebrovascular injuries (BCVIs) are caused by
hemorrhage, and subdural and epidural hematomas. blunt trauma to the head, face, or neck. They result from
Their impact on morbidity and mortality is based on high-speed deceleration to the thoracoabdominal areas,
their location, size, and progression. Diffuse brain inju- which leads to sudden hyperextension or hyperflexion
ries include concussion and diffuse axonal injury (DAI) of the cervical spine. Crissey and Bernstein have
secondary to the shearing of axons. described the following mechanisms of injury for BCVI:
Secondary brain injury occurs as a result of biochemi- (1)direct blow to the neck; (2) hyperextension with con-
cal substances released because of the initial injury, tralateral rotation of the head; (3) laceration of the
which lead to further neural tissue damage and cause artery by adjacent fractures of the sphenoid or petrous
progressive neurologic deterioration and functional bones; (4) direct intraoral trauma.101 The most common
mechanism is hyperextension caused by stretching of the

carotid artery as it crosses over the lateral articular pro- BOX 8-2 Screening Criteria and Risk Factors for Blunt
cesses of C1 to C3.102 The different mechanisms that lead Cerebrovascular Injury (BCVI)
to injury cause an intimal tear, with exposure of suben- WESTERN TRAUMA ASSOCIATION ALGORITHM
dothelial collagen that leads to platelet aggregation and Patients with the following findings should undergo diagnostic
thrombus formation. Stenosis or occlusion may occur, as evaluation for screening and diagnosis of BCVI:
well as the development of a pseudoaneurysm from the • Any neurologic abnormality that is unexplained by a diag-
passage of blood through the area of the intimal tear.103 nosed injury
Patients may present with a latent asymptomatic period, • Blunt trauma patient with epistaxis from suspected arterial
usually of 10 to 72 hours before the onset of a stroke.102 source
Practice management guidelines and algorithms have Asymptomatic patients with significant blunt head trauma
been developed for the screening and treatment of and the following risk factors for BCVI should also be consid-
patients with BCVI (Box 8-2). ered for screening:
The two major types of vascular injuries after head • GCS < 8
trauma are traumatic carotid-cavernous fistulas (TCCFs) • Petrous bone fracture
and arterial dissection. TCCFs are rare and are associated • Diffuse axonal injury
• C-spine fracture, particularly those of C1-C3 and fracture
with skull base fractures.104,105 Liang et al, in a retrospec-
through the foramen transversarium
tive review of 312 patients with skull base fracture, found
• Cervical spine fracture with subluxation or rotational
an overall incidence of TCCF of 3.8%. The incidence was component
higher in middle cranial fossa fractures (8.3%) when • LeFort II or III facial fracture
compared with anterior (2.4%) and posterior (1.7%)
cranial fossa fractures. TCCFs develop because of the EASTERN ASSOCIATION FOR THE SURGERY OF
abnormal communication between the carotid artery TRAUMA GUIDELINES
and the veins of the cavernous sinus, creating a high- Trauma patients with these signs and symptoms should
pressure, high-flow fistula. The most frequent signs and undergo diagnostic evaluation for screening and diagnosis of
symptoms include proptosis, bruit, chemosis, vision BCVI:
• Arterial hemorrhage from neck, mouth, nose and ears
impairment, ophthalmoplegia, and facial pain. Loss of
• Large or expanding cervical hematoma
vision can occur in up to 25% of patients.105,106 The abdu-
• Cervical bruit in a patient < 50 yr
cens nerve is affected commonly because of its location • Focal or lateralizing neurologic deficit; includes hemipare-
within the cavernous sinus. The differential diagnosis for sis, transient ischemic attack, Horner’s syndrome, oculo-
TCCF should include superior orbital fissure syndrome, sympathetic paresis, signs of vertebrobasilar insufficiency
orbital apex syndrome, retrobulbar hematoma, and • Cerebral infarction evident on CT or MRI
cavernous sinus thrombosis. Angiography provides the • Any neurologic deficit incongruous with CT or MRI
definitive diagnosis of TCCF, although magnetic reso- findings
nance (MR) angiography and CT angiography can also Patients with the following risk factors are at high risk of
be used for the diagnosis. Transvascular detachable BCVI:
balloon embolization has become part of the treatment • Injury mechanism compatible with severe cervical hyperex-
algorithm for TCCF.107 tension with rotation or hyperflexion
Dissection of the internal carotid artery (ICA) occurs • LeFort II or III midface fracture
commonly along the cervical and petrous segments of • Basilar skull fracture involving the carotid canal
the artery. The presence of a carotid canal fracture (35%) • Closed head injury consistent with diffuse axonal injury;
is associated with an ICA dissection. Of patients with a GCS score < 6
traumatic ICA injury, 10% exhibit immediate symptoms, • Cervical vertebral body or transverse foramen fracture, sub-
55% experience symptoms within the first 24 hours, luxation, or ligamentous injury at any level; any fracture at
and 35% experience no symptoms until 24 hours after level of C1-C3
injury.108 Patients can present with a headache, Horner’s • Near-hanging resulting in cerebral anoxia
syndrome, unilateral facial weakness, or paralysis.85,108 • Seat belt or other clothesline-type injury with significant
cervical pain, swelling, or altered mental status
ICA injuries are typically diagnosed after the develop-
ment of an unexpected neurologic deficit. Approxi-
mately 80% of patients will progress to cerebral infarction
within 1 week after the onset of initial symptoms108 The
diagnosis of an ICA dissection can be made with CT significant dissections and hematomas (grade II),
angiography, magnetic resonance imaging (MRI), MR pseudoaneurysms (grade III), occlusions (grade IV),
angiography, or catheter angiography. Diagnostically, and vessel transections (grade V).109 On MRI, the most
an irregular stenosis or occlusion of the artery can be common finding is that of a crescent-shaped hyperin-
seen, as well as the presence of an intimal flap or a tense signal indicative of an intramural hematoma and
pseudoaneurysm. suggestive of an ICA dissection.85 The treatment of trau-
An arteriography grading scale with therapeutic and matic carotid injuries is influenced by the type of injury,
prognostic implications has been proposed for the mechanism of injury, and neurologic findings. Antico-
management of ICA injury. In this scale, the injuries agulation, direct repair, and endovascular repair can be
are categorized into nonhemodynamically significant performed depending on the type of lesion present and
intimal injuries (grade I), potentially hemodynamically neurologic findings.110,111
SUPERIOR ORBITAL FISSURE SYNDROME Depressed fractures can be present in up to 6% of

Superior orbital fissure syndrome (SOFS) was first head injuries and are associated with significant morbid-
reported by Hirschfield in 1858.112 Traumatic SOFS is ity and mortality because of parenchymal injury.123 Com-
uncommon, with a reported incidence from 0.3% to pound or open fractures account for up to 90% of
0.8% in craniomaxillofacial fractures. It can result from depressed fractures.124 They are clinical indicators of sig-
direct compression of displaced bone segments on the nificant injuries, given their 1.4% to 19% mortality rate.
contents of the superior orbital fissure or from an indi- Depressed cranial fractures have an infection rate of
rect mechanism, such as edema or hematoma secondary 1.9% to 10.6%124 and a 15% incidence of late epilepsy.125
to the traumatic event.113 The superior orbital fissure is Treatment of depressed cranial fractures is aimed toward
pear-shaped and is approximately 22 mm in length and improving cosmesis, decreasing the incidence of late-
2 to 3 mm in width at its narrower part and 7 to 8 mm onset post-traumatic epilepsy, and improving neurologic
at its broadest portion.113 Its width has been estimated in deficits. Surgical treatment of compound depressed frac-
cadaveric studies to be 3.21 ± 1.09 mm.114 tures is performed as soon as possible after the injury.
The clinical findings in SOFS are secondary to injury The wound is débrided and the displaced bone segments
to the neurovascular structures that pass through the are elevated in an attempt to decrease the risk of infec-
superior orbital fissure. These include the lacrimal nerve, tion and late epilepsy. Operative delay of longer than 48
frontal nerve, nasociliary nerve, oculomotor nerve, abdu- hours for compound depressed fractures increases the
cens nerve, trochlear nerve and superior ophthalmic infection risk to 36.5%.94,126
vein. The clinical symptoms consist of ophthalmoplegia, The management of the bone fragments in compound
ptosis, numbness along the forehead and upper eyelid, fractures has traditionally been removal after elevation
and a fixed, dilated pupil. The symptoms can be present and delayed cranioplasty for reconstruction of the defect.
in various degrees depending on the severity and timing Evidence suggests that in a selected group of patients,
of the examination in relation to the injury. In a series such as those with absence of gross wound infection, the
of 33 patients with SOFS, the most commonly associated immediate replacement of the bone fragments appears
fractures were those of the zygomatic and orbital bones. not to carry an increased risk of infection.124 Patients with
SOFS can also be caused by a carotid-cavernous fistula; compound depressed fractures can be treated nonopera-
when it is the causative mechanism, a better functional tively if there are no clinical or radiographic signs of
recovery after treatment is achieved when compared with dural involvement, significant intracranial hematoma,
the fracture group. Recovery of CN II, IV, and VI appears depression greater than 1 cm, frontal sinus involvement,
to reach a plateau approximately 6 months after injury.115 wound infection, gross deformity, and presence of pneu-
Of the cranial nerves, the trochlear nerve appears to be mocephalus or gross wound contamination.123,124 Closed
the least severely injured and also has the highest level or simple depressed fractures are treated surgically if the
of functional recovery. This can be correlated to its ana- extent of the depression is greater than the full thickness
tomic position within the superior orbital fissure, where of the adjacent intact bone or if there is an intracranial
it passes above the tendinous ring. hematoma with mass effect that requires evacuation.
The management of traumatic SOFS is still controver- The skull base is comprised of five bones—the orbital
sial and no definitive guidelines exist. Some studies have plate of the frontal bone, cribriform plate of the ethmoid
shown partial or complete recovery of motor and sensory bone, sphenoid bone, occipital bone, and squamous and
function following no intervention,116,117 leading some petrous portions of the temporal bone. Skull base frac-
authors to recommend a conservative approach with tures may involve the anterior, middle, or posterior fossa.
steroid therapy alone.118 Others favor surgical reduction In cases of high-velocity trauma, the frontal and anterior
of concomitant facial fractures to improve functional skull base regions are frequently involved. The upper
outcomes.113,119 cranial nerves (CN I, II, III, IV, and VI), paranasal sinuses
and cavernous sinus could be injured as a result of this
SKULL FRACTURES fracture pattern. In patients with frontobasal fractures,
Cranial fractures are associated with a high incidence of CSF rhinorrhea is seen in 4% to 48% of patients and
intracranial lesions, neurologic compromise, and poor pneumocephalus is seen in 10% to 50% of patients.
outcomes.120,121 They can be classified by location in the There are several classifications of anterior skull base
skull vault or those involving the skull base. Vault frac- fractures that use the location of the injury, the force
tures can be linear, stellate, or comminuted. They are vector, or clinical findings as part of the scheme. In the
also categorized according to the degree of bone dis- classification by Manson et al,127 frontobasal fractures are
placement as depressed or nondepressed fractures. The divided into three types: type I, isolated, linear, skull base
most common type of vault fracture is the linear type; fractures; type II, vertical-linear vault (frontal bone) frac-
this is associated with the lowest incidence of intracranial tures with basilar involvement; and type III, comminu-
injury. Despite this, the presence of a cranial fracture and tion of lateral and frontal vaults and orbital roof. In the
loss of consciousness indicate a high risk of developing Sakas et al classification, type I are cribriform plate frac-
an intracranial hematoma.122 An epidural hematoma tures, type II are frontoethmoidal fractures, type III are
could be present in temporal and occipital bone frac- lateral frontal fractures, and type IV are mixed fractures,
tures, with injury to the middle meningeal artery or dural with any combination of types I to III. In the Raveh et al
venous sinuses, respectively. Closed linear fractures are classification,128 an injury to the frontobasal region is clas-
nonoperative lesions unless they are associated with an sified into two broad categories—type 1, which consists
intracranial pathology. of frontonasoethmoidal and medial orbital frame
Temporal Bone Temporal Bone

Cross-section: Coronal view Skull Base: Superior View
Temporal bone
Facial nerve
(through the internal Fracture Internal carotid artery
acoustic opening)
Right labyrinth External auditory canal
Greater petrosal nerve
Vagus nerve Greater petrosal nerve
Glossopharyngeal Fracture
Internal carotid artery
nerve Facial nerve Right labyrinth
© MAYO Styloid process External auditory canal
2006
Facial nerve
Vestibular nerve
FIGURE 8-6 Longitudinal fracture of the temporal bone. (By Cochlear nerve
permission of Mayo Foundation for Medical Education and Glossopharyngeal nerve
Research. All rights reserved.) Vagus nerve
Sigmoid sinus
© MAYO
2006
fractures without skull base involvement and type 2,
which consists of combined skull base, frontonasoeth-
moidal, and medial orbital frame fractures, with frequent
FIGURE 8-7 Transverse fracture of the temporal bone. (By
optic nerve compression. Type 2 fractures in this classifi-
permission of Mayo Foundation for Medical Education and
cation are associated with significant cosmetic deformity,
neurologic injury, dural tears, and intracranial pathology
because of the displacement of the posterior frontal
sinus wall, telescoping of the nasal pyramid, and intracra-
nial displacement of the orbital roof and sphenoidal-
parasellar regions. present in 30% of patients with a CSF leak.131 In CSF leaks
Temporal bone fractures are classified according to with a delayed onset, it is thought that lysis of a blood
their relationship to the long axis of the petrous pyramid. clot blocking the fistulous tract, an increase in ICP, or
As noted, 80% of temporal bone fractures are longitudi- secondary trauma to the area contributes to the delayed
nal and occur after a direct lateral blow to the temporo- presentation. Delayed otorrhea is a rare finding. Early
parietal region (Fig. 8-6). These fractures begin in the post-traumatic CSF fistulas resolve spontaneously within
weaker squamous portion of the temporal bone and 1 week in 70% of patients and, in 80%, they heal by 6
course toward the carotid and jugular foramen. Clinical months. However, there is a 10% recurrence of rhinor-
findings can include a tympanic membrane tear and con- rhea after initial spontaneous cessation. Otorrhea usually
ductive hearing loss secondary to middle ear ossicle dis- resolves spontaneously.132,133
ruption. Patients can also present with bleeding from the A CSF fistula is not always clinically apparent. Patients
external auditory canal; approximately 25% will have a can experience headaches, decreased hearing, and a
facial nerve injury at the geniculate ganglion or facial salty taste. To facilitate the diagnosis of a CSF leak, a few
canal that leads to paresis of the muscles of facial expres- drops of the fluid can be placed on a tissue. CSF has a
sion on the affected side. Transverse temporal bone frac- more rapid diffusion than blood, leading to a larger,
tures occur after severe trauma to the occipital region clearer CSF ring surrounding a sanguineous central ring.
(Fig. 8-7). These fractures begin in the jugular foramen This is termed the double-ring or halo sign. Laboratory tests
and course across the petrous pyramid, through the for CSF detection include the presence of glucose
foramen spinosum and foramen lacerum, and into the oxidase, CSF glucose levels greater than 30 mg/dL,
foramen magnum. Approximately 50% of patients will protein content less than 2 g/L, and detection of beta-2
have facial paralysis from CN VII involvement at the transferrin.
internal auditory meatus or at the medial wall of the Bacterial meningitis is the primary cause of morbidity
tympanic membrane. Transverse fractures involving and mortality in patients with a CSF fistula. The inci-
the otic capsule and internal auditory canal can lead to dence has been estimated to be from 2% to 50%.134 The
severe sensorineural hearing loss. Vestibular symptoms most common organism is Pneumococcus, followed by
secondary to temporal bone injury can result for various Streptococcus and H. influenzae.135 In anterior cranial base
reasons, including direct otic capsule injury, labyrinth fractures, the proximity to the midline (cribriform plate),
injury, brainstem or nuclei injury, and presence of a peri- fractures larger than 1cm, and prolonged rhinorrhea
lymphatic fistula. (lasting 8 days) are associated with an increased risk
Approximately 20% of skull base fractures will develop of meningitis134 The value of antibiotic prophylaxis in
a CSF leak manifested as rhinorrhea or otorrhea; these patients with CSF leakage is debatable. Current evidence
are the result of a tear of the dura and arachnoid at the does not support prophylactic antibiotic use in patients
skull base. Of these, approximately 80% occur within with skull base fracture whether or not there is evidence
48 hours of the injury129,130 and pneumocephalus is of a CSF leak.136
In patients with a CSF leak, the head is elevated 30

degrees, fluid intake is restricted, and the patient is cau-
tioned against blowing her or his nose because of the risk
of intracranial space contamination. If a leak persists
beyond 72 hours, a lumbar drain may be effective in
reducing ICP and sealing the leak. Fewer than 5% of
patients with traumatic CSF leaks actually require repair.
Immediate surgical intervention is indicated for open
wounds that communicate with the dura or by the pres-
ence of an intracranial abscess or hematoma. Delayed
surgical repair is indicated for persistent or increased
CSF leakage over 1 or 2 weeks, persistent or enlarging
pneumocephalus, and the presence of meningitis. Endo-
scopic extracranial techniques have effectively replaced
the intracranial approach for the surgical repair of CSF
fistulae.137 Accurate identification of the site of CSF
leakage is necessary if a surgical repair is required. The
most reliable methods for achieving this are high-
resolution CT and MR tomography.
EPIDURAL HEMATOMA
Acute epidural hematomas (EDHs) are hemorrhagic col-
lections in between the inner table of the skull and dura.
Their incidence among traumatic brain injury is between
2.7% and 4%. The mortality rate of EDH is approxi-
mately 10%138 and among patients in a coma, up to 9%
had an EDH that required a craniotomy. The peak inci-
dence of EDH is in the second decade of life, with it
being rare in patients older than 60 years. Historically,
bleeding from the middle meningeal artery was consid-
ered the main source of EDH, although it can also result
from injury to the middle meningeal vein, diploic veins,
and venous sinuses. EDHs are most frequently located
in the temporoparietal and temporal regions138 and are
caused by a low-velocity lateral blow to the head. There
appears to be a slight right-sided predominance and
from 2% to 5% of patients can have bilateral EDH.138,139
The clinical presentation in EDH is typically of a
comatose patient on admission or prior to surgery. A FIGURE 8-8 Hematomas—epidural (top) and subdural (bottom).
lucid interval, during which the patient is initially uncon- (By permission of Mayo Foundation for Medical Education and
scious, wakes up, and proceeds to deteriorate neurologi- Research. All rights reserved.)
cally thereafter occurs in up to 47% of patients with an
EDH.138 This could lead to a patient being discharged
from the hospital with an undiagnosed EDH and who
could have subsequent serious neurologic consequences
from the hematoma expansion and brain edema. The thickness and volume of the hematoma. The typical CT
presence of an altered level of consciousness is caused by appearance is that of a biconvex, hyperdense, extra-axial
cortical compression, which could proceed to transtento- fluid collection (Fig. 8-8). An EDH typically does not
rial herniation, in which the patient is in a coma, with cross suture lines unless there is a dural tear present.
fixed dilated pupils and decerebrate posture. If not Management of EDH is dependent on the neurologic
treated promptly at this stage, death will follow. Clinical and CT findings. Surgical decompression through a cra-
presentation could also be that of seizures and hemipa- niotomy is indicated when the hematoma is larger than
resis caused by the contralateral compression of the cere- 30 cm3 regardless of the GCS score. Observation in a
bral peduncles. Associated intracranial lesions such as neurosurgical unit with serial CT and serial neurologic
contusions, intracerebral hemorrhage, subdural hemato- evaluations can be done in the presence of an EDH
mas, and diffuse brain swelling can also be found in up smaller than 30 cm3, less than 15 mm in thickness,
to 50% of patients with a surgically evacuated EDH.138,140 midline shift less than 5 mm, and GCS score greater than
CT is the imaging modality of choice for the diagnosis 8, with no focal findings.138 The patient’s age, presence
of an acute EDH. It not only allows for identification of of pupillary abnormalities, associated intracranial lesions,
the lesion but also for determining the presence of a time interval between neurologic deterioration and
midline shift, traumatic subarachnoid hemorrhage, oblit- surgery, and ICP have all been identified as prognostic
eration of the basal cisterns, and calculation of the factors in the management of EDH.
SUBDURAL HEMATOMA neurologically stable, have no pupillary abnormalities,

Acute subdural hematomas (SDHs) have a 30% inci- and no intracranial hypertension (ICP > 20 mm Hg).124
dence in severely-injured patients. Their estimated mor-
tality rate is 40% to 60%141 in patients requiring surgery DIFFUSE AXONAL INJURY
and is frequently associated with skull fractures. An acute DAI is relatively common in patients who sustain a severe
SDH can have three different causes—a direct laceration closed head injury. It is the predominant mechanism of
of a cortical artery or vein with a penetrating brain injury, injury in 40% to 50% of patients admitted for a TBI and
a large contusion and, the most common mechanism, is the most common cause of persistent vegetative state
tearing of the bridging veins of the brain to the dural and severe disability in TBI.144 DAI is caused by shearing
sinuses. The mechanism of injury leading to an SDH forces during rapid head accelerations that affect the
differs among age groups. In young adults (18 to 40 white matter. The predominant sites affected are the
years), most SDHs are caused by MVAs; in patients older parasagittal white matter of the cerebral cortex, corpus
than 65 years, falls are the predominant mechanism. In callosum, and pontine-mesencephalic junction adjacent
this patient population, brain atrophy leaves the bridging to the superior cerebellar peduncles. It is assumed that
veins exposed to a higher risk of injury secondary to the DAI has occurred when there is any loss of consciousness
increase in extra-axial CSF space. Acute SDHs are caused in a trauma situation.144,145 Depending on the severity of
by the strain rate sensitivity of the bridging veins being the injury, patients have an immediate loss of conscious-
exceeded, even in the setting of seemingly minor trauma ness or confusion at the time of the injury that can persist
and not necessarily the impact of an object contacting as a coma or cognitive dysfunction.
the head.142 This is the phenomenon observed in shaken DAI is caused by axonal degeneration, which repre-
baby syndrome, in which the violent shaking of the head sents a progression that evolves from axonal transport
exceeds the bridging vein tolerance and leads to the disruption to axonal swelling and, finally, to wallerian
development of an SDH. degeneration.146 DAI lesions can be hemorrhagic or non-
There is no consensus in the literature with regard to hemorrhagic. DAI is graded by its anatomic location into
the terms acute, subacute, and chronic when referring to grade I, injuries isolated to the gray-white matter junc-
SDH. An acute SDH is one that is typically 1 to 2 days tion, grade II, lesions present in the corpus callosum, and
old, whereas subacute is one that has been present for 3 grade III, lesions isolated to the brainstem.147 CT is rela-
to 14 days after the initial injury. The term chronic SDH tively insensitive for the detection of DAI, particularly if
can be used for an SDH present for 15 or more days. Up the lesions are nonhemorrhagic. Gentry et al have found
to 80% of patients141 with an acute SDH present with a that only approximately 19% of DAI lesions have an asso-
GCS score of 8 or less. Most cases of SDH are also associ- ciated hemorrhage.148 Hemorrhagic lesions appear as
ated with contusions and intracerebral hematomas, punctate hyperattenuating foci at the corpus callosum,
which can lead to a greater degree of mass effect on the gray matter junction of the cerebrum, and pontine-
brain than that which would typically be seen with an mesencephalic junction adjacent to the superior cerebel-
SDH alone. SDHs usually occur along the cerebral con- lar peduncles on CT scans. However, only 10% of patients
vexities, falx cerebri, and tentorium cerebelli. On CT demonstrate these classic CT findings.143,148 MRI allows
scans, they tend to have a crescent-shaped appearance for better identification of DAI, especially in nonhe
(see Fig. 8-8) because of the dural attachments and can morrhagic lesions. These lesions are hypointense on T1-
be supratentorial or infratentorial. SDHs can also cross weighted images and hyperintense on T2-weighted
suture lines and be large enough to surround a cerebral images. Blood-sensitive MR sequences (e.g., GRE T2
hemisphere. When interpreting CT scans, intra-axial and sequences) can detect more lesions than CT.147 DAI can
extra-axial hemorrhages have a typical appearance and also be detected using diffusion-weighted imaging (DWI),
pattern of evolution. Acute to subacute hemorrhage is susceptibility-weighted imaging (SWI), and diffusion-
hyperattenuating and becomes isointense and eventually tensor imaging (DTI); tractography also has shown
hypointense to the brain over days to weeks. Subacute, promise in the evaluation of DAI.143
isodense, and chronic subdural hematomas may be dif- A broad spectrum of cognitive deficits can be present
ficult to recognize.143 MRI is more sensitive than CT for as a result of DAI. Patients can experience difficulties
the detection of small SDHs and also has a characteristic with encoding and retrieving new information and pro-
temporal progression that is influenced by the hemoglo- cessing of information; those who can speak may have
bin level, field strength, and oxygen tension.143 well-preserved retrograde memories but are unable to
Surgical evacuation of an SDH is indicated when the recall new information. Potential therapeutic targets
clot thickness is more than10 mm or there is a midline aimed at preventing the progression of injured axons,
shift more than 5 mm, regardless of the GCS score.124 In such as cyclosporine A and erythropoietin, have been
patients requiring surgery, there is a poor outcome in identified and could be used in the future for the man-
patients older than 60 years who have a severe traumatic agement of patients with TBI.149
brain injury.141 Evacuation of an SDH hematoma can be
performed by twist drill trephination or craniostomy, CEREBRAL CONTUSIONS
burr hole trephination, craniotomy, or subtemporal Cerebral contusions account for approximately 40% of
decompressive craniectomy. Patients in a coma (GCS < traumatic brain injuries.85 These lesions are caused by
9), an SDH with a thickness less than 10 mm, and a injuries to capillaries, which leads to a small amount
midline shift less than 5 mm can be treated nono of petechial hemorrhage and edema. The most common
peratively with ICP monitoring as long as they are location for contusions are the anterior and inferior
surfaces of the frontal lobes and the temporal and occipi- evaluation of the trauma patient, given that a missed
tal poles.143 These lesions result from translational move- injury could have devastating consequences. This could
ments along the floor of the anterior and middle cranial be difficult from a clinical perspective because of swell-
fossa. Cortical contusions can result from coup or con- ing, anatomic distortion, or the presence of distracting
trecoup injuries. In a coup injury, the brain strikes the injuries. Knowledge of the prevalence of cervical spine
skull at the site of the direct impact; a contrecoup injury injury in relationship to facial bone fractures, head injury,
occurs opposite to the site of the external force. and other risk factors could provide early SCI recognition
Approximately 50% of contusions are hemorrhagic on and prompt management for the prevention of adverse
CT. They typically have the appearance of round or oval events. The repair of a facial fracture in the presence of
hyperdense foci, with associated edema and mild mass an occult cervical spine injury could lead to permanent
effect.85 Nonhemorrhagic contusions are difficult to neurologic injury and long-term disability. A retrospec-
detect initially on CT. After a few days, a hypodense tive review of the National Trauma Bank from 2002 to
lesion might be apparent as a result of delayed hemor- 2006 found that in 1,309,311 of reported patients with
rhage, which represents a severe injury. Hemorrhagic an injury, the incidence of facial fracture was 13.5% in
contusions are hypointense on T2-weighted MRI during patients with a C-spine injury, 21.7% in patients with a
the first few days and become hyperintense on T1-weighted head injury, and 24.0% of patients with combined C-spine
and T2-weighted images. Nonhemorrhagic contusions and head trauma. The possible severity of a maxillofacial
are hypointense on T1-weighted images and hyperin- and neck injury in a trauma patient is reflected by the
tense on T2-weighted images.85,150 fact that in this study, head injuries were found in 40.2%
Patients with progressive neurologic deterioration, of patients with a C-spine injury and in 71.5% of patients
intracranial hypertension refractory to medical manage- with combined C-spine injury and facial fracture.158
ment, or radiographic evidence of mass effect should be The cervical spine is divided into an upper cervical
treated surgically. Also, patients with a frontal or tempo- spine and lower or subaxial spine. This reflects the ana-
ral contusion larger than 20 cm3 in volume, GCS score tomic and functional differences between the upper two
of 6 to 8, and midline shift of 5 mm or more should also and lower five cervical vertebrae. C1 and C2 have the
be treated operatively. Surgical treatment options include most rotational mobility, with limited frontal and sagittal
craniotomy with evacuation of mass lesion, bifrontal plane mobility, whereas the lower cervical spine allows
decompressive craniectomy, subtemporal decompres- for flexion-extension and inclination–rotation. The
sion, and temporal lobectomy. Nonoperative manage- widest portion of the spinal canal is from C1 to C3, with
ment in the intensive care unit (ICU) with serial imaging a midsagittal diameter that ranges from 16 to 30 mm.
and monitoring can be done for patients who are neuro- There is also a safety zone between the anterior wall of
logically stable, with controlled ICP, and no significant the spinal canal at the level of the atlas and axis. At this
signs of mass effect.151 level, one third of the canal is occupied by the spinal
cord, one third by the odontoid process and one third is
CERVICAL SPINE INJURY free space (safe zone), referred to as Steel’s rule of
thirds.159 The diameter of the spinal canal narrows from
Spinal cord injury (SCI) carries a high morbidity and 14 to 23 mm at C4 to C7.
mortality rate in addition to its emotional, financial, Most cervical spine fractures occur at the upper or
social, and medical impacts on the patient and family lower ends of the cervical spine.160-162 Upper cervical
members. Most SCIs are caused by MVAs (42.1%), fol- spine injuries are those that involve the occipital con-
lowed by falls (26.7%), violence (15.1%), and sports dyles, atlanto-occipital articulation, C1, C2, and the atlan-
(7.6%).152 Survival after an acute SCI is associated with toaxial joint. C1 to C3 injuries have a high mortality rate
age, level of injury, and neurologic grade.153 Most patients and also show the greatest recovery after an initial com-
with an SCI have a complete injury according to the plete injury in survivors when compared with thoracic
American Spinal Cord Association (ASCA) grading and thoracolumbar injuries.157 In older adults, falls lead
system. It has been estimated that more than half (57.5%) to most spine injuries, with the presence of degenerative
of patients with an SCI are employed at the time of changes and osteopenia complicating treatment and out-
their injury and, at postinjury year 1, only 22% remain comes.152,163 Ligamentous injuries and fractures of the
employed.154 The average initial hospitalization and reha- upper cervical spine are more common in children
bilitation charges for a SCI have been reported to be younger than 11 years, whereas adolescents more fre-
$282,245. This is in addition to the cost of home and quently sustain fractures to the lower cervical spine.164,165
vehicle modifications and attendant care for assistance Management of the potentially traumatized spine
with activities of daily living that patients with an acute focuses on three principles: (1) restoration and mainte-
SCI may require.155 These direct and indirect costs can nance of spinal alignment; (2) protection of the spinal
lead to a medical debt burden that produces financial cord; and (3) establishment of spinal stability.166 Trauma
insolvency and ultimately bankruptcy filing.156 patients may require an emergency airway prior to a full
In acute SCI, the cervical spine is involved 55% of the assessment for cervical spine injuries. Patients with a GCS
time in comparison to 15% for each of the other regions less than 9 have a high risk of a spinal injury167 and are
of the spine.157 Cervical spine injuries, including fractures also most likely to require an emergent airway. Manual
and ligamentous injuries, are primarily caused by trauma in-line immobilization (MILI) is used to prevent head
to the head and neck regions. Ruling out a cervical spine movement during intubation or any other intervention
injury remains an essential component of the initial that might be required in the maxillofacial region.166
in trauma patients has led to an increase in its diagnosis,

with reported incidence between 4% to 19%.169 The clini-
cal presentation is variable because of the proximity of
the condyles to neurovascular structures. The brainstem,
CN IX, X, XI, and XII, and venous and arterial vessels
are at risk. The clinical presentation could be that of
lower cranial nerve palsies (Collet-Sicard syndrome) in
one third of patients. Two thirds of patients present with
these neurologic findings acutely; in those in whom it
presents in a delayed fashion, progressive compression
from displaced bone segments or scar formation
accounts for the delayed presentation.169,170
The Anderson and Montesano classification171 is
generally used for the categorization of OCFs. Type I
fractures occur from excessive axial loading and can
produce comminution of the occipital condyle, with no
fragment displacement. Type II fractures occur as an
extension of a linear skull base fracture, with the condyle
FIGURE 8-9 The three-column theory of Denis divides the spinal maintaining its attachment to the cranial base. A condy-
column into anterior, middle, and posterior columns. (By lar avulsion, which can result from excessive loading
permission of Mayo Foundation for Medical Education and
during rotation or lateral bending, leads to a type III
fracture, which is considered to be unstable and could
require internal fixation. Types I and II fractures are
stable and isolated. Type I fractures do not need immo-
MILI is typically provided by an assistant positioned at bilization. Type II fractures with intact ligaments are
the head or side of the bed. The patient’s head and neck treated with hard collar immobilization; in those with
are maintained in neutral position. If the assistant is at ligamentous disruption, a halo vest or internal fixation
the head of the bed, the mastoid process is grasped with might be required.
the fingertips and the occiput is cradled in the palms
of the hands. If at the side, the mastoid process is cradled ATLANTO-OCCIPITAL DISLOCATION
and the occiput is grasped with the fingertips. When Atlanto-occipital dislocation is a rare injury. It is more
MILI is in place, the anterior portion of the cervical commonly found in children because of their large
collar can be removed, facilitating examination and cranium in relation to the facial bones.152 It carries a
access for an airway intervention. high mortality rate; those who survive will have neuro-
Mechanical stability and neurologic findings are logic impairment, including lower cranial neuropathies,
important in determining the appropriate treatment unilateral or bilateral weakness, and quadriplegia. They
strategy for SCIs. The three-column theory of Denis is are highly unstable injuries; treatment involves an
used to predict the stability of the spine after an injury.168 occipital C1-C2 fusion to prevent further neurologic
It divides the spinal column into anterior, middle, and compromise.172
posterior columns (Fig. 8-9). The anterior column con-
sists of the anterior part of the vertebral body, anterior ATLAS FRACTURES
longitudinal ligament, and anterior annulus fibrosus. Atlas fractures account for 25% of craniocervical injuries
The middle column is formed by the posterior vertebral and 3% to 13% of cervical spine injuries.173 Axis fractures
body, posterior longitudinal ligament, and posterior are present in 40% to 44% of atlas fractures. In 1920,
annulus fibrosus. The posterior column is composed of British neurosurgeon Sir Geoffrey Jefferson presented a
the posterior bony elements, which include the pedicles, series of patients with atlas fractures. The following clas-
lamina, facets and spinous processes. The ligamentum sification is based on that description and was later modi-
flavum, interspinous ligaments, supraspinous ligaments, fied by Gehweiler et al.174 Type I fractures involve the
and facet joint capsule are also part of the posterior posterior arch alone and, in type II, the anterior arch is
column. A spinal injury is considered mechanically stable involved. Type III fractures are bilateral posterior arch
when only one column is involved and unstable when two fractures associated with a unilateral or bilateral anterior
columns are disrupted. An SCI could be the result of arch fracture (Fig. 8-10). Type IV fractures involve the
primary and secondary mechanisms, with the primary lateral mass and type V fractures are transverse fractures
mechanism being the initial impact and compression, as of the anterior arch.
seen with fracture dislocation and burst fractures.157 The The classic Jefferson fracture is a type III burst fracture
secondary mechanism of injury can be triggered by local caused by severe axial compression. Patients with an atlas
vascular, electrolyte, or biochemical changes, apoptosis, fracture could present with neck pain, muscle spasms,
and edema.157 limited neck motion, difficulty swallowing secondary to
retropharyngeal swelling, and CN IX, X, XI, and XII
OCCIPITAL CONDYLE FRACTURES involvement. However, in the classic Jefferson fracture,
Occipital condyle fractures (OCFs) are difficult to diag- neurologic deficits are not common because of the
nose on plain films. The use of computed tomography expansion of the spinal canal as a result of the injury.
FIGURE 8-10 Atlas fracture types. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)
FIGURE 8-11 Dens fracture types and bilateral

fractures of the pars interarticularis (hangman’s
fracture). (By permission of Mayo Foundation for
Medical Education and Research. All rights
reserved.)
Atlas fractures are considered to be stable or unstable, wiring fixation, Halifax clamps, and screw fixation. Older
depending on the integrity of the transverse ligament, patients treated with halo immobilization have a high
which is crucial in atlantoaxial stability. Atlas fractures are rate of nonunion and complications.
treated with halo brace immobilization or surgical fixa- Bilateral fractures of the pars interarticularis of the
tion, depending on whether they are present in isolation axis was first described in 1866 by Haughton in criminals
or in conjunction with other cervical spine injuries and executed by hanging180 (see Fig. 8-11). Since then, these
on the integrity of the transverse ligament. fractures have been known as a hangman’s fracture, frac-
ture of the neural arch, fracture of the ring of the axis,
AXIS FRACTURES and traumatic spondylolisthesis.172 The incidence of neu-
Axis fractures account for approximately 20% of cervical rologic findings with this injury is low, given the spacious
spine fractures and have an estimated 8.5% rate of neu- canal space at this level.172,181,182 Clinical presentation is
rologic deficit.175 There are three types of axis fractures— typically that of neck pain. Most patients with a hang-
odontoid fractures involving the dens, bilateral traumatic man’s fracture are treated with halo immobilization for
spondylolisthesis of the pars interarticularis (termed a approximately 12 weeks.172,181
hangman’s fracture), and nonodontoid, non–hangman’s
fractures. LOWER CERVICAL SPINE FRACTURES
The prevalence of dens fractures ranges from 10% to There are several methods to classify subaxial cervical
15%.172,176,177 The classification of odontoid (dens) frac- spine injuries; they are typically categorized depending
tures is based on that of Anderson and D’Alonzo.178 Type on the mechanism of injury. The subaxial cervical spine
I fractures are rare and involve an oblique fracture of the injury classification system uses the injury pattern, integ-
tip of the dens. Type II odontoid fractures are the most rity of the discoligamentous complex, and neurologic
common type of axis fracture and also the most difficult status of the patient to categorize the injury and guide
to treat. They occur at the junction between the odon- treatment strategies.183 The treatment of subaxial cervical
toid process and the vertebral body. They have the spine trauma is based on a number of variables, including
highest rate of nonunion, from 5% to 63%.172 Type III fracture pattern, mechanism of injury, spinal alignment,
fractures extend into the vertebral body and have a high neurologic injury, and expected long-term stability.
fusion rate with the use of rigid bracing (Fig. 8-11). The clay shoveler fracture (Fig. 8-12) is an oblique
Odontoid fractures are a common pediatric cervical avulsive fracture of the lower cervical or thoracic spinous
spine injury, with rare neurologic problems.172,176,179 process. It is a hyperflexion injury whose name came
Overall, the treatment strategy of odontoid fractures is from laborers who sustained this injury when shoveling
based on the fracture type, degree of displacement, age soil, rubble, or snow over their head. Currently, it is not
of the patient, transverse ligament integrity, and angle of a common fracture and is more likely to occur in the
the fracture line. The treatment options include the use trauma setting. The clay shoveler fracture is a stable frac-
of cervical collar or traction, halo device immobilization, ture, although it may be painful. In most patients, immo-
and anterior and posterior surgical approaches with bilization of the neck by means of a collar and restriction
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fracture-dislocation birth injury: prevention, recognition, and
CHAPTER
Abdominal Trauma: Evaluation
9 and Management
Rui Z. Fernandes
| Srinivas Ramachandra
| Phillip Pirgousis
OUTLINE
Epidemiology Evaluation of Penetrating injuries
Mechanisms of Injury Blunt Abdominal Injury
Examination Hollow Organ Injury
Trauma Scores and Indices Abdominal Vascular Injury
Adjuncts To Physical Examination Solid Organ Injury
Diagnostic Workup Pelvic Injuries
Laboratory Studies Pediatric Abdominal Trauma
Imaging Studies Occult Abdominal Trauma
Diagnostic Peritoneal Lavage Abdominal Trauma in Pregnancy
Rigid Sigmoidoscopy SUMMARY
Diagnostic Laparoscopy
Laparotomy
A
bdominal trauma assessment and management is precipitates gastrointestinal (GI) content spillage into
a significant part of trauma management. Primary the peritoneal cavity, frequently leading to peritonitis
survey and circulation both involve an abdominal and delayed mortality from severe sepsis.
examination for determining hemodynamic stability. The abdomen can be deceptively benign on initial
Thus, maxillofacial trauma surgeons must be cognizant assessment, with a precipitous change in clinical status.
of concomitant abdominal injuries and be proficient The most significant pitfall is delayed recognition of
in the diagnosis, prioritization of acute management, occult abdominal injury.2
and application of abdominal trauma management
principles. EPIDEMIOLOGY
Many algorithms and treatment protocols have been
devised over the years to assess and treat individuals with Injury is the fifth leading cause of death in the United
multisystem traumatic injuries. The most widely accepted States and is the leading cause of death for those in their
and used worldwide is the Advanced Trauma Life Support first 3 decades of life. Abdominal trauma is commonly
(ATLS) system developed by the American College of encountered in these cases. The United States, South
Surgeons Committee on Trauma. This begins with an Africa, and some South American countries have a high
initial assessment or primary survey of the trauma patient incidence of penetrating injuries from stab and gunshot
comprised of the familiar ABCDE—airway, breathing, wounds. In the United Kingdom, Australia, New Zealand,
circulation, disability, and exposure. and most European countries, blunt trauma predomi-
Abdominal examination is an adjunct to primary nates as the cause for hospital admissions, although the
survey in hemodynamically unstable patients forming incidence of penetrating trauma is rising.
part of the assessment of circulation, specifically to
confirm or exclude the abdomen as the source of con- MECHANISMS OF INJURY
cealed bleeding. In a stable patient with a history of chest
or abdominal injury or symptoms, the abdominal exami- A concentrated area of force on the abdominal area has
nation is part of a secondary and tertiary survey.1 Facial a higher risk of injury to underlying organs (Fig. 9-1).
or closed head injury examination is secondary in the The impact can be in the form of a blunt object such as
evaluation unless significant airway instability impedes a steering wheel or car door. The vector and velocity of
proper access and control of ventilation. Any wound the trauma become important to the clinician. To under-
from the nipple to perineum anteriorly, to the vertebral stand the mechanism of injury better, the treating
column posteriorly, and bilateral flanks are the boundar- physician should seek to obtain information from the
ies of abdominal review and the common areas of trauma. injury report or from the paramedics. Often, the trans-
Mechanisms of injuries may be penetrating or blunt. The porting medical personnel have obtained the accounts
most common cause of mortality in abdominal trauma is from witness information as well as assessment from the
secondary to delayed resuscitation or excessive hemor- injury scene. This information forms a vital component
rhage with inadequate volume resuscitation. Intra- of the clinical history and the likelihood of underlying
abdominal organ injury and rupture or perforation injury.
167
Mechanism of injury
Plus
Physical Laboratory
exam tests
Suspected abdominal
visceral injury
Hemodynamically
Plus No
stable?
Abdominal/pelvic Resuscitation
CT scan with protocol
IV contrast
Hemodynamically
Solid Fluid with no Yes
Normal stable?
visceral injury visceral injury
No
Signs/ Liver/
Pancreas Renal Lumbar
symptoms spleen
protocol protocol fx?
develop protocol
Hidden causes
for hypoperfusion
Yes No Continued No Yes

non-operative
No Yes
therapy?
D/C
Correct/
Yes No treat
D/C Suspect
To operating room
hemoperitoneum
FIGURE 9-1 Mechanism of injury algorithm.
EXAMINATION A rectal examination is invaluable, because the pres-

ence of frank blood frequently indicates anorectal
The abdomen is divided into three parts for consider- disruption; prostrate position and sphincter tone on vol-
ation of injury—retroperitoneum and peritoneal and untary squeeze by the patient yields critical neurologic
pelvic cavities. The pelvic cavity is comprised of the information. Similarly, inspection of the urethral meatus
rectum, bladder, iliac, and uterine structures. may indicate underlying pelvic, bladder, and urethral
Abdominal examination in trauma must be a contin- trauma.
uum of evaluative and diagnostic steps rather than a brief
physical review of the patient. Any patient with chest and
abdomen complaints is assumed to have intra-abdominal TRAUMA SCORES AND INDICES
injury until proven otherwise.3 Trauma grading systems are comparative indices for
Undress and expose the patient from chest to perineum. quantification and description. These can be extrapo-
Inspect and note the size, shape, and injury type: abra- lated for diagnostic, therapeutic, and prognostic mea-
sions, lacerations, point of entry and exit of penetrating sures. Commonly used indices are the Abbreviated Injury
wounds, and evisceration of structures and organs. Gentle Scale (AIS) and the Penetrating Abdominal Trauma
palpation of the abdomen may suffice in most cases, Index (PATI).4,5 Previous editions of AIS (severity scale
including an examination for pelvic stability. Urethral, from 1 to 6) were for blunt trauma; the most current
perineal, and rectal examinations are mandatory in modification extends to include penetrating trauma.
abdominal review. Any induration of the abdominal wall PATI has individual organ scores summative to a score of
or underlying organs is a notable finding and needs 25. Its major drawbacks are inadequate quantification for
further diagnostic workup. Auscultation findings may be multiple complex injuries involving a specific anatomic
nonspecific unless followed by further examination. area.
Abdominal Trauma: Evaluation and Management CHAPTER 9 169
marker on entry wounds of a penetrating injury may aid

ADJUNCTS TO PHYSICAL EXAMINATION in determining the trajectory and path of missiles.
Most adjunctive examinations are not performed in a
stable, alert, cooperative, and asymptomatic patient who Focused Assessment Sonography in
has suffered low-force transfer to the abdominal wall or Trauma: Ultrasonography
internal organs. Any complaints of shoulder or abdomi- Focused assessment sonography in trauma (FAST)7 is a
nal pain, nausea, unrestrained patients, impairment by well-established trauma assessment by ultrasound of the
alcohol or drugs, visible contusive signs, and open inju- cardiac, bilateral renal, and pelvic area that has been
ries mandate abdominal examination adjuncts.3 validated in several prospective randomized studies.
FAST is operator-dependent but has great sensitivity,
Adjunctive Diagnostic Studies specificity, and accuracy comparable to diagnostic peri-
Gastric Tubes. Gastric air is common in trauma, requir- toneal lavage (DPL) and computed tomography (CT) for
ing decompression with nasogastric or orogastric tubes. assessing intra-abdominal fluid and involves no radiation
Gastric tube insertion is a diagnostic and therapeutic exposure or contrast administration. The advantages of
procedure if no contraindication exists. Craniofacial FAST are immediate bedside intra-abdominal visualiza-
injuries with unstable upper midfacial fractures are par- tion, its noninvasive portable nature, avoidance of trans-
ticular situations in which nasogastric tube insertion is port to radiology, and ability of repeat examinations to
contraindicated. monitor interval changes. It is performed to document
Urinary Catheters. Urinary catheters are useful for fluid in the pericardial sac, hepatorenal space (Morri-
decompression of the bladder, urinalysis for macroscopic son’s pouch), splenorenal fossa, and pelvis (pouch of
and microscopic hematuria, and monitoring adequacy of Douglas). Negative FAST results do not preclude the
fluid resuscitation. Scrotal hematoma, perineal ecchymo- need for further evaluations with further CT imaging.8
sis, pelvic fractures, blood at the meatus, high-riding Equivocal studies should prompt immediate evaluation
prostrate with unstable pelvis, hematuria (>50 red blood with contrast-enhanced CT for determination of solid
cells [RBCs] per high-power field [HPF]) and inability organ injury. Disadvantages of FAST are poor sensitivity
to void are relative contraindications to urethral cathe- in pediatric patients, interference because of bowel gas
terization. In these cases, retrograde urethrography and increased adiposity, uncooperative patients, and
(RUG) is often used to diagnose urethral injury.6 ascites (Box 9-1).
DIAGNOSTIC WORKUP
LABORATORY STUDIES
Along with clinical examination, concurrent hematology BOX 9-1 Focused Assessment Sonography in
and biochemical laboratory tests are required. These Trauma Procedure
include blood typing and cross-matching for unstable 1. A nasogastric tube is inserted before the examination, if
patients as well as operative candidates, with a direct needed, but the urinary catheter is withheld so that the
communication to the blood bank. Hematocrit is a distended bladder provides an acoustic window for visual-
worthy evaluation for ongoing management. A leukocyte ization of blood in the pelvis.
count will not be specific but a significant increase is 2. Using a 3.5-MHz transducer, FAST surveys for blood in the
noted in solid organ injuries caused by catecholamine- pericardial sac and three dependent abdominal regions,
induced demargination. The leukocyte count may not be including Morison’s pouch, splenorenal recess, and pelvis.
an absolute essential for acute trauma management. 3. Ultrasound transmission gel is applied to the pericardial
Serum amylase and lipase levels are not specific but ele- area, right and left upper quadrants, and pelvis. (The peri-
vated levels or serial escalation may suggest pancreatic cardial area is visualized first, so that blood in the heart can
injury, as well as peripancreatic trauma. Correlation with be used as a standard to set the gain appropriately for the
imaging is mandatory. Base deficit is a frequently unde- detection of hemoperitoneum and hemopericardium.)
rused biochemical test for abdominal trauma resuscita- 4. The transducer is oriented for sagittal sections and posi-
tion. Liver function tests, lactate levels, coagulation tioned in the subxiphoid region to identify the heart and
studies, creatinine kinase, and toxicology screens are also examine for blood in the pericardial sac.
useful. Urinalysis with gross hematuria confirming renal 5. The transducer is placed in the right midaxillary line
damage, microscopic hematuria of less than 50 RBCs/ between the 11th and 12th ribs to identify the sagittal
HPF, or a visual inspection of blood-tinged urine is a section of the liver, kidney, and diaphragm.
6. With the transducer positioned in the left posterior axillary
good clinical indicator of urogenital injury.
line between the ninth and tenth ribs, the spleen and kidney
are visualized.
IMAGING STUDIES 7. The transducer is directed for a transverse section and
Plain Radiography placed 4 cm superior to the symphysis pubis. It is swept
inferiorly to obtain a coronal view of the full bladder and
Anteroposterior (AP) chest and pelvic radiographs are both sides of the pelvis.
standard initial assessments of patients with multisystem
blunt trauma. If the patient is unstable, no radiographs From Rozycki GS, Root HD: The diagnosis of intra-abdominal visceral
are needed in the emergency room.1,3 A radiographic injury. J Trauma 68:1019–1023, 2010.
Contrast Studies
Simple contrast studies can be performed in the acute BOX 9-2 Steps in the Performance of FAST
trauma setting to determine structural defects. Any con-
trast material can cause artifacts with CT imaging, which 1. The urinary bladder and stomach are decompressed.
must be accounted for if CT is also indicated for other 2. A vertical incision is made approximately 2 cm above or
injuries. Upper gastrointestinal series can be performed below the umbilicus, down through the fascia, until the
in patients by swallowing or instilling water-soluble con- peritoneum is identified.
trast and taking interval plain x-ray films or carrying out 3. The peritoneum is grasped with two hemostats, pulled
fluoroscopic studies. Esophageal, gastric, duodenal per- upward gently, and a purse-string suture of 3-0 chromic
foration, hematoma, and delayed transit of contrast into catgut is placed.
the distal small bowel can indicate injury. Extravasation 4. The peritoneum is incised and an adult peritoneal dialysis
patterns may indicate spasm and hematoma and define catheter (without the stylet) is passed downward into the
the anatomic location (e.g., intraperitoneal or extraperi- pelvis.
toneal, proximal or distal defect). Air contrast can be 5. The purse-string suture is tightened and tied, and the
used if insufflation is safe and performed by instilling air fascia is closed around the catheter with permanent or
via nasogastric tube and noting any free subdiaphrag- semipermanent sutures.
6. Aspiration of > 10mL of blood, GI contents, vegetable
matic peritoneal or retroperitoneal air from proximal
fibers, or bile through the lavage catheter is considered a
duodenal perforation.
positive finding.
Using endoscopic retrograde cholangiopancreato-
7. If < 10 mL of blood is aspirated, a lavage is performed by
graphic techniques, distal pancreatic duct injuries can be instilling 1 liter of warm crystalloid solution (10 mL/kg in
visualized by instilling contrast. This is indicated for pos- children).
sible pancreatic injuries in which the pancreatic head 8. Recovery of the fluid is facilitated by siphon drainage after
and duodenum are intact. placing the bag on the floor.
Cystography and RUG are invaluable bedside diagnos- 9. The catheter is removed and the effluent (minimum,
tic procedures for pelvic and suspected urethral injuries— 300 mL) is sent for analysis. A positive test is indicated by
for example, in the setting of hematuria, blood at the >100,000 RBCs/mm3, ≥500 white blood cells/mm3, or a
meatus, or a differential prostrate examination. Instilling Gram stain with bacteria.
contrast material with controlled pressure, and interval
before and postvoid plain x-rays can reveal disruptions in
the bladder and urethra.5 An intravenous pyelogram
(IVP) confirms renal parenchymal, pelvic, calyceal, and
ureteric integrity in the presence of hematuria and
truncal trauma. Cystography reveals fine bladder detail
better than IVP. If CT is indicated, IVP is redundant. IV has no gross blood aspirate, further diagnostic consider-
contrast of 50 to 100 mL with plain film prior to lapa- ation needs to be applied to determine other possible
rotomy in penetrating injuries with hematuria yields causes. First described by Rozycki and Root, DPL is an
detailed evaluation in the acute setting. invasive but highly sensitive test for the identification of
intraperitoneal hemorrhage.9 DPL involves a controlled
Computed Tomography infusion of 1 liter of warm normal saline (10 to 15 mL/
The first published study was by Federle et al in 1982 for kg for children) through a needle inserted intraperitone-
blunt abdominal trauma. CT scanning, with its speed and ally by a Seldinger technique. A gross aspirate of blood-
resolution in a stable patient, has been a reference stained fluid with a count of more than 100,000 RBCs/
test for abdominal trauma. Intra-abdominal fluid visual- mm3 is a positive examination for blunt abdominal injury.
ization, solid parenchymal injuries, sites of active bleed- There is debate in penetrating abdominal injuries regard-
ing, retroperitoneal, and vertebral column injuries are ing the number of microscopic RBCs seen in the aspirate
well visualized by abdominothoracic CT. For the poly- that indicate positivity. Patients with pelvic injuries,
trauma patient, a single visit to the scanner can be com- ascites, or retroperitoneal hemorrhage and hemodynam-
bined with C-spine, head, chest, abdomen, and pelvis. ically unstable patients are all situations in which DPL
The necessity of oral contrast is never a consideration but has limited usefulness. CT has replaced DPL in many
IV contrast enhances organ visualization. Contraindica- institutions. Retroperitoneal hemorrhage cannot be
tions include hemodynamically unstable patients in assessed by this intraperitoneal sampling technique—
whom rapid deterioration may occur while they are in hence, the superiority of CT (Box 9-2).
the scanner. These patients progress to immediate sur
gical exploration. Radiation and IV contrast have their RIGID SIGMOIDOSCOPY
inherent morbidity. Other significant limitations of Penetrating or ballistic injuries to the gluteal areas cross-
CT include poor sensitivity for the visualization of ing the midline can cause undetected extraperitoneal or
superficial, mesenteric, diaphragmatic, and pancreatic rectal injuries. These may also be undetected during
injuries.1 rectal examination; thus, careful rigid sigmoidoscopy is
helpful in evaluating the extraperitoneal rectum with
DIAGNOSTIC PERITONEAL LAVAGE careful air insufflation. The limitations of this technique
DPL aspiration instead of a full lavage is also used in are poor visualization because of blood and fecal
some institutions.8 If a hemodynamically unstable patient contents.
10. GI or GU structure rupture in the intraperitoneal or

TABLE 9-1 Incidence of Penetrating Injuries extraperitoneal space or disruption by blunt or pen-
etrating injury (Table 9-1)
PENETRATING INJURY
Blunt Injury Stab Wound Missile Wound EVALUATION OF PENETRATING INJURIES
Spleen, 40%-55%
Transient cavitation causes more severe organ injury
Liver, 35%-45% Liver, 40% Small bowel, 50% from high-velocity missiles compared with tissue lacera-
Small bowel, Small bowel, 30% Colon, 40% tion from stabbing and low-velocity injuries. Of gunshot
5%-10% injuries, 90% cause intraperitoneal injury compared with
Retroperitoneal, Diaphragm, 20% Liver, 30% 30% from stab wounds. Current ATLS practice can lead
15% to underestimation of the significant damage of low-
Colon, 15% Abdominal vascular, velocity, blunt, and high-velocity energy transfer to the
25% viscera. Serial examination and local wound exploration
are options prior to an extensive workup. DPL or CT can
be used to evaluate anterior abdominal stab wounds.
Contrast CT with a double- or triple-contrast medium is
DIAGNOSTIC LAPAROSCOPY used for flank and back injuries.4 The mainstay of treat-
Diagnostic laparoscopy is an essential surgical tool for ment is exploratory laparotomy after astute rapid diag-
patients with blunt and penetrating trauma. Experienced nosis in gunshot wounds; stabbing injuries can be
surgeons and meticulous surgical laparoscopic technique conservatively managed in stable patients in whom
can obtain a less invasive view of the intraperitoneal con- imaging has excluded underlying visceral trauma and
tents, diaphragm, hepatic surfaces, and bowel condi- occult hemorrhage. Less than one third of stab wounds
tion.10 It could resolve ambiguity of any peritoneal involving the abdomen penetrate the fascia; thus, an
process and diaphragm injury with direct visualization experienced surgeon may choose local exploration.11
and prevent further unnecessary imaging or exploratory Any fascial penetration or left-sided thoracoabdominal
intervention. Laparoscopy has its limitations—the hemo- gunshot wounds warrant laparotomy. Serial examination,
peritoneum can obscure the view and there could be chest x-ray, thoracoscopy, laparoscopy, and CT can be
small perforations of the bowel, retroperitoneal injuries, used for the evaluation of right-sided thoracoabdominal
and a state of shock because venous return to the heart wounds to identify diaphragmatic hernias.
is impaired secondary to abdominal insufflation.
LAPAROTOMY BLUNT ABDOMINAL INJURY

Laparotomy is a definitive surgical diagnostic and thera- Trauma can be a combination of blunt and penetrating
peutic maneuver in acute abdominal trauma. Intra- wounds in blast injuries. The management approach is
abdominal bleeding, unexplained refractory hypotension the same. Blunt trauma results from crushing or shearing
in an acute setting, an unexplained fall in the hematocrit forces. The compressive forces of the fall or from the
value, progressive peritonitis, and confirmed organ impact of automobile parts can cause rupture and sec-
injury are indications for laparotomy. Any suspicion of ondary hemorrhage. Shearing forces of the lap belt or
intra-abdominal bleeding in blunt and penetrating inju- shoulder harness can often cause crush injuries because
ries by FAST, DPL, or CT is an absolute indication for of improper fit. If, on examination a seat belt sign is
laparotomy, because failure to explore can have life- noted, blunt injury is a consideration. With ligamental
threatening consequences.4 Evidence of peritoneal cavity attachment of solid organs and their nonattached free
perforation by a missile in gunshot and penetrating parts subject to differential velocity impact, bleeding and
wounds also warrants immediate surgical exploration. organ disruption are common. Air bags can also cause
abdominal injury, along with facial injuries. The spleen
Indications for Laparotomy is the most commonly injured solid organ. Solid viscous
These include the following3,9: injury is also a predictor of major hollow viscous injury
1. Blunt abdominal trauma with hypotension and posi- in blunt abdominal trauma.12
tive FAST or clinical evidence of intraperitoneal
bleeding HOLLOW ORGAN INJURY
2. Blunt trauma causing subdiaphragmatic or retroperi- Hollow abdominal organ injury is comparatively less
toneal air common than solid abdominal organ injury. Common
3. Blunt abdominal trauma with positive DPL hollow organ injuries include a compressive injury
4. Penetrating abdominal wound with hypotension against the duodenum and upper intestinal structures,
5. Penetrating injury causing bleeding from the such as the jejunal and ileal components, which may be
stomach, rectum, or genitourinary (GU) tract compressed against the vertebral column. Colon perfora-
6. Gunshot wounds traversing the peritoneal cavity or tion may also occur and, if missed, will lead to significant
visceral or vascular retroperitoneum morbidity and mortality.4 Stomach injury is less common
7. Evisceration compared with other parts of the intestine and esopha-
8. Unabating peritonitis following trauma gus. Proximal GI injuries are more conservatively
9. Progressive abdominal distress over 6 to 12 hours managed. However, the injury with the highest morbidity
and potential for misdiagnosis is a duodenal injury. proximal superior mesenteric artery, proximal renal
Missed intestinal injuries can cause externalization of the artery, superior mesenteric vein
intraluminal microflora, which would manifest as perito- Zone 2: Upper lateral retroperitoneum renal artery and
nitis. Uninfected urinary bladder perforations can be vein
managed conservatively. Urinary bladder injuries are Zone 3: Pelvic retroperitoneum iliac artery and vein
commonly caused by pelvic ramus compressions and These injuries progress because of a delay in interven-
blunt injury against a distended bladder. The presenting tion and surgical access. Survival rates in penetrating
symptoms of a bladder injury are lower abdominal pain, abdominal aortic injuries are dismal, especially for supra-
hematuria, azotemia from urine reabsorption, and inabil- renal injury. Blunt injury to the suprarenal aorta is rare.13
ity to void. A common CT finding is pelvic fluid and
further imaging with cystography will confirm this. A SOLID ORGAN INJURY
flame configuration is noted because of extraperitoneal Liver, kidney, pancreatic, and splenic injuries can cause
extravasation. After contrast infiltrates the paravesical shock and hemodynamic instability and may necessitate
tissues, bladder base and neck injury need to be evalu- urgent laparotomy. Conservative management has a role
ated further. Intraperitoneal injuries need to be further in stable patients, but they require close observation,
evaluated by a urologist and usually are serious. Any repeated evaluation, and a low threshold for surgical
finding of bony fragments in the bladder or pelvic area exploration if deterioration is noted.
is to be considered serious if noted on imaging.6 Urinary
extravasation can be intraperitoneal or extraperitoneal, Spleen Injuries
and drainage by a urinary catheter may allow healing of The adult spleen is less pliable than the pediatric spleen.
the ruptured bladder. Percutaneous drainage of extrava- The presence of Kehr’s sign, a rare presentation, should
sated urine can be performed. Surgical repair is consid- increase suspicion for splenic injury. Additional intra-
ered an elective procedure, if necessary. Urethral injuries abdominal injury in patients with splenic injury can be
are diagnosed with RUG and confirmed by contrast seen on CT scan, particularly in the bowel, pancreas, and
extravasation. left hemidiaphragm. Even though most splenic injuries
are nonoperative, significant numbers require surgical or
ABDOMINAL VASCULAR INJURY angiographic intervention and splenectomy. Morbidity
Blunt or penetrating abdominal trauma can cause hem- and mortality from continued occult hemorrhage from
orrhage from the viscera, mesentery artery, or major splenic injury remain high.14 Coagulopathy must be cor-
abdominal vessels. Exploration should only be consid- rected prior to exploratory surgery and abdominal
ered with impending bowel ischemia and expanding closure. A patient’s status postsplenectomy or with non-
hematomas (Fig. 9-2) Pancreaticoduodenal hematoma functional splenic remnants requires the administration
from blunt injury is explored, whereas stable hematomas of prophylactic immunization against capsular organisms
in retroperitoneal, pelvic, perirenal, and retrohepatic such as Streptococcus pneumoniae, Haemophilus influenzae,
sites are monitored. In penetrating injuries other than and meningococcus. Although splenic remnants survive
stable retrohepatic hematomas, all other sites are and autotransplantation is no longer indicated, disrupted
explored. Angiographic studies are indicated with color splenic vascularity results in loss of the spleen’s immune
flow Doppler in vascular injuries of concern.3 function. Antimicrobial prophylaxis and immunization
Abdominal vascular injury, according to Feliciano status in splenectomy patients should be noted because
et al, refers to injury to major intraperitoneal or retro- any sepsis or unexplained illness may result in over-
peritoneal vessels.4 These are classified as follows: whelming postsplenectomy infection (OPSI), which has
Zone 1: Midline to retroperitoneum; supramesocolic significant mortality. Further information regarding
region; suprarenal abdominal aorta, celiac axis, the spleen is discussed later, in the pediatric section
(Tables 9-2 and 9-3).
Older age, injury severity at presentation, and admit-
ting hospital trauma designation are among many con-
siderations in regard to nonoperative outcomes of blunt
splenic injuries.15 Rest and noncontact activity, with clini-
cal and hematocrit monitoring, are undertaken in con-
servative management. These extrapolations are made
for renal and nonpediatric injuries.16 For example, a
grade II splenic laceration is managed conservatively,
with 3 days of strict bed rest and 3 weeks of noncontact
activity.
Duodenal Injuries
Rupture and wall hematomas are seen with drivers not
using seat belts and direct falls onto and blows to the
abdomen. Frontal impact by automobile and bicycle
handlebars impaling the abdomen are common present-
FIGURE 9-2 Bowel ischemia with vascular and mesenteric inury is ing histories. Bloody gastric aspirate, retroperitoneal air,
noted with blunt abdominal injury and contrast leak on upper GI series are frequent pre-
cholangiopancreatography (MRCP), and endoscopic ret-

TABLE 9-2 American Association for the Surgery of rograde cholangiopancreatography (ERCP) are helpful
Trauma Organ Injury Scale: Spleen adjuncts to diagnosis. Surgical exploration is mandated
Grade Injury Type Injury Description if suspicion of injury persists. Various concerns exist in
I Hematoma <10% area subcapsular surgical management of pancreatic trauma because
Laceration <1 cm depth undiagnosed and unresolved pancreatic injuries carry a
II Hematoma 10%-50% area subcapsular; <5 cm high fatality rate.
Laceration intraparenchymal, 1-3 cm depth, not
Urethral Injuries
involving trabecular vessel
III Hematoma >50% area or ruptured subcapsular; Urethral injury and disruption is seen with anterior
ruptured intraparenchymal; ≥5 cm pelvic fractures. Saddle and isolated injuries cause ante-
intraparenchymal rior urethral disruption below the urogenital diaphragm.
Laceration >3 cm depth or involving trabecular Posterior injury or injury above the urogenital diaphragm
vessels occurs in multisystem injuries and pelvic fractures.3
IV Laceration Segmental or hilar vessels with >25%
Diaphragm Injuries
devascularization
V Laceration Shattered spleen The left posterolateral diaphragm is the most common
Vascular Hilar injury with devascularization site of diaphragm injury. An initial x-ray can be normal,
with subsequent development of a diaphragmatic hernia.
Adapted from American Association for the Surgery of Trauma: Spleen
injury scale, 1994 revision (http://www.aast.org/Library/TraumaTools/
As for all abdominal trauma, reassessment cannot be
InjuryScoringScales.aspx#spleen). overemphasized. Radiographic presentation varies from
a normal blurred hemothorax to gastric loops in chest
fields.
TABLE 9-3 American Association for the Surgery of PELVIC INJURIES

Trauma Organ Injury Scale: Liver
Pelvic injuries can result from falls, crushing injuries, and
Grade Injury type Injury description
ligamentous disruptions. Pelvic injuries always suggest
I Hematoma <10% area subcapsular significant impact.1 Typically, pedestrians or motorists are
Laceration <1 cm depth involved. The impact forces are often significant and may
II Hematoma 10%-50% area subcapsular; <10 cm cause bony, solid organ, or vascular injuries of the peri-
Laceration intraparenchymal 1-3 cm depth, toneal structures. Pelvic fractures may be described as
<10 cm length open or closed in anteroposterior or transverse direc-
III Hematoma >50% area or ruptured subcapsular; tions. In the acute setting, pelvic injuries may lead to
ruptured intraparenchymal; 10 cm hypotension, shock, displacement of pelvic structures
intraparenchymal with disruption of the urethra, and arteriovenous struc-
Laceration >3cm depth tures.17 Edema, ecchymosis, and laceration at the flanks
IV Laceration Lobar disruption 25%-75% or 1-3 may be other signs of pelvic injury. Rectal examination
Couinaud’s segments can detect a high-riding prostrate, blood, and sphincter
V Laceration Lobar disruption >75% or >3
tone. A pelvic x-ray is part of an initial trauma workup
Couinaud’s segments adjunct.
In shock, prior to insertion of a urinary catheter for
Vascular Juxtahepatic venous injury.
urine output monitoring, any urethral disruption must
Adapted from American Association for the Surgery of Trauma: Liver be excluded. Urgent urologic consultation is necessary if
injury scale, 1994 revision (http://www.aast.org/Library/TraumaTools/ there is renovascular injury or disruption of perineal
InjuryScoringScales.aspx#spleen). structures. As noted earlier, ultrasound augments pelvic
x-ray in the initial evaluation. A carefully performed
RUG can diagnose any urethral injury. In most series,
85% to 95% of patients have gross hematuria with pelvic
sentations on imaging. CT with double contrast is indi- fractures and approximately 10% of all patients with a
cated for detail. pelvic fracture have bladder injuries. Microscopic hema-
turia with more than 30 RBCs/HPF can be seen with
Pancreatic Injuries most injuries and contusions. Further investigation is rec-
Frontal direct epigastric blows to the abdomen compress ommended for any positive finding.18
the pancreas against the vertebral column. One elevated In pelvic ring disruptions, external pelvic stabilization
pancreatic enzyme level seen immediately postinjury is by binders is an effective and simple technique for pelvic
not a criterion for diagnosis unless followed in series. circumferential compression. A pelvic belt encircling the
Even double-contrast CT may not identify immediate sig- hips and greater trochanters reduces bleeding until
nificant pancreatic injury in 40% of patients. Repeat external fixation devices can be applied in the operating
scans and subtle changes in peripancreatic areas on mag- room. Clamp devices are used in emergency conditions
netic resonance imaging (MRI), magnetic resonance to apply transverse compression on the sacroiliac joints
by implanting percutaneous pins at the coccyx and sac- PEDIATRIC ABDOMINAL TRAUMA
roiliac joint. Angiographic embolization and surgical
exploration are alternative considerations for hemor- The abdominal examination following trauma is the
rhage control. same for children as for adults; however, a gentler tech-
Damage control surgery by packing the pelvis, together nique is required. Decompression by orogastric tubes
with parietal closure, can be performed while waiting for and bladder contents could aid in the examination
arterial embolization, which requires monitored transfer, because children tend to swallow air while crying. Find-
arterial access, and specialists.17 Embolization is sequen- ings of a seat belt sign and/or hemodynamic instability
tial, with review of any macrovascular lesions, missing are important signs of the magnitude of injury (Fig. 9-3).
arteries, wall irregularities, and contrast extravasation. In The splenic capsule is thicker and the parenchymal con-
descending order of frequency, the superior gluteal, sistency is firmer in children, unlike the adult spleen
lateral sacral, iliolumbar, obturator, vesical, and inferior (Figs. 9-4 to 9-6). Thus, children are often managed
gluteal arteries are the most frequently involved. Nonse- without surgery. The anatomy and physiology in the
lective embolization is also carried out in cases of hemo- pediatric population differs from that of the adult. The
dynamic instability and failure to identify specific arterial diaphragm is lower, so the pattern of liver and bladder
lesions. injury is different. Also, frequent lower spine injury is
noted.19
The presence of free fluid on a CT scan in children
should not always be an indication for laparotomy
because the incidence of intra-abdominal injury is only
3%.3 FAST is increasingly used, but the amount of intra-
peritoneal blood is not a proportional guide to operative
intervention. The DPL technique and interpretation
FIGURE 9-3 Seat belt mark necessitates further careful evaluation

and low threshold for surgical intervention.
FIGURE 9-5 Splenic laceration with capsule disruption (arrow).
A F B
FIGURE 9-4 A, B, Chance fractures are noted with a lap seat belt
and improperly worn shoulder restraint. Flexion of the
thoracolumbar spine after a head-on collision can lead to fracture
of the spine and laceration and contusion of the pancreas,
duodenum, and mesentry. FIGURE 9-6 Left renal laceration.
similar to those for adults but should be performed by precedence and physiologic changes of pregnancy have
pediatric surgeons because interpretation further affects to be considered in management.
operative intervention. Nonoperative management is a
frequent treatment option in blunt abdominal trauma, SUMMARY
especially with blunt solid organ injury. Guidelines of bed
rest and avoiding contact activity have been extended to Abdominal trauma may often occur concurrent with
the adult population from various pediatric trauma maxillofacial trauma; hence, a thorough understanding
studies.16 of relevant clinical findings, investigation, and manage-
ment approaches of these injuries is vital to every maxil-
OCCULT ABDOMINAL TRAUMA lofacial surgeon. A thorough understanding of ATLS
principles and their application is imperative, allowing
Head trauma, bruising, abrasions, burns, falls, and frac- for rapid systematic evaluation and triaging of trauma
tures are common presentations of occult abdominal patients, as well as avoiding misdiagnoses that could lead
trauma (OAT) from abusive physical injuries. Abusive to unnecessary significant morbidity and mortality.
abdominal trauma has been found to have significant Serial clinical abdominal examinations and a high
morbidity in various studies. As a facial injury is reviewed, index of suspicion are the key to abdominal trauma man-
clinicians should have a suspicion regarding unexplained agement. Any change with expectant trends must be
falls, delayed attention, and a changing history of the managed with indicated imaging or surgical interven-
injury and screen for occult abdominal trauma. Liver tion. Trauma units, which can manage facial and abdomi-
transaminase levels are more specific in screening than nal injuries, are preferred for a multisystem injury
pancreatic enzyme levels, urine occult blood (dipstick patient. Delayed manifestations, as late as 36 to 48 hours
and microscopic analysis), or hemoccult blood.20 Imaging with hemorrhagic shock and sepsis, should always be
with ultrasound and CT can be used to diagnose visceral a consideration and emergency trauma care should
lacerations and injuries. Most of these injuries may be be available. Urine output and vital signs are essential,
conservatively treated. with ongoing monitoring of trauma resuscitation, as is
repeated clinical examination. Prolonged ileus fre-
ABDOMINAL TRAUMA IN PREGNANCY quently follows abdominal trauma and prolonged NPO
status may be indicated. Nutritional support is initiated
Trauma is a leading cause of nonobstetric maternal mor- as part of early trauma diagnosis in the first 48 hours,
bidity and mortality.21 Pregnancy does not predispose to because facial and abdominal injury can prevent normal
trauma or mortality but alters the pattern of injury. intake of diet and the increased caloric demands of
Advanced gestation makes the gravida more prone to trauma can lead to a negative caloric balance. Nasoen-
abdominal trauma. Unrestrained motor vehicle accident teric feeding aids, gastrojejunostomy, and central venous
(MVA) victims have higher maternal and fetal mortality hyperalimentation are frequently used. Enteral alimenta-
rates.22 Diagnostic studies, even though limited, have tion is preferred to other forms. Deep vein thrombosis
similar indications as for nonpregnant patients. Ultra- prevention is vital because trauma patients are deemed
sound also helps in fetal heart rate confirmation and at high risk for this, but actual data on prophylactic mea-
determination of gestational age and placental condi- sures are scarce.
tion. The uterus should be shielded, with the greatest Massive transfusion protocols and early anesthesiology
fetal risk at 2 to 15 weeks of gestation. Hypotension, involvement, monitoring and managing hypothermia,
respiratory failure, and head and neck trauma cause and cardiac perfusion parameters are key to successful
maternal morbidity, even though these are uncommon trauma management. Therapists and trauma nurses with
in blunt abdominal injuries. Injuries to the spleen, liver, a systems-based approach to error reduction can have a
and cephalad bladder with pelvic injury are common huge impact on missed injuries, as well as monitoring
blunt abdominal injuries. Gunshot and knife wounds are dressings, ambulation, and review of patients on pro-
more common penetrating injuries. These cause preterm longed bed rest with spleen and liver injuries. There is
delivery, rupture of membranes, abruption, and hemor- ample evidence that the trauma level designation of the
rhage. The patients present with hypotension, abdomi- surgical unit has a positive impact on outcome.
nal pain, back pain, vaginal bleeding, and uterine
contractions. Uterine rupture is rare but, if it occurs, can
cause fetal mortality and intra-abdominal hemorrhage, REFERENCES
necessitating emergent surgical management. All 1. Kool DR, Blickman JG: Advanced Trauma Life Support. ABCDE
Rh-negative pregnant abdominal trauma victims should from a radiological point of view. Emerg Radiol 14:135–141, 2007.
receive appropriate Rh immune globulin within 72 2. Mackersie RC: Pitfalls in the evaluation and resuscitation of the
trauma patient. Emerg Med Clin N Am 28:1–27, 2010.
hours. Upper abdominal injury in advanced pregnancy 3. American College of Surgeons Committee on Trauma: Abdominal
is critical because of upward peritoneal content displace- trauma. In Advanced trauma life support student course manual, ed 8,
ment. Laparotomy is typically performed but, in stable Chicago, 2008, American College of Surgeons.
patients, observant management is done after appropri- 4. Feliciano DV, Mattox KL, Moore EE: Trauma, ed 6, New York, 2008,
McGraw-Hill.
ate imaging. DPL is challenging in advanced pregnan- 5. Croce MA, Fabian TC, Stewart RM, et al: Correlation of abdominal
cies. Exploratory laparotomy is not an indication for trauma index and injury severity score with abdominal septic com-
cesarean delivery unless direct penetrating trauma has plications in penetrating and blunt trauma. J Trauma 32:380–388,
occurred, causing fetal death. Maternal stability takes 1992.
6. Tonkin JB, Tisdale BE, Jordon GH: Assessment and initial manage- A call for dissemination of American Pediatric Surgical Association
ment of urologic trauma. Med Clin North Am 95:245–251, 2011. benchmarks and guidelines. J Am Coll Surg 202:247–251, 2006.
7. Rozycki GS, Shackford SR: Ultrasound: What every trauma surgeon 17. Brandes S, Borrelli J, Jr: Pelvic fracture and associated urologic
should know. J Trauma 40:1–4, 1996. injuries. World J Surg 25:1578–1587, 2001.
8. Demetriades Demetrios D, Velmahos GC: Indications for and tech- 18. Geeraerts T, Chhor V, Cheisson G, et al: Clinical review: Initial
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editors: Trauma, ed 6, New York, 2008, McGraw-Hill. instability. Crit Care 11:204, 2007.
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injury. J Trauma 68:1019–1023, 2010. characteristics of abdominal injuries sustained during children’s
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67:589–595, 2009. inal trauma in children with suspected physical abuse. Pediatrics
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12. Nance ML, Peden GW, Shapiro MB, et al: Solid viscus injury pre- 22. Hill CC, Pickinpaugh J: Trauma and surgical emergencies in the
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pediatric spleen injury at trauma centers versus nontrauma centers: 2001.
PART THREE
Management of Head and
Neck Injuries
CHAPTER
Applied Surgical Anatomy of the Head
10 and Neck
Janelle E.K. Meuten
| Katharine Powers
| David E. Frost
|
Barry D. Kendell
OUTLINE
Skin Lines and Lines of Langer Veins of the Head and Neck
Scalp Internal Jugular Vein
Skin of the Face Common Facial Vein
Osteology Anterior Facial Vein
Midface Retromandibular Vein
Lower Face External Jugular Vein
Mandibular Surgical Approaches Anterior Jugular Vein
Extraoral Surgical Approaches Neurologic Anatomy
Risdon and Submandibular Approaches Trigeminal Nerve
Intraoral Surgical Approaches Facial Nerve
Angle Hypoglossal Nerve
Parasymphysis and Body Regional Anatomy
Muscles Orbital Anatomy
Muscles of Facial Expression Orbital Nerves
Muscles of Mastication Nasal Anatomy
Suprahyoid Muscles External Nasal Anatomy
Infrahyoid Muscles Nasal Cavity Anatomy
Soft Palate Musculature Parotid Region
Pharyngeal Musculature Parotid Gland
Arterial Blood Supply to the Head and Neck Submandibular Gland
External Carotid Artery Floor of the Mouth
B
ecause traumatic injuries disrupt the anatomy, the anatomy, its inherent relationships, and some technical
surgeon who is to repair and replace these trauma- problem areas that should be considered in the manage-
tized structures must have an in-depth knowledge ment of traumatic facial injuries.
of normal anatomy. In addition, the operator must con-
sider possible variations of normal and other associated
structures that may be in close relationship to the trau- SKIN LINES AND LINES OF LANGER
matized area. Although numerous texts have been written
on basic anatomy,1-11 it is thought that for completeness, The natural skin lines and wrinkles are major factors in
this textbook should include a review of major head and determining the final soft tissue aesthetic result for the
neck anatomy. Details on specific problems and treat- patient with facial trauma. The character and aesthetics
ment modalities are found in the appropriate chapters. of a scar are affected by its relationship to the location
It is the intent of this chapter to discuss the general and direction of normal skin lines.
177
178 PART III Management of Head and Neck Injuries
The natural skin lines and wrinkle lines are different

from the lines of Langer, which denote the direction of
the collagen fibers within the dermis. Langer believed
that the skin was less extensible in the direction of the
lines of tension that cross them.2,12 In the face, Langer’s
lines have been shown to run across natural creases and
flexion lines, thus making scars generated by incisions
and trauma along those lines more noticeable. It is there-
fore recommended that elective incisions be made in or
parallel to the lines of facial expression or the natural
skin lines, when possible (Fig. 10-1).13 Skin wrinkles
provide an excellent template for areas of relaxed skin
tension. Old scar lines and hairlines can also direct a
surgeon to the most appropriate placement of an inci-
sion. Considerations as the ethnicity of the patient must
also be taken into account because hyperpigmentation
and hypopigmentation issues might arise.
SCALP
The scalp is made up of five layers, three of which are
closely bound together. These are the skin, dense con-
nective tissue, and galea aponeurotica. Beneath these
layers are the loose connective tissue and the periosteum
or pericranial layer.1,6,8 The scalp bleeds freely because
the vessels are bound firmly in the dense connective
tissue layer (Fig. 10-2). This firm union and the extensive FIGURE 10-1 Natural skin lines and wrinkle lines are recommended
blood supply frequently make bleeding excessive and for elective incisions.
often difficult to control rapidly with hemostats. Pressure
usually controls the open bleeders, and the rapid applica-
tion of Raney’s clips controls full-thickness lacerations or
FIGURE 10-2 Layers of scalp. (From Aehlert B: Paramedic practice today, St. Louis, 2010, Mosby/JEMS.)
Applied Surgical Anatomy of the Head and Neck CHAPTER 10 179
FIGURE 10-3 Cross-section of eyelid. (From Zitelli B,

McIntire SC, Nowalk AJ: Atlas of pediatric physical
diagnosis, ed 6, Philadelphia, 2012, Mosby.)
elective incisions. Because of the nature of the loose con- lamellae: the external lamellae formed by the orbicularis
nective tissue layer, dissection of the scalp is rather easy muscle and its overlying skin and the internal lamellae
in this tissue plane. In a similar manner, however, the of the tarsal plate and conjunctiva.15 The skin of the
effusion of fluid spreads rapidly in this plane, leading to eyelid is extremely thin and delicate and contains small
a boglike edema. lacrimal, sweat, and sebaceous glands and hair follicles
The innervation of the scalp comes from the trigemi- (Fig. 10-3).16
nal nerve anteriorly and laterally and from the cervical The skin of the nose is tightly attached to the lower
nerves (C2 and C3) posteriorly.1,4 If dissection is kept lateral cartilage in the tip area. In other areas, the skin
within the loose connective tissue layer, these nerves are is less tightly adhered to the underlying infrastructure.
avoided. In the supraorbital region, the superior orbital The skin is thin in the nasal root and tip areas and thicker
branch of the trigeminal nerve passes through a notch in the supratip region.4
or foramen to innervate this area of the scalp. The supra-
trochlear nerve is located slightly medially and inner- OSTEOLOGY
vates the upper lid and the medial area of the forehead.14
Care should be taken when elevating flaps and managing The bones will be considered in the traditional facial
lacerations in this area. As with most areas of the anatomy, thirds (Fig. 10-4).3,5
when the skeleton makes angles or muscles insert, there
is a denser attachment of the skin and soft tissue. In the MIDFACE
scalp, this attachment is most notable in the glabella and The maxilla, zygoma, lacrimal, nasal, palatine, inferior
supraorbital regions. nasal concha, and vomer bones are collectively referred
to as the middle third of the facial skeleton.4,17,18 Although
SKIN OF THE FACE the sphenoid, frontal, and ethmoid bones are not classi-
cally facial skeleton bones, they are frequently trauma-
The skin of the face becomes specialized in the area of tized in midfacial fractures and thus should be considered
the eyelids, which are comprised of two structural in the midfacial skeleton. The bones will be discussed
Upper third Frontal bone

Superior orbital
foramen/notch Metopic
suture
Superior orbital
Frontozygomatic fissure
Middle third suture
Inferior orbital
Optic fissure
canal
Infraorbital
foramen
Lower third
Mental foramen
A
Coronal suture
Parietal
bone Frontal bone Upper third
Squamosal Sphenofrontal
suture suture
Lambdoid Nasal bone
suture Lacrimal bone
Middle third
Occipital Zygomaticofacial
bone foramen
External Anterior nasal
auditory spine
meatus Lower third
Maxilla
Mastoid
process Zygomatic
bone
Styloid
process Mandible
B
FIGURE 10-4 A, Frontal view of skull. B, Lateral view of skull. Facial thirds are noted.
separately, but their interconnections are of utmost The frontal process arises from the anteromedial
importance. corner of the body and articulates with the frontal
bone to form the medial orbital rim. The medial
Maxilla portion of the frontal process fuses with the nasal bone
The maxilla (Figs. 10-5 and 10-6) is a paired bone of the and may therefore be termed the nasofrontal process.
upper jaw,* fused to form one bone, and is the central Posteriorly, the process articulates with the lacrimal
focus of the middle third of the face. Each hemimaxilla bone to form the anterior portion of the medial orbital
contains a large pyramid-shaped body, the maxillary wall. This area of articulation with the frontal bone,
sinus (antrum of Highmore), and four prominent nasal bone, and lacrimal bone is prominent in the
processes—the frontal, alveolar, zygomatic, and palatine facial skeleton and is frequently fractured by blunt
processes. trauma.
The body of the maxilla is hollow and contains the The inferiorly extending portion of the maxilla is the
maxillary sinus. The anterior wall of the sinus is the facial alveolar process, which contains the maxillary teeth. The
surface of the maxilla and is usually thin. The medial wall teeth are key to the accurate management of many mid-
is the lateral nasal wall. The sinus opens superiorly and facial fractures. The alveolar process may be fractured by
medially into the nasal cavity at the semilunar hiatus in direct trauma and therefore may be functionally separate
the middle meatus. The superior wall or roof of the sinus from other portions of the maxilla.
is the orbital floor, and the floor of the sinus is the pala- The palatine process arises horizontally from the
tine and alveolar processes of the maxilla. lower edge of the medial surface of the body. It joins
the opposite process and forms the major portion of the
*References 1, 2, 4, 6, 8, 10, and 19. hard palate.
Frontal process
Incisive
foramen Anterior lacrimal crest
Median
palatine
suture Zygomatic
process
Transverse
Greater palatine Anterior
and lesser suture nasal
palatine
Posterior spine Alveolar
foramen
nasal process
spine
Tuberosity
A B
FIGURE 10-5 A, Maxilla and horizontal portion of palatine bone. B, Lateral aspect of maxilla.
FIGURE 10-6 Medial aspect of maxilla

and palatine bones. (From Liebgott B:
The anatomical basis of dentistry,
ed 3, St. Louis, 2009, Mosby.)
The zygomatic process of the maxilla arises from the Surgical Note: The classic Le Fort I fracture passes through
anterolateral corner of the maxilla and articulates the anterior wall of the maxilla, extending posteriorly
laterally with the zygoma. Together, they form the infe- to the pterygoid plates. It is important to remember
rior orbital rim and the greatest portion of the orbital that this is a paired bone and, even though it is fused
floor. The infraorbital foramen is on the anterior surface in the midline, in adults it behaves like two separate
of the zygomatic process of the maxilla. bones when manipulated. It may often be separated
is with the greater wing of the sphenoid bone and forms

the lateral wall of the orbit.
The only foramina of the zygomatic bone are the zygo-
maticofacial foramen, which opens from the orbital
surface of the bone and passes to the eminence, and the
zygomaticotemporal foramen, which opens to the infra-
temporal fossa. The zygomaticofacial and zygomatico-
temporal branches of the second division of the trigeminal
nerve pass from within the orbit to the surface and give
sensory innervation to the associated structures.
Surgical Note: The classic zygomaticomaxillary fracture

(tripod, zygomaticomaxillary complex, and trimalar)
involves this bone and its articulations. Details on the
fracture and its management are found in Chapter 16.
The options of surgical manipulation for reduction are
discussed in the following sections.
Temporal Fossa Approach. The Gillies approach is
made via an incision in the hair-bearing area of the scalp,
approximately 2 cm above and 1 cm anterior to the
ear.14,20-23 This incision is carried down to the level of the
temporalis fascia. The only structure of anatomic impor-
tance is the superficial temporal artery. This vessel courses
across the area of the incision and can be identified
through palpation and thus avoided by the properly
placed incision. If it is encountered, it can be ligated and
cut without complications. The temporalis fascia runs to
the arch of the zygoma. An incision is made through this
FIGURE 10-7 Zygoma (malar) showing articulations.
fascia to expose the muscle and develop a path for the
passage of instruments to manipulate the zygoma. The
main anatomic concern is being too superficial to the
along the midpalatal suture in the more extreme facial fascia, thus introducing the elevator lateral to the arch.
fractures. Lateral Brow Approach. The lateral brow incision* is
made to allow easy access to the frontozygomatic suture,
Zygoma because this area frequently requires open inspection,
The zygoma (zygomatic bone, malar bone) is a paired manipulation, and stabilization. Again, no major ana-
bone that makes up the essence of the cheek promi- tomic structures lie in close approximation. The incision
nence (Fig. 10-7; see also Fig. 10-4).* This thick, strong, is made full thickness to the bone, and the periosteum
diamond-shaped bone forms the lateral and anterior pro- is reflected to expose the fracture. Generally, some form
jections to the midface and is composed of four proof elevator is placed posteriorly in the infratemporal
cesses. The frontal process forms the lateral orbital wall fossa to aid in elevation of the fracture. Care should be
and articulates with the frontal bone at the frontozygo- taken not to lever against the temporal bone and displace
matic suture. It is this articulation that is separated or any nondiagnosed, nondisplaced skull fractures. The
rotated in isolated zygomatic fractures. The temporal incision is generally placed in the hair of the brow. The
process forms the zygomatic arch and articulates with the usual rule of making an incision perpendicular to
temporal bone. The maxillary process articulates with the skin margin can be altered in this area because the
the maxilla to form the infraorbital rim and part of the incision should be made with the long axis of the hair
floor of the orbit. Finally, the fourth process joins the follicle to prevent damaging the follicles, which could
maxilla on the lateral wall, producing the zygomatic emi- prevent the regrowth of hair. This hair should not be
nence. This is an area of thickened bone that is usually shaved for numerous reasons. The hair will grow back,
available for fixation in the treatment of zygomaticomax- but slowly, and it will be of a different texture and may
illary complex (ZMC) fractures. Along the crest of the often be sparse. The most notable problem is that of
zygoma, on the inferior aspect, is the insertion of the aligning the hair-bearing skin margins during suturing.
masseter muscle. The direction of force for this muscle If this is not performed properly, there will be an unsightly
is down and backward and its contraction contributes to step in the brow when the hair does regrow.
displacement of the complex fracture of the zygoma, Approaches to the Inferior Rim. The multiple surgical
which may precipitate redisplacement in the improperly approaches to the inferior rim† and articulation of the
fixated fracture. zygoma and maxilla are described in Chapter 16. These
The zygoma articulates with the sphenoid bone on the approaches provide access to the inferior orbital rim,
posterior aspect of the frontal process. This articulation
*References 14, 15, 20, 21, and 24.
*References 1, 2, 4-6, 11, 15, and 20. †
References 12, 14, 15, 18, 20, and 25.
Frontal bone
Nasal bone
Perpendicular Sphenoid
plate of ethmoid bone
Septal
cartilage Vomer
Palatine
Maxilla bone
FIGURE 10-8 Nasal septum, nasal bones, vomer,

and ethmoid bone.
orbital floor, lacrimal duct area and, in some cases,

medial and lateral orbital walls. There are few anatomic
problems if care is used to locate the layers of the inferior Frontal bone
lid, most specifically the orbicularis oculi muscle, orbital
septum, and inferior orbital rim. The approaches from Cribriform plate
the skin include the infraciliary incision and a lower inci-
sion through an existing skin crease. The infraciliary Ethmoid
incision is aesthetically pleasing but may result in exces- air cells
sive and prolonged edema of the eyelid. The lateral Orbit
extent of this incision, combined with the frequently Lamina
needed lateral brow incision, compromises the lymphatic papyracea
drainage of the lower lid. The skin is thin in this area and
the skin flap must be developed carefully. The incision
through the orbicularis oculi muscle is performed longi-
tudinally to expose the inferior orbital rim. The incision
through the periosteum should be on the facial aspect
of the bone but above the infraorbital nerve.
Transoral Approach. The floor of the orbit and infra- FIGURE 10-9 Frontal section of ethmoid bone.
temporal fossa can be approached through a buccal
mucosa incision in the posterior maxillary vestibule.15,17-19
The eminence of the zygoma becomes available for sta-
bilization via this approach. The maxillary sinus can be Nasal Bones
entered and the floor of the orbit, inferior rim, and The nasal bones (Fig. 10-8; see also Fig. 10-4)1,2,4,6 are
eminence of the zygoma can be elevated from within. rectangular and articulate with the frontal bone superi-
The infratemporal fossa can be entered posteriorly and orly and with each other at the midline. At the superior
superiorly, and the zygomatic arch and zygomatic body articulation, they are relatively thick, but inferiorly, they
may be elevated. The buccal fat pad often interferes with are much thinner. It is in this area that most fractures
visualization but is generally of no notable anatomic occur. The nasal bones articulate posteriorly with the
concern. frontal process of the maxilla.
Transconjunctival Approach. The final approach to the
orbital floor is via the transconjunctival incision.5,14,21 Its Ethmoid Bone
only advantage is the avoidance of the slight facial scar The ethmoid bone is an unpaired bone that is central to
from the infraciliary approaches. In the case of trauma, the facial structure (Fig. 10-9),* and it is an integral part
this is usually not a major factor. The incision is made of the nasal structure, to both orbits and to the anterior
through the conjunctiva at the lower border of the infe- cranial base. The perpendicular plate forms the superior
rior tarsal plate, with the lower lid retracted inferiorly. A and anterior portions of the nasal septum and attaches
preseptal or retroseptal dissection can be made, although to the cribriform plate. It articulates posteroinferiorly
the preseptal dissection offers better control of the with the vomer and posterosuperiorly with the sphenoid
orbital fat. The approach to the orbital floor is otherwise bone.
the same and there are no notable anatomic problems
associated with any of these approaches. *References 1, 2, 4-6, 11, and 19.
The cribriform plate articulates anteriorly and later- posteromedial aspect. The junction of the sphenoid and
ally with the frontal bone and posteriorly with the sphe- palatine bones forms the sphenopalatine foramen. This
noid bone. Hanging bilaterally from the cribriform plate foramen attaches the posterior aspect of the nasal cavity
are the superior and middle nasal conchae. The middle with the pterygopalatine fossa.
concha has thin-walled ethmoidal air cells, which extend
laterally to it. The multiple septa, which pass relatively Surgical Note: Manipulation of the maxilla generally
perpendicular to the conchae, extend laterally to the accomplishes adequate reduction of the palatine
thin plate of bone that constitutes most of the medial bones.8,17 It is important to remember the small contribu-
orbital wall. This bone is the lamina orbitalis of the tion of the palatines to the orbital floor because extreme
ethmoid bone. It is extremely thin; hence the term lamina trauma to the maxilla and palate may cause some dis-
papyracea. placement or involvement of the orbital contents.
Surgical Note: The thin lamina orbitalis may be fractured Inferior Nasal Concha
in blunt orbital trauma.11,15,17 The anterior ethmoid artery The inferior nasal concha is a paired bone2 that forms
is a point for ligation as it passes from the orbital to the the bony support of the inferior turbinate bilaterally. It
nasal aspect of the ethmoid bone. Because this artery is is of surgical importance only when it obstructs the infe-
one of the terminal branches of the ophthalmic artery, rior meatus and the nasal lacrimal duct.
which is a branch of the internal carotid artery, it is not
affected by the usual measures to control facial bleeding Frontal Bone
and may require direct ligation via a medial canthal The frontal bone (Fig. 10-11; see also Fig. 10-4)* is a
approach. The anterior ethmoid foramen is approxi- cranial bone that is unpaired and forms the anterior
mately 1.5 cm deep, measured from the medial orbital
rim. Rarely is any surgical manipulation of this bone *References 1, 4, 14, 26, and 27.
necessary or possible.
Orbital process
Vomer
The vomer (see Fig. 10-8)1,4,7 is a plow-shaped bone that
is located in the midline of the nasal fossa and forms the
posterior portion of the nasal septum. It articulates with
the palatine, maxillary, and ethmoid bones and rarely is Sphenopalatine
of notable concern in the primary management of facial notch
trauma. Sphenoidal
process
Palatine Bones Perpendicular
The paired palatine bones connect the maxilla with the plate
sphenoid bone (Fig. 10-10; see also Figs. 10-5A and Nasal crest
10-6).1,2,4,5 This extremely irregularly shaped bone is com-
posed of a major horizontal portion and vertical perpen-
dicular plates. The horizontal plate articulates anteriorly
with the maxilla and with the palatine bone of the oppo-
site side in the midline to form the posterior aspect of Horizontal plate
the hard palate.
The vertical plate passes superiorly behind the maxilla Posterior view,
and articulates posteriorly with the lateral pterygoid plate right palatine bone
of the sphenoid bone. A ledge of the vertical plate ter- FIGURE 10-10 Palatine bone. Note orbital surface and nasal and
minates in a small contribution to the orbital floor at the palatal aspects.
FIGURE 10-11 Frontal bone from inferior view. Note articulation with the nasal and ethmoid bones. (From Fehrenbach M, Herring S:
Illustrated anatomy of the head and neck, ed 4, St. Louis, 2012, Saunders.)
FIGURE 10-12 Sphenoid bone (frontal view). (From Liebgott B: The anatomical basis of dentistry, ed 3, St. Louis, 2009, Mosby.)
portion of the calvaria. The importance of this bone in Surgical Note: There are multiple incisions and techniques
facial trauma is its relationship to the anterior midfacial of management for the frontal sinus. The major ana-
skeleton and the paranasal sinuses. The frontal bone tomic point of concern is the inner table, which, when
articulates laterally with the zygoma and medially with fractured, demands a neurosurgical evaluation. Other
the maxilla and nasal bones. Inferiorly and deep in the areas of concern are the supraorbital nerves, which can
middle of the face, it articulates with the ethmoid and usually be saved with careful dissection and removal from
lacrimal bones and posteroinferiorly articulates with the the supraorbital foramen by the use of a small osteotome.
wings of the sphenoid bone. The frontal bone articulates The neurovascular bundle can then be retracted with the
posterolaterally with the parietal bones. orbital contents.
The frontal bone forms a great portion of the roof of
the orbit. Its thickened projections articulate laterally Sphenoid Bone
with the zygoma at the frontozygomatic suture and form The sphenoid bone (Fig. 10-12)* is a single midline bone
the lateral orbital walls. The thickening of the frontal situated at the base of the skull that creates the antero-
bone in the anterior region forms the supraorbital ridges. inferior extent of the cranial base and the posterior tran-
These curved elevations connect the zygomatic portion sition from facial bones to cranial bones. This complex
of the frontal bone with its midportion, articulating with bone has many processes that have delicate articulations
both the maxilla and nasal bones. The supraorbital notch with the adjacent cranial and facial bones.
or foramen crosses this rim and transmits the frontal The sphenoid bone articulates with the temporal and
vessels and nerves. occipital bones to form the cranial base. It joins the pari-
The frontal sinus lies in the frontal bone in an area etal and frontal bones anteriorly and superiorly to com-
superior to the articulation with the nasal bones. plete the cranial complex. It meets the vomer and ethmoid
Approximately 4% of the population do not have a bones in the midline anteriorly and meets the zygoma, pala-
frontal sinus. The sinus is not a simple chamber but tine bones, and sometimes the tuberosity of the maxilla to
rather is subdivided into compartments or recesses by complete its articulation with the facial skeleton.
incomplete bony partitions. There is usually an intra- The body of the sphenoid bone is hollow and forms
sinus septum that divides the left from the right. Drain- two cavities separated by a thin bony septum. The hollow
age into the nose is by a well-formed duct, the nasofrontal cavities are the sphenoidal sinuses; these drain into the
duct. The duct itself is soft tissue and may follow a ser- sphenoethmoid recess above and behind the superior
pentine course to the anterior middle meatus of the nasal concha. Although air-fluid levels can frequently be
nose, where it empties. The frontal sinuses are protected noted on radiographs, surgical management in the
somewhat from injury by the supraorbital ridges. The trauma patient is rarely necessary.
anterior wall of the sinus has low resistance, but the
ridges are highly resistant. *References 1, 2, 4, 6, and 19.
Condylar head
Condylar neck
Coronoid process
Oblique line
Alveolar process
Mental foramen
Mental protuberance
FIGURE 10-13 Mandibular osteology (anterior view). (Modified

from Abrahams PH, Hutchings RT, Marks SC Jr: McMinn’s
color atlas of human anatomy, ed 6, St. Louis, 2008, Mosby.) Mandibular body Mental tubercle
Coronoid process
Condylar head
Condylar neck
Mandibular foramen
Lingula
FIGURE 10-14 Mandibular osteology (lingual view). (Modified Sublingual fossa

from Abrahams PH, Hutchings RT, Marks SC Jr: McMinn’s
color atlas of human anatomy, ed 6, St. Louis, 2008,
Mosby.) Superior/inferior mental spines
Articulating
External Pterygoid Coronoid Coronoid Mandibular surface of
oblique line fovea notch process notch condlye
Mandibular
teeth
Alveolar
process
Mental
protuberance
FIGURE 10-15 Mandibular osteology (oblique view). (From

Fehrenbach M, Herring S: Illustrated anatomy of the head Body Mental Ramus Angle Neck
and neck, ed 4, St. Louis, 2012, Saunders.) foramen
Mandibular fractures occur twice as often as midfacial

LOWER FACE fractures29,32; however, it has been shown in cadaver
Mandible experiments that almost four times as much force is
Despite the fact that the mandible (Figs. 10-13 to 10-15)* required to fracture the mandible versus the maxilla.30
is the largest and strongest facial bone by virtue of its The osteology of the mandible, various muscle attach-
position on the face and its prominence, it is commonly ments and their influence, and the presence of develop-
fractured when maxillofacial trauma has been sustained. ing or completed dentition all play a notable role in
producing inherent weaknesses. Therefore, fractures
*References 4, 6, 10, 16, 18, and 28-31. are seen more frequently in certain isolated areas.
The mandible is composed of the body and two rami, ramus to transmit pressures up to the condylar region.35,36
with their junction or angle forming the prominent The thickening on the inner aspect of the condylar neck
gonion. The angle formed may vary between 110 and 140 or crest of the neck apparently acts as a main buttress
degrees (mean, 125 degrees).15 The angle decreases of the mandible as it transmits pressure to the temporo
slightly during growth because of changes in the condy- mandibular joint (TMJ) and the base of the skull.29,32 The
lar process, shape, and size. With aging, the angle temporal crest runs from the coronoid process to
becomes more obtuse.30 The body is U-shaped and has the retromolar triangle distal to the terminal molar. The
an external and internal cortical surface. The external thickened posterior border of the mandible may act as
cortical plate is thickest at the mental protuberance and an additional crest.28
in the region of the third molar. There is also a thickened Major structural forces are created at the angle of the
triangular mental protuberance bounded laterally by the mandible because of the cantilevered nature of its shape.
mental tubercles. The mental foramen is located on the The bone height at this angle is therefore critical in
external surface in the vicinity of the root apices of determining its strength and the presence of the per-
the first and second premolars. There are variations in fectly aligned muscle sling created by the masseter and
the exact location of the foramen, as noted by Tebo and medial pterygoid muscles.37 Thus, aging, with its poten-
Telford.33 The opening is directed backward and laterally tial for bone and alveolar resorption, weakens this area.
and transmits the mental nerves and vessels.18,34 The Areas that exhibit weakness include the area lateral to
oblique line runs from just inferior to the mental foramen the mental protuberance, mental foramen, mandibular
posteriorly and superiorly to the ascending ramus. angle, and condylar neck.29 If teeth are present, the
The internal cortical surface is elevated in the midline socket is a weak zone, especially if teeth are impacted or
near the inferior border by the mental spine. Associated unerupted. This would seem to indicate that a child in
with this may be two pairs of discrete bone prominences the mixed dentition stage may be highly susceptible; the
termed the genial tubercles. They represent the origin of fact that the child’s bones are so resilient and flexible
the geniohyoid muscles inferiorly and the genioglossus offsets the disadvantage of the unerupted teeth.30
muscles superiorly. Running horizontally and slightly
superior from front to back is an oblique ridge, the mylo- Temporomandibular Joint
hyoid line, which represents the attachment of the mylo- The TMJ (Figs. 10-16 and 10-17)* is a freely movable
hyoid muscle. Below this is the shallow depression created synovial joint located between the glenoid fossa of the
by the submandibular gland, called the submandibular temporal bone and the head of the mandibular condyle
fossa. Superior to the mylohyoid line and located anteri- below. The anatomic classification of the TMJ is a diar-
orly is the sublingual fossa, where the sublingual gland is throdial joint, with independent discontinuous move-
found in close approximation. ment between the two bones. An articular disc (meniscus)
The ramus of the mandible, when viewed from the divides the joint into two cavities. The superior compart-
side, is a quadrilateral structure. The lateral surface may ment permits hinge or rotational movement, whereas the
be rough and thickened in the region of the angle by the inferior joint space permits translatory motion. The bony
insertion of the masseter muscle. On the medial surface surfaces within the joint spaces are lined by synovial
is the mandibular foramen, which leads downward and membrane, which is responsible for secreting synovial
forward into the mandibular canal and transmits the
inferior alveolar nerve and vessels. The lingula is a medial *References 1, 6, 10, 17, 18, 35, and 38-42.
bony projection to which the sphenomandibular liga-
ment is attached. The mylohyoid groove extends from SRL SC AS ACL
the lingula and runs anteriorly and inferiorly to the sub-
mandibular fossa. Below this is a roughened area created
by insertion of the medial pterygoid muscle.
The mandibular notch is located on the superior edge
of the ramus. It is bounded anteriorly by the coronoid IC
process and its temporalis attachments, while also bound RT
posteriorly by the neck and head of the mandibular IRL
condyle. A detailed description of condylar head anatomy
SLP
is given later (see “Temporomandibular Joint”). Attached
anteriorly to the neck of the condyle is the insertion of
the lateral pterygoid muscle and attached laterally is the ILP
lateral ligament.
The body of the mandible supports the alveolus and FIGURE 10-16 Temporomandibular joint showing the anatomic
dental structures. The body and alveolus have dense cor- components. ACL, Anterior capsular ligament (collagenous); AS,
tical outer and inner tables of bone, with central spongy articular surface; IRL, inferior retrodiscal lamina (collagenous); RT,
or cancellous bone. retrodiscal tissues; SC and IC, superior and inferior joint cavity;
The strengths of the mandible are apparent when one SLP and ILP, superior and inferior lateral pterygoid muscles; SRL,
evaluates the thick, round inferior border and the mental superior retrodiscal lamina (elastic); the discal (collateral) ligament
protuberance. The periodontal ligament and bone alveo- has not been drawn. (From Okeson JP: Management of
lus also combine with the trabecular pattern in the can- temporomandibular disorders and occlusion, ed 7, St. Louis,
cellous bone and are directed in a parallel fashion up the 2012, Mosby.)
separating the fossa from the middle cranial fossa. The

anterior portion of the fossa or articular eminence is a
broad horizontal ledge that is convex in the anteroposte-
AD rior direction and concave in the transverse direction.
The fibrous capsule surrounding the joint is thickest
SC on the lateral surface and is considered a separate, dis-
tinct ligament—the temporomandibular ligament. It
IC
extends from the tubercle on the root of the zygoma to
the lateral surface of the neck of the mandible, behind
and below the lateral pole of the condyle. The temporo-
LDL mandibular ligament has a superficial fan-shaped layer
of obliquely oriented connective tissue fiber and a deeper
narrow band of fibers that are horizontally oriented.
CL
MDL The articular capsule in general attaches from the
temporal bone to the neck of the condyle. There is a
loose attachment between the temporal bone and menis-
CL
cus, with considerable ability to move. The attachment
from the meniscus to the condyle, however, is much
stiffer and is reinforced medially and laterally. These
paired ligaments act to restrict movement of the menis-
cus away from the condyle. This stabilizes the complex
and aids in synchronizing the condyle and meniscus.
Other ligaments to consider in this region are the stylo-
mandibular and sphenomandibular ligaments, which
FIGURE 10-17 Temporomandibular articulation (anteroposterior view). serve as passive restraints to mandibular movement. The
AD, Articular disc; CL, capsular ligament; IC, inferior joint cavity, LDL, stylomandibular ligament originates from the styloid
lateral discal ligament; MDL, medial discal ligament; SC, superior process and extends downward to the posterior border
joint cavity. (From Okeson JP: Management of Temporomandibular of the ramus of the mandible. The sphenomandibular
Disorders and Occlusion, ed 7, St. Louis, 2012, Mosby.) ligament runs from the spine of the sphenoid bone and
squamotympanic fissure to the lingula on the medial
fluid that functions as nutritional support and a lubricat- aspect of the mandibular ramus. The maxillary artery, its
ing medium. This membrane is extremely thin, smooth, middle meningeal and inferior alveolar branches, and
and highly vascular. Cells in the synovial membrane have auriculotemporal and inferior alveolar nerves pass
the ability to differentiate into chondrocytes and provide between this ligament and the mandible.
the synovium’s ability to regenerate following injury. The The articular disc or meniscus, a dense fibrocartilagi-
articular surfaces of the joint and condyle and the central nous structure, histologically may show varying degrees
portion of the meniscus are composed of collagen. This and locations of cartilage cells.1 The meniscus is nonvas-
feature differentiates this joint from most other articula- cular and has no sensory innervation. When viewed
tions because the surfaces are not covered by hyaline from the lateral direction, there are three anatomic divi-
cartilage. Histologically, this avascular fibrous tissue may sions or zones—the anterior band, intermediate zone,
contain cartilage cells and therefore may be termed fibro- and posterior band. The thin intermediate or central
cartilage.10,17 This tissue has the ability to regenerate and zone corresponds to the functional area between the
to remodel under functional stress or following anatomic mandibular condyle and posterior slope of the articular
alteration, such as fracture. eminence. When viewed from above, the meniscus is an
The condylar head is a semicylindroid process 15 to oval biconcave structure that is thicker posteriorly. The
20 mm long and 8 to 10 mm thick. The long axis of the posterior tissues are highly vascularized and innervated
condyle is related to the position of the ramus of the man- and are referred to as the bilaminar zone. The superior
dible and not to the skeletal or frontal plane. The angle elastic fibers of the retrodiscal tissue attach to the tym-
formed by the two condylar axes varies between 145 and panic plate and function to restrict anterior meniscus
160 degrees. The articulating surface of the condylar movement during extreme translation.43 The inferior
head faces superiorly and forward, giving the condylar fibers of the retrodiscal tissue are composed of collagen
neck an appearance of being bent forward. When viewed and attach to the articular surface of the condyle. They
anteriorly, the condylar head notably projects medially to act as a check ligament to prevent extreme rotation of
the inner surface of the ramus, but less so laterally. the meniscus during rotational movement of the man-
The temporal bone provides the articulating surface dible. The anterior attachment of the meniscus is con-
to the skull. This bone is located anterior to the tympanic tiguous with the lateral pterygoid muscle. The overall
bone. The fossa is composed of a posterior slope and the shape and size of the meniscus, therefore, vary depend-
convex part of the articular eminence. The squamotym- ing on age, functional remodeling, and pathologic
panic suture forms the boundary between the tympanic condition.
bone and temporal squama. The posterior part of the The vascular supply to the TMJ arises anteriorly from
fossa has a raised crest joining the articular tubercle the masseteric artery and posteriorly from branches of
and postglenoid process. The roof is relatively thin, the superficial temporal and maxillary arteries. The
retrodiscal region has a rich venous plexus that fills and

empties under the influence of mandibular movement. Anatomic Factors in Fracture Displacement
The nerve supply to the joint is principally from the The direction of the causative blow, the direction of the
auriculotemporal nerve, with some additional innerva- line of fracture, and muscle pull all influence the amount
tion via the masseteric nerve and the deep temporal and direction of bone displacement.† Muscle forces
nerve. acting in the anterior region of the mandible, including
those inserting in the mental region on the inner surface,
Mandibular Fracture Location are the geniohyoid, genioglossus, digastric, and mylohy-
The mandible has various strengths and weaknesses, as oid muscles. These forces act to displace anterior seg-
noted.* The common sites of mandibular fracture, ments inferiorly and posteriorly, with some possible
therefore, are the mandibular condyle region, mandibu- medial component.13,41
lar angle region (especially in the presence of an In the posterior mandible, the muscles of mastication
impacted or semierupted third molar), mental foramen generally cause upward and forward displacement. This
or body region, mandibular parasymphysis, and any com- observation is especially true in the pterygomasseteric
ponent of the dental alveolus. In the very young and sling region. The medial pterygoid muscle also creates a
older patient with mandibular atrophy,30 other factors medial component of pull. The temporalis muscle has
such as tooth buds developing in the child or a decrease two components of attachment and creates elevating
in the cancellous-to-cortical ratio in older adults come forces and retraction forces. In a similar way, the lateral
into play. Because of the U shape of the mandible, eccen- pterygoid muscle has two attachments. The internal com-
tric forces often create bilateral fractures—one at the site ponent is responsible for superior, anterior, and medial
of injury and the other contralaterally. Nahum36 has forces, whereas the external component pulls the condyle
shown that forces in excess of 800 lb are required to down, anteriorly, and medially. If the balance is disrupted
fracture the symphysis and both condylar necks, and because of a fracture, displacement results.
further demonstrated that the mandible is more sensitive The fracture angulation or direction of the mandibu-
to lateral impact than to impact from the front. lar angle and body region can vary. Depending on its
orientation, muscle influence may be enhanced or pre-
*References 31, 28, 32, 35-37, and 44. vented from actively displacing the proximal segment
†
References 4, 6, 18, 30, 33, 36, 41, and 45. (Fig. 10-18). A fracture is regarded as favorable if it is in
A B
C D
FIGURE 10-18 Mandibular angle fracture. A, Horizontally favorable. B, Horizontally unfavorable. C, Vertically favorable. D, Vertically
unfavorable.
a downward and forward direction horizontally because MANDIBULAR SURGICAL APPROACHES

of locking effects at the fracture site. If the horizontal
direction is downward and posterior, the active pull of Mandibular surgical approaches are as follows (Fig.
the posterior elevator muscles, such as the temporalis, 10-19): extraoral approaches include the (1) Risdon, (2)
masseter, medial pterygoid, and lateral pterygoid muscles, condylar, and (3) symphysis approaches; intraoral
will displace the proximal segment superiorly. The verti- approaches are the (1) angle and (2) mental or parasym-
cal angulation of the fracture or bevel will inhibit the physis approaches.
medial forces of the elevator group if the fracture direc-
tion is posterior and medial. This condition is regarded EXTRAORAL SURGICAL APPROACHES
as vertically favorable. The opposite is true of the verti- An absolute description of various surgical procedures is
cally unfavorable fracture traveling anteriorly and possible in an elective situation. However, when dealing
medially. with a trauma patient, each approach is designed while
Other factors affecting the amount of displacement taking into consideration the location of the injury,
are the presence or absence of teeth in occlusion, muscle extent of the injury, method of stabilization to be used,
protection, such as in the pterygomasseteric sling region, possible coexisting soft tissue injuries, and potential ana-
and the exact relationship of the fracture position to tomic factors.* The basic principles of making soft tissue
muscle insertion. This last factor is especially apparent in incisions in natural skin folds may be more difficult to
condylar neck injuries and their relationship to the apply in the presence of severe edema and lacerations.
lateral pterygoid muscle insertion. If a fracture occurs In dealing with mandibular trauma in this section, the
above the insertion of this muscle on the neck of the more common surgical approaches used for open reduc-
condyle, little displacement occurs. If a lower level fraction and exploration are discussed.
ture occurs, displacement of the condyle will be medial
and anterior because of the action of the lateral ptery- Preauricular and Condylar Approaches
goid muscle. Several soft tissue incision designs have been described,
including the inverted L, as described by Blair,38 the T,
Surgical Note: Fractures that may compromise the patient’s as described by Wakely,46 and the endaural approach
airway are important to the treating surgeon. Whenever advocated by Lempert.47 Dingman and Moorman1 slightly
the fracture creates an unstable situation for the tongue, modified Lempert’s approach and reported it in 1951.
consideration must be given to immediate temporary The facial nerve, when damaged, poses the most notable
stabilization, intubation, or other means of supporting obstacle and potentially the most serious complications.
the airway. Mandibular fractures that may create airway A detailed description of the facial nerve appears later
problems include bilateral subcondylar fractures, bilat- in this chapter (see “Facial Nerve”). Other anatomic
eral parasymphysis fractures, and any maxillofacial structures that must be considered in the overall dissec-
trauma with massive edema or oral lacerations with sub- tion in the preauricular approach include the parotid
sequent bleeding. gland, superficial temporal vessels, and auriculotemporal
nerves.
The parotid gland is located below the zygomatic arch
in front of the external auditory meatus, with the super-
P1 ficial pole of the gland lying directly on the TMJ lateral
capsule. The parotid gland is enclosed in fascia derived
E
from the superficial layer of the deep cervical fascia or
I parotideomasseterica fascia.
The superficial temporal vessels, along with the auric-
P2
ulotemporal nerve, emerge from the superior aspect of
the parotid gland. Bleeding from these vessels can be
brisk and often requires ligation. The vein lies superficial
and posterior to the artery; the auriculotemporal nerve
is located posterior and superficial to the artery. By
keeping dissection close to the cartilaginous portion of
PA
the external auditory meatus, trauma to the auriculotem-
poral nerve can be minimized.
The endaural incision is started in the skin crease
immediately adjacent to the anterior helix and is carried
downward to the level of the tragus. The incision can
then be placed in the gap between the spine of the helix
R
and tragus, which is filled with fibrous attachments for
the lamina of the tragus. (While in the auditory meatus,
the incision remains in contact with the bony tympanic
FIGURE 10-19 Surgical approaches to the posterior mandible and plate.) This incision results in a better cosmetic appear-
temporomandibular joint. E, Endaural approach; I, inverted hockey ance. It is important not to extend the incision or
stick approach; P1 and P2, preauricular approach; PA,
postauricular approach R, Risdon approach. *References 16, 31, 32, 29, 35, 37-41, and 45.
dissection inferiorly because damage to the facial nerve • Anteroposterior fracture location
as it exits the stylomastoid foramen may result. • Natural skin folds
The initial incision is made through skin and subcu- • Langer’s skin lines
taneous connective tissues, which include the temporo- • Position of the marginal mandibular branch of the
parietal fascia to the depth of the superficial layers of the facial nerve
temporalis fascia. In the upper aspect of the incision, the For this reason, the incision is usually located approxi-
superficial temporal vessels may be encountered, as may mately 2 cm or two fingerbreadths below the inferior
the auriculotemporal nerve. The nerve is retracted and border of the mandible. It is necessary to make an incision
the vessels are retracted or ligated. The temporalis fascia long enough to expose and identify anatomic structures,
is incised by an oblique incision above the zygomatic such as the facial artery and vein, and to obtain sufficient
arch. The intervening fat is visualized between the two access to the fracture. The incision may be extended pos-
layers of temporalis fascia and blunt dissection is carried teriorly to within 0.5 cm below the lobe of the ear. After
out inferiorly beneath the superficial layer of the tempo- marking the skin, the head is extended and turned to one
ralis muscle. The periosteum is stripped off the zygo- side. The incision may be cross-hatched to reapproximate
matic arch from above. A sharp incision posteriorly along soft tissues during final suturing in an anatomic manner
the plane of the initial incision can safely be made down without making a so-called dog ear at one end.
to the periosteal level. The flap is elevated anteriorly, The initial incision is made through the skin and sub-
exposing the articular eminence. The temporomandibu- cutaneous tissue. Any bleeding is controlled by electro-
lar capsule is now visualized totally. The condyle is pal- cautery. If a local anesthetic is administered, it is
pated with the help of manual movements of the body important not to inject it deep to the platysma muscle if
of the mandible. Scissors or a scalpel can be used to enter electrical nerve stimulation is used to detect facial nerve
the upper joint space horizontally, if necessary, to evalu- function. The skin and subcutaneous tissue are then
ate the condylar head surface or meniscus integrity. undermined adequately. At this point, the operator
Depending on the extent of the dissection necessary at should visualize the well-demarcated muscle lines of the
this point, the operator should be cognizant of the platysma. The muscle may be entered carefully at one
medial structures, including the maxillary artery, middle end of the incision by a mosquito hemostat and bluntly
meningeal artery, auriculotemporal nerve inferiorly, and dissected from beneath toward the other end of the inci-
pterygoid plexus of veins lying anteromedially. It may be sion, staying parallel to the inferior border of the man-
necessary in some cases to use a Risdon approach as well dible. The corner of the patient’s mouth should be
when performing an open reduction in low fractures. carefully observed during this procedure because the
marginal mandibular branch of the facial nerve travels
RISDON AND SUBMANDIBULAR APPROACHES just below the platysma muscle. The surgeon can check
During the procedures to reduce and stabilize mandibu- the undermined muscle by carefully clamping portions
lar angle fractures and, in some cases, low subcondylar or using an electrical nerve stimulator, followed by com-
fractures, some form of approach from the inferior man- plete sectioning by knife or scissors. If the marginal man-
dible is required (Fig. 10-20). Parameters used to estab- dibular branch of the facial nerve is encountered, it
lish an incision include the following: should carefully be dissected free and retracted.
Next, the facial artery should be located by palpation
initially and then by blunt dissection, if necessary. The
marginal mandibular nerve should run directly over this
artery. The artery is usually found anterior to the vein. If
necessary, these structures can be isolated and ligated.
The submandibular gland should be visible at this point.
It may be necessary to separate the lower pole of the
parotid gland from the submandibular gland. In other
individuals, these structures may be separated by the sty-
lomandibular ligament.
Palpation and isolation of the inferior border of the
mandible reveal the thickened pterygomasseteric sling.
Masseter This can be sharply divided, along with periosteum, and
muscle can be elevated from the bony mandible until adequate
visualization and mobilization of the mandible are
Marginal achieved. Bleeding will be reduced if the sling is incised
mandibular in the posterior portion rather than laterally through the
branch of VII
masseter muscle.
The Risdon modification of this incision involves a
Periosteal
incision more posterior and vertical incision, posteroinferior to
the angle of the mandible. The advantage to this
Skin incision approach is that there is less likelihood of damage to the
FIGURE 10-20 Risdon approach illustrating the relationship of the marginal mandibular branch of the facial nerve, but
marginal mandibular branch of the facial nerve (VII) to the inferior good exposure is maintained for most procedures, except
border of the mandible and periosteal incision (dotted line). angle fractures located more anteriorly.
safely if access to the fracture is restricted. Stripping of

INTRAORAL SURGICAL APPROACHES the attachment of the various muscles of facial expres-
sion, such as the depressor anguli oris and platysma, does
ANGLE not seem to produce any deleterious effects on the post-
Often, when the presence of an impacted or partially operative result. However, release of these attachments
impacted lower third molar in the line of fracture at the does increase the chances of postoperative hematoma
angle necessitates removal, an intraoral approach is rea- formation, and pressure dressings are recommended.
sonable for fixation by wire osteosynthesis or with plates. The mentalis muscle is the only elevator of the lower lip
Generally, the anatomic considerations in flap design are and chin and, if not properly repositioned during final
based on the position of the tooth (e.g., buccal, lingual, closure, may lead to drooping of the lower lip. The
erupted), amount of bone displacement, and type of paired mentalis muscles begin at the root of the lower
fixation that will be used (e.g., rigid internal fixation may incisor teeth. Their fibers pass inferiorly and insert into
require a more extensive incision). It may be necessary the skin at the soft tissue pogonion. With proper incision
to strip some of the superficial tendon of the temporalis placement, there should be sufficient mentalis muscle
muscle off the ascending ramus. When dissection is mass in superior and inferior tissues to suture deeply
carried down to the inferior border of the mandible, the when closing.
operator must stay within the periosteal sheath to prevent
damage to branches of the facial nerve and to the facial
artery and vein as they course around the mandible in
the antegonial notch region. MUSCLES
PARASYMPHYSIS AND BODY MUSCLES OF FACIAL EXPRESSION
The intraoral approach to the parasymphysis and mental Although the muscles of facial expression (Fig. 10-21) do
nerve region of the mandible affords the operator the not have a strong influence on the displacement of frac-
following advantages—excellent visualization, the ability tures, soft tissue damage found in major maxillofacial
to observe the occlusion at the same time as reduction trauma and the various surgical approaches necessary for
and stabilization are performed, and an extraoral scar repairing deeper structures invariably affect these
can be avoided. Two types of incisions can be used, a muscles. If consideration is not given to their presence
vestibular or gingival sulcus incision. In the parasymphy- during repair and treatment planning, unsatisfactory aes-
sis and midline area, a vestibular incision should be thetic results will be encountered.
placed far enough into the unattached mucosa to prevent Muscles in this group all lie superficially and hence
postoperative gingival stripping by scar contracture. Care influence the skin.18 They perform major activities, such
should also be taken to avoid the mental foramen region as closing the eyelids and moving the lips. All muscles in
with the incision. Careful dissection of the mental nerve this group are innervated by the facial nerve. They can
and, if necessary, nerve relocation can be carried out be categorized into the following areas:
• Muscles of the scalp and auricle
Epicranial aponeurosis Procerus

Occipitofrontalis, frontal belly Corrugator supercilii
Depressor supercilii Levator labii superioris alaeque nasi
Orbicularis oculi, palpebral part Nasalis
Levator labii superioris alaeque nasi Orbicularis oculi, orbital part
Orbicularis oculi, orbital part Levator labii superioris
Zygomaticus minor
Levator labii superioris
Zygomaticus major
Zygomaticus minor
Zygomaticus major
Parotid gland
Orbicularis oris, marginal part
Levator anguli oris
Levator anguli oris
Buccal fat pad
Risorius
Parotid duct
Depressor labii inferioris
Buccinator
Depressor anguli oris Masseter, superficial part
Platysma
Depressor anguli oris
Depressor labii inferioris
Mentalis Platysma
Depressor septi nasi Orbicularis oris, labial part
FIGURE 10-21 Muscles of facial expression. (From Standring S, editor: Gray’s anatomy: The anatomical basis of clinical practice, ed 40,
Philadelphia, 2008, Churchill Livingstone.)
Lateral
pterygoid
Medial
pterygoid
A B C
FIGURE 10-22 Muscles of mastication. A, Masseter muscle illustrating two heads. B, Temporalis muscle. C, Medial pterygoid muscle and
lateral pterygoid muscle.
• Muscles around the orbit border as far anteriorly as the second molar. The mas-
• Muscles of the nose seter muscle is innervated by the masseteric nerve, which
• Muscles of the mouth reaches the deep surface of the muscle through the man-
• Platysma muscle extending down the neck dibular or coronoid notch. The blood supply is furnished
Anatomically, these muscles blend together at various by the masseteric artery, which is a branch of the internal
points, and it is impossible to dissect or differentiate maxillary artery.
individual muscles at these spots. This is especially true This muscle acts as a powerful elevator. The deep
near the corners of the mouth, where the modiolus con- fibers are also involved in mandibular retraction.
sists of a convergence of six muscles. Included in this
group is the buccinator muscle, which has no bone origin Temporalis Muscle
but instead arises from the pterygomandibular raphe The temporalis muscle is a fan-shaped muscle lying
and forms a continuous sheet with the orbicularis oris in the temporal fossa (see Fig. 10-22B). Its origin is from
muscle. The other muscles arise from bone attachments. the floor of the fossa below the inferior temporal line. It
also arises from the deep surface of the temporal fascia.
MUSCLES OF MASTICATION The temporal muscle bundles converge toward the deep
As discussed in prior sections, the muscles of mastication surface of the zygomatic arch and insert into the coro-
(Fig. 10-22)* play a notable role in bone displacement noid process medially at the apex and along its anterior
following mandibular fracture. Their actions must also border.
be considered during treatment planning because the The attachment extends down to the ramus of the
type and direction of placement of fixation devices may mandible. There are some fibers of the posterior part
be influenced by future muscle pull. All muscles of mas- that may radiate into the articular disc of the TMJ.17
tication are innervated by branches of the mandibular The innervation to the temporalis muscle is via the
nerve, which is a division of the trigeminal nerve. deep temporal branches of the mandibular nerve. The
blood supply is furnished by the middle and deep tem-
Masseter Muscle poral arteries, branches of the superficial temporal
The masseter muscle is a large, rectangular, superficial artery, and internal maxillary artery, respectively.
muscle composed of superficial, middle, and deep por- The action of the temporalis muscle is primarily eleva-
tions (see Fig. 10-22A). The superficial portion arises tion, although there are some retracting capabilities of
from the lower border of the zygoma and the most ante- the posterior fibers.
rior fibers arise from the zygomatic process of the maxilla.
These fibers generally run downward and posteriorly. Medial Pterygoid Muscle
The middle part of the masseter muscle arises from the The medial pterygoid muscle is found on the medial side
medial posterior third of the zygomatic arch, whereas the of the mandibular ramus. It is considered the counter-
deep part arises from the medial surface of the zygomatic part of the masseter muscle; however, overall, it is weaker.
arch and from the fascia over the temporalis muscle. It possesses two heads of origin (see Fig. 10-22C). The
These fibers are directed more vertically downward com- larger deeper head arises from the medial surface of the
pared with the superficial fibers. All three portions insert lateral pterygoid plate and from the pyramidal process
together into the lateral surface of the mandible. The of the palatine bone. The superficial head arises from
attachments extend to include the lower third of the the pyramidal process of the palatine bone and from the
posterior border of the ramus in addition to the lower tuberosity of the maxilla. The two heads unite, pass
downward and backward, and insert into the medial
surface of the mandible near the angle.
*References 4, 6, 18, 32, and 36.
The innervation of the medial pterygoid muscle is via

the masseteric and buccal nerve branches of the man- SUPRAHYOID MUSCLES
dibular nerve. A branch of the maxillary artery provides The suprahyoid muscles connect the hyoid bone with the
the blood supply. skull (Fig. 10-23). Their basic functions are elevation of
The medial pterygoid muscle acts mainly as a synergist the hyoid bone and depression of the mandible, depend-
of the masseter muscle during elevation of the mandible. ing on the activity of these muscles and coincident activ-
It can also act along with the lateral pterygoid muscle to ity of the infrahyoid muscle group.
cause the mandible to protrude.
Digastric Muscle
Lateral Pterygoid Muscle The digastric muscle consists of two bellies united by an
The lateral pterygoid muscle occupies the infratemporal intermediate tendon. The posterior belly arises from the
fossa (see Fig. 10-22C). It has two heads; the large inferior mastoid notch of the temporal bone, from which the
head arises from the lateral surface of the lateral ptery- fibers are directed forward and downward. The anterior
goid plate, whereas the upper head arises from the infra- belly is shorter and attaches to the lower border of the
temporal surface and crest of the greater wing of the mandible at the digastric fossa close to the symphysis.
sphenoid bone. The muscle fibers are oriented posteri- Fibers from here are directed downward and posteriorly.
orly and converge and insert partly into the capsule of A tendon between these two bellies is attached to the
the TMJ, mainly into the front of the mandibular condy- body of the muscle and greater horn of the hyoid bone
lar neck. by fibers of the cervical fascia, which form an aponeuro-
Innervation comes from the masseteric and buccal sis. The tendon can slide in the formed loop.
nerves. The blood supply is via a branch of the maxillary Innervation to the posterior belly is by a branch of the
artery. facial nerve and innervation to the anterior belly is by
FIGURE 10-23 Suprahyoid muscles. (From Deslauriers J: Anatomy of the neck and cervicothoracic junction, Thorac Surg Clin 17:529,
2007.)
the mylohyoid branch of the inferior alveolar nerve. The right and left make contact and may fuse. The fibers
digastric muscle pulls the chin backward and downward, proceed downward and slightly posterior to attach to the
which assists the lateral pterygoid muscle in rotating the upper half of the hyoid bone.
mandible into an open mouth position. Innervation is provided by the hypoglossal nerve,
which consists of branches of the first and second cervical
Mylohyoid Muscle nerves. The action of the geniohyoid muscle is to pull
The mylohyoid muscle is found above the anterior belly the hyoid bone up and forward, or to pull the mandible
of the digastric muscle, arising from the mylohyoid line down and posteriorly.
on the internal surface of the mandible from the third
molar region posteriorly to almost the symphysis anteri- Stylohyoid Muscle
orly. The direction of the fibers is toward the midline, The stylohyoid muscle is a slender muscle arising from
where they form a tendinous raphe. The posterior fibers the lateral and inferior surfaces of the styloid process.
insert into the body of the hyoid bone. The mylohyoid Fibers insert into the hyoid bone at the junction between
therefore forms the floor of the oral cavity. The dia- the body and greater horn. The tendon of the digastric
phragm formed is thicker in the free posterior margin, muscle commonly splits the stylohyoid muscle near its
resulting in an important surgical landmark. The lingual insertion.
nerve, deep process of the submandibular gland, and Innervation is provided by the facial nerve. The muscle
hypoglossal nerve pass deep to the posterior border. functions as an elevator and retractor of the hyoid bone
Innervation is by the mylohyoid branch of the inferior or as a stabilizer of the hyoid bone during other muscle
alveolar nerve; vascular supply is via the submental artery, functions.
which is a branch of the facial artery. The principal action
of the mylohyoid muscle is elevation of the tongue. INFRAHYOID MUSCLES
The infrahyoid muscles are four straplike muscles that
Geniohyoid Muscle anchor the hyoid bone to the sternum, clavicle, and
The geniohyoid muscle is situated above the mylohyoid scapula (Fig. 10-24). Their function is to depress the
muscle and arises from the inferior genial tubercle hyoid and larynx or to stabilize and fix the hyoid bone
behind the mandibular symphysis. It inserts into the in position during contraction of the suprahyoid muscle
front of the body of the hyoid bone. The muscles of the group.
Anterior belly of
digastric muscle
Mylohyoid muscle
Stylohyoid muscle
Posterior belly of
digastric muscle
Hyoid bone
Sternocleidomastoid
muscle
Thyrohyoid membrane
Superior belly of
omohyoid muscle
Cricoid cartilage
Sternohyoid muscle
Thyroid gland
Sternothyroid muscle
FIGURE 10-24 Infrahyoid muscles.

accidents. Their anatomic description will be addressed

Sternohyoid Muscle here.
The sternohyoid muscle arises from the back of the
manubrium and medial end of the clavicle. The muscle Levator Veli Palatini
fibers run superiorly and converge, but remain separated Arising from the petrous portion of the temporal bone
by the fascia termed the linea alba colli. The sternohyoid and eustachian tube, the levator veli palatini also extends
fibers attach to the inferior border of the hyoid bone. medially and inferiorly to join its counterpart from the
opposite side. The levator veli palatini functions to
Omohyoid Muscle elevate the vertical posterior portion of the soft palate. It
The omohyoid muscle consists of two bellies united by a functions in harmony with the tensor veli palatini and
tendon. The muscle origin is the upper border of the pharyngeal constrictors to close the oral pharynx from
scapula near the suprascapular notch. The inferior belly the nasal pharynx.
runs forward and upward under the sternomastoid Motor innervation is via the vagus nerve (cranial nerve
muscle to the tendinous attachment. The superior belly [CN] X); sensory innervation is from the pharyngeal
runs upward and inserts into the lower border of the plexus and CN IX.
hyoid bone. The intermediate tendon is attached to the
manubrium and to the first costal cartilage by a facial Tensor Veli Palatini
sling. Taking its origin from the base of the medial pterygoid
plate, spine of the sphenoid bone, and eustachian tube,
Sternothyroid Muscle the tensor veli palatini then courses vertically to the pter-
The sternothyroid muscle lies under the sternohyoid ygoid hamulus, where it passes around and courses hori-
muscle, where it arises from the back of the manubrium zontally into the soft palate. Its function is to raise or
and inserts into the thyroid cartilage. tense the soft palate and open the eustachian tube during
swallowing. Innervation is via the mandibular division of
Thyrohyoid Muscle the trigeminal nerve (CN V).
The thyrohyoid muscle originates where the sternothy-
roid muscle attaches at the oblique line of the thyroid Muscle of Uvula
cartilage and, therefore, may be considered an extension The muscle of uvula arises from the posterior nasal spine
of this muscle. It inserts into the lateral part of the greater and aponeurosis of the palate. The muscle passes poste-
horn of the hyoid bone. riorly and inserts on the mucous membrane of the uvula.
Innervation of the infrahyoid muscles is by the first, Its function is to shorten the uvula. The nerve supply is
second, and third cervical nerves. The sternohyoid, omo- from the vagus.
hyoid, and sternothyroid muscles are supplied by the
ansa cervicalis, whereas the thyrohyoid muscle receives PHARYNGEAL MUSCULATURE
innervation from the hypoglossal nerve. See Figure 10-26.2-4,6,10
SOFT PALATE MUSCULATURE Superior, Middle, and Inferior Constrictors
The soft palate and pharynx are functionally and ana- The superior, middle, and inferior constrictor muscles
tomically related (Fig. 10-25).2-4,6,10 Although rarely make up the lateral and posterior walls of the pharynx
involved in minor traumatic episodes, they are frequently and function in harmony to close or constrict the
involved in gunshot wounds and more severe traffic pharynx. Their origins, from superior to inferior respec-
tively, are the medial pterygoid plate, pterygomandibular
raphe, which is the upper border of the greater cornu of
the hyoid, and larynx. They all insert on the fibrous
median raphe. The three are paired and overlap each
other vertically. Innervation is via the vagus nerve by the
pharyngeal plexus.
Dilators and Elevator Muscles
Palatopharyngeus Muscle. This is the posterior tonsillar
pillar. It originates in the soft palate and passes vertically
Tensor veli
palatini to insert on the posterior border of the thyroid cartilage.
Innervation is via the pharyngeal plexus.
Salpingopharyngeus Muscle. This is generally consid-
Hamulus
Palatopharyngeus ered part of the palatopharyngeus muscle. It runs verti-
Levator cally from the auditory tube to blend with the
Palatoglossus veli palatini palatopharyngeus muscle. It is also innervated by the
Muscle pharyngeal plexus.
uvulae Palatoglossus Muscle. This muscle forms the anterior
tonsillar pillar, arising from the anterior aponeurosis of
the soft palate and inserting on the lateral side of the
FIGURE 10-25 Soft palate musculature. tongue, where it merges with the transverse fibers of the
Eustachian tube
Tensor veli palatini muscle
Levator veli palatini muscle

Salpingopharyngeus muscle
Palatoglossus muscle
Superior pharyngeal
constrictor muscle
Palatopharyngeus muscle
Glossopharyngeus muscle
Middle pharyngeal
constrictor muscle
Stylohyoid ligament
Stylopharyngeus
muscle
FIGURE 10-26 Pharyngeal musculature.
tongue. Innervation is from the pharyngeal plexus of mandibular neck. Here it gives off its branch, the super-
nerves. ficial temporal artery, and continues deep to the condyle,
Stylopharyngeus Muscle. Arising from the styloid turning medially and anteriorly as the internal maxillary
process, this cylindrical muscle passes inferiorly between artery (see Fig. 10-27).
the superior and middle pharyngeal constrictors. As it
Branches of the External Carotid Artery
passes behind the middle constrictor, it spreads and
unites with its counterpart from the opposite side. Its Superior Thyroid Artery. The superior thyroid artery
function is to dilate or widen the pharynx. The stylopha- arises from the common carotid artery or from the front
ryngeus muscle is innervated by a branch of the glosso- of the external carotid artery below the hyoid bone and
pharyngeal nerve. under the sternocleidomastoid muscle. Its course is
downward and forward, deep into the infrahyoid muscles
to the apex of each lobe of the thyroid gland, where it
ARTERIAL BLOOD SUPPLY TO THE HEAD divides into infrahyoid, superior laryngeal, cricothyroid,
AND NECK and glandular branches.
Lingual Artery. The lingual artery arises from the front
Generally speaking, the external carotid artery and its of the external carotid artery as a common vessel with
branches are responsible for the arterial blood supply to the facial artery or as a separate entity. The artery lies
the facial region (Fig. 10-27).4,6,16,18 Exceptions include level with or above the hyoid bone. Its course begins
those areas supplied by branches of the internal carotid horizontally forward of the posterior border of the hyo-
artery to the upper face and portions of the nasal cavity. glossus muscle, continuing forward deep into the hyo-
The aortic arch is the origin of the common carotid glossus muscle along the upper border of the hyoid bone
artery on the left side. The right common carotid artery lying on the middle constrictor muscle. Superiorly, it
is a branch of the brachiocephalic or innominate artery. reaches a space between the genioglossus and inferior
Surgical Note: When performing ligation of the exter- longitudinal muscles of the tongue. At this point, it turns
nal carotid artery, it is important that the surgeon be horizontally and runs along the lower surface of the
cognizant of the relationship of the external and internal tongue, toward its tip, in a tortuous fashion. In severe
carotid arteries at their origin. At this point, the internal facial trauma with penetrating wounds, ligation of the
carotid artery is posteromedial and the external carotid lingual artery may be necessary. Branches include the
artery is anterolateral. The level of this division is gener- following.
ally at the superior border of the thyroid cartilage. Suprahyoid Artery. The suprahyoid artery runs along
the upper border of the hyoid bone, sending branches
EXTERNAL CAROTID ARTERY to muscles attached to the bone and anastomosing with
During its earliest course, the external carotid artery is the opposite side.
superficial, lying below the investing layer of deep cervi- Dorsales Linguae Artery. The dorsales linguae artery
cal fascia, platysma muscle, superficial fascia, and skin. arises under the hyoglossus muscle and ascends to the
As it progresses superiorly, it runs through the subman- dorsum of the tongue.
dibular triangle to the retromandibular fossa, through Sublingual Artery. The sublingual artery arises at the
the substance of the parotid gland to the level of the anterior border of the hyoglossus muscle. From there, it
Superficial
temporal artery
Posterior
auricular artery
Occipital artery
Maxillary artery
Ascending
pharyngeal artery
Lingual artery
Facial artery
Internal carotid
artery
External carotid artery
Superior thyroid artery
Vertebral artery
Common carotid artery
Subclavian artery
Brachiocephalic artery
FIGURE 10-27 Arterial blood supply to the head and P A

neck. (From Thibodeau: Anatomy and physiology, ed 7, I
St. Louis, 2010, Mosby.)
runs forward in the floor of the mouth medially to the mandible. The facial artery is generally considered to
sublingual gland, which it supplies, and along with have cervical and facial divisions.
mucous membranes of the floor of the mouth and mylo- Cervical Division
hyoid muscle. 1. Ascending palatine branch. The origin of this branch is
Deep Lingual Artery. This is actually the terminal con- close to the lateral pharyngeal wall and runs along the
tinuation of the lingual artery in the substance of the outer surface of the superior pharyngeal constrictor.
tongue. It supplies the tongue and then forms an anas- It accompanies the levator veli palatini and supplies
tomosis with the opposite side, the arcus raninus. the soft palate, portions of the pharynx, and the
Facial Artery. The facial artery arises from the front of tonsils.
the external carotid artery in common with the lingual 2. Tonsillar branch. This is the main artery to the tonsil.
artery (linguofacial trunk) or as a separate branch just It may arise from the anterior border of the masseter
below the posterior belly of the digastric muscle. It muscle. The facial artery also runs upward with the
ascends in the carotid triangle and enters a groove on the ascending palatine branch.
posterior border of the submandibular gland. It turns 3. Glandular branch. This branch supplies the subman-
downward and forward between the submandibular dibular gland.
gland and medial pterygoid muscle, where it then winds 4. Submental branch. This is the largest branch given off
around the lower border of the mandible at a point in by the facial artery in the neck. Its course is forward
front of the anterior border of the masseter muscle. At on the mylohyoid muscle, where it supplies muscles in
this point, the facial artery is usually located anteriorly to the area; it then turns upward over the lower border
the facial vein. The facial artery runs upward and forward of the mandible.
on the face, ending as the angular artery at the medial Facial Division
angle of the eye by anastomosing with branches of the 1. Inferior labial artery. This artery penetrates the orbicu-
ophthalmic artery. Its general course is tortuous through- laris oris muscle, supplying the skin, muscles, and
out the face, with considerable individual variations. mucous membranes of the lower lip. From here it
anastomoses with the opposite side.
Surgical Note: Ligation of the facial artery and vein is often 2. Superior labial artery. This branch is larger than the
required during the open approach to the inferior inferior branch. It has a course and distribution
similar to the inferior labial artery, although to the design are usually such that the artery is anterior to the
upper lip. approach and is reflected in the soft tissue flap.
3. Lateral nasal branch. This branch supplies the ala and Maxillary Artery. The maxillary artery is the larger of
dorsum of the nose. the terminal branches arising in the parotid gland behind
4. Angular artery. This is the termination of the facial the neck of the mandible. At this point, the maxillary
artery. It anastomoses with the dorsal nasal and palpe- artery turns at right angles to the superficial temporal
bral branches of the ophthalmic artery, thereby estab- branch, where it courses anteriorly and upward through
lishing a possible route of communication between the infratemporal fossa. There is a varying relation
the external and internal carotid arteries. between the artery and lateral pterygoid muscle.14 In
Occipital Artery. The occipital artery arises from the more than 50% of individuals, the artery is on the outer
back of the external carotid artery at about the same side of the muscle, passing between the mandible and
level as the facial artery; however, its origin can vary in sphenomandibular ligament. In the rest, the artery is
either direction. Near its origin, the hypoglossal nerve located medially to the lateral pterygoid muscle.
winds around it. The artery runs through the carotid Branches of the maxillary artery are numerous and
triangle backward and upward to the lower border of complicated (Fig. 10-28). In an attempt to group the
the posterior belly of the digastric muscle and then branches for ease of understanding, they are divided into
crosses the internal carotid artery and internal jugular the following parts.
vein. Under the sternocleidomastoid muscle, it occupies Mandibular Part of the Maxillary Artery. The first part
the occipital groove on the temporal bone. Posterior to runs forward between the neck of the mandible and the
the sternocleidomastoid muscle, it pierces the trapezius sphenomandibular ligament. Most of its branches accom-
muscle and divides into various scalp branches. Branches pany those of the mandibular nerve.
include a sternomastoid branch, a mastoid branch, a Deep Auricular Artery. This artery ascends through
descending branch, which can be important because of the parotid gland to supply the meatus and tympanic mem-
anastomoses with the opposite side during external brane.
carotid ligation, meningeal branches, and occipital ter- Anterior Tympanic Artery. This artery supplies the tym-
minal branches. panic membrane.
Posterior Auricular Artery. The posterior auricular Middle Meningeal Artery. Clinically, this is the most
artery arises from the back of the external carotid artery important branch of the maxillary artery. It runs upward
above the posterior belly of the digastric muscle. It between the sphenomandibular ligament and lateral
follows the stylohyoid muscle upward under cover of the pterygoid muscle. It passes between the two roots of the
parotid gland and terminates between the mastoid auriculotemporal nerve and enters the cranium via the
process and the auricle. Branches include the stylomas- foramen spinosum, which is located in the sphenoid
toid, posterior tympanic auricular, and occipital branches. bone (Fig. 10-29). It then divides into a tympanic branch
Ascending Pharyngeal Artery. The ascending pharyn- and splits into anterior and posterior branches.
geal artery is a small vessel that is the only medial branch
of the external carotid artery. It arises low, just before the Surgical Note: This artery, because of its medial location
division above the common carotid artery, and ascends to the condyle, could be potentially damaged during
between the internal carotid artery and pharyngeal wall open procedures in the condylar region or directly
to the base of the skull. Branches are given off to the wall damaged by severe condylar displacement.
of the pharynx and adjacent muscles. Near the base of Inferior Alveolar Artery. This artery descends between
the skull, there is an anastomosis with the pterygoid the sphenomandibular ligament and ramus of the man-
artery of the maxillary artery. dible. The nerve lies anteriorly, and enters the mandibu-
Superficial Temporal Artery. The superficial temporal lar canal via the mandibular foramen. The branches of
artery is the smaller terminal branch of the external the inferior alveolar artery include the lingual and mylo-
carotid artery, with its origin in the parotid gland behind hyoid branches before entering the canal and the dental,
the neck of the mandible. It crosses the zygomatic arch mental, and incisor branches after entering the canal. In
and divides into frontal and parietal branches. The auric- the mandibular canal, the artery sends branches into the
ulotemporal nerve runs posteriorly to the superficial tem- marrow spaces and the teeth via apical branches and
poral artery. Branches include the transverse facial artery, periodontal branches, with the mental artery branching
which arises in the parotid gland and runs forward across off and exiting via the mental foramen to supply the soft
the masseter muscle between the zygomatic arch above— tissue of the chin. The continuation terminal branch is
and the duct of the parotid gland below—and is accom- the incisive artery, which continues its course within the
panied by zygomatic branches of the facial nerve. There mandible to anastomose with the incisive artery of the
it supplies the parotid gland and duct, the masseter opposite side.
muscle, the skin, the auricle, and the joint capsule. The Second Part of the Maxillary Artery. The second
terminal branches divide above the zygomatic arch into portion of this artery consists of the following.
the frontal and parietal branches. There are also deep Anterior and Posterior Deep Temporal Arteries. These
branches during its course to the middle temporal artery. arteries ascend between the temporalis muscle and skull
to supply the temporalis muscle.
Surgical Note: The identification and protection of the Masseteric Artery. This artery travels with the corre-
superficial temporal artery are important during open sponding masseteric nerve behind the temporalis muscle
procedures involving the condyle. Incision and flap to pass through the coronoid notch and enter the deep
FIGURE 10-28 Maxillary artery and branches.
surface of the masseter muscle. It also has branches sup- greater palatine canal, running forward to the roof of
plying the joint capsule. the mouth and supplying the hard palate. The lesser
Pterygoid Branches. These branches supply the ptery- palatine artery passes through the lesser palatine canal
goid muscles. to supply the soft palate.
Buccal Artery. This artery accompanies the buccal Artery of the Pterygoid Canal. This vessel frequently
nerve to the buccinator, which it supplies, along with the arises from the descending or greater palatine artery,
skin and mucous membranes of the cheek. which runs backward through the pterygoid canal along
Third Part of the Maxillary Artery. This portion of the with the corresponding nerve.
maxillary artery branches extensively and supplies the Sphenopalatine Artery. This is the last of the terminal
upper teeth, portions of the face and orbit, palate, and branches. It enters the nasal cavity through the spheno-
nasal cavity. palatine foramen and gives off the posterior and lateral
Posterior Superior Alveolar Artery. This artery takes a nasal arteries, which then proceed to the conchae,
tortuous course down in the infratemporal fossa and meatus, and paranasal sinuses. It eventually terminates
onto the posterior surface of the maxilla. Here, small in the nasal septum and, as such, is important in
branches supply the gingiva and dental branches, enter- epistaxis.
ing canals to the molars and premolars and to the maxil-
Internal Carotid Artery
lary sinus lining.
Infraorbital Artery. This artery arises in the pterygo- The origin of the internal carotid artery4,6 is approxi-
palatine fossa; it enters the orbit through the inferior mately at the level of the thyroid cartilage (see Fig. 10-27).
orbital fissure and courses anteriorly in the infraorbital It is at first behind and medial to the external carotid
sulcus, proceeding through the infraorbital canal, and artery but, during its course, it moves away from the
finally through the infraorbital foramen with the corre- external carotid artery and eventually separates near
sponding nerve. Before leaving the canal, the anterior the styloglossal and stylopharyngeal muscles. It enters the
and superior alveolar branches form. Branches develop middle cranial fossa through the carotid canal and travels
and supply various orbital muscles throughout its route into the cavernous sinus, dividing into the anterior and
through the orbit. middle cerebral arteries.
Descending Palatine Artery. This artery is one of the No branches form during the internal carotid artery’s
terminal branches arising in the pterygopalatine fossa. course through the neck. Its curved shape can follow
After descending through the pterygopalatine canal, the neck movements without stretching. The internal carotid
greater palatine artery develops and passes through the artery is closely related to the internal jugular vein and
Posterior deep Masseteric

temporal nerve nerve
Branch to lateral
pterygoid muscle
Auriculotemporal
nerve
Middle meningeal
artery
Mylohyoid
nerve
Branch to medial Inferior alveolar

pterygoid muscle nerve
Lingual
Buccal nerve nerve
FIGURE 10-29 Mandibular division of the trigeminal nerve.
the vagus nerve. The internal jugular vein travels in a only to the internal carotid artery but also to the vagus
half-spiral trajectory around the artery. nerve. Various deep structures drain into the internal
After leaving the cavernous sinus, the internal carotid jugular vein. Those of relevance here include the
artery branches into several other arteries; the most sig- common facial vein, which drains the superficial and
nificant is the ophthalmic artery, which follows the optic deep parts of the face, and lingual and sublingual veins.
nerve into the orbit. This branch supplies the eyeball,
muscles, lacrimal gland, and eyelids. Other branches of COMMON FACIAL VEIN
note include the central artery of the retina, posterior The common facial vein drains from an area that cor-
and anterior ethmoid branches to the nasal cavity, medial responds more or less with the distribution of the facial,
and lateral palpebral branches, and supraorbital branch. maxillary, and superficial temporal arteries. It originates
The final facial branch of the ophthalmic artery is the from the intersection of the facial and retromandibular
nasal branch. veins near the angle of the mandible. The common facial
vein empties into the internal jugular vein at the level of
VEINS OF THE HEAD AND NECK the hyoid bone.
Venous drainage to the head and neck (Fig. 10-30)4,6,16 Surgical Note: The common facial vein is often violated in
can be considered from the standpoint of being superfi- cases of traumatic hemorrhage or iatrogenic hemor-
cial and deep in function. The superficial drainage is rhage during various approaches to the maxilla, zygoma,
mainly via the external and anterior jugular veins, condylar ramus, or body of the mandible. Ligation, pres-
whereas most of the deep venous drainage is via the inter- sure, and hemostatic cautery are all useful for controlling
nal jugular vein. There is significant anastomosis between venous bleeding in these areas.
all veins, intracranially and facially, and superficially and
deep. The superficial veins empty into the internal ANTERIOR FACIAL VEIN
jugular vein at a low point and, in turn, it joins the subcla- The frontal vein, which drains the anterior scalp region,
vian vein to form the brachiocephalic or innominate vein empties into the angular vein at about the bridge of the
behind the sternoclavicular articulation. nose, where the angular vein continues downward toward
Consideration of the potential disruption of a vein the cheek. Near the commissure, the facial vein descends
with subsequent bleeding is always important in the along with the facial artery, where it crosses the inferior
trauma patient, as is a potential retrograde spread of border of the mandible close to the anterior edge of the
infection in the postoperative phase. masseter muscle attachment. The vein is normally poste-
rior to the artery at this location.
INTERNAL JUGULAR VEIN
Beginning at the jugular foramen, the internal jugular Surgical Note: The vein is normally identified, ligated,
vein is located posteromedially to the internal carotid and cut during submandibular approaches to the
artery. During its descent, the vein is closely related not mandible.
FIGURE 10-30 Veins of the head and neck.
RETROMANDIBULAR VEIN EXTERNAL JUGULAR VEIN

At approximately the level of the neck of the mandible, The posterior auricular and occipital veins join below the
the retromandibular vein is created by the junction of ear to form the superficial external jugular vein. From
the superficial temporal and maxillary veins. The vein is this point, the vein descends across the sternocleidomas-
located within the substance of the parotid gland, from toid muscle and eventually drains into the internal
which it descends to leave the gland at its lower pole. jugular vein.
Initially, the vein and external carotid artery are closely
related but, as it descends into the face, the vein and ANTERIOR JUGULAR VEIN
artery diverge. In the preauricular region, the superficial There is notable variability in the position and presence
temporal artery is often closely related to two veins—the or absence of one or both sides of the anterior jugular
superficial temporal vein and the more anteriorly located vein. This vein is located anteriorly, or even as a single
middle temporal vein. Surrounding the maxillary artery midline vein, coursing inferiorly around the anterior
in the infratemporal fossa is the pterygoid plexus of aspect of the sternocleidomastoid muscle to empty into
veins. The pterygoid plexus empties into the retroman- the internal jugular vein.
dibular vein below the level of the neck of the mandible
medially. NEUROLOGIC ANATOMY*
Surgical Note: Many of the deep veins of the face drain Surgical Note: The most common injuries to nerves of the
into this plexus, which is an area for potentially signifi- head and neck subsequent to major maxillofacial trauma
cant bleeding during mobilization of Le Fort–type maxil- involve the superficially positioned facial nerve or the
lary fractures, which separate at or through the pterygoid
plates. Because this is essentially a blind area during the
treatment of most fractures, pressure and local measures
are the only methods of hemostasis available. *References 4, 6, 16, 18, 32, 29, 34, and 47.
FIGURE 10-31 Cutaneous sensory distribution of the trigeminal nerve. (From Drake R, Vogl AW, Mitchell A: Gray’s anatomy for students,
ed 2, Philadelphia, 2009, Churchill Livingstone.)
cranial nerves found within bony canals that are frac- sensory root ganglion, is found in Meckel’s cavity near
tured, such as the inferior alveolar nerve, infraorbital the foramen lacerum. From this location, the three
nerve, and optic nerve. The surgeon must also be cogni- sensory divisions of the trigeminal nerve arise. The motor
zant of neuroanatomy when designing soft tissue flaps or portion eventually joins the mandibular division in its
applying any form of a stabilizing appliance. Discussion course. The first division of the trigeminal nerve is the
in this chapter is limited to the trigeminal, facial, and ophthalmic nerve, which enters the orbit through the
hypoglossal nerves. medial part of the superior orbital fissure. The second
division is the maxillary nerve, which exits the foramen
TRIGEMINAL NERVE rotundum and goes into the pterygopalatine space. The
The trigeminal nerve is composed of sensory and motor mandibular nerve, or third division, leaves the foramen
fibers. The sensory distribution essentially covers the ovale and continues into the infratemporal fossa. Figure
entire anterior head and face, whereas the motor divi- 10-31 illustrates the normal cutaneous innervation of the
sion innervates the muscles of mastication. The trigemi- three divisions of the trigeminal nerve. The mandibular
nal nerve arises from the ventral surface of the cerebral angle region is variably innervated by branches of the two
pons. The semilunar or gasserian ganglion, which is the upper cervical nerves.
Posterior ethmoid
FIGURE 10-32 Superior orbital view. Right, Nerves and musculature. Left, Cutaway showing arterial supply.
Ophthalmic Nerve canal, some small branches enter the nasal cavity and
In the orbit, the ophthalmic nerve (Fig. 10-32) divides supply the inferior nasal concha, along with the middle
into three branches. The nasociliary nerve travels along and inferior nasal meatus. Further into the canal, a
the medial orbital roof, where it branches into the nasal branch enters the greater palatine foramen and sends
cavity. The frontal nerve proceeds anteriorly to the skin branches anteriorly in the palate. Another branch passes
of the forehead and the lacrimal nerve courses along the through the lesser palatine foramen and supplies the
lateral orbital roof to the lacrimal gland and the skin at tonsillar and soft palatine tissues.
the corner of the eye. Infraorbital Nerve. This nerve courses from the infra-
temporal fossa through the inferior orbital fissure and
Maxillary Nerve into the orbit, where it runs in the infraorbital groove,
After exiting the skull through the foramen rotundum, which transforms into the infraorbital canal and then
the maxillary nerve (Figs. 10-33 and 10-34; see also Fig. exits through the infraorbital foramen to supply superfi-
10-32) enters the pterygopalatine fossa, where it splits cial structures of the face. Branches of the infraorbital
into three major branches. nerve include the posterior and superior alveolar nerve,
Pterygopalatine Nerve. Shortly after leaving the main which exits from the infratemporal fossa. From here, it
trunk of the maxillary nerve, the pterygopalatine nerve divides and sends branches through the posterior maxil-
seems to enter the pterygopalatine ganglion, but instead lary wall and into the maxillary sinus. The middle supe-
the fibers are only closely adherent. Near the ganglion, rior alveolar nerve leaves the infraorbital nerve while in
the superior and posterior nasal branches enter the sphe- the groove, where it enters the superior aspect of the
nopalatine foramen into the nasal cavity, where they maxillary sinus. The anterior and superior alveolar nerves
supply the middle nasal concha. Lateral branches supply leave while the infraorbital nerve is in the canal, which
the upper and middle conchae, whereas medial branches sends branches to the maxillary sinus and nose. Sensory
supply the septum, and terminal branches enter the distribution is provided to the maxillary teeth, alveolar
nasopalatine or incisive foramen to innervate the incisor bone, periodontal ligaments, and gingiva.
teeth, gingiva, and palatal tissue. Zygomatic Nerve. In some cases, this nerve may be a
The major portion of the pterygopalatine nerve con- branch of the infraorbital nerve. Its course is lateral
tinues through the pterygopalatine canal. While in the through the orbit, where it sends a branch up to the
FIGURE 10-33 Lateral view of orbital nerves.
Superior orbital Levator palpebrae

fissure superioris muscle Superior oblique
muscle
Superior rectus
muscle
Medial rectus
muscle
Trochlear nerve (IV)
Optic nerve
Lacrimal nerve
Nasociliary nerve
Frontal nerve
Inferior rectus
Ophthalmic vein muscle
Superior division Abducens nerve (VI)
of oculomotor nerve
Inferior division Infraorbital nerve

of oculomotor nerve
Lateral rectus muscle
FIGURE 10-34 Orbital apex, superior orbital fissure, and relations of contents; right orbit.
lacrimal nerve, which consists of postganglionic para the zygomaticotemporal nerve exits into the temporal
sympathetic fibers from the pterygopalatine ganglion. fossa, where it supplies the skin of the temple region.
The zygomatic nerve then continues through the
zygomatico-orbital foramen and into the zygomatic Mandibular Nerve
bone. Here, a branch, the zygomaticofacial nerve, exits The mandibular nerve (see Fig. 10-29) contains sensory
the bone and supplies the skin over the cheek, whereas and motor nerve fibers and exits the skull through the
foramen ovale and into the infratemporal fossa. The

motor branches to the muscles of mastication are given
off as the masseteric nerve, posterior and anterior tem- A
poral nerves, medial pterygoid nerve, and lateral ptery-
goid nerve.
Buccal Nerve. The course of the buccal nerve begins B
near the greater wing of the sphenoid bone and runs
along the medial surface of the lateral pterygoid muscle,
where it passes between its two heads. It innervates the
lateral pterygoid and temporalis muscles. The buccal
nerve then follows the anterior edge of the temporalis
muscle and perforates the buccinator muscle. The
sensory distribution of the buccal nerve includes the
buccal gingiva in the posterior mandible, cheek, and a
portion of the mucous membranes of the upper and
lower lips.
Lingual Nerve. During its initial course, the lingual
nerve is found in close proximity to the inferior alveolar
nerve. Later, it separates and is found anteromedially in
relationship to this nerve. The lingual nerve descends Lingual Lingual
between the medial and lateral pterygoid muscles. At the
inferior border of the lateral pterygoid muscle, the 4 mm 1–2 mm
chorda tympani fibers connect. As the lingual nerve Buccal Buccal
passes beyond the lateral pterygoid muscle, it proceeds
laterally along the lateral surface of the medial pterygoid
muscle and then turns sharply anteriorly on the superior
surface of the mylohyoid muscle. In the floor of the B A
mouth, the course of the lingual nerve is very close to
the oral mucous membranes, especially posteriorly in the FIGURE 10-35 Position of the inferior alveolar canal as it travels
area of the superior pole of the submandibular gland. As anteriorly in the mandible.
it moves anteriorly, the nerve runs medially and proceeds
below the submandibular, or Wharton’s, duct and ends
by sending fibers into the tongue substance. The lingual course (Fig. 10-35).34 The mylohyoid nerve branches off
nerve provides sensory distribution to the gingiva and the inferior alveolar nerve before entering the canal.
mucous membranes of the mandibular lingual and This nerve runs downward and anteriorly in the mylohy-
mucous membranes of the floor of the mouth, and the oid groove before innervating the mylohyoid muscle,
lower and upper surfaces of the body of the tongue back anterior belly of the digastric muscle, and sensory fibers
to the circumvallate papillae. The lingual nerve carries of the chin area. Exiting the mental foramen, the inferior
terminal taste fibers to the anterior two thirds of the alveolar nerve divides into three terminal mental nerves,
tongue. These fibers originate from the facial nerve and which supply sensation to the chin, lower lip, and mucous
relay impulses to the lingual nerve via the chorda tympani membranes of the lower lip.
nerve. The regional anatomy of the floor of the mouth Auriculotemporal Nerve. The auriculotemporal nerve
will be discussed later. separates from the mandibular nerve immediately below
Inferior Alveolar Nerve. As noted, in its initial course, the cranial base and divides to encircle the middle men-
the inferior alveolar nerve has a close relationship to the ingeal artery. After reuniting, it courses downward and
lingual nerve. After separating approximately 5 mm posteriorly, crossing the neck of the mandibular condyle.
below the cranial base, the inferior alveolar nerve travels It enters the substance of the parotid gland and divides
between the lateral and medial pterygoid muscles. The into two branches, one of which turns upward anterior
inferior alveolar nerve passes around the lower border to the outer ear—closely related to the superficial tem-
of the lateral pterygoid muscle and then proceeds to the poral artery crossing the zygomatic arch. Its position is
medial aspect of the ramus of the mandible to enter the important to consider in an open approach to the pre-
mandibular foramen. It has been shown that in approxi- auricular region. Terminal branches supply the outer ear,
mately 34% of mandibles, the neurovascular bundle external auditory meatus, capsule of the mandibular
divides soon after the beginning of the inferior alveolar joint, and areas of the parotid gland. Other terminal
canal.44 Other studies have not shown as high an inci- branches supply the skin in the greater posterior temple
dence, varying from 0.96% to 8%.34 The superoinferior region.
course of the nerve in the mandible is such that it
descends to the lowest point near the first molar and
then rises again. In a lateromedial position, the canal and FACIAL NERVE
bundle are closest to the lateral cortical plate in the third The motor fibers of the facial nerve provide innervation
molar area, but the nerve remains fairly constant in its to the muscles of facial expression, occipital and auricu-
relationship to the medial cortical plate throughout its lar muscles, platysma muscle, posterior belly of the
Branches of the facial nerve
Temporal
branches
Zygomatic
branches
Buccal
branches
Marginal mandibular FIGURE 10-36 Distribution of the facial nerve. The exact
branch Parotid configuration can vary considerably; this illustration is only an
gland example. (From Langdon RC, Sattler G, Hanke CW: Minimum
Cervical branches
incision face lift. In Robinson JK, Hanke CW, Siegel DM,
Sengelmann RD, editors: Surgery of the skin, St. Louis, 2005,
CV Mosby.)
digastric muscle, and stylohyoid muscle. In addition, it deep into the skin surface. From this point, the two
supplies fibers for deep sensitivity of the face and for taste branches curve around the posterior mandible, where
to the anterior two thirds of the tongue and palate. The they form a plexus between the parotid gland and mas-
facial nerve also transmits preganglionic visceral efferent seter muscle. The terminal branches of the facial nerve
fibers to the lacrimal gland, sublingual and submandibu- then spread in a fanlike fashion as five separate nerves
lar glands, and other minor glands. (Fig. 10-36). These branches are the temporal, zygo-
After leaving the brain, the facial nerve enters the matic, buccal, mandibular, and cervical branches. There
inner auditory meatus. The nerve bends sharply at the are often variations in the pattern of distribution.16
tympanic cavity and travels posteriorly above the oval
window, continuing to the posterior wall of the tympanic Temporal Branch
cavity. The facial nerve then leaves the canal and exits The temporal branch exits the parotid gland anterior to
through the stylomastoid foramen. the superficial temporal artery. Muscles innervated via
this branch include the auricular muscles, frontal muscle,
Surgical Note: Damage to the facial nerve is possible in superior portion of the orbicularis oculi muscle, and cor-
severe maxillofacial injuries with basilar skull fractures rugator muscle to the eyebrows.
at any point near the pathway of the nerve and would
result in ipsilateral paralysis of the muscles of facial Surgical Note: During an open approach to the TMJ, viola-
expression. tion of the nerve is possible. Often, temporary weakness
Of concern to the surgeon is the close proximity of the is apparent because the patient cannot squeeze the ipsi-
main trunk of the facial nerve where it exits the stylomas- lateral eye together or wrinkle the forehead. This inabil-
toid foramen and mandibular condyle. After exiting the ity is usually caused by retractor trauma or soft tissue
foramen, which is situated posterolaterally to the styloid edema. If this is the case, it should resolve itself during
process, the nerve enters the substance of the parotid the first postoperative week.
gland, where it divides into its upper and lower divisions
just posterior to the mandible. The approximate distance Zygomatic Branch
from the lowest point of the external bony auditory The course of the zygomatic branch is anterosuperior,
meatus to the bifurcation of the facial nerve is 2.3 cm. crossing the zygomatic bone. Innervation is to the orbi-
Posterior to the parotid gland, the nerve is at least 2 cm cularis oculi muscle.
FIGURE 10-37 Marginal mandibular branch of the facial

nerve and its relationship to the facial artery. (From Hanke
CW, Sattler G: Procedures in cosmetic dermatology
series: Liposuction, Philadelphia, 2005, Saunders.)
Surgical Note: Inadvertent damage may occur during digastric muscles. It curves slightly upward across the
open reduction of the zygomatic arch or with the use of internal and external carotid arteries and the occipital
a Byrd screw or zygomatic hook during a closed approach. and lingual arteries on their lateral side (Fig. 10-38). Con-
tinuing forward along with the sublingual vein, the nerve
Buccal Branch follows the lateral surface of the hyoglossus muscle. At the
Running almost horizontally, the buccal nerve will often posterior extent of the mylohyoid muscle, the nerve runs
divide into a separate branch above and below the parotid along the superomedial surface to split into several fibers
duct as it runs anteriorly. within the substance of the tongue in a fanlike fashion.
The hypoglossal nerve is responsible for motor innerva-
Surgical Note: Injury is possible in association with soft tion to all the muscles of the tongue. The nerve, however,
tissue trauma to the cheek region. contributes fibers to the ansa cervicalis, which descends
along the internal carotid artery and joins branches of the
Mandibular Branch second and third cervical nerves to contribute to the
The marginal mandibular branch (Fig. 10-37) originates hypoglossal ansa. From the loop, branches are sent to the
after the facial nerve divides into the temporofacial and omohyoid, sternothyroid, and sternohyoid muscles.
cervicofacial division and extends anteriorly and inferi-
orly within the substance of the parotid gland. There may
be two or even three branches of this nerve. REGIONAL ANATOMY
These branches run anteriorly parallel to the inferior
border of the mandible. In some cases, the course of this ORBITAL ANATOMY
nerve is above the inferior border but, in as many as 19% The configuration of the bony structure of the orbit
of cases, it is found below this border.48 In essentially all (Figs. 10-39 to 10-42; see also Figs. 10-32 to 10-34)* is that
cases, the nerve is located above the inferior border of of a pyramid with its base facing anteriorly, with each
the mandible beyond the facial artery. orbit having an intrabony volume of approximately
35 mL. Each bony orbit is composed of seven bones (see
Surgical Note: The marginal mandibular branch is an Fig. 10-39), as follows:
important structure encountered at the inferior border • Frontal bone
of the mandible just beneath the platysma muscle fibers • Zygoma
during an open approach to the mandibular angle and • Maxilla
body area. For this reason, an initial incision made • Lacrimal bone
approximately 1 to 1.5 cm below the inferior border • Ethmoid bone
should prevent direct exposure or trauma. The terminal • Sphenoid bone
innervation of this nerve is to the ipsilateral muscles of • Palatine bone
the lower lip and to the mentalis muscle. The medial walls (lamina papyracea of the ethmoid,
lacrimal, and palatine bones) are almost parallel to the
Cervical Branch sagittal plane. The medial wall is the thinnest wall of the
The cervical branch exits the parotid gland above its orbit, but derives some increased strength from the tra-
inferior pole and runs downward underneath the pla- beculation of the ethmoidal air cells. The lateral walls
tysma muscle, which it innervates. (zygoma, sphenoid, and frontal bones) diverge from the
apex at approximately 45 degrees. The lateral orbital rim
HYPOGLOSSAL NERVE is formed by the zygoma and is posterior to the medial,
After exiting the brain, the hypoglossal nerve passes superior, and lateral orbital rims. The floor of the orbit
through the hypoglossal canal and winds around the (maxilla) is the roof of the maxillary sinus and is relatively
vagus nerve inferiorly; it is bound to this nerve with some thin and anatomically weakened by the passage of the
connective tissue. The hypoglossal nerve then passes infe-
riorly across the medial aspect of the stylohyoid and *References 1, 4, 11, 15, 17, and 49.
Hypoglossal nerve
Stylohyoid muscle Occipital artery
Hyoglossus muscle Internal jugular vein
Sternocleidomastoid
branch of occipital artery
FIGURE 10-38 Hypoglossal nerve. (From Drake R, Vogl
External carotid artery Posterior belly of
AW, Mitchell A: Gray’s anatomy for students, ed 2,
digastric muscle (cut)
infraorbital nerve. The roof of the orbit is formed mainly sensation to the skin of the face in this region and to the
by the frontal bone and partly by the sphenoid bone. The conjunctiva of the lower lid. The anterior and superior
trochlea, which transmits the tendon of the superior alveolar nerve descends as a terminal branch in or along
oblique muscle, is a special periosteal attachment in the the maxilla. This nerve supplies the sensation to the
area of the junction of the medial wall and roof of the anterior maxillary teeth and gingivae. The associated
orbit—approximately 4 mm posterior to the orbital rim— small arteries that run with these nerves generally are not
and its integrity must be maintained during medial orbital of surgical concern and are rarely identified. Although
exploration. If it is disrupted, it must be securely reat- their sacrifice is not problematic, every attempt should
tached. The roof of the orbit continues forward to form be made to maintain or decompress the sensory nerves
the superior orbital rim, which has a notch or canal for in this area.
the supraorbital and supratrochlear neurovascular The orbital soft tissue is separated from the orbicularis
bundles. As with the trochlea, the frontal orbital rim and oculi muscle and extraorbital soft tissue by the orbital
its integrity must be maintained during medial orbital septum. This septum constitutes a diaphragm at the
exploration; if it is disrupted, it must be reattached entrance to the orbit that functionally separates the
securely. The frontal bone articulates laterally with the tissue spaces of the lid from those of the orbit. It essen-
zygoma at the frontozygomatic suture. The orbital rims tially is a continuation of the periosteum of the orbit
are extremely strong and provide protection for the globe. (periorbita) and the periosteum of the outer surface of
Consideration must be given to the position of the the adjacent facial bones. From here it extends into the
infraorbital nerve and terminal branches of the trigemi- upper and lower lids. The septum fuses with the connec-
nal nerve (CN V2) during any dissection of the inferior tive tissue anterior to the superior and inferior tarsus.
rim or orbital floor. The infraorbital nerve supplies Medially, it passes posterior to the posterior lacrimal
Lesser wing of sphenoid

Frontal bone
Superior orbital fissure
Optic canal
Greater wing Ethmoidal foramina
of sphenoid
Ethmoid bone
Zygomatic bone Lacrimal bone Lacrimal

FIGURE 10-39 Orbital osteology. (From Drake R, Vogl Inferior orbital fissure Palatine bone groove
AW, Mitchell A: Gray’s anatomy for students, ed 2,
Philadelphia, 2009, Churchill Livingstone.) Maxilla
Medial palpebral ligament
Orbicularis oculi
muscle
Orbital part
Palpebral
part
Lateral palpebral
ligament
FIGURE 10-40 Orbicularis oculi muscle. (From Drake R,

Vogl AW, Mitchell A: Gray’s anatomy for students, ed 2,
crest, thus eliminating the lacrimal sac from the orbit

proper.
Orbital Muscles*
Orbicularis Oculi Muscle. The orbicularis oculi muscle
(see Fig. 10-40) is composed of a palpebral division,
which further divides into preseptal and pretarsal subdi-
visions, and an orbital division. The palpebral division
arises from the medial palpebral ligament and inserts
Anterior lacrimal into the lateral palpebral raphe. A portion closest to the
crest medial margin of the lid arises from the posterior lacri-
mal crest and is known as the pars lacrimalis or muscle
Posterior lacrimal of Horner. The larger portion of the medial palpebral
crest
ligament arises from the anterior lacrimal crest. The
lateral palpebral raphe is attached to the osseous protu-
Anterior heads
of orbicularis muscles berance on the inner aspect of the lateral orbital rim of
(preseptal and pretarsal) the zygoma (Whitnall’s orbital tubercle) and passes
medially to the lateral commissure of the eyelid, where
it divides into two slips. The muscle is innervated by
temporal and zygomatic branches of the facial nerve (CN
Posterior heads VII) at the lateral and inferior raphe. Paralysis prevents
of orbicularis muscles tight closure of the eye and can predispose the patient
(preseptal and pretarsal)
to ectropion and epiphora.
FIGURE 10-41 Medial palpebral ligament. *References 1, 4, 6, 11, and 49.
MOTOR NERVES
oculomotor nerve,
branch to levator
palpebrae superioris
muscle
oculomotor nerve,
branch to superior
trochlear nerve rectus muscle
abducens nerve
oculomotor nerve, oculomotor nerve,

branch to medial branch to inferior
rectus muscle rectus muscle
oculomotor nerve,
branch to inferior
oblique muscle
FIGURE 10-42 Frontal view of orbital musculature and its nerve relationship. (Adapted from Dutton JJ. Atlas of clinical and surgical orbital
anatomy. Philadelphia, 1994, WB Saunders.)
Surgical Note: The medial palpebral ligament gives ana- on the bony side of the inferior rectus muscle and then
tomic support to the lacrimal sac and is involved in emp- inserts into the sclera posterior to the equator of the globe
tying of the sac. Its position dictates the shape of this area and between the superior and lateral rectus muscles.
(see Fig. 10-41). Every attempt to correct a traumatic Innervation is supplied by the oculomotor nerve.
displacement should be made and, in a similar fashion,
care should be taken to avoid displacing this ligament in Medial Palpebral Ligament
the reduction of fractures and treatment of soft tissue Medial Canthal Ligament. The medial canthal ligament*
trauma. attaches the tarsal plates to the medial wall of the orbit
Levator Palpebrae Superioris. The levator palpebrae and aids in the attachment of the orbicularis oculi mus-
superioris is a muscle of the upper lid and is a direct culature to the medial orbit. It gives structure and con-
antagonist to the orbicularis oculi muscle; it raises the figuration to the palpebral configuration (see Fig. 10-41).
upper lid and exposes the globe. It arises deep in the Traumatic disruption leads to pooling of lacrimal flow in
orbit from the lesser wing of the sphenoid bone. It passes the medial palpebral area.
above the superior rectus muscle as a thin flat muscle The medial canthal ligament attaches to the anterior
and becomes broad as it ends anteriorly in an aponeuro- lacrimal crest of the maxilla and posterior lacrimal crest
sis, which splits into three lamellae. Innervation is by the of the lacrimal bone. Between these slips of muscle runs
oculomotor nerve (CN III) as it enters the orbit through the lacrimal sac. The orbicularis oculi muscle, which
the superior orbital fissure (see Fig. 10-34). arguably contributes a portion of its musculature to the
Rectus Muscles. The rectus muscles arise from a prominent posterior slip of the ligament, is referred to
fibrous ring that surrounds the superior, inferior, and as the pars lacrimalis or Horner’s muscle. The position
medial aspects of the optic foramen (see Fig. 10-34). The of this muscle aids in the efficient collection of tears by
ring continues as a tendinous band over the inferior and creating a positive and negative pressure change on
medial aspects of the superior orbital fissure. This fibrous opening and closing the eyelids. This pressure change
ring in its lower division (tendon of Zinn) gives rise to ensures the flow of tears through the lacrimal sac.
the inferior rectus muscle, part of the medial rectus Proper replacement of the traumatically displaced
muscle, and inferior head of the lateral rectus muscle. medial canthal ligament is essential to restore proper
The upper division of this fibrous band (superior liga- function to this area. Options for the management of this
ment of Lockwood) gives rise to the superior rectus ligament are discussed in detail in Chapter 17.
muscle, remainder of the medial rectus muscle, and
superior head of the lateral rectus muscle. Each rectus Orbital Blood Supply
muscle then passes anteriorly in the orbit in the position The ophthalmic artery is the branch of the internal
implied by its name and inserts as a tendinous area of carotid artery that supplies the orbit (see Fig. 10-32).6,7,11,17
the sclera, anterior to the equator of the globe and This vessel enters the orbit through the optic canal with
approximately 6 mm behind the margin of the cornea. the optic nerve. It initially passes inferiorly and laterally
All except the lateral rectus muscle are innervated on to the optic nerve. The first branch is the central retinal
their deep surface by the oculomotor nerve (see Fig. artery. From the inferior lateral position, it passes over
10-32). The lateral rectus muscle is innervated by the the optic nerve toward the medial orbital wall. As the
abducens nerve (CN VI). These muscles form a cone that ophthalmic artery passes around the optic nerve, it gives
gives some protection to the optic nerve (CN II), which off branches to the lacrimal gland and long posterior
passes anteriorly within their confines (see Fig. 10-42). ciliary branches to the lateral aspect of the globe. As the
Between the two heads of the lateral rectus muscle, the lacrimal artery passes anteriorly along the superior aspect
two divisions of the oculomotor nerve, nasociliary nerve, of the lateral rectus muscle, it supplies muscular branches
abducens nerve, and ophthalmic vein enter the muscular and terminates in the lateral palpebral artery and zygo-
cone. The optic canal, which lies within the confines of matic branches. The lateral palpebral branches supply
the origin of these muscles, transmits the optic nerve and the lateral eyelids and the zygomatic branch passes
ophthalmic artery (see Fig. 10-34). through the zygomaticotemporal foramen to reach the
Superior Oblique Muscle. The superior oblique muscle temporal fossa.
takes its origin immediately above the optic foramen, As the artery crosses over the optic nerve, it gives off
superiorly and medially to the superior rectus muscle. It branches of short posterior ciliary arteries to the globe
passes anteriorly and ends in a tendon that passes through and large supraorbital branch. Numerous small muscular
a fibrocartilaginous ring attached at the trochlear fovea branches arise in this area as well. This branch passes
of the frontal bone. The tendon bends posteriorly at this anteriorly and superiorly along the superior rectus and
ring and passes beneath the superior rectus muscle to levator palpebrae superioris muscles to the supraorbital
insert into the sclera posterior to the equator of the globe foramen or notch. It supplies the muscles associated with
on the laterosuperior aspect (see Fig. 10-32). This muscle its course.
is innervated by the trochlear nerve (CN IV), which The posterior and anterior ethmoidal arteries are the
enters the orbit through the superior orbital fissure and next branches of the ophthalmic artery as it continues
passes above the other orbital nerves and enters the on the medial and superior aspects of the orbit. These
muscle from the inferior aspect. arteries give blood to the ethmoidal air cells and frontal
Inferior Oblique Muscle. The inferior oblique muscle is sinus and finally terminate as they enter the cranium as
a thin muscle that arises from the orbital surface of the
maxilla, laterally to the lacrimal groove. It passes laterally *References 4, 6, 7, 11, 13, 15, and 49.
small meningeal branches to the dura mater. The medial back of the globe to the optic canal (≈20 to 25 mm).
palpebral arteries arise slightly anteriorly and inferiorly Surgically, this allows a fair degree of forward displace-
to the pulley of the superior oblique muscle. They leave ment of the globe in retrobulbar surgery and manipula-
the orbit and supply the eyelids from the medial aspect. tion; however, the nerve is tightly bound at the optic
The terminal branches are the supratrochlear and foramen, where the meninges blend with the periorbita.
dorsal arteries. The former leaves the orbit at the medial Careful attention to the position of the retractors when
angle and supplies the skin of the forehead in this area. exploring the medial wall prevents trauma to the nerve,
The latter exits the orbit above the medial palpebral liga- which exits the canal approximately 2.5 to 3 cm deep
ment and supplies the dorsum and root of the nose and into the anterior lacrimal crest.
skin in this area. Motor Nerves. The remaining nerves of the orbit all
enter the orbit through the superior orbital fissure (see
Orbital Nerves Fig. 10-34). The abducens nerve (CN VI) and oculomo-
The complex structure and function of the orbit neces- tor nerve (CN III) pass through the oculomotor foramen,
sitate an intricate neural system (see Figs. 13-32 to which is created by the tendinous ring of the rectus
13-34).7,8,11,49 From a surgical anatomic view, the sympa- muscles crossing the superior orbital fissure, and thus are
thetic and parasympathetic nerve functions are interwo- contained within the muscular cone. The trochlear nerve
ven with the larger, more readily identified cranial nerves. (CN IV) passes above the ring and stays outside the mus-
Therefore, only the cranial nerves and their positions cular cone throughout its course. The trochlear nerve
and anatomic considerations will be discussed here. then rises to the roof of the orbit and passes medially to
Sensory Nerves. CN II, the optic nerve, enters the orbit the superior oblique muscle, which it supplies.
through the optic canal or foramen in the sphenoid The abducens nerve supplies the lateral rectus muscle.
bone and takes a direct route to the posterior aspect of It enters the orbit between the heads of the lateral rectus
the globe. As this nerve enters the orbit, it is immediately muscle and below the inferior division of the oculomotor
enclosed in the muscular cone of the extraocular muscles nerve and passes along the inner surface of the lateral
and is afforded some protection by these structures. rectus muscle. As noted, the trochlear nerve supplies the
There is also some protection given by the laxity of the superior oblique muscle, whereas the oculomotor nerve
nerve. It is approximately 5 mm longer than the distance supplies all the other extraocular muscles.
from the orbital canal to the posterior aspect of the globe As the oculomotor nerve enters the superior orbital
(2 to 2.5 cm). fissure, it separates into two divisions—a small superior
The general sensory nerves of the orbit are all branches and larger inferior division. They both pass between the
of the ophthalmic nerve, the first division of the trigemi- heads of the lateral rectus muscle. The superior division
nal nerve (CN V). This nerve branches just before enter- passes above the optic nerve and innervates the superior
ing the orbit via the superior orbital fissure. Two branches rectus and the levator palpebrae muscles, whereas the
enter the orbit superiorly and laterally to the ophthalmic inferior division passes below the optic nerve and inner-
foramen, whereas the third enters through the ophthal- vates the inferior and medial rectus muscles and the
mic foramen. inferior oblique muscle.
The lacrimal nerve is the smallest branch and courses Surgical Note: Direct or indirect trauma to the area of
along the upper border of the lateral rectus muscle to the confluence of anatomy at the posterior aspect of the
the lacrimal gland and then down to the conjunctiva and orbit (accidental or surgical in nature) may cause the
skin of the upper eyelid. The frontal nerve is largest and rarely seen complications of superior orbital fissure syn-
runs above the levator palpebrae muscle. It divides into drome and orbital apex syndrome. The symptoms
a supraorbital branch, which exits through the supraor- depend on the structures involved and localize the lesion
bital notch and supplies the upper eyelid, forehead, and anatomically. The advisability of surgical intervention in
scalp in this area, and supratrochlear nerve, which passes the presence of pretreatment complications such as
over the trochlea of the superior oblique muscle to the these is discussed in Chapter 18.
conjunctiva of the upper eyelid and the forehead.
The third branch of the ophthalmic nerve is the naso-
ciliary branch, which passes through the ophthalmic NASAL ANATOMY
foramen, over the optic nerve, and below the superior
rectus muscle to the medial wall of the orbit, where it EXTERNAL NASAL ANATOMY
distributes its many branches. These include communi- The prominence of the nose makes it a frequent target
cations to the ciliary ganglion, a long ciliary branch to in interpersonal conflict and an often traumatized struc-
the globe, an infratrochlear branch, which supplies the ture in other forms of facial injury. Injuries result in
medial angle of the conjunctiva, lacrimal sac, and skin of cosmetic and, if untreated, functional problems. Thus,
the nose and eyelid in this area, and finally the anterior an in-depth understanding of the anatomy of this area is
and posterior ethmoidal branches, which pass through important.
the associated foramen to supply the ethmoidal, frontal, The substructure of the external nose* is composed
and sphenoidal sinuses and the nasal cavity. of the cartilaginous lower half and nasal bones superiorly
(Fig. 10-43). The inferior cartilaginous structure derives
Surgical Note: The optic nerve is protected in the orbit by some of its support from the alveolar process of the
the extraocular muscular cone and the fact that it is
approximately 5 mm longer than the distance from the *References 1, 2, 4, 7, 16, and 17.
Frontal process
of maxilla
Upper lateral
cartilage
Nasion
Septal cartilage
Accessory cartilages
Nasal bones Accessory alar

(sesamoid) cartilage
Rhinion
Lower lateral
Upper lateral cartilages:
cartilages
Lateral crus
Accessory
Medial crus
cartilage
Septal cartilage
Lower lateral
cartilage Alar fibrofatty tissue
Medial crus
Fibroareolar Lower lateral cartilage:
tissue
Medial crus
Nasal dome Lateral crus
Membranous Alar fibrofatty tissue

septum
Septal cartilage
Anterior nasal spine
of maxilla
FIGURE 10-43 Left, Substructure of external nose. Right, Inferior view of nasal septum and alar cartilages. (From Nouri K: Complications in
dermatologic surgery, Philadelphia, 2008, Mosby.)
maxilla in the piriform apertures. The area of union of The alar cartilages are paired curved cartilages that
the maxillas in the midline forms an anterior projection, support the nasal openings. They have a medial and
the anterior nasal spine, which lends support to the nasal lateral crus. The crura are formed by a bending of the
tip. The bony opening of the nose is composed of two cartilage on itself, with the medial crus of one side loosely
paired bones, the maxilla inferiorly and the nasal bones connected with the opposite medial crus (see Fig. 10-43).
superiorly. The part that forms the lateral crus curves gently to form
The nasal bones are thinner toward the tip of the the alae of the nose. Laterally and inferiorly, fibrofatty
nose, gradually thickening as one proceeds toward the tissue makes up the remainder of the alar base.
upper half. Similarly, the lower segments of the nasal The nasal septal cartilage articulates with the perpen-
bones are convex in shape, whereas the upper portions dicular plate of the ethmoid, vomer, maxilla, and nasal
tend toward concavity. The cartilaginous portion of the bones and the upper and lower nasal cartilages. This
external nose consists of the septal cartilage and lateral midline structure forms the support for much of the
and alar cartilages. Termed the keystone area, this cartilagi- external nasal structure.
nous section extends 4 to 7 mm beneath the nasal bones. The arterial supply to the external nose is largely via
The paired upper lateral cartilages are attached to the the external carotid system by the branches of the facial
septal cartilage in the midline and to the undersurface and maxillary arteries. It is supplemented by a small
of the nasal bones superiorly. A portion of the upper portion from the internal carotid system via the ophthal-
lateral cartilage attaches to the septum via connective mic artery as its terminal branches perforate the orbital
tissues. They are often continuous with each other at the septum and pass downward on the lateral aspect of the
superior margin and, along with the septal cartilage, are nose (see Fig. 10-27). The blood supply to the nose is
considered the nasoseptal cartilage. found primarily in the soft tissue layers, necessitating that
The lateral cartilages are triangular. The base of the care be taken during surgical repairs. Dissection should
triangle is superior and articulates with the nasal bones. be directed as close to the cartilage as possible.
The lateral border thins to connective tissue, which sepa- The external nasal neural innervation is complex,
rates it from the superior aspect of the alar cartilage. The being derived from the supratrochlear and infratroch-
medial border is thicker and blends into the septal car- lear branches of the ophthalmic nerve superiorly, infra-
tilage superiorly; inferiorly, it has a free edge just lateral orbital branch of the maxillary nerve laterally and
to the nasal midline. inferiorly, and external nasal branch of the nasociliary
Supratrochlear nerve
Infratrochlear nerve
External nasal
branch of anterior
ethmoidal nerve
Infraorbital nerve
FIGURE 10-44 Sensory nerves to the external nose.
nerve from the ophthalmic nerve to the nasal tip and ethmoidal air cells. The supreme nasal concha, with its
skin over the dorsum inferiorly (Fig. 10-44). associated meatus, is not generally identifiable, but in
this area, above and behind the superior concha, is the
NASAL CAVITY ANATOMY opening of the sphenoidal sinus and sometimes the pos-
Internally, the nasal septum (see Fig. 10-8) divides the terior ethmoidal air cells.
nasal cavity.7,16,17 The nasal cavity is roughly teardrop- The blood supply to the nasal septum is via branches
shaped in the frontal section, with a narrow area above. of the sphenopalatine artery, anterior and posterior eth-
The walls of the internal nose are formed medially by the moidal arteries, and facial artery. Thus, the blood supply
nasal septum, laterally by the maxilla, ethmoid bone, and is from the internal and external carotid systems.
nasal cartilages, inferiorly by the maxilla and palatine The innervation of the internal nose is general sensory
bones, and superiorly by the cribriform plate of the and special sensory. The special sensory innervation is via
ethmoid bone. the olfactory nerve (CN II) and passes into the skull
The nasal cavity is lined by mucous membranes that through the foramina of the cribriform plate of the
are tightly attached to the underlying periosteum or peri- ethmoid bone. The general sensory innervation of the
chondrium, except in the vestibule, where facial skin internal nose is via the nasociliary branch of the ophthal-
rolls into the nasal aperture. These mucous membranes mic nerve, filaments from the anterior alveolar branch
are highly vascular. of the maxillary nerve, nerve of the pterygoid canal,
The nasal septum is the common medial wall of the nasopalatine nerve, anterior palatine nerve, and nasal
two nasal cavities (see Fig. 10-8). It is formed posterosu- branches of the pterygopalatine nerve.
periorly by the perpendicular plate of the ethmoid bone, The nasociliary branch of the ophthalmic division of
by the vomer posteroinferiorly, and by the septal carti- the trigeminal nerve gives filaments to the anterior part
lage and medial crus of the alar cartilages anteroinferi- of the septum and lateral nasal wall (Figs. 10-45 and
orly. Below, the nasal crests of the maxilla and palatine 10-46). The anterior alveolar nerve supplies the inferior
bones complete the septum. The septum rests in the meatus and concha, whereas the nerve of the pterygoid
groove formed by these bones and, if displaced by trauma, canal supplies the superior and posterior septa and supe-
requires replacement in the groove to prevent functional rior concha. The superior branches from the pterygo-
and aesthetic problems. palatine nerve have a distribution similar to that of the
The lateral wall of the nose is formed inferiorly by the nerve of the pterygoid canal. The nasopalatine nerve
lateral wall of the maxilla and inferior nasal concha, supplies the middle of the septum, whereas the anterior
which is an independent bone. Below the concha is the palatine nerve supplies the lower nasal branches to the
inferior meatus. This meatus contains the opening of the middle and inferior conchae.1,4,7
nasolacrimal duct. Superiorly, the lateral wall is formed
by the segments of the ethmoid bone, which form the
middle and superior conchae. Beneath the middle PAROTID REGION
concha is the middle meatus, which receives the opening
of the frontal sinus, anterior ethmoidal air cells, and PAROTID GLAND
maxillary sinus. Posterior to the middle concha on the The parotid gland is the largest of the salivary glands and
lateral wall is the sphenopalatine foramen. Superior and occupies the parotid facial space (Fig. 10-47). This space
posterior to the middle concha is the superior concha. generally extends from the ramus of the mandible ante-
It is much shorter and smaller than the others. Below it, riorly, from the tympanic bone and the mastoid process
in the superior meatus, is the opening to the posterior posteriorly, and from the zygomatic arch superiorly. The
FIGURE 10-45 Innervation to the nasal septum.
FIGURE 10-46 Lateral nasal wall innervation. (From Fehrenbach M, Herring S: Illustrated anatomy of the head and neck, ed 4, St. Louis,
2012, Saunders.)
inferior extent reaches to the angle of the mandible and into the mouth. The course of the duct approximates a
a cervical portion reaches below, along the sternocleido- line drawn from the concha of the ear to the commissure
mastoid muscle. There is a connective tissue investment of the lips. Its length is normally about 5 cm.
that sends septa inward among the lobules of the gland. The most important structures entering and leaving
The parotid gland is composed of a large superficial the gland are the facial nerve and its branches, posterior
portion and is shaped like an inverted triangle lying on facial vein, external carotid artery with its branches,
the ramus of the mandible. This portion may have an superficial temporal artery, and internal maxillary artery.
accessory glandular mass extending beyond the limits of The auriculotemporal nerve traverses the upper portion
the masseter muscle anteriorly. The smaller deeper of the parotid gland.
portion of the gland is connected by a broad isthmus Incisions to deep soft tissue and hard tissue should be
around the posterior border of the mandible. This deep horizontal rather than vertical, when possible, to prevent
portion may extend as far as the pharyngeal wall. potential damage to the parotid duct and terminal
The parotid duct, or Stensen’s duct, usually leaves from branches of the facial nerve. Soft tissue trauma to the
the apical portion of the superficial lobe and then runs duct could lead to extraoral fistula formation.
forward on the masseter muscle to its anterior margin.
The duct then turns medially, piercing the buccinator SUBMANDIBULAR GLAND
muscle obliquely to reach the mucous membranes of the The submandibular gland (Fig. 10-48)3,6,18 occupies a
cheek. At approximately the second molar, the duct opens space on the medial aspect of the mandible in the
FIGURE 10-47 Parotid regional anatomy.
FIGURE 10-48 Submandibular regional anatomy.
submandibular fossa. Its lower pole extends inferiorly, along the inner surface of the sublingual gland after
covering the intermediate tendon of the digastric muscle. crossing the lingual nerve superiorly. The duct ends at
This gland is closely related medially to the stylohyoid, the base of the tongue near its tip.
digastric, and styloglossus muscles and to the hyoglossus Like the parotid gland, the submandibular gland is
muscle and posterior border of the mylohyoid muscle enclosed in a facial capsule, a derivative of the investing
anteriorly. The submandibular duct, or Wharton’s duct, layer of the deep cervical fascia. Structures closely related
arises from the upper inner aspect of the gland and is to the gland include the facial artery, which may be
often accompanied by the extension of the gland itself. embedded, but is at least closely related to its inner
The duct courses around the posterior border or free surface and upper border. During extraoral open reduc-
margin of the mylohyoid muscle and then runs anteriorly tion of the body or angle of the mandible, the fascia and
FIGURE 10-49 Floor of the mouth. (From Hupp J, Ellis E, Tucker M: Contemporary oral and maxillofacial surgery, ed 5, St. Louis, 2008,
Mosby.)
FIGURE 10-50 Sublingual anatomy.
gland may come into view. If the fragments are notably nerve, which descends laterally to the duct. At this point,
displaced, the fascia may be disrupted and may require both the duct and lingual nerve pass around the lower
repair. border of the sublingual gland and then are positioned
medially. The lingual nerve continues to run below the
FLOOR OF THE MOUTH duct and curls medially on the genioglossus muscle. This
arrangement forms almost a complete loop. As Whar-
Key to the surgeon in repairing soft tissue trauma to the ton’s duct passes on the medial side of the sublingual
floor of the mouth (Figs. 10-49 and 10-50)3,6,18 is an gland, it may receive the major sublingual duct, or Bar-
understanding of the anatomic position of various impor- tholin’s duct. The last few millimeters of the anterior
tant structures, such as Wharton’s duct and the lingual portion of the submandibular duct lie immediately below
nerve, sublingual artery, sublingual gland, hypoglossal the oral mucosa, where the duct terminates by emptying
nerve, and submandibular gland itself. Each of these from the sublingual papilla.
structures has been described, but here it is important to The sublingual artery passes along the side of the
visualize the relationship of these structures to one genioglossus muscle between the muscle and the sublin-
another (see Fig. 10-49). gual gland, where it supplies the gland and muscles of
The submandibular, or Wharton’s, duct exits the supe- the tongue. The deep lingual artery runs more medially
rior aspect of the gland, coursing above the posterior below the mucous membranes on the inferior surface of
free edge of the mylohyoid muscle between the inner the tongue. Bleeding from either of these vessels may be
surface of the mandible and lateral surfaces of the hyo- brisk in superficial lacerations of the mouth floor, or the
glossus and genioglossus muscles. The duct lies laterally vessels may be inadvertently transected during explora-
to the hypoglossal nerve; it begins below the lingual tion, requiring ligation.
ACKNOWLEDGMENT 26. Converse JM, Hogan VM: Open sky approach for reduction of
naso-orbital fractures. Plast Reconstr Surg 46:396, 1970.
27. Peri G, Chabannes J, Menes R, et al: Fractures of the frontal sinus.
Artwork was provided by GERYGRAPHICS, 2020 W. Main J Maxillofac Surg 9:73, 1981.
St., Durham, NC. The artist is Elizabeth West. 28. Dingman RO, Natvig P: The mandible. Part I: general characteris-
tics. In Dingman RO, Natvig P, editors: Surgery of facial fractures,
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York, 1968, Harper & Row. pp 335-342.
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Charles C Thomas. WB Saunders.
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Mosby. Wright.
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20. Matsunaga RS, Simpson W, Toffel PH: Simplified protocol for the 46. Wakely CPG: Surgery of temporomandibular joint. Surgery 5:697,
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21. Briggs PC, Heckler FR: Lacrimal gland involvement in zygomatico- 47. Lempert J: Improvement of hearing in cases of otosclerosis: New
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compound: With a description of a new x-ray position. Br J Surg ramus of the facial nerve based on the dissection of 100 facial
14:651, 1927. halves. Plast Reconstr Surg 29:266, 1962.
23. Karlan MS, Cassisi NJ: Fractures of the zygoma: A geometric bio- 49. Jones LT: Orbital anatomy. In Smith BC, Converse JM, editors:
mechanical and surgical analysis. Arch Otolaryngol 105:320, 1979. Proceedings of the Second International Symposium on Plastic and Recon-
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25. Crewe TC: Significance of the orbital floor in zygomatic injuries. Philadelphia, 1995, Lippincott Williams & Wilkins.
Int J Oral Surg 7:235, 1978.
CHAPTER
Early Assessment and Treatment
11 Planning of the Maxillofacial
Trauma Patient
Larry L. Cunningham Jr.
| Ruba Khader
OUTLINE
Airway (With Cervical Spine Protection) Naso-orbital-ethmoid complex
Breathing and Ventilation Nose
Circulation Orbit
Scalp Malar Area
Nose Ear
Oral Cavity Maxilla, Mandible, and Dentoalveolar Structures
Disability Neck
Exposure Cranial Nerves
History of Present Illness Radiographic Evaluation
Review of Systems Postoperative Considerations
Clinical Examination
Soft-tissue and Scalp
Forehead
A
dvanced Trauma Life Support (ATLS) has been hemorrhage, or relieving the intraocular pressure
recognized as the gold standard for the initial via cantholysis.
management of multiple injured patients. • Treatment required within a few hours: Facial inju-
Although the priority of maxillofacial injuries is usually ries that are extremely contaminated in a patient
subordinated to more critical, life-threatening injuries, who is hemodynamically stable.
the role of the maxillofacial surgeon in the primary and • Treatment required within 24 hours: Some facial
secondary surveys of patients with maxillofacial injuries fractures and lacerations.
should be emphasized. • Treatment can be delayed for more than 24 hours
The treatment of patients with maxillofacial injuries if necessary: Most other facial fractures.
can be managed by a maxillofacial trauma team if the Details of the ATLS primary survey are discussed else-
injuries are isolated to the maxillofacial area or by a where in this text. The goal of this section is to highlight
designated hospital trauma team. Although initial diag- the role of the maxillofacial surgeon in the ABCDEs. This
nosis and emergency treatment (e.g., controlling hemor- role is often crucial and includes life-preserving and
rhage) are intuitive even to the novice, the experienced sight-preserving procedures. A few examples are detailed
surgeon will remember that significant injuries can be here.
missed after initial management of the trauma patient.
The incidence of missed injuries after trauma has been
reported to range from 8% to 65%.1 Missed injuries are AIRWAY (WITH CERVICAL
especially likely when the mechanism of injury has caused SPINE PROTECTION)
substantial internal damage, as can be the case with
decelerating injuries, for example. All members of the If a patient has an unfavorable bilateral mandibular frac-
treatment team should assume the responsibility of con- ture causing airway obstruction, the maxillofacial surgeon
stant patient reassessment. can assist by simply stabilizing the fracture with a bridle
Facial injuries are classified into four categories wire. By restoring spontaneous breathing, this maneuver
according to the urgency of necessary treatment: may eliminate the need for endotracheal intubation.
• Immediate, resuscitative, or emergent treatment
required: Facial injuries that are life-threatening BREATHING AND VENTILATION
(causing airway obstruction or severe hemorrhage)
or sight-threatening (causing increases in intraocu- If the patient’s Glasgow Coma Scale score is lower than
lar pressure) and that require immediate interven- 15, performing a procedure to stabilize a bilateral man-
tions aimed at securing the airway, stopping the dibular fracture will permit the patient to breathe
220
Early Assessment and Treatment Planning of the Maxillofacial Trauma Patient CHAPTER 11 221
spontaneously and will reduce the likelihood of airway anteriorly so that posterior advancement and aspiration
obstruction if the patient’s level of consciousness can be prevented.
decreases. This procedure will allow the patient to The anterior nasal packing material is standard half-
breathe and ventilate without the aid of an advanced inch gauze moistened with bacitracin (or petrolatum
airway; in turn, the absence of endotracheal intubation gauze) placed in an overlapping fashion, beginning at
allows neurologic assessment of the patient at regular the floor of the nose and extending superiorly.
intervals. Two ready-made commercial packing systems can
control bleeding more rapidly than traditional packing,
CIRCULATION the Nasostat epistaxis balloon (Sparta, Pleasanton, Calif)
and the Storz epistaxis catheter (Storz, St. Louis).
The face and neck are heavily vascularized regions of the Packs should remain in place for no more than 24
body and this large blood supply facilitates a level of hours; antibiotic coverage is recommended so that
healing that is unmatched elsewhere in the body. On the serious infections can be avoided. If packs are needed for
other hand, however, this robust vascularity means that more than 24 hours, they should be changed daily.
injuries to this region of the body can produce copious Although the posterior nasal packing procedure is
bleeding that requires immediate attention. A few key safe and effective, it should be performed with caution
examples follow. if the patient has a fracture of the base of the skull.
Other control measures include the following:
SCALP • Reducing facial fractures
The connective tissue layer of the scalp contains a rich, • Performing additional procedures for uncontrolled
subcutaneous vascular supply. A laceration to the scalp bleeding, if necessary
can cause the loss of a large amount of blood and result Interventional radiology and angiography can detect
in hypovolemic or hemorrhagic shock. Occasionally, the bleeding vessels and perform embolization.
scalp is an occult source of hemorrhage. When a patient If interventional radiology is unavailable, surgical
is in shock and the blood pressure is low, bleeding from exploration and ligation of the affected vessels may
a scalp wound is not obvious. Once resuscitation has be necessary—transantral ligation of the maxillary
been performed and the blood pressure has increased, artery or its terminal branches; ligation of the anterior
however, bleeding will begin again and will become dif- or posterior ethmoid arteries through the medial
ficult to control. Thus it is necessary for scalp lacerations orbital wall
to be stabilized before any interhospital transfers or Although historically the ligation of the external
lengthy diagnostic procedures are performed.2 The del- carotid artery has been described, the collateral circula-
eterious events that may follow a scalp hemorrhage tion is very rich, and ligation of the external carotid
should not be underestimated. artery will not always stop the hemorrhage.
Scalp lacerations can be most rapidly stabilized with
Raney clips, which should be available in emergency ORAL CAVITY
trauma bays and in operating rooms. Other potentially Bleeding from the oral cavity can typically be managed
useful temporary stabilizing measures are staples and temporarily with packing and pressure. Severe hemor-
sutures. rhage can indicate that the inferior alveolar vascular
bundle has been severed. Applying a bridle wire or an
NOSE arch bar (with or without maxillomandibular fixation)
Epistaxis is a serious problem that may lead to airway will stop the bleeding or substantially reduce it.
obstruction, aspiration, shock, and exsanguination if not
recognized and managed early. Many cases of unrecog- DISABILITY
nized and untreated fatal epistaxis have been reported.3-5
The most frequent cause of massive hemorrhage among Ocular examination is a routine part of the primary
patients with facial trauma is midface fractures, which survey and includes pupil size, reactivity to light, and
typically cause epistaxis with bleeding through the oral symmetry. In addition, the examiner should rule out a
cavity.6 Control of a massive and a potentially lethal epi- relative afferent pupillary defect (RAPD, or Marcus Gunn
staxis consists of the following: pupil) and palpate the globe (hard or soft).7 These ele-
• Protecting the airway with endotracheal intubation or ments of the eye examination can be performed quickly
tracheotomy, if necessary and easily and yield a large amount of information.
• Ruling out coagulopathy
• Packing the posterior and anterior nasal cavities EXPOSURE
Posterior nasal packing is best performed with a 14-,
16-, or 18-Fr Foley catheter with a 10-mL balloon. The tip In the maxillofacial region, any dentures or other remov-
of the catheter is inserted through the nostril and is able appliances that impede a clear view of the site of
advanced until it is seen through the nasopharynx. This potential bleeding should be removed.
visualization is a crucial step, because the balloon of the
catheter should not be inflated at the base of the skull. HISTORY OF PRESENT ILLNESS
The catheter is then tugged forward to tamponade bleed-
ing in the posterior nasal cavity. Bilateral posterior packs It can be difficult to obtain a history from the trauma
may be necessary. The catheter should be sutured or tied patient; often, information must be gathered from the
prehospital personnel and the patient’s family members. of consciousness, amnesia, vomiting, headaches, or
The following points should be addressed when the seizure activity after the traumatic incident, a traumatic
history is obtained (AMPLE is a familiar mnemonic)7: brain injury should be suspected and a neurosurgical
Allergies consultation should be requested. Loss of vision or
Medications change in visual acuity is another serious symptom that
Pregnancy, previous illnesses should prompt rapid intervention and consultation with
Last meal ophthalmology. If the patient reports a change in the
Events or Environment related to and leading to the dentition or occlusion that is associated with pain and
trauma limited mouth opening, a mandibular fracture should be
Intuitively, a knowledge of the patient’s medical suspected.
history, medications, and allergies helps determine
whether modifications in management may be necessary.
The last meal and pregnancy status of the female patient CLINICAL EXAMINATION
are important pieces of information, primarily as they
relate to possible timing of surgery and to the evaluation SOFT TISSUE AND SCALP
and safety of the fetus. Treatment indicated for soft tissue wounds depends on
Certain mechanisms of injury should produce a high the type of injury. Abrasions and contusions are usually
level of suspicion for distinct types of trauma. For treated with wound cleansing or observation, whereas
example, a history of a decelerating injury (restrained lacerations or avulsive injuries may need more advanced
passenger in a motor vehicle accident [MVA]) should repair. Attention should be paid to all areas of the scalp;
lead to a high suspicion of serious life-threatening con- wounds to the back of the head in a patient with long
sequences caused by shearing forces (e.g., lung or aortic hair can be easy to miss.
injuries).7 Knowledge of the mechanism of injury also The degree of wound contamination and the wound
assists the surgeon in identifying specific maxillofacial contaminant should be considered during the examina-
injuries. Blunt injuries to the midface, for example, tion of facial soft tissue injuries. Facial wounds can be
should prompt the performance of a thorough orbital classified as clean or contaminated, depending on the
examination and appropriate radiologic imaging for a wounding agent. The most recent guidelines for tetanus
proper diagnosis. vaccination and booster doses should be followed.8
Bleeding is often associated with facial soft tissue
REVIEW OF SYSTEMS trauma. Definitive repair of these wounds should be
deferred until the trauma examination has been com-
When the trauma patient is awake and oriented, a pleted and a comprehensive treatment plan has been
detailed review of systems (ROS) is invaluable because it created. Some lacerations could be used as access to
directs the examiner’s attention to the site and type of facial fracture repair.
injury. Many physical examination textbooks provide
examples of various methods for completing the ROS; FOREHEAD
every provider should develop and follow his or her own Injuries to the forehead can be easily recognized and
routine to avoid missing important information. may indicate frontal bone fractures. The soft tissue over-
A full-body review of systems should be performed. lying the frontal bone should be examined and special
Table 11-1 is a suggested sequence for performing a head attention should be paid to the closure of any lacerations
and neck ROS. The ROS allows the inference of various involving the hairline or the eyebrows.
levels of severity of injuries. If the patient has a history of
clear discharge from the nose (rhinorrhea) or ears (otor- NASO-ORBITAL-ETHMOID COMPLEX
rhea), a fracture of the base of the skull should be sus- The naso-orbital-ethmoid (NOE) complex must be sys-
pected until ruled out. If the patient has a history of loss tematically inspected during the physical examination. A
TABLE 11-1 Suggested Sequence for Performing Head and Neck Review of Systems in a Maxillofacial Trauma Patient
Region Symptom(s)
Head, CNS Headaches, nausea, vomiting, loss of consciousness after trauma, weaknesses in limbs, numbness, dizziness
Eyes Change in visual acuity, double vision, pain, pulsatile eye
Ears Changes in hearing acuity, ringing in ears, history of discharge or bleeding from the ear after trauma, dizziness,
pain
Nose Discharge or bleeding from nose after trauma, pain
Oral cavity Change in bite, pain, limited mouth opening, bleeding, teeth missing as result of trauma
Neck Tenderness in cervical spine region, throat pain, voice change, pain on swallowing
Cranial nerves Numbness or weakness of particular area of face
missed NOE fracture can lead to serious aesthetic conse-

quences that cannot be easily corrected by revision surgi-
cal procedures. Because the NOE complex is rarely
fractured in isolation, the examination of this area is
complex.
Inspection
NOE fractures will be accompanied by ecchymosis and
edema in the periorbital region and eyelids; subconjunc-
tival hemorrhage may also be seen. If the NOE fracture
occurs in combination with other facial fractures, edema
and ecchymosis are generalized. NOE fractures produce
a depression in the nasal bridge, causing the nose to
appear short and retruded. Because telecanthus
(increased intercanthal distance) is indicative of an NOE
fracture, the intercanthal distance should be measured
when an NOE fracture is suspected. This distance varies
according to race and gender, but a rough estimate is
that the intercanthal distance should typically equal 50%
of the interpupillary distance.9,10 When NOE fractures A
are present, the medial canthus is rounded and the pal-
pebral fissures are shortened. The position of the globe
may also be affected if NOE fractures occur in combina-
tion with orbital wall fractures; enophthalmos is a
common finding when wall fractures increase the orbital
volume. Because NOE fractures can also occur in combi-
nation with fractures at the base of the skull, it is impor-
tant to look for any signs of cerebrospinal fluid (CSF)
leakage. B
Palpation FIGURE 11-1 A, Bimanual palpation test. B, Bowstring test.
If a fracture is present, palpation of the NOE complex
will demonstrate crepitus and mobility. Palpation should
be performed with the index finger and thumb placed
on either side of the NOE complex, specifically on the
medial orbital wall adjacent to the area of the medial leakage. The nasal septum should be examined for per-
canthal tendon (MCT). A Kelly clamp can be placed foration, deviation, or septal hematoma.
intranasally; its tip is placed deep to the attachment of A nasal septal hematoma detaches the supplying
the MCT. This positioning places the MCT and the mucoperichondrium from the cartilage, thereby reduc-
attached bone between the Kelly clamp and the exam- ing the blood supply to the cartilage. The late recogni-
iner’s finger. The examiner can then easily assess the tion of a septal hematoma may result in deforming
mobility of the complex (Fig. 11-1A). aesthetic consequences, such as a saddle nose deformity
The bowstring test is performed by gently holding the or a retruded nasal bridge. Septal hematomas should be
NOE complex (in a manner similar to that described evacuated; needle aspiration with or without nasal
earlier) and pulling the lateral canthal tendon laterally. packing is usually effective for this purpose, but a more
When a fracture is present, the examiner will be able to formal incision and evacuation may be necessary if the
detect movement of the MCT and any detached bone hematoma has solidified.
fragments (see Fig. 11-1B).
ORBIT
Untoward sequelae of orbital fractures and periorbital
NOSE injuries include serious injuries to the optic nerve, the
The nasal complex should be examined with good illu- globe, or both. These sequelae can result in partial or
mination, a nasal speculum, and suction. The overlying total loss of vision. Even orbital and periorbital injuries
soft tissue should be examined first; wounds should be that appear to be trivial should be evaluated carefully so
thoroughly inspected, and any involvement of cartilage that any vision-threatening injuries can be ruled out. A
should be noted. The nasal bones should be evaluated thorough and systematic examination of the orbit should
for deformities; the examiner can perform this evalua- be performed when the patient has sustained an injury
tion by looking at the nose from above (bird’s-eye view) to the maxillofacial area. Details regarding the orbital
or by facing the patient. Nasal bones should then be anatomy, detailed examination of the orbit, and manage-
palpated and checked for mobility. Intranasally, the ment of orbital injuries are presented elsewhere in this
examiner should look for signs of bleeding or CSF text. The goals of this section are to list the elements of
the clinical examination and to discuss the early findings Even if the patient exhibits no initial signs of injury,
that require immediate intervention. a compartment syndrome could develop as the result
The orbital examination of a patient with a maxillofa- of continued hemorrhage, inflammation, increased
cial injury is challenging. The timing of the examination intraocular pressure, or other interventions or proce-
is especially problematic when the patient is comatose or dures that are performed. Therefore, patients with sus-
sedated. Early identification of the signs and symptoms pected ocular injury should be reassessed at regular
of injuries to the globe and the optic nerve will lead to intervals, especially if they are unconscious and unable
prompt emergency interventions that can preserve to communicate the fact that their symptoms are
vision. For any injury to the globe, consultation with an worsening.
ophthalmologist is prudent as soon as the patient’s
immediately life-threatening problems have been
addressed. MALAR AREA
Injuries to the orbit and the periorbital region include Depression of the malar eminence, crepitus, facial asym-
the following: fractures of one or more of the orbital metry, and periorbital ecchymosis are all signs of frac-
walls (medial, floor, lateral, or roof), associated retrobul- tures of the zygomaticomaxillary complex (ZMC) (Fig.
bar hemorrhage or hematoma, injuries to the cranial 11-3). Malar depression is best seen from a bird’s-eye view
nerves in the apex of the orbital cavity, foreign bodies in (Fig. 11-4). This finding should be documented with
the globe or the orbital cavity, injuries to the globe, and high-quality pictures for many reasons, including intra-
injuries affecting the soft tissues that surround and operative guidance. The malar area should be examined
support the orbit (lacrimal apparatus, canthal tendons, with care because edema in the area may mask the malar
eyelids) (Fig. 11-2, Table 11-2). depression.
D
FIGURE 11-2 A, Anisocoria. B, RAPD—Marcus Gunn pupil. C, Fixed dilated pupil. D, Ptosis.
E F
G
FIGURE 11-2, cont’d E, Conjunctival injection. F, Subconjunctival hemorrhage. G, Hyphema. H, Restriction in the upward gaze of the left
eye caused by muscle entrapment will result in binocular diplopia.
TABLE 11-2 Clinical Findings Associated With Eye Examination
Condition or Finding Definition, Clinical Significance, and Methods of Identification

PUPILS
Anisocoria Inequality in size of the pupils. The pupils should be examined with the patient in a dimly lit room.
Head injury and injury to cranial nerve III (oculomotor) should be suspected if anisocoria is present (see
Fig. 11-2A).
RAPD—Marcus Gunn Asymmetry in the response of the pupils to light. RAPD indicates injury to cranial nerve II (optic nerve).
pupil Directing a light at the normal (uninjured) eye will cause both pupils to constrict. Moving the light to the
injured eye will result in dilation of both pupils because of poor or no light perception. Injury to the
optic nerve may be caused by many factors, including compression caused by retrobulbar hematoma
or hemorrhage, traumatic optic neuropathy, and direct injuries (see Fig. 11-2B).
Irregularly shaped pupils If the pupil is irregularly shaped, globe injury should be highly suspected. If the pupil is tear-shaped,
the point of the teardrop will usually be pointing to the area of the globe rupture, especially if eyelid
lacerations are present.
Fixed and dilated pupil If the pupil is fixed and dilated, head injuries should be ruled out before other causes are considered
(see Fig. 11-2C).
EYELIDS
Ptosis Drooping of the eyelid. Ptosis can be the result of paresis of the oculomotor nerve. Horner’s syndrome
also causes this symptom; the syndrome includes ptosis, miosis, and anhydrosis and is related to
interruption of sympathetic nerve stimulation (see Fig. 11-2D).
Lagophthalmos Inability to close the eyelids completely. This condition is most likely caused by damage to cranial
nerve VII (facial nerve).
TABLE 11-2 Clinical Findings Associated With Eye Examination—cont'd
Condition or Finding Definition, Clinical Significance, and Methods of Identification

CONJUNCTIVA
Conjunctival injection Dilation of the conjunctival vessels. This condition, which causes a reddish conjunctiva, is not the same
as subconjunctival hemorrhage (see later; also see Fig. 11-2E).
Subconjunctival Accumulation of blood beneath the conjunctiva. The hemorrhage usually resolves without intervention
hemorrhage (see Fig. 11-2F).
Chemosis Edema of the conjunctiva; usually resolves without intervention.
ANTERIOR CHAMBER
Hyphema Blood in the anterior chamber. Examination should be performed with the patient sitting up at a
30-degree angle. Blood can be seen in the anterior chamber. Various degrees of blood accumulation
can be seen; infrequently, the entire anterior chamber is filled with blood and vision is impaired (see
Fig. 11-2G).
Corneal abrasions and These painful injuries often require examination with fluorescein dye and a Wood’s lamp. They are
lacerations usually treated with ophthalmic ointment and resolve spontaneously.
POSTERIOR CHAMBER
Vitreous bleeding, retinal These findings will be seen during fundoscopic examination. They result in impairment of vision.
detachment
VISUAL DISTURBANCES
Reduced visual acuity Decrease in the ability to see. A Snellen card should be used, if possible, but having the patient read
(VA) any fine print is often substituted. Patients who wear glasses or contact lenses or use reading glasses
should do so during the test, if possible. Reduced VA, particularly the inability to see light, is a serious
finding. VA as determined during the initial encounter with the patient is a strong indicator of the final
visual outcome.
DIPLOPIA
Binocular Diplopia Double vision that occurs when the patient looks at objects with both eyes. Testing for diplopia at the
extremes of visual fields frequently yields positive results. Such diplopia is often related to swelling but
can also be the result of entrapment of the extraocular muscles, which results in an asymmetrical
movement of the globe, or of injury to cranial nerve III, IV, or VI. Positive results from a forced duction
test indicate that the cause of diplopia is entrapment, not nerve injury (see Fig. 11-2H).
Monocular diplopia Defined as double vision in one eye. Possible causes are lens dislocation or bleeding in the anterior
chamber, or any other disturbances in the clear media along the visual access.
INTRAOCULAR PRESSURE
Increased intraocular IOP should be measured with a tonometry device. Elevated IOP could be related to glaucoma
pressure (IOP) (unrelated to the injury). Alternatively, it could be the result of an elevated intraorbital pressure, which in
turn increases the pressure exerted on the globe by the periorbita and leads to elevated IOP. A
unilateral increase in the IOP should prompt a search for retrobulbar hematoma and a lateral
canthotomy should be considered.
Decreased intraocular A soft globe indicates that the globe has ruptured. In such cases, the affected globe should be
pressure exenterated urgently so that the good eye can be protected from sympathetic ophthalmitis, a condition
that results from the formation of antibodies caused by uveal prolapse.
PERIORBITAL SOFT TISSUE
Telecanthus Increased intercanthal distance. See the discussion of the NOE complex.
Epiphora Excessive tearing. This finding may be caused by blockage of the nasolacrimal duct, disruption of the
canalicular system, or presence of foreign bodies causing corneal irritation. If a disruption of the
canalicular system is suspected, a thorough evaluation should be performed and a
dacryocystorhinostomy should be considered.
GLOBE POSITION
Vertical dystopia Unequal vertical positioning of the globes.
Hypoglobus The affected globe is positioned inferior to the normal globe. This finding is usually the result of
superior mass effect or trauma.
Hyperglobus The affected globe is positioned superior to the normal globe. This finding is usually caused by an
inferior mass defect or trauma. Vertical dystopia can be visualized by using a straight edge (e.g., ruler)
to align both medial canthi and comparing the globes.
Exophthalmos, proptosis Anterior displacement of the globe (>2 mm). This finding can be related to increased IOP, blow-in
fracture, or systemic disease.
Enophthalmos Posterior displacement of the globe (>2 mm). Enophthalmos and exophthalmos can be measured by an
exophthalmometer. It can also be roughly established by looking at the patient from above (bird’s-eye
view) or from below (worm’s-eye view).
FIGURE 11-3 Periorbital ecchymosis associated with a left-sided

ZMC fracture.
FIGURE 11-5 Hematoma in the maxillary vestibule.
FIGURE 11-4 Bird’s-eye view evaluating the patient for malar

depression.
EAR
The ear is a complex structure with many details that
must be carefully examined. Battle signs (ecchymosis
behind the ear), laceration in the ear canal, and blood
or CSF in the ear canal may indicate a fracture of the
skull base or of the glenoid fossa. The tympanic mem-
brane should be examined for integrity.
MAXILLA, MANDIBLE, AND DENTOALVEOLAR

STRUCTURES FIGURE 11-6 Occlusal disharmony. Note the premature occlusion
The maxilla, mandible, and the dentoalveolar structures on the left posterior segment causing an anterior open bite and
should be carefully examined. Missing teeth should be marked dental midline discrepancy.
noted and accounted for. Radiographs (e.g., anteropos-
terior [AP], lateral chest films, and/or an abdominal
film) may be necessary to rule out aspiration or swallow- maxilla while assessing the nasal complex for mobility
ing of teeth; it is also possible that these teeth could be (Fig. 11-7). Any lacerations should be thoroughly
lodged in associated soft tissue wounds. Ecchymosis or explored, especially if injuries to nerves, vessels, and sali-
lacerations in the maxillary or mandibular buccal vesti- vary glands or ducts are suspected.
bules or in the floor of the mouth indicate underlying
fractures (Fig. 11-5). If the patient is responsive, the NECK
maximal incisal opening and any deviation of the man- Anatomically, the neck is one of the most condensed
dible upon opening should be evaluated; abnormal find- areas of the body. It contains major blood vessels, nerves,
ings will indicate the location of mandibular fractures. nerve plexuses, a portion of the spinal column and cord,
The patient’s occlusion should be evaluated next; for endocrine organs, the trachea, esophagus, hypopharynx,
example, an anterior open bite indicates a condylar or and oropharynx, and many lymphatics and the thoracic
subcondylar fracture (Fig. 11-6). duct (Table 11-3).
Palpation should be used to detect step deformities The neck has been typically divided into three zones—
and associated segment mobility. Testing for the pres- I, II, and III.11 Management of penetrating neck injuries
ence of a LeFort fracture requires that the nasal complex has been historically influenced by the zone of injury.
be held gently with one hand and the premaxilla with Although the methods of managing these types of inju-
the other. The examiner should attempt to move the ries have changed, an understanding of these zones is
Zone III
Zone II
FIGURE 11-7 Examination of the maxilla. The examiner is holding

the nasal complex gently while attempting to move the maxilla.
Mobility felt in the nasal complex indicates a LeFort fracture.
TABLE 11-3 Structures of the Neck Zone I
Structure Features FIGURE 11-8 Zones of the neck.

Arteries Common carotid, internal carotid,
external carotid (and cervical
branches), vertebral artery, historically provided by exploration and angiography.
innominate artery, subclavian artery Additionally, physical examination is more time- efficient
Veins Internal jugular vein, external jugular and, unlike surgery and angiography, is not associated
vein, vertebral vein, subclavian vein with complications.12 Positive findings that warrant inter-
Nerves and nerve Vagus nerve, phrenic nerve, ventions will be discussed in this section.
plexuses hypoglossal nerve, spinal accessory The following hard signs of vascular injuries indicate
nerve, lingual nerve, branches of the the need for immediate intervention11-13:
third division of the trigeminal nerve, • Expanding hematoma
facial nerve, sympathetic chain, • Exsanguinating hemorrhage
cervical plexus, brachial plexus, • Shock unresponsive to fluid resuscitation
spinal cord • Airway compromise
Digestive system organs Esophagus, hypopharynx, oropharynx • Massive subcutaneous emphysema
Lymphatic system Thoracic duct, multiple lymph nodes • Absent carotid pulse
Respiratory system Lung apices, trachea, larynx • Carotid bruit or thrill
Musculoskeletal system Vertebral column, clavicle, neck
• Diminished radial pulses
musculature
• Differential peripheral blood pressure reading
between the right and left arms
Endocrine organs Thyroid gland, parathyroid glands
• Clavicle fracture
The following are signs of injuries to the aerodigestive
tract:
still beneficial and assists in the decision making process • Dysphagia
(Fig. 11-8). • Hoarseness
Zone I: From the level of the clavicles to the cricoid • Air bubbling from a wound
cartilage • Crepitus
Zone II: From the level of the cricoid cartilage to the • Dyspnea
level of the angle of the mandible • Subcutaneous emphysema
Zone III: From the level of the angle of the mandible The patient should also be examined for potential
to the base of the skull neurologic defects. This examination should include
The approach to penetrating neck injuries has evaluation of the sensory and motor functions of the
changed in recent years. Previous recommendations cranial nerves, cervical plexus, and brachial plexus.14 If
included angiography of all penetrating injuries to zones the examination yields any positive findings, further
I and III and elective exploration of all zone II injuries treatment is warranted. Because no universal algorithm
deeper than the platysma muscle, with minimal emphasis exists to guide the management of neck injuries, the
on the findings of physical examination. One study has examiner should follow the institution’s protocol. In
shown that detailed physical examination has a higher general, a hard sign of vascular injury in zone II warrants
yield and better sensitivity and specificity than those emergent surgical exploration and a hard sign of
A B C
FIGURE 11-9 A, The patient sustained multiple stab wounds to the face. B, C, Note the weakness of the muscles of facial expression
during animation. (Courtesy Dr. Daniel Plank.)
nerve should be suspected. Injury confined to one branch

vascular injury in zones I or II warrant an emergency of the facial nerve will produce a localized loss of func-
angiogram. Signs and symptoms of laryngeal, tracheal, tion associated with the affected muscles. Any lacerations
or esophageal injury should lead to rapid surgical inter- in the face, especially those proximal to an imaginary
vention. Injuries involving the thoracic duct or the vertical line dropped from the lateral canthus, should be
thyroid or parathyroid glands are not as pressing as are explored for facial nerve injuries. Delayed diagnosis
the injuries detailed here, but they do require urgent and leads to serious aesthetic sequelae16 (Fig. 11-9).
thorough treatment. The examination of facial sensation is important in
determining the presence of injuries to the trigeminal
CRANIAL NERVES nerve. Sensory changes in the lower lip and chin are
A thorough head to toe clinical examination can rule out frequently seen with fractures of the mandibular body
injury to most of the cranial nerves. Of interest to the because of involvement of the inferior alveolar nerve,
maxillofacial surgeon are the fifth (trigeminal) and part of the third division of the trigeminal nerve. Pares-
seventh (facial) cranial nerves. Any motor or sensory thesia, hypoesthesia, or anesthesia in the upper lip region
defects should be noted, and a high suspicion of nerve in a patient with evidence of malar flattening indicates
injury should prompt the surgeon to explore any wounds damage to the second division of the trigeminal nerve.
so that early nerve repair can be performed if necessary. The same findings on the forehead indicate an injury to
The second (optic), third (oculomotor), fourth (troch- the first branch of the trigeminal nerve. This specific
lear), and sixth (abducent) cranial nerves are examined finding should alert the surgeon to a possible orbital
as part of the orbital examination. An objective examina- apex or superior orbital fissure syndrome.
tion of the first (olfactory) cranial nerve is difficult, espe- Neck injuries should prompt examination of the
cially if the patient is traumatized or uncooperative; spinal accessory, vagus, glossopharyngeal, and hypoglos-
however, a gross abnormality in the sense of smell is sal nerves. The sympathetic cervical chain can also be
indicative of injury to this nerve. Fractures of the cribri- affected. Hearing disturbances should alert the examiner
form plate or anterior base of the skull should be sus- to injuries of the vestibulocochlear nerve (cranial nerve
pected if this symptom is reported. VIII).
Facial nerve injury can result from blunt or penetrat-
ing injuries to the face. Clinical examination and record- RADIOGRAPHIC EVALUATION
ing of the baseline function of the facial nerve are
essential but are extremely difficult if the patient is unre- In today’s level I trauma centers, imaging technology is
sponsive; however, a fingernail pinch or sternal rub can advanced, and diagnostic abilities are extremely high. It
produce a grimace and facial animation. A responsive may be tempting for the craniofacial trauma surgeon to
patient should be asked to animate all the facial muscles; rely heavily on reports from emergency room physicians
the results should be recorded by using a facial nerve and radiologists. However, it is in the best interest of all
grading system such as the House-Brackmann scale.15 If involved (patient, surgeon, health care payers) to order
the patient exhibits loss of motor function in the upper scans that are dictated by the findings of the clinical
and lower face, injury to the main branch of the facial examination and mechanism of injury. For a young
healthy patient who has sustained an isolated fracture of immediate reduction of the facial bones; these include
the mandible as the result of a low-energy event (e.g., a social and psychological support to ensure the patient’s
punch to the face), plain radiographs of the mandible in return to the community with minimal delay and easy
three spatial planes are sufficient. Conversely, the same integration.
patient who has sustained a mandible fracture as the Each patient presents unique challenges associated
result of ejection from a motor vehicle will require a with the planning of an airway in the immediate postop-
much more extensive evaluation, including neurologic erative period. The patient could arrive in the operating
and maxillofacial computed tomography (CT) scans, cer- room awake and alert and breathing, without need of a
vical spine evaluation, possibly with plain films, CT scans, protected airway, or an airway device associated with a
and magnetic resonance imaging (MRI), plain films of resuscitation procedure may still be in place. Often, the
the chest, abdominal ultrasound and CT, and other indi- situation is further complicated by the presence or sus-
cated images of the thorax and extremities. picion of a cervical spine injury. When patients with
When the findings of physical examination indicate maxillofacial injuries exhibit airway compromise or cog-
the possibility of fractures of the midface, frontal bone, nitive impairment, securing the airway is an emergency
or skull, CT scanning is the most commonly used tech- procedure.17
nique. Head CT scans are routinely ordered for patients There are many options for securing the airway,
who have lost consciousness or have exhibited changes including orotracheal or nasotracheal intubation, crico-
in the level of consciousness. CT imaging of the face is thyroidotomy, and tracheotomy. When possible, postop-
most effective diagnostically when axial, coronal, and erative airway issues should be considered prior to any
sagittal views are obtained. When orbital injuries are sus- operative intervention.
pected, coronal images will most definitively diagnose Nutrition is usually affected in patients with facial
orbital floor fractures and muscle entrapment (e.g., trauma. Postoperative pain frequently limits the oral
entrapment of the inferior rectus of the globe). In our intake of these patients. Dietary suggestions, consultation
opinion, plain radiographs are indicated for the diagno- with nutritional experts while the patient is hospitalized,
sis of midface trauma only when a CT scanner is and postoperative pain management should be part of
unavailable. the planning for the postoperative course. Maxilloman-
Plain radiographs are more commonly ordered to dibular fixation (MMF) presents a special consideration
establish fractures of the mandible. The mandible must for postoperative management. When patients are awake
be viewed in three spatial planes. Panographic radio- and responsive, teaching them to feed themselves is
graphs offer a two-dimensional representation of the essential. Generally, they should be instructed to main-
lower jaw; posteroanterior (PA) and Towne’s views of the tain a high-protein, high-calorie diet while MMF is in
mandible identify the mediolateral position of condylar place.
fractures and indicate the amount of mediolateral dis- For patients who are unresponsive or unable to main-
placement of horizontal mandible fractures. CT scans of tain an oral diet, planning should include enteral feeding
the mandible offer an occlusal view that is useful when with a nasogastric feeding tube, such as a Dobhoff tube
bilateral condylar and symphyseal fractures are present. or percutaneous endoscopic gastrotomy (PEG) tube.
Coronal CT scans also help localize the position and size Because enteral feeding has many advantages (e.g., low
of condylar fracture segments. Occlusal and periapical cost, maintenance of an intact gastrointestinal mucosal
radiographs are invaluable for the further diagnosis of lining, reduction of the risk of gastric bleeding, ease of
dentoalveolar fractures, avulsed and fractured teeth, and delivery of a large amount of good-quality nutrition,
foreign bodies. When maxillofacial CT scans have been improved wound healing), it should be planned when-
obtained because of suspected midface fractures and the ever possible. It has also been linked to shorter hospital
mandible is included, plain films of the mandible are stays.18 If enteral feeding is impossible, parenteral feeding
unnecessary. A traditional dental radiographic survey can should be started without delay.
contribute to treatment planning by highlighting the
patient’s oral health before the accident. Treatment plan-
ning for a mandibular fracture that is amenable to closed ACKNOWLEDGMENT
reduction may be modified if the remaining dentition is
We would like thank Ms. Flo Witte for her editorial
mobile and unhealthy.
assistance.
POSTOPERATIVE CONSIDERATIONS
REFERENCES
Multiple goals should be considered when formulating
the operative plan for the stable maxillofacial trauma 1. Brooks A, Holroyd B, Riley B: Missed injury in major trauma
patients. Injury 35:407–410, 2004.
patient. Intuitively, the immediate goal is restoring the 2. Fitzpatrick MO, Seex K: Scalp lacerations demand careful attention
maxillofacial skeleton and soft tissue drape to their pre- before interhospital transfer of head injured patients. J Accid Emerg
traumatic condition, both functionally and aesthetically. Med 13:207–208, 1996.
The intermediate goals also address the patient’s postop- 3. Thaller SR, Beal SL: Maxillofacial trauma: A potentially fatal injury.
Ann Plast Surg 27:281–283, 1991.
erative rehabilitation, including nutrition and airway 4. Murakami WT, Davidson TM, Marshall LF: Fatal epistaxis in cra-
considerations (see later). These considerations often niofacial trauma. J Trauma 23:57–61, 1983.
require operative modifications, such as a short-term tra- 5. Shimoyama T, Kaneko T, Horie N: Initial management of massive
cheostomy. The long-term goals are as important as the oral bleeding after midfacial fracture. J Trauma 54:332–336, 2003.
6. Buchanan RT, Holtmann B: Severe epistaxis in facial fractures. Plast 13. Bell RB, Osborn T, Dierks EJ, et al: Management of penetrating
Reconstr Surg 71:768–771, 1983. neck injuries: A new paradigm for civilian trauma. J Oral Maxillofac
7. Perry MT, Moutray T: Advanced Trauma Life Support (ATLS) and Surg 65:691–705, 2007.
facial trauma: Can one size fit all? Part 4: “Can the patient see?” 14. Bagheri SC, Khan HA, Bell RB: Penetrating neck injuries. Oral
Timely diagnosis, dilemmas and pitfalls in the multiply injured, Maxillofac Surg Clin North Am 20:393–414, 2008.
poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg 15. House JW Brackmann DE: Facial nerve grading system. Otolaryngol
37:505–514, 2008. Head Neck Surg 93:146–147, 1985.
8. Howdieshell TR, Heffernan D, Dipiro JT: Surgical infection society 16. Greywoode JD, Ho HH, Artz GJ, Heffelfinger RN: Management of
guidelines for vaccination after traumatic injury. Surg Infect traumatic facial nerve injuries. Facial Plast Surg 26:511–518, 2010.
(Larchmt) 7:275–303, 2006. 17. Mohan R, Iyer R, Thaller S: Airway management in patients with
9. Ellis E, 3rd: Sequencing treatment for naso-orbito-ethmoid frac- facial trauma. J Craniofac Surg 20:21–23, 2009.
tures. J Oral Maxillofac Surg 51:543–558, 1993. 18. Ziccardi VB, Ochs MW, Braun TW: Indications for enteric tube
10. Papadopoulos H. Salib NK: Management of naso-orbital-ethmoidal feedings in oral and maxillofacial surgery. J Oral Maxillofac Surg
fractures. Oral Maxillofac Surg Clin North Am 21:221–225, 2009. 51:1250–1254, 1993.
11. Monson DO, Saletta JD, Freeark RJ: Carotid vertebral trauma.
J Trauma 9:987–999, 1969.
12. Azuaje RE, Jacobson LE, Glover J, et al: Reliability of physical
examination as a predictor of vascular injury after penetrating neck
trauma. Am Surg 69:804–807, 2003.
CHAPTER
Radiographic Evaluation of
12 Facial Injuries
Maria B. Papageorge
| Daniel Oreadi
OUTLINE
Maxillofacial Skeleton and Significance of Osseous Structures Facial Fractures
Causes and Classification of Facial Injuries Upper Face Fractures
Diagnostic Imaging of Maxillofacial Injuries Midface Fractures
Imaging Modalities Lower Face Fractures
Radiographic Evaluation
M
axillofacial trauma is becoming an increasingly maxillofacial region and of the basic biomechanical
prevalent part of the multiple trauma victim and strengths and weaknesses of the facial skeleton are neces-
can be extremely complex in nature. Of all sary. In addition, focusing on certain anatomic land-
trauma patients, 25% sustain a facial injury. Although marks will facilitate radiographic evaluation.
facial trauma alone is rarely life-threatening, associated There are a number of inherent structural strengths
injuries can be devastating to the precarious patient if and weaknesses in the facial skeleton. The strengths
not diagnosed early. Therefore, the treating clinical team include the maxillofacial buttresses, which are important
must constantly be aware of the overall stability of the in the structural support of the facial skeletal complex.
trauma patient and quickly diagnose and treat any threat- Their function is the transmission of forces to the
ening conditions. One must also always maintain a high cranium. The weaknesses in the facial skeleton include
index of suspicion based on the mechanism of injury. the lack of complete incongruity between the base of the
Accurate diagnosis is essential for the proper treat- facial skeleton and cranium and the presence of numer-
ment of facial injuries and minimizing postoperative ous air-filled sinuses and passages with thin membranous
morbidity for the patient. Knowledge of the bony and walls. In addition, the attachments between the maxilla,
soft tissue anatomy of the craniofacial region and proper zygoma, and cranium are through sutures that can readily
clinical and radiographic evaluation are paramount. separate.
Although the basic treatment principles for the manage- There are three vertical buttresses of the midface that
ment of maxillofacial trauma remains unchanged, there provide the primary support in the vertical and antero-
have been significant advances in diagnostic techniques, posterior (AP) directions. These are the nasomaxillary,
thus improving postoperative clinical results and patient zygomatic, and pterygomaxillary buttresses2 (Fig. 12-1A).
comfort and reducing morbidity. In the AP direction. the structures that support the facial
Until the 1980s, diagnostic imaging of facial injuries projection are the frontal bone, zygomatic arch and
consisted almost exclusively of standard facial and zygoma complex, maxillary alveolus, palate, and basal
panoramic radiographs and, if available, tomographic segment of the mandible from one angle to the other.3
studies. Although standard radiographs are still useful The main objective of the vertical buttresses is to dissi-
for assessing these injuries and their repair, especially pate forces and transmit them along a vertically oriented
during the intraoperative and early postoperative periods, vector. In addition, the buttresses also maintain the
computed tomography (CT) is widely and routinely used spatial position of the maxilla in relation to the cranium
as initial or supplemental diagnostic imaging of facial above and the mandible below.
trauma. This chapter will review the role of diagnostic There are also three horizontal buttresses of the max-
imaging in the evaluation of the patient with maxillofa- illofacial region—the superior, middle, and inferior but-
cial trauma, radiographic maxillofacial anatomy, and tresses (see Fig. 12-1B). The superior horizontal buttress
various imaging techniques.1 is composed of the orbital plate of the frontal bone and
cribriform plate of the ethmoid. The middle horizontal
buttress consists of the zygomatic process of the temporal
MAXILLOFACIAL SKELETON AND bone, body and temporal process of the zygoma, infraor-
SIGNIFICANCE OF OSSEOUS STRUCTURES bital process, orbital surface of the maxilla, and segments
of the frontal process of the maxilla. This buttress pro-
In the presence of trauma, there will be alteration of the vides lateral stability to the facial skeleton and protects
normal anatomy and symmetry; therefore, a basic under- the central facial skeleton from horizontally directed
standing and knowledge of the osseous structures of the forces. The inferior horizontal buttress consists of the
232
Radiographic Evaluation of Facial Injuries CHAPTER 12 233
of injury, comminution, bone loss, occlusal disharmony,

loss of teeth, alveolar fractures, presence of condylar
fracture, displacement of segments, and entrapment of
vital structures.
The facial radiographic examination should also
depend somewhat on the clinical assessment and sus-
pected involvement based on signs and symptoms. The
purpose of the radiograph is to confirm the suspected
clinical diagnosis, rule out the presence of fractures or
foreign bodies, and obtain information that may not be
clear from the clinical examination to determine the
diagnosis and extent of injury more accurately. The
radiographic examination should also document frac-
tures from different angles or perspectives to classify
them and determine the best treatment for the patient.
DIAGNOSTIC IMAGING OF
MAXILLOFACIAL INJURIES
IMAGING MODALITIES
Plain Films
FIGURE 12-1 Vertical buttresses (red lines) and horizontal
butresses (green and blue lines). Radiographic evaluation of severe facial trauma requires
some essential radiographic projections and, although
CT with three-dimensional reformatting has become the
alveolar ridge and hard palate.4 Because of their func- imaging modality of choice in complex facial trauma,
tions, realignment and proper reconstruction of the but- plain films are still widely used in the initial evaluation
tresses in three dimensions during repair of maxillofacial of the trauma patient. The facial bone series consists of
fractures is an important step for preserving function three to five projections, including the lateral cephalic,
and appearance.5 Caldwell’s lateral oblique, and Waters’ views. The sub-
mentovertex (SMV) and Towne’s view can also be
obtained to help delineate fractures not seen on the
CAUSES AND CLASSIFICATION OF other views (Fig. 12-2).
FACIAL INJURIES Towne’s view is the most useful for assessing subcon-
dylar fractures because it is the only plain radiographic
The most common causes of facial injuries include motor study that optimally demonstrates lateral or medial angu-
and other vehicular accidents, altercations, falls, and lation and/or displacement in these fracture patterns
sports- and work-related injuries.4 The degree of force (Fig. 12-3). It is also useful for the evaluation of the orbits
delivered by the impact to the skeletal tissue plays a role because it provides optimal demonstration of the inferior
in the severity or complexity of the resultant injury. Low- orbital fissure. Towne’s view also provides additional
energy forces may cause little comminution or displace- exposure of the maxillary sinuses and inferior orbital
ment, moderate-energy injuries have an increased chance rims, aiding in the postoperative evaluation after fracture
of fracture displacement, and high-energy injuries could repair. When Towne’s view is obtained from a posteroan-
result in highly comminuted fractures, accompanied by terior (PA) angulation it is useful to evaluate areas such
dramatic instability and marked alteration in facial skel- as the petrous ridges and mastoid air cells, as well as the
etal architecture.1 Therefore, the cause of the injury is foramen magnum, dorsum sellae, and occipital bone.6 In
an important component of the patient’s evaluation and the reverse Towne’s projection, which is a reverse of the
assessment. Knowing the mechanism of the trauma may half-axial or Towne’s view, the same fracture patterns
lead to more specificity in the clinical examination and seen on the PA Towne’s view can be observed.7
acquisition of radiographic images and their assessment. Lateral cephalic views can provide information for
Classification of facial injuries is also important to define evaluation of the airway, retropharyngeal soft tissue, ante-
the treatment better and develop a successful plan. rior and posterior maxillary antral walls, and anterior
In addition to a thorough clinical examination of the alveolar ridge, as well as fractures involving the midface,
patient, radiographic analysis is extremely helpful in clas- such as LeFort I, II, and III fractures and nasal fractures
sifying facial injuries and plays a central role in providing (Fig. 12-4). PA films are also useful for evaluating midface
essential information for the initial diagnosis and treat- and mandibular fractures (Fig. 12-5). The Caldwell view
ment. Maxillofacial injuries can range from isolated frac- is used for evaluation of the midface and paranasal
tures involving only one or two osseous structures of the sinuses and provides the best view of the orbits and pos-
facial skeleton to complex facial injuries involving the terior facial structures. This view is particularly useful
entire osseous facial skeleton, with different degrees of for evaluating the nasofrontal and vertical segments of
displacement. Important clinical and radiographic find- the zygomatic buttresses, nasal fossa, and mandible.
ings that need to be adequately defined include severity Lateral oblique views can be used for evaluation of the
A B
C D
FIGURE 12-2 Facial series. A, Waters’ view. B, Lateral cephalic view. C, Lateral oblique view. D, SMV view.
mandibular angle and condyles. Waters’ view is useful for occur in 15% to 30% of patients and lateral views have a
evaluating the midface and delineating fractures of the false-negative rate of 26% to 40%.8 In equivocal clinical
orbital rims, zygomatic arches, and anterior facial struc- cases, CT is recommended because it identifies more
tures. The SMV view provides a good view for zygomatic fractures and is more accurate in locating the position of
arch and midface fractures. bone fragments. CT scans are also recommended for all
As supplemental films, the panoramic radiograph is unconscious patients with suspected neck trauma and all
extremely useful when evaluating for mandibular frac- alert conscious patients who complain of neck pain and
tures, including fractures of the condyle. In addition, spasms after high-velocity injuries. CT, however, is not
occlusal films can be used to evaluate dentoalveolar adequate for identifying ligamentous injuries in the cer-
injuries. vical spine and, although they can be identified in
flexion-extension lateral views, this is a potentially haz-
ardous procedure. It must be done only for alert and
Cervical Spine Films cooperative patients with minimal spasm who have no
In cases of facial trauma, cervical spine (C-spine) injuries evidence of a potentially unstable fracture on plain film
should be ruled out with a complete cervical spine series, or CT imaging. MRI, on the other hand, can identify
which includes lateral view (cross table), odontoid ligamentous injuries and should be considered if the
(open mouth), and oblique views before any manipula- previous investigations remain unhelpful or cannot be
tion of the neck. Undiagnosed cervical spine injury can undertaken.
FIGURE 12-5 PA view showing evidence of mandibular fracture.
FIGURE 12-3 Towne’s view showing clear appreciation of the

subcondylar region.
3
FIGURE 12-4 Lateral cephalic view showing repaired LeFort I
fracture. 2
One of the primary purposes of C-spine imaging is to FIGURE 12-6 Denis classification—columns dividing the C-spine in
identify potentially unstable injuries; one of the most anterior, middle, and posterior segments.
helpful classifications of instability has been proposed by
Denis.9 This classification divides the spine into three
columns (Fig. 12-6): 3. Posterior: This is comprised of the posterior liga-
1. Anterior: This is comprised of the anterior longitu- mentous complex, pedicles, lamina, and spinous
dinal ligament, anterior disc, and anterior vertebral processes.
body. An injury is considered unstable if two or three
2. Middle: This is comprised of the posterior longitu- columns are disrupted. An alert asymptomatic patient
dinal ligament, posterior disc, and posterior verte- without a distracting injury or neurologic deficit,
bral body. and who can complete a functional range of motion
evaluation, may safely be cleared from cervical spine conventional tomography.12 Interpretation of three-
immobilization, even without radiographic evaluation.10 dimensional reconstruction allows for easier evaluation
and the use of three-dimensional images for the assess-
Computed Tomography ment of facial injuries ensures a high degree of reliability
Although plain films will often provide adequate infor- in morphologic diagnosis.
mation, CT scans will often yield additional information CT can also be useful to rule out neurologic injury in
or can be used when C-spine precautions or other inju- the maxillofacial patient and thus can be used to supple-
ries do not permit standard facial films. There is wide ment the facial injury evaluation. This imaging is also the
agreement that the exact anatomic identification and most useful in acute situations because of the rapid
quantification of facial fractures, recognition of the true acquisition times, excellent detail of bone, and ability to
extent of bone displacements, and precise assessment of examine anatomy in multiple planes. CT scans should
major bone and soft tissue complications can be effec- also be considered in patients in whom plain films are
tively and accurately imaged with high-resolution CT.11 difficult to assess. For example, midface fractures are
Since the introduction of CT in the late 1970s and difficult to evaluate with plain radiographs because of the
early 1980s, there have been major advancements in the overlap of anatomic structures. In these cases, CT scans
diagnostic imaging of maxillofacial injuries. CT scanning in several spatial planes of space—axial and coronal and
allows for the visualization of injuries of each of the possibly three-dimensional reconstruction—should be
osseous components of the facial skeleton in the axial considered.
and coronal planes and allows for the evaluation of With the increasing role of CT for the assessment of
various soft tissue injuries. Continued improvements in trauma patients, most clinicians advocate its use. It is
software have enabled multiplanar reconstruction of considered the gold standard for radiographic evalua-
image slices in various planes using the digitized data tion of the facial trauma patient. In the past, the use of
obtained in the initial axial evaluation. These advances traditional or single-slice acquisition CT produced images
in computer technology enable automatic reconstruc- by data collected from detectors after a 360-degree rota-
tion of surface models using digitized contour lines and tion. After each tomographic image, the patient table was
three-dimensional representation on a graphic terminal moved and another image obtained. A time delay of 10
(Fig. 12-7). Three-dimensional reconstruction of facial to 15 seconds between each slice was necessary, which
bones from two-dimensional images can help guide made image acquisition a slower process. The develop-
treatment of facial injuries; in addition to trauma, it is ment of spiral or helical scanning has allowed for faster
helpful for the evaluation of congenital malformations image acquisition.13,14 Spiral CT involves the simultane-
and pathology. ous movement of the patient table and x-ray tube, which
Although two-dimensional CT scans can be helpful results in a volume acquisition of data from which indi-
when evaluating facial trauma, one of the difficulties is vidual tomographic images can be reconstructed. Because
obtaining coronal sections because they require signifi- a volume data set is acquired, excellent multiplanar ref-
cant movement of the patient’s neck. Thus, the examina- ormations are possible when using thin image slices
tion is restricted to axial sections and the impossibility of (≤3 mm).9 Thus, spiral CT scanners can rapidly scan
obtaining sagittal sections requires the additional use of acutely traumatized patients in less than 1 minute and
can generate direct images in the scan plane and three-
dimensional images in a matter of seconds.
Multidetector CT is another improvement over spiral
CT; whereas spiral CT uses a single row of detectors,
multidetector CT uses a matrix of detectors that allows
for the acquisition of multiple tomographic images per
revolution, which greatly increases the speed of imaging.
Also, fracture detection has been shown to be signifi-
cantly higher with thin multiplanar reformations.15 These
are currently considered state of the art imaging for the
patient with severe maxillofacial injuries.
Although CT scans of maxillofacial injuries have
proven to be invaluable for the diagnosis and treatment
of these fractures, one must remember that a treatment
plan is based on other variables, including the patient’s
age, physical status, and preexisting conditions. CT scans
should be used as an adjunct in the development of the
treatment plan.
Computed Tomography Angiography
CT angiography (CTA) is an important tool in the maxil-
lofacial field for a variety of indications, ranging from the
management of traumatic injuries to the treatment of
pathologic conditions such as vascular malformations
FIGURE 12-7 Three-dimensional reconstruction from CT scan. or vessel aneurysms. CTA in combination with MR
angiography (MRA) is highly efficient for the diagnosis the direction of the main magnetic field. On precession
of most arterial and venous traumatic lesions in the acute back to their original alignment in the magnetic field,
setting and when patients develop delayed symptoms. the protons reemit some of the absorbed energy, which
Conventional angiography is mainly recommended for induces an electric current in an especially designed RF
therapeutic purposes or when the diagnosis remains receiver coil. The induced current (magnetic resonance
unclear after performing cross-sectional imaging.16 signal) is then transformed into an image by computer-
Taking into consideration that approximately 25% of ized mathematical methods. Several parameters affect
penetrating injuries to the neck result in vascular injury, the signal intensity—the density (concentration) of the
in addition to an 80% chance of carotid artery injury and hydrogen nuclei, characteristics of the nuclei as deter-
a 43% chance of vertebral artery injury in the trauma mined by two different relaxation time constants (T1 and
patient, the development of vascular imaging techniques T2), and bulk flow of protons in tissues. Maximal tissue
has been beneficial for the diagnosis of these injuries. contrast, therefore, can be obtained by properly selecting
Additional diagnostic modalities include dacrocystog- the data acquisition parameters. Varying the pulse
raphy, ultrasound, and sialography, which become useful sequence imaging variable, such as pulse repetition time
in the delayed management of lacrimal/salivary duct or echo delay time, allows for the discrimination of dif-
injury.17 Currently, multidetector row CT provides isotro- ferent tissue types (e.g., fat, blood, bone, muscle).19
pic data acquisition, allowing imaging reformats with This technique does not depend on x-rays, which is an
high resolution. This provides an excellent noninvasive advantage over CT. A disadvantage is that the demonstra-
evaluation of the major vascular structures of the head tion of fine bone detail in the maxillofacial region is
and neck regions. Studies have reported 100% sensitivity inferior to that of CT. Furthermore, ferromagnetic
and 98% specificity in diagnosing vascular occlusion, objects and materials on or inside the patient, such as
pseudoaneurysms, fistulas, and partial thrombosis.7 orthodontic appliances, cardiac pacemakers, neurotrans-
mitters, electronic cochlear implants, and some intra
Magnetic Resonance Imaging cranial aneurysm clips may move, with disastrous
MRI has become the preferred diagnostic tool for exami- consequences. Also, these objects could produce arti-
nation of the soft tissue structures of the extracranial facts, which would degrade the resultant image. In addi-
head and neck. In the early 1980s, the first MRI scan tion, poor access and difficulty with some forms of
became available after the independent and simultane- monitoring equipment make MRI less attractive than CT
ous work of Felix Bloch and Edward Purcell in the 1940s, for examining acute maxillofacial trauma. However, MRI
which led to their being awarded the Nobel Prize for has growing applications in a number of specific areas,
Physics in 1956.18 such as evaluation of the temporomandibular joint,
Magnetic resonance is a dynamic and flexible technol- detection of cerebrospinal fluid (CSF) leaks and intra-
ogy that allows one to tailor the imaging study to the ocular injuries, and evaluation of the optic nerve sheath
anatomic part of interest and disease process being complex. Technologic advancements have also allowed
studied. With its dependence on the more biologically for the evaluation of vascular lesions and structures with
variable parameters of proton density, longitudinal relax- the advent of MRA, making this technique extremely
ation time (T1), and transverse relaxation time (T2), valuable in the delayed treatment of traumatic injuries.
variable image contrast can be achieved by using differ- When reviewing an MR image, the easiest way to deter-
ent pulse sequences and by changing the imaging param- mine which pulse sequence was used, or the weighting
eters. Signal intensities on T1, T2, and proton of the image, is to look at the CSF. If the CSF is bright
density–weighted images relate to specific tissue charac- (high signal), it is a T2-weighted image. If the CSF is
teristics. For example, the changing chemistry and physi- dark, it is a T1-weighted image. Then one should look at
cal structure of hematomas over time directly affects the the signal intensity of the brain structures. On MRI scans
signal intensity on MRI scans, providing information of the brain, the primary determinants of signal intensity
about the age of the hemorrhage. Moreover, with MRI and contrast are the T1 and T2 relaxation times. The
multiplanar capability, the imaging plane can be opti- contrast is distinctly different on T1- and T2-weighted
mized for the anatomic area being studied and the rela- images. Also, brain pathologies have some common
tionship of lesions to eloquent areas of the brain can be signal characteristics. Pathologic lesions can be separated
defined more accurately. Flow-sensitive pulse sequences into five major groups by their specific signal character-
and MRA yield data about blood flow and can display the istics on the three basic images—T2-weighted, proton
vascular anatomy. Even brain function can be investi- density–weighted (PD) and fluid-attenuated inversion
gated by having a subject perform specific mental tasks recovery (FLAIR), and T1-weighted. As an imaging tech-
and noting changes in regional cerebral blood flow and nology, MRI has advanced considerably over the past 10
oxygenation. MR spectroscopy has enormous potential years, but it continues to evolve, and new appplications
for providing information about the biochemistry and will likely be developed.20
metabolism of tissues.18
The images obtained by MRI are made when the RADIOGRAPHIC EVALUATION
hydrogen nuclei or protons in the body align along the Evaluation of radiographs requires an organized and sys-
direction of the main magnetic field. A short radiofre- temic approach to identify the injury accurately and
quency (RF) pulse at the proper frequency and duration minimize the possibility of overlooking the extent of the
is then transmitted into the body. The protons absorb RF trauma or underdiagnosing the patient. The skeletal
energy and flip over into a plane that is at an angle with anatomy of the face is the most complex in the body. A
3 FIGURE 12-9 Approach to evaluation based on the four Ss. Note

the marked asymmetry secondary to the ZMC fracture on the
right side in this axial cut of the CT scan.
5
FIGURE 12-8 Trapnell lines facilitate radiographic examination of
those parts of the facial skeleton where fractures and other signs
are likely to be found.
number of approaches to image assessment in the context

of facial injury have been suggested.
McGrigor and Campbell21 have described a search
pattern of four lines that the eye should follow when
examining the frontal views. These lines, in addition to
a fifth one described by Trapnell,15 allow one to examine
all parts of the facial skeleton where fractures and other
signs are likely to be found, thereby reducing chances of
misdiagnosis (Fig. 12-8). Dolan et al22 have described
three lines for evaluation of the occipitomental projec-
tions that can be used as an adjunct. These lines, known FIGURE 12-10 Trap door sign. A bone fragment is partially avulsed
from the orbital floor and hangs into the right maxillary sinus in
collectively as Dolan’s lines are described as the orbital
this coronal cut of the CT scan.
line, zygomatic line, and maxillary line.
Another systemic approach to evaluating radiographs
has been presented by Delbalso et al.19 They described a and railroad track radiographic signs. The trap door sign
useful tool as a reminder of what we should be looking is described in a blowout fracture involving the orbital
for during the evaluation of radiographs. This approach floor, in which a bone fragment is partially avulsed from
to evaluation involves the four Ss—symmetry, sharpness, the orbital floor and hangs into the maxillary sinus (Fig.
sinus, and soft tissue. 12-10). The bright light sign refers to a displaced free
Symmetry. Each radiographic image should be exam- bone fragment in the maxillary sinus (Fig. 12-11). The
ined for symmetry or loss of symmetry between respective railroad track sign refers to an additional oblique line in
contralateral structures. Loss of symmetry will result fol- the lateral orbit following a tripod fracture (Fig. 12-12).
lowing facial trauma with displacement of facial struc- This results from rotation of the zygoma and its frontal
tures. This is particularly helpful in the evaluation of process. When this occurs, the x-ray beam hits the frac-
prominent structures such as the zygoma, nose, maxillary tured edge of the frontal process in a tangential plane,
sinus, and orbits (Fig. 12-9). resulting in an accentuated linear density parallel to the
Sharpness. This refers to the accentuated sharpness of linea innominata (innominate line). This is a radiodense
margins or bone fragments in a fracture. Any displace- oblique line normally observed in the lateral orbit on the
ment of the fractured segments can result in the frag- Waters’ and Caldwell views formed by the greater wing
ment being tangential to the x-ray beam, thus leading to of the sphenoid.
accentuation on the radiographic image. This principle Sinus. Because all major bone structures of the maxil-
has led to the description of the trap door, bright light, lofacial region border at least one paranasal sinus, trauma
FIGURE 12-11 Bright light sign. A displaced free bone fragment is

seen in the maxillary sinus.
FIGURE 12-13 Complete opacification of the right maxillary antrum

secondary to blowout fracture of the orbit. Note the difference
when compared with the uninjured left side.
surrounding bony structures more closely. The presence

of air emphysema could also signal air introduced by a
penetrating injury or a sinus fracture, or could be the
result of tracheal or esophageal rupture, with dissection
of air superiorly.
In addition to the approaches just described, one
should also evaluate systematically and precisely certain
key structures of the craniofacial skeleton, including the
cranium, nasal structures, paranasal sinuses, and man-
dible individually. We recommend the use of diagrams
(Fig. 12-14) to aid in the systematic and structural radio-
graphic evaluation of the maxillofacial skeleton by iden-
tifying each fracture as the CT images are loaded or as
the films are viewed. This could be done after the search
patterns described earlier are followed, therefore mini-
FIGURE 12-12 Railroad track sign. This is evident as an oblique mizing the possibility of overlooking a fracture. This
line in the left lateral orbit. modality will also allow the surgeon to develop a treat-
ment plan as the diagnoses are made.
Not all fractures are evident radiographically by plain
in these regions will often result in radiographic changes films or CT scanning. Some skeletal injuries are only
of these sinuses. These changes can include haziness visible microscopically. Hairline fractures may become
caused by mucosal edema, opacification, an air-fluid level visible radiologically after approximately 7 to 10 days,
caused by bleeding secondary to a mucosal tear, and a when decalcification at the fracture site edges occurs.
well-defined mass caused by hematomas. Although hazi- Greenstick fractures, in which there is a fracture through
ness and opacification of the sinus can have other causes, one side of the cortex and buckling on the other, and
such as acute and chronic sinusitis, these changes in pure buckle fractures are common in children, particu-
the trauma patient must be highly suspicious for frac- larly in the condylar neck. In addition, separation and
tures (Fig. 12-13). movement may occur at suture lines and be indiscernible
Soft Tissue. Evaluation of the soft tissue for abnormali- radiologically hence the importance of clinical correla-
ties is also important when assessing maxillofacial injury. tion and knowledge of the mechanism of injury.
Soft tissue abnormalities such as edema, signs of pene-
trating injury with a foreign body, soft tissue emphysema, FACIAL FRACTURES
and intraorbital air could all be signs of osseous injury.
Thus, along with radiodense foreign body fragments, the These can occur in the upper face, midface, or lower
presence of these signs should lead one to examine the face.
A B
FIGURE 12-14 Skeletal diagrams for fracture identification during imaging review. A, Maxillofacial skeleton. B, Midface for orbital and NOE
fractures.
UPPER FACE FRACTURES

Frontal Bone Fractures
Poor outcomes after the treatment of frontal sinus frac-
tures typically result from misdiagnosis and inadequate
planning. In the past, it was mainly Waters’ and reverse
Towne’s projections, lateral skull films, and laminar
tomograms that were used to visualize midface and upper
face fractures. These films often did not show a complete
picture of these fractures, leading to misdiagnosis and
thus poor outcomes; they are now secondary to CT scans,
which are currently the gold standard for imaging these
types of fractures. The CT scan plane of choice for frontal
sinus imaging is the axial view, preferably with a slice
thickness of 1.0 or 1.5 mm (Fig. 12-15). Using two and
three-dimensional CT scans, proper identification of the
nasolacrimal duct is important in order to asses for
patency and determining the appropriate treatment of
choice (Fig. 12-16). Also, in the case of naso-orbital-
ethmoid (NOE) involvement, CT scans provide the most
information about the medial orbital wall, medial maxil-
lary buttress, and piriform aperture. FIGURE 12-15 Frontal bone fracture seen in axial view of the CT
scan.
Naso-Orbital-Ethmoid Complex Fractures
NOE complex fractures can sometimes be difficult to
interpret and classify radiographically because of the
complex anatomy of the region. The NOE region of the A simple approach in identifying these fractures from
face has a large number of air spaces within it and a radiographic standpoint is to determine the predomi-
the walls of the septa dividing them are relatively thin, nant area of injury. NOE fractures resulting from a point
thus making them particularly susceptible to trauma. of impact below the nasofrontal suture result in injury
Fractures in this region can be isolated fractures con- primarily to the ethmoid complex, nose, medial orbit,
fined to one segment of the complex or multiple frac- and upper maxillary sinus (Fig. 12-17). These fractures
tures resulting in massive depression of the entire are often termed naso-orbital-ethmoid maxillary fracture
midface. In light of this anatomic complexity, findings complexes.
on plain films are also highly variable and often do not NOE fractures occur when the point of impact is
demonstrate the full extent of the injury, making CT above the nasofrontal suture, producing an involvement
scans essential for their evaluation. of the adjacent frontal sinus. These fractures can have
patients to undergo a thorough examination of the intra-

cranial content, because these injuries are often associ-
ated with significant intracranial injuries.
Radiographic findings associated with nasoethmoidal
fractures include the following:
• Midface depression
• Fractures of the lamina papyracea
• Opacification of the frontal and ethmoidal sinuses
• Fractures of the inferior, medial, and supraorbital
rims
• Fracture of the frontal sinus walls
• Fracture of the superior orbital walls
• Fracture of the sphenoid bones
• Presence of infraorbital and intracranial air
• Fracture of the nasal bones and nasofrontal process
of the maxilla
• Fracture of the clivus and base of skull
The high degree of detail required for evaluating
NOE fractures necessitates CT axial and coronal views,
with slice thicknesses of 1.0 or 1.5 mm. It has been shown
that for severe fractures of the NOE region, CT scans
provide the most information about the medial orbital
FIGURE 12-16 Evidence of involvement of the nasofrontal duct is wall, medial maxillary buttress, and piriform aperture.
seen in axial cuts of the CT scan.
MIDFACE FRACTURES
Orbital Fractures
Orbital fractures can occur isolated or in combination
with other injuries, usually zygomaticomaxillary complex
(ZMC), NOE, and LeFort II fractures. When isolated, the
mechanism of injury is likely caused by an increase in
intraocular pressure (IOP), resulting in what is known as
blowout or blow-in fractures, referring to floor and
medial wall fractures, respectively. It is important to iden-
tify these fractures properly because any changes in
orbital volume can negatively affect the patient’s vision,
as well as the involvement of orbital muscles affecting
extraocular movements.
The accuracy of plain radiography in diagnosing
orbital fractures is poor, with obvious signs being seen
only in 10% of cases. Rarely will a fracture or displaced
fragment be directly identified. More often, there may
be indirect suggestive signs, such as opacification of the
ethmoid air cells or orbital emphysema on the affected
side, seen in slightly more than 50% of cases. Medial wall
fractures rarely cause diplopia but may contribute to
enophthalmos. They may be seen in 20% to 40% of cases
FIGURE 12-17 NOE fractures from a point of impact below the with blowout fractures.21 Both CT and MRI may be used
nasofrontal suture result in injury primarily to the ethmoid complex, to address the questions posed at the beginning of this
nose, medial orbit, and maxillary sinus. section. CT has the advantage of delineating the skeletal
tissues more effectively than MRI and is frequently indi-
cated for the evaluation of possible concomitant injuries.
notable intracranial extension and result in complica- MRI, on the other hand, is more sensitive in assessing
tions such as damage to the nasolacrimal ducts, intracra- soft tissue components, including orbital fat, muscle, and
nial air, dural tears, CSF rhinorrhea, and injury to the their possible displacement. In the setting of trauma, fat
anterior ethmoid artery. Severe NOE injuries can result density (<−10 Hounsfield units [HU]) in the maxillary
in internal telescoping, with a wide range of radiographic or ethmoid air cells is related to fracture until proven
findings. These include fractures of the cribriform plate otherwise. The same rule applies to the presence of intra-
of the ethmoid, fracture of the clivus, and orbital injuries, orbital emphysema.
including disruption of the trochlea of the superior CT imaging is best reviewed in coronal reformats
oblique muscle.23,24 because it displays the floor of the orbits better than the
Because of the anatomic proximity of the NOE axial cuts, allowing a clearer assessment (see Fig. 12-11).
complex to the cranium, it is also important for these The sagittal view on the CT scan will provide optimal
FIGURE 12-18 Fracture involving the zygomaticomaxillary

articulations at the level of the infraorbital foramen.
FIGURE 12-19 Water’s view showing evidence of repaired ZMC
fracture.
demonstration of the AP aspect of the orbital floor, allow-

ing for better appreciation of soft tissue displacement process of the zygoma as well as the lateral orbit, and best
and the anterior and posterior limits of the fracture. defines fractures and diastases involving the zygomatico-
frontal suture and lateral orbit. The SMV view is essential
Zygomaticomaxillary Complex Fractures for demonstrating the status of the zygomatic arch, poste-
ZMC fractures, also known as tripod fractures, represent rior displacement, and lateral or medial rotation on the
the most common isolated midfacial fracture. They are vertical axis. Towne’s view is useful for evaluating these
usually caused by a direct blow to the zygomatic bone, fractures because it provides an additional demonstration
resulting in disruption of its three major attachments. of displacement of the zygoma, depression of the zygo-
The disruptions occur in the region of the zygomatico- matic arch, and disruption of the inferior orbital rim, as
maxillary, zygomaticotemporal, and zygomaticofrontal well as the relationship of an orbital floor component.
articulations. The fractures involving the zygomatico- CT, however, is the accepted imaging modality of
maxillary articulations usually occur medially to the zygo- choice for use in the evaluation of ZMC fractures. CT
maticomaxillary suture at the level of the infraorbital with three-dimensional reformatting provides an excel-
foramen (Fig. 12-18). It extends circumferentially around lent demonstration of the injury to the osseous orbit and
the anterior and posterolateral walls of the maxillary may demonstrate additional osseous injuries that may
sinus and may involve the orbital floor and lateral aspect not be readily apparent on plain film (Fig. 12-20). These
of the inferior orbital fissure, which can be visualized by include fractures to the orbital apex, greater and lesser
Towne’s view. The zygomaticotemporal component of a wings of the sphenoid bones, and anterior or posterior
ZMC fracture consists of a separation of the suture line cortex involvement of the frontal bones. CT evaluation
or fracture of the zygomatic arch, at or near the zygo- of the orbit is especially important in trauma because
maticotemporal suture. Finally, to complete the tridi- these injuries may be occasionally associated with soft
mensional description of a tripod fracture, we must tissue entrapment involving the ocular muscles.
include the fracture and/or diastasis extending infero-
medially from the zygomaticosphenoid articulation to Zygomatic Arch
the inferior orbital foramen. These disruptions result in The dense composition of the zygoma makes it structur-
the mobilization of the zygomatic bone, allowing for ally functional as a unit, allowing forces to dissipate along
varying degrees of rotation and/or displacement. Iso- its body, with fractures typically occurring at the suture
lated zygomatic fractures result from direct trauma to the level. The zygomatic arch is susceptible to fractures when
arch, causing its fracture in two or more places, and may direct impact is sustained, making it the most common
also involve the coronoid process, depending on the isolated fracture of the zygoma, comprising 10% to 16%
force of the trauma. of zygomatic fractures.22 Fractures involving the proximal
Plain film evaluation of the patient suspected to have end of the zygomatic process of the temporal bone may
a ZMC fracture includes Waters’, Caldwell’s, and SMV extend posteriorly to involve the adjacent glenoid fossa
views (Fig. 12-19). Waters’ view is the most useful view to of the temporomandibular joint, a finding mostly noted
evaluate for zygomatic injuries because it defines the on axial CT scan section examination only. If sufficient
injury involving the arch, lateral wall of the maxillary medial displacement of the zygomatic arch occurs,
sinus, inferior orbital rim, and floor of the orbit. The impingement of the coronoid process (Fig. 12-21) may
Caldwell view provides an undistorted view of the frontal cause limitations in mandibular motion.
FIGURE 12-20 Three-dimensional reconstruction clearly

demonstrating zygomaticomaxillary complex involvement and
degree of fracture displacement.
FIGURE 12-22 Submentovertex view showing evidence of

zygomatic arch fracture. This is easily visualized when compared
with the contralateral uninvolved side.
For accurate evaluation of the zygoma, both axial and

coronal images of CT scan are needed. The lateral orbital
wall is often interrupted or angulated on axial images. A
common confounder is confusing the normal suture for
a fracture and, occasionally, a slight widening of the
suture (diastasis) is the only clue. Comparison with
the opposing site is valuable, as well as evaluation of the
orbital floor, which is difficult on axial images. This is
why obtaining coronal and sagittal reformats is of extreme
importance when evaluating this fracture. The curvilin-
ear orbital floor should appear smooth and interrupted
only by the inferior orbital fissure.
LeFort Fractures
A simplified approach to understanding the LeFort
classification system of midfacial fractures is to consider
FIGURE 12-21 Fracture of the zygomatic arch causing the human head as being composed of four principal
impingement of tissues surrounding coronoid process. components—the oval-shaped cranium, the pyramid-
shaped facial skeleton, and the paired three-legged
Some of the radiographic signs of zygomatic arch frac- zygoma.12
ture seen on plain films include the following: The LeFort I fracture usually results from a direct
1. Displacement of the arch seen on Water’s and horizontal blow to the lower face, resulting in fractures
Caldwell’s views involving all three walls of the maxillary sinus and ptery-
2. Superimposed radiopaque band over the body of goid processes. Radiographically, one may see opacifica-
the zygoma on Water’s and Caldwell’s views tion of the maxillary sinuses and fractures involving the
3. Diastasis of the zygomaticotemporal suture seen on sinus walls on Water’s and Caldwell’s views. CT scans
Water’s and SMV views demonstrate LeFort fractures with more detail, even
4. Depression of the temporal process of the zygoma when there is involvement of the hard palate and alveolar
and zygomatic process of the temporal bone, result- ridges (Fig. 12-23). In contrast to the LeFort II and III
ing in a so-called W deformity better visualized on fracture complexes, the LeFort I fracture does not involve
a SMV view (Fig. 12-22) the glabella or zygoma. The LeFort II fracture results
The vertical radiopaque band superimposed over the from horizontal trauma to the midface. The fracture
body of the zygoma occurs in fracture depression of the lines start in the region of the nasion and extend in an
zygomatic arch in more than 80% of fractures involving oblique fashion through the medial aspect of the orbits
the arch. This is caused by the anterior end of the frac- and inferior orbital rims. It then continues posteriorly in
tured fragment being tangential to the x-ray beam. a horizontal fashion above the hard palate to involve the
FIGURE 12-24 Axial view of noncontrast CT scan of patient with

FIGURE 12-23 Coronal view of noncontrast CT scan showing
panfacial fractures.
LeFort fracture pattern.
pterygomaxillary buttresses, resulting in a disarticulation that do not fully involve the entire fracture line. A uni-
of the pyramid-shaped facial skeleton from the rest of the lateral or hemi-LeFort fracture represents a transverse
skull. In contrast to the LeFort III fracture complex, the fracture of the maxilla that extends to the pterygoid
zygoma remains attached to the cranium. plates and is limited to one side of the face. The pure
Radiographic signs of LeFort II fractures include LeFort fracture is an unusual occurrence because patients
disruption of the nasion and nasal bones and bilateral with severe midfacial trauma usually have multiple frac-
fractures of the inferomedial orbital rims on frontal pro- ture complexes (Fig. 12-24), which led to the introduc-
jections, depression of the midface and disruption of the tion of these descriptive terms. If elements of two LeFort
nasion and pterygoid plates on lateral projections. Similar fractures are present on the same side, the higher LeFort
findings are noted on axial and coronal CT scan category is applied when naming the fracture. One
sections. should always describe the injury in terms of location,
The LeFort III fracture is the most severe of the LeFort displacement at the fracture site(s), and involvement of
fractures. It represents a complete disarticulation of the adjacent structures.
pyramidal facial skeleton, along with the zygomas from
the ovoid-shaped cranium. The fracture lines extend LOWER FACE FRACTURES
through the superior aspect of the nasofrontal buttress Mandibular and Dentoalveolar Fractures
and then posteriorly through the ethmoid bone along Mandibular fractures are prevalent in facial trauma, typi-
the attachment between the facial skeleton and cranial cally with four anatomic sites being mostly affected—
base to involve the pterygomaxillary buttresses. Bilateral angle (32%), condyle (23.3%), body (17.7%), and
fractures or diastases also occur in the region of the parasymphysis (15.6%).12 They can occur as single or
zygomaticofrontal and zygomaticomaxillary sutures. In multiple fractures involving multiple locations, including
contrast to the LeFort II fracture complex, the zygomas the contralateral side, dentoalveolar complex, condyles,
are avulsed from the cranium, along with the maxilla. and dentition. Mandible fractures can also be classified
The classic imaging findings in the LeFort III fracture as simple, comminuted, compound, or complex. They
include the folllowing: can occur as isolated injuries or in association with other
1. Fracture through the nasion, posterior orbital wall facial fractures. Ellis et al have reported that 50% of
and vertical and horizontal segments of the zygoma patients with maxillofacial injuries have at least one asso-
2. Fractures or diastases at or near the zygomatico- ciated mandibular fracture and 33% of midfacial injuries
frontal or zygomaticotemporal sutures occur in conjunction with mandibular fractures.20
3. Disruption of the nasion and pterygoid plates and There are inherent weaknesses in the mandibular
separation between the facial skeleton and calvar- anatomy that predispose it to be such a common frac-
ium as seen on the lateral view ture. These are the condylar process, mandibular angle,
LeFort fractures may be further classified as being mental foramen, and areas containing impacted teeth or
pure, complete, incomplete, and unilateral or hemi- pathologic entities such as cysts, neoplasms, or vascular
LeFort.22 A complete LeFort fracture represents a pure lesions. The thinnest portion of the mandible is the con-
LeFort fracture in addition to a fracture(s) in other parts dylar neck; thus, it is often associated with fractures in
of the maxillary supporting buttresses. An incomplete other parts of the mandible, such as the angle and
LeFort fracture complex represents a fracture along one parasymphysis areas (Fig. 12-25). This is caused by trans-
of the three major lines of weakness in the facial skeleton mission of the forces sustained by the trauma superiorly
FIGURE 12-25 Panoramic xray showing subcondylar

fracture in conjunction with parasynphyseal fracture.
FIGURE 12-26 Panoramic xray showing evidence of

symphyseal fracture compound to no. 26.
and posteriorly along the entire mandible from the point higher sensitivity and specificity than panoramic radio-
of impact. The alveolar complex can also be a point of graphs in the assessment of children suspected of having
weakness, depending on the presence or absence of condylar fractures. In view of the high rate of false-
teeth. If associated dentoalveolar injuries are present, all negative and false-positive results associated with pan-
teeth must be accounted for. If it is suspected that teeth oramic radiographs, coronal CT scans should be
are missing, the patient should undergo chest radiogra- considered routine investigation in patients whom this
phy to rule out inhaled foreign bodies. type of injury is suspected.25 Therefore, additional views
As with all facial trauma patients, the radiographic to the panoramic radiograph should be considered in
examination of the mandibular trauma patient will patients in whom there is a clinical indication of fracture
depend on a number of factors, including the clinical not evident on a panoramic image or to assess the angula-
examination, patient symptoms, and type of force sus- tion and/or displacement of the fractures better.
tained. The panoramic radiograph and intraoral films, The mandibular series, which includes lateral oblique,
including occlusal radiographs, can provide a good initial PA or AP, Towne’s, and lateral views can provide further
evaluation of mandibular trauma. The panoramic radio- information on the displacement, degree, and/or com-
graph allows visibility of the entire mandible, including plexity of the fractures. The PA view, if obtainable, is
the condyles, dentoalveolar complex, and dentition. It is preferred to the AP view because it provides less distor-
especially useful in observing the anterior mandible, tion of anatomic structures. The lateral oblique projec-
which is often not well observed in other plain films tion of the mandible provides views of the condylar and
(Fig. 12-26). Panoramic radiographs are generally easily subcondylar regions, coronoid process, mandibular
obtained, as long as the patient’s clinical condition ramus, and angle and proximal portion of the mandibu-
allows. The panoramic is a tomographic film that images lar body of the side closest to the film (see Fig. 12-2).
the mandible in a two-dimensional plane and thus carries This view does not provide adequate visualization of the
some limitations in accurately assessing the displacement contralateral mandible and only poor visualization of the
and angulation of fractured segments, including the con- mandibular symphysis because of the overlap of osseous
dyles. A recent study comparing the sensitivity and speci- structures. The PA projection provides an excellent view
ficity of panoramic radiographs with those of coronal CT of the entire mandible, except for the condyles, which
scans in the diagnosis of mandibular condylar fractures are superimposed by the temporal bone. Also, nondis-
in the pediatric population has concluded that CT scans placed symphyseal fractures may be partially obscured by
provide consistently greater accuracy of diagnosis, with a the superimposed cervical spine. This projection allows
visualization of the ramus and coronoid process fractures include basic facial films, especially when CT is not avail-
and can aid in determining the degree of mediolateral able. However, CT, in particular facial multidetector CT,
displacement of fractures in these regions and in the if available, is the most accurate imaging technique and
mandibular body. Towne’s projection allows for optimal is considered the standard for identification of facial
visualization of the condyle and subcondylar regions, fractures, as well as associated injuries. Three-dimensional
including the degree of mediolateral displacement or reformatting allows better conceptualization and better
dislocation of fractures. Although not an optimal projec- presurgical planning. CT scanning, along with MRI and
tion, the lateral view can add information to the other MRA, will provide the surgeon with the necessary tools
views of the mandibular series and is often taken for to assess the facial trauma patient fully and provide better
evaluation of the facial bones and skull. If taken for evalu- treatment outcomes.
ation of mandibular trauma, it should be obtained with
the traumatized side close to the film. As with all films, REFERENCES
the side closest to the film will appear sharper and non-
magnified. A true lateral projection would show com- 1. Perrott DH: Maxillofacial trauma assessment and treatment. Curr
Opin Dent 1:271–276, 1991.
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which is rarely the case. The lateral view usually varies eton: An approach to the management of the Le-Fort fractures.
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4. Afzelius L, Rosen C: Facial fractures: A review of 368 cases. Int J
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facial trauma: Can one size fit all? Part 4: “Can the patient see?”’
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veolar fractures, including AP displacement of the poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg
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views of the anterior mandible will show the area between study of two imaging techniques for the diagnosis of condylar
the canines and a clear view of the inferior border of the fractures in children. J Oral Maxillofac Surg 61:668–672, 2003.
mandible, thus making it easier to identify a symphysis 11. Salvolini U: Traumatic injuries: Imaging of facial injuries. Eur
Radiol 12:1253–1261, 2002.
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Plain films will often provide adequate information ment algorithm from complex surfaces: Applications in surgery.
for assessing mandibular trauma. However, when plain J Oral Maxillofac Surg 53:158–162, 1995.
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Am 12:311–324, 2002.
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21. McGrigor DB, Campbell W: The radiology of war injuries. Part VI:
evaluation. Currently, advances in radiographic tech- Wounds of the face and jaw. Br J Radiol 23:685–696, 1950.
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anatomy in detail. Radiographic examination may tures. Radiographics 4:575–663, 1984.
23. Duval AJ, Banovetz JD: Nasoethmoid fractures. Otolaryngol Clin 26. Heiken J, Brink J, Vannier M: Spiral (helical) CT. Radiology
North Am 9:507–515, 1976. 189:647–656, 1993.
24. Holt GR, Holt JE: Nasoethmoid complex injuries. Otolaryngol Clin 27. Philipp MO, Funovics MA, Mann FA, et al: Four-channel multide-
North Am 18:87–98, 1985. tector CT in facial fractures: Do we need 2 × 0.5 mm collimation?
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An analysis of 2137 cases. Oral Surg Oral Med Oral Pathol 59:120–129,
1985.
CHAPTER
Diagnosis and Management of
13 Dentoalveolar Injuries
Joel S. Reynolds
| Michael T. Reynolds
| Michael P. Powers
OUTLINE
Examination and Diagnosis Injuries to the Supporting Bone
Classification Splinting Techniques
Injuries to Hard Dental Tissue and Pulp Restoration
Injuries to the Periodontal Tissue Mouth Protectors
Injuries to the Supporting Bone Types of Mouth Protectors
Injuries to the Gingiva or Oral Mucosa
Treatment
Injuries to Hard Dental Tissue and Pulp
Injuries to the Periodontal Tissue
T
raumatic injuries to the teeth and supporting mouthguard, they are forced into occlusion, resulting in
structures are commonly seen in the injured damage to the posterior teeth, anterior soft tissue, or
patient. Orofacial trauma is involved in approxi- both (Figs. 13-2 and 13-3).7 The extent of the dental
mately 15% of all emergency room visits, and 2% of injury can be characterized by the energy of the impact.
these cases involve isolated dentoalveolar trauma.1 These A low-velocity blow usually causes damage to the support-
injuries can be isolated, as in childhood falls (the major ing dentoalveolar structures and a high-velocity impact
cause of all dental injuries),2 or can occur in association usually results in crown fractures. Objects that are cush-
with other injuries, as seen in motor vehicle ioned on impact typically result in alveolar damage and
accident (MVA) victims. Children commonly sustain a reduced incidence of crown fractures. Sharp objects
dentoalveolar injury usually between the ages of 8 usually favor clean crown fractures as opposed to blunt
through 12 years.3 Dentoalveolar injuries pose a major objects, resulting in luxation, or root fractures. Variations
threat to dental health that may even surpass that of in the direction of the impacting force usually result in
caries and periodontal disease.4 multiple fracture sites.11,18
Dentoalveolar trauma ordinarily results from falls, Injuries to the dentoalveolar structures increase in
playground accidents, abuse and domestic violence, frequency substantially as a toddler begins to attempt to
bicycle accidents, MVAs, assaults, altercations, and ath- walk and run, at approximately 1 year of age.7,10,19,20 The
letic injuries. The dentoalveolar structures can be injured incidence of injury to the dentoalveolar structures in
from direct trauma to the teeth or from indirect trauma, school-age children is reported to be approximately 5%,
usually from forced occlusion, as the mandibular denti- usually resulting from falls on playgrounds and from
tion is forcibly closed against the maxillary dentition.5-7 bicycle accidents.13,21-25 Lacerations to the chin and ver-
Direct trauma usually causes injury to the maxillary milion border of the lip and crown fractures are com-
central incisors because of their relatively exposed monly seen in children.26 Lacerations of the lip account
position.8-13 Predisposing factors include abnormal occlu- for most injuries to oral structures.27 Participation in
sions, overjet exceeding 4 mm, labially inclined incisors, contact sports, such as hockey, soccer, football, basket-
lip incompetence, a short upper lip, and mouth breath- ball, boxing, and wrestling, can result in oral trauma. The
ing (Fig. 13-1A).14 These conditions can be seen in indi- use of an intraoral mouthguard during athletic practice
viduals with class II division I malocclusions or oral and competition has been found to reduce intraoral inju-
habits, such as thumb sucking. Dental injuries are ries, notably in contact and noncontact sports.28 Skiing
approximately twice as frequent among children with and snowboarding have also been shown to increase the
protruding incisors as among children with normal risk of dentoalveolar trauma. Helmets with faceguards
occlusions.15,16 Therefore, early orthodontic treatment in can help prevent serious trauma to the head and maxil-
predisposed children may be an effective prevention lofacial structures.29
strategy.17 Dental injuries are also common in patients Multiple injuries of the hard and soft tissues are the
who have been identified as accident prone (see Fig. result of automobile accidents, with the greatest inci-
13-1B and C). Indirect trauma to the teeth and support- dence of dental injuries occurring through the ages of
ing structures usually results from a blow to the chin or 18 to 23 years.13 Dental trauma in older age groups may
from a forceful whiplash to the head and neck. If the result from assault and domestic abuse, usually closely
teeth are out of occlusion or not protected by a related to the abuse of drugs or alcohol, or both.11,30
248
Diagnosis and Management of Dentoalveolar Injuries CHAPTER 13 249
A B,C
FIGURE 13-1 A, Exposed maxillary incisors, with incompetent upper lip coverage, are frequently involved in trauma associated with falls
and facial injury. Teeth may be fractured or avulsed, and associated injury to the lower lip is commonly encountered. B, Predisposing
factors for direct trauma include abnormal occlusions, overjet exceeding 4 mm, and labially inclined incisors. C, Direct trauma to the
maxillary incisors is approximately twice as frequent in children with protruding incisors as in children with normal occlusions.
A B
FIGURE 13-2 A, Indirect trauma to the dentoalveolar structure is usually the result of falls and blows to the chin. Abrasions and lacerations
of the soft tissue of the chin should be investigated further for damage to the posterior teeth or anterior vestibule of the mandible.
B, Low-velocity trauma associated with falls may result in abrasions to the facial soft tissue and damage to the underlying dentoalveolar
structures, especially tooth avulsion in children 7 to 10 years of age. (B, Courtesy Dr. Johnson, Iowa City, Iowa.)
Mucosal or gingival lacerations and mobile incisors Many dentoalveolar injuries are associated with the
are seen in oral injuries as a result of child abuse.31,32 In management of the comatose patient37 or the patient
1996, 4.3% of children younger than 18 years in the undergoing general anesthesia.14,38-48 Lockhart et al44
United States were reported to be victims of maltreat- have surveyed 133 directors of training programs in anes-
ment.33 More than 3 million cases of child abuse are thesiology and found that an average of 1 in 1000 tra-
reported each year, with 1 million cases later being sub- cheal intubations resulted in dental trauma. They also
stantiated.34 Approximately 50% to 75% of the physical reported that 90% of the dental complications might
abuse cases had trauma to the facial and oral regions, have been prevented with a screening dental examina-
with injuries to the upper lip and maxillary labial tion of the patient and the use of a mouth protector (Fig.
area.11,14,35,36 Abuse should always be considered if the 13-5).45,46 It is important to remember that a mouth pro-
child’s injuries show a marked discrepancy between the tector can be useful in protecting the anterior teeth
clinical evaluation and the history reported by the super- during intubation, but it will not protect the teeth from
vising adult, or if there appears to be a considerable poor technique. A retrospective analysis of 14 years of
period between the time of injury and when treatment general anesthetic cases from a university hospital showed
is sought (Fig. 13-4).6 a 0.02% incidence in dentoalveolar trauma related to
general anesthesia. Only 50% of these incidents occurred

during intubation or extubation procedures, and 80% of
all incidents were deemed by anesthesiologists to be
unavoidable. Despite adequate prescreening, damage to
dentoalveolar structures can occur. Care must be taken
to avoid trauma to the dentoalveolar structures at all
times during general anesthesia, not just during endotra-
cheal intubation.47
Dental professionals are often asked to evaluate these
injuries. Good documentation of the injury is essential
because these cases may become involved in litigation.
In the United States, damaged teeth constitute the
most frequent anesthetic-related claim.48 An increased
number of dentoalveolar injuries have also been seen
FIGURE 13-3 Indirect trauma from traumatic occlusion can result in in patients with mental retardation, epilepsy, drug
crown fractures of the posterior teeth, lacerations to the anterior abuse, and congenital abnormalities, such as familial
vestibule and gingiva of the mandible, and alveolar fractures or dysautonomia.11,27
displacement of the anterior teeth of the maxillary or mandibular Dental trauma (single and multitooth) of the primary
arch.
and permanent dentition occurs primarily in boys,
A B
FIGURE 13-4 Abuse should be considered if the patient’s injuries do not appear to correlate with history reported by the supervising
individuals and the mechanism of trauma. A, Falls commonly result in lacerations to the chin rather than to the side of the cheek, which
are more commonly seen with blows. B, Domestic physical abuse cases commonly involve trauma to the orofacial region of the body,
especially the perioral structures. (A, Courtesy Dr. J. Berg, Houston.)
B
A
FIGURE 13-5 Trauma to the maxillary central incisors may be associated with endotracheal intubation from a fulcrum effect on the teeth
with elevation of the tongue. Many operating rooms have mouthguards, which can be used to protect the teeth during oral intubation. An
effective preanesthetic dentoalveolar evaluation and consultation by a dentist are recommended for all patients before oral intubation to
minimize the risk of dentoalveolar trauma and injury. (From Andreasen JO, Andreasen FM: Textbook and color atlas of traumatic injuries
to the teeth, ed 3, Copenhagen, 1994, Munksgaard.)
originally related to participation in contact sports. The with dentoalveolar trauma may have concomitant head
incidence of dentoalveolar injury in girls has increased injury and that continual evaluation must be made of the
notably as more competitive athletic opportunities have patient’s neurologic status.53,54
become available. A 2003 study reported that 9% of A history can provide valuable information regarding
young adults aged 18 to 19 years who participated regu- the nature of the injury and any alterations in the normal
larly in at least one sport had experienced dental injuries occlusion, such as open bites or crossbites that were
during sports participation at some point in their life- present before the injury. The nature of the accident can
times.49 Several studies have shown a proportional rela- provide insight into the type of injury suspected, such as
tionship between the frequency of dental injuries and injuries to the maxillary anterior teeth with falls or associ-
the summer months. Injuries to the deciduous teeth ated jaw fractures with blows to the chin. If the history of
involve the supporting bone, because of its resilient the injury does not correspond to the clinical presenta-
nature, whereas injuries in the permanent dentition tion, abuse should be considered. The patient should be
usually result in a higher percentage of crown and crown- referred for a medical examination.52,55-57 The time inter-
root fractures. Therefore, impact absorption injuries are val between the injury and presentation to the clinic is
preponderant among younger children and sharp impact critical because the success of treating luxated teeth,
injuries are preponderant among older children.11-13,24,25,50 avulsed teeth, crown fractures with and without pulp
exposure, and alveolar fractures may be influenced by
EXAMINATION AND DIAGNOSIS delayed treatment. The sooner the injury is treated, the
more favorable the prognosis in most situations.7 Many
Injuries to the teeth and supporting structures should be post-traumatic dentoalveolar complications may also be
considered an emergency situation because successful associated with delays in treatment.1 Alterations in
management of the injury requires proper diagnosis and normal occlusion reported by the patient may indicate
treatment within a limited time, especially in the case of displaced teeth, dentoalveolar fractures, jaw fractures, or
avulsions and alveolar fractures.51 a combination.
The initial evaluation must include a general assess- It is prudent that all teeth be accounted for at the time
ment of the patient’s overall condition. The patient of examination. Extraoral as well as intraoral photo-
should be relieved of pain and displaced teeth and alveo- graphs have become increasingly beneficial in trauma
lar fractures should be reduced as quickly as possible to cases. They not only aid in diagnosis and treatment plan-
improve the prognosis for survival of these structures. A ning, but can serve as further documentation of the
complete history of the mechanism and events of the trauma. Because trauma can result from abuse, assault,
injury should be obtained and a thorough clinical and or even medical procedures, pictures can provide further
radiographic examination performed quickly to ensure evidence for medicolegal proceedings.58 Missing teeth or
proper diagnosis and treatment (Fig. 13-6) because teeth pieces of teeth that have not been left at the scene of the
have the lowest potential of any tissue for returning to a accident must be considered to have been aspirated,
normal healthy state after injury. An incomplete exami- swallowed, or displaced into soft tissue of the lip, cheek,
nation can lead to inaccurate diagnosis and less success- floor of the mouth, neck, nasal cavity, or maxillary sinus.59
ful treatment.52 It is important to remember that patients A radiographic examination of the head and neck, chest,
and abdomen must be performed to rule out the pres-
ence of teeth or teeth fragments within these tissues or
organs (Figs. 13-7 to 13-11). It is important to note that
in patients with maxillofacial trauma, teeth that are unac-
counted for and loose may complicate anesthetic proce-
dures.60 Early diagnosis and surgical removal of theses
fragments could prevent undesirable foreign body reac-
tion and scarring. In such cases, the need for taking
routine facial soft tissue radiographs and chest x-ray
before starting treatment is emphasized.61 The patient or
those who have who transported the patient with avulsed
teeth should be questioned regarding the storage media
in which the avulsed tooth was transported, as well as how
long the tooth has been out of the mouth.
A clinical examination should include an inspection
of soft tissue for embedded fragments of tooth or debris.
Lacerations, abrasions, and contusions should be exam-
ined and evaluated for damage to vital structures, such
as the parotid duct, submandibular duct, nerves, and
FIGURE 13-6 A thorough clinical evaluation may be difficult in the blood vessels. Extraoral wounds may indicate underlying
pediatric trauma victim. Alterations in occlusion, lacerations of the dentoalveolar injuries. A wound under the chin suggests
gingiva, and mobility of teeth are suggestive of additional injury to the premolar and molar regions, mandibular
dentoalveolar injury. General anesthetic or IV sedation may be fractures, or both, which may be associated with condylar
necessary for complete examination and treatment. (Courtesy Dr. trauma. Patients with suspected condylar trauma should
Eric Fort, West Chester, Pa.) have a full neurologic examination to rule out deficits
A B
FIGURE 13-7 In cases of suspected tooth avulsion injury, care must be taken to examine adjacent tissue fully. Radiographs must be used
to visualize any foreign body and/or dentition that may be lodged in soft tissue and an attempt made to account for any missing teeth.
A, Trauma to the maxillary anterior teeth from an automobile accident resulted in apparent avulsion of the maxillary left central and left
lateral incisors, along with displacement of the right central incisor and gingival lacerations. B, This occlusal film reveals an avulsed
maxillary right central incisor and possible alveolar injury to the partially resorbed primary right maxillary lateral incisor.
FIGURE 13-8 Panoramic radiograph revealing that teeth had

intruded into the soft tissue and nasal cavity. (Courtesy Dr. G.
Pedersen, Chardon, Ohio.)
FIGURE 13-9 A young man involved in an MVA suffered multiple
avulsion injuries when he was hit by a piece of wood. A thorough
clinical and radiographic examination recovered all the segments,
and the improbable but reported protrusion of the but reimplantation was not possible. Two large segments were
condyle into the middle cranial fossa.54 Abnormalities in found at the scene.
occlusion can indicate fractures of the jaws, dentoalveo-
lar structures, or displacement of teeth. The direction of
tooth displacement should be noted. In the primary den-
tition, the dislocation of the apex of the displaced primary All the crowns of the teeth should be cleansed of
tooth can possibly damage the succedaneous tooth. The blood and debris before evaluation for fractures of the
direction of the dislocation and extent should be crown and exposure of the pulp (Fig. 13-12A). Bleeding
recorded (in millimeters). Fracture of the alveolar socket may be from lacerated mucosal tissue and nonlacerated
is common in displaced teeth. All teeth should be tested marginal gingiva with damage to the periodontal liga-
for abnormal mobility, horizontally and axially, which ment. Blood covering the alveolar process must be
would suggest displacement of teeth or alveolar or jaw removed and the teeth and tissue evaluated for possible
fractures. Disruption of the vascular supply to the pulp fracture, damaged teeth, and damaged periodontal
should be expected when axial mobility is present.7 tissue. The color of the traumatized tooth should be
Tongue blades can be found in emergency rooms to noted with the use of digital photographs or transillumi-
assess tooth mobility. Erupting teeth may exhibit some nation techniques because color changes may occur over
mobility that is unrelated to the injury. Movement of time, indicating alterations in tooth vitality and repre-
several teeth en bloc during the evaluation of a single senting gradual pulp necrosis.60-62 The involved teeth
tooth suggests fracture of the alveolar process. Uneven should be tapped or percussed with the handle of a
contours of the alveolar process may indicate a bony mouth mirror or with a calibrated percussion instrument
fracture.52,56 (e.g., Periotest, Medizintechnik Gulden, Modautal,
B
A
C
FIGURE 13-10 Radiographs taken after a traumatic incident to locate missing teeth. A, An anteroposterior (AP) head and neck radiograph
located a canine tooth that was pushed across the oral cavity and into the soft tissue of the lateral neck. B, A molar can be seen in the
midline within the esophagus in this AP chest radiograph. The patient evidently swallowed the tooth following a traumatic avulsion of
the tooth in an automobile accident. C, The patient is clinically followed without any invasive intervention to remove the tooth because the
radiograph demonstrates that the lost molar was within the esophagus and should pass without difficulty through the gastrointestinal
structures. D, Axial CT image of an avulsed tooth in right lower lobe of the lung after a traumatic incident.
E F
FIGURE 13-10, cont’d E, Coronal CT image of the tooth in the right lower lobe. F, Coronal CT image of the same patient with a tooth also
in the distal esophagus. (A-C, Courtesy Dr. B. Zargari, New York.)
such as with heated gutta-percha, ice, ethyl chloride,

carbon dioxide, and dichlorodifluoromethane, are
usually of little value until several months have passed.
Also, the reliability and the value of these tests have been
questioned because noninjured teeth may also fail to
respond. Although the functional repair of pulp nerve
fibers has been shown to be reestablished approximately
35 days after reimplantation, the electric pulp tester is of
little or no value in teeth with incompletely formed
apices.63 The interpretation of vitality tests performed
immediately after traumatic injuries is complicated by
the fact that sensitivity responses are temporarily
FIGURE 13-11 The premolar in this patient was located on a chest decreased, especially after luxation injuries. Repeated
radiograph in the right mainstem bronchus. Teeth are frequently vitality tests show that normal reactions can return after
aspirated during the traumatic episode and are usually located in
a few weeks or months.7,62 Teeth that have been loosened
this position. The tooth was removed by bronchoscopy before
can elicit pain responses merely from pressure of the
repair of the facial injury.
pulp testing instrument; therefore, it is important to
immobilize these teeth before testing. Teeth at different
stages of eruption may sometimes show no reaction to
Germany) to evaluate damage to the periodontal liga- stimulation. A 2007 study has shown that recently trau-
ment. Pain elicited with percussion is suggestive of injury matized teeth yield positive responsiveness in thermal or
to the periodontal ligament (see Fig. 13-12B). Teeth that electric pulp tests, which increased from no teeth showing
have undergone lateral luxation and intrusion usually do responsiveness on day 0 (day of trauma) to 29.4% teeth
not demonstrate tenderness to percussion because these on day 28, 82.35% of teeth at 2 months, and 94.11%
teeth are normally locked into their displaced position. teeth at 3 months.63 However, vitality readings with a
The sound elicited by percussion is also of diagnostic pulse oximeter have yielded positive vitality readings that
value. A sound resembling a hard metallic ring is elicited remained constant over the study period, from day 0 to
with teeth that are locked into bone, whereas a dull 6 months in all patients. This is because blood flow in
sound indicates a subluxated tooth.52 the tooth was being measured rather than thermal or
Testing pulp vitality in acutely traumatized teeth is of electrical response in the tooth, which indicates the func-
questionable value because these procedures require the tioning of A delta nerve fibers.64,65
cooperation of a relaxed patient to prevent false-negative Another new method that has been developed to
reactions. Mechanical stimulation and electric pulp measure pulp vitality by measuring blood flow in the
testing have been advocated for examining the vitality pulp is laser Doppler flowmetry (LDF). This noninvasive
and sensory perception of the dental pulp. Thermal tests, technique measures blood flow in the pulp and has been
A B
C
FIGURE 13-12 A, The crowns of the teeth should be cleansed of blood and debris for evaluation of crown fractures and possible pulp
exposures. B, This central maxillary incisor suffered direct trauma, with no obvious injury noted immediately after the fall from a bicycle.
The tooth crown color darkened over the next 24 hours as a result of bleeding from the pulp chamber into the open dentinal tubules.
The gingival tissue became swollen and erythematous as a result of secondary damage to the periodontal ligament with the fall. C, The
discoloration of the crown of the maxillary left central incisor developed several months following trauma to a primary tooth. The
discoloration of the primary tooth did not require treatment and, because there had been no damage to the underlying permanent tooth
or alveolar bone, the tooth was retained until it was replaced by the eruption of the permanent central incisor. (B and C, Courtesy Dr.
Seth Canion, Case Western Reserve University, School of Dental Medicine, Department of Pediatric Dentistry, Cleveland.)
used in studying traumatized and luxated teeth to dif- radiographs and are helpful in diagnosing fractures of
ferentiate between those that are vital and those that are the teeth, roots, and supporting bone. Patients who are
nonvital. Because this test produces no noxious stimuli, evaluated in the hospital setting will often have CT per-
apprehensive or distressed patients accept it more readily formed if there is evidence of trauma to the head and
than current methods of pulp vitality assessment.66,67 maxillofacial structures. These images can be helpful in
There has been some promise with this technique, espe- diagnosis and treatment planning for further reconstruc-
cially in the case of deferred treatment. Studies have tion after dentoalveolar injury. Use of CBCT in the oral
shown that vitality of a traumatized tooth can be ascer- and maxillofacial surgery office is becoming more preva-
tained in the first month with LDF and other modalities— lent and should be considered for dentoalveolar trauma
ethylene chloride, CO2, or ice—do not elicit a clinical patients. Valuable information for implant therapy can
response until the 6-month follow-up.62,68 This may be obtained by CT and CBCT images regarding bone
prevent the need for early invasive techniques that would height and width and location of anatomic structures.70-72
otherwise be carried out if LDF were not used. However, The radiographic examination reveals the stage of
this technique has been limited in its diagnostic value root formation and discloses injuries affecting the root
because measurements are difficult to evaluate through portion of the tooth and periodontal structures. Multiple
the crown of a tooth discolored by blood pigments and periapical radiographs taken at different angles are
LDF relies on measurement of light transmission to func- useful to demonstrate root fractures that are minimally
tion. The high cost of an LDF unit is also a limiting factor displaced. Ideally, three different angles should be
in its use.60,69 obtained for each traumatized tooth.52 The radiographic
Radiographic evaluation of dentoalveolar injuries examination should provide information concerning the
should include at a minimum a panoramic radiograph following73:
and periapical radiographs of the involved teeth. Com- • Presence of root fractures
puted tomography (CT) and cone beam CT (CBCT) • Degree of extrusion or intrusion
provide more detail than panoramic and periapical • Presence of preexisting periodontal disease
A B
D
FIGURE 13-13 A, A fracture of the mandible was noted on this periapical radiograph through the second premolar. Note the widened
periodontal ligament (PDL) associated with the second premolar. B, Two fractures of the mandible, a right parasymphyseal fracture
associated with the right mandibular first premolar and a left mandibular angle fracture associated with the impacted mandibular third
molar, are demonstrated in this panoramic radiograph. There is PDL involvement with tooth 17 and a noticeable change in the occlusal
plane involving the right mandibular premolars, as shown in the clinical picture. C, With the mandibular parasymphyseal fracture, an
obvious step in the occlusion is noted between the mandibular premolars and extravasation of blood into the adjacent tissue. D, The
lateral oblique film of the left mandibular angle fracture further demonstrates the fracture of the mandible through the angle, with a
communication involving an impacted mandibular third molar.
• Extent of root development the alveolar process may appear radiographically as a

• Size of the pulp chamber and root canal small radiolucent line, which in some cases is blurred on
• Presence of jaw fractures the panoramic radiograph but detectable on periapical
• Tooth fragments and foreign bodies lodged in soft radiographs (Fig. 13-13).
tissue Foreign bodies within the soft tissue of the floor of the
• Presence of dental caries mouth, lips, or cheeks can be viewed radiographically by
The radiographic appearance of teeth following luxa- placing the film between the soft tissue and alveolus. The
tion injuries is important in assessing pulp survival or floor of the mouth can best be visualized by an occlusal
necrosis. Teeth that have been displaced laterally or film, with the beam directed from a submental approach.
extruded radiographically exhibit a widening of the peri- The exposure time for radiographs of soft tissue should
odontal ligament space or displacement of the lamina be reduced by approximately 25% to 50% of the normal
dura, whereas intruded teeth often demonstrate an exposure time; the use of low kilovoltage is advocated for
absence of the periodontal ligament space. Fracture of these exposures.
A B C D
E F G
FIGURE 13-14 Injuries to the hard dental tissue and pulp tissue. A, Crown infraction. B, C, Uncomplicated crown fracture. D, Complicated
crown fracture. E, Uncomplicated crown-root fracture. F, Complicated crown-root fracture. G, Root fracture.
CLASSIFICATION INJURIES TO THE PERIODONTAL TISSUE

Concussion. A concussion (Fig. 13-15A) is an injury to
Many systems have been developed to classify various the tooth-supporting structures without abnormal loos-
traumatic injuries to the teeth and supporting struc- ening or displacement of the tooth but with marked
tures.21,74-78 The present classification is based on a system reaction to percussion.
presented by the World Health Organization26 and modi- Subluxation (Loosening). Subluxation (see Fig. 13-15B)
fied by Andreasen.7 It includes injuries to the teeth, sup- is an injury to the tooth-supporting structures with abnor-
porting structures, gingiva, and oral mucosa based on mal loosening but without displacement of the tooth.
anatomic, therapeutic, and prognostic considerations. Intrusive Luxation (Central Dislocation). Intrusive luxa-
tion (see Fig. 13-15C) is displacement of the tooth into
INJURIES TO HARD DENTAL TISSUE AND PULP the alveolar bone with comminution or fracture of the
Crown Infraction. A crown infraction (Fig. 13-14A) is an alveolar socket.
incomplete fracture or crack of the enamel without loss Extrusive Luxation (Peripheral Dislocation, Partial Avul-
of tooth substance. sion). An extrusive luxation (see Fig. 13-15D) is partial
Uncomplicated Crown Fracture. An uncomplicated displacement of the tooth out of the alveolar socket.
crown fracture (see Fig. 13-14B and C) is a fracture con- Lateral Luxation. A lateral luxation (see Fig. 13-15E and
fined to the enamel or involving the enamel and dentin F) is displacement of the tooth in a direction other than
without exposing the pulp. axially, accompanied by a comminution or fracture of the
Complicated Crown Fracture. A complicated crown frac- alveolar socket.
ture (see Fig. 13-14D) involves enamel and dentin with Retained Root Fracture. A retained root fracture (see
exposure of the pulp. Fig. 13-15G) is a fracture with retention of the root
Uncomplicated Crown-Root Fracture. An uncomplicated segment but loss of the crown segment out of the socket.
crown-root fracture (see Fig. 13-14E) involves enamel, Exarticulation (Complete Avulsion). An exarticulation
dentin, and cementum without exposure of the pulp. (see Fig. 13-15H) is a complete displacement of a tooth
Complicated Crown-Root Fracture. A complicated crown- out of the alveolar socket.
root fracture (see Fig. 13-14F) is a fracture involving
enamel, dentin, and cementum with exposure of the INJURIES TO THE SUPPORTING BONE
pulp. Comminution of the Alveolar Socket. Crushing and com-
Root Fracture. A root fracture (see Fig. 13-14G) involves minution of the alveolar socket (Fig. 13-16A) can occur
dentin, cementum, and the pulp. together with intrusive and lateral luxation.
A B C D
E F G H
FIGURE 13-15 Injuries to the periodontal tissue. A, Concussion. B, Subluxation. C, Intrusive luxation. D, Extrusive luxation. E, F, Lateral
luxation. G, Retained root-crown fracture. H, Exarticulation.
A B C
D E F G
FIGURE 13-16 Injuries to the supporting bone. A, Comminution of the alveolar socket. B, C, Fracture of the alveolar socket wall.
D, E, Fracture of the alveolar process. F, G, Fracture of the mandible and maxilla.
Fracture of the Alveolar Socket Wall. A fracture of the and teeth with maximal bone support.82 Any blow to a
alveolar socket (see Fig. 13-16B and C) is confined to the tooth, even in the absence of obvious dental injury, can
facial or lingual socket wall. endanger pulp vitality by severing the apical vessels or
Fracture of the Alveolar Process. A fracture of the alveo- through secondary pulp hyperemia and congestion,
lar process (see Fig. 13-16D and E) may or may not resulting in ischemia and possibly leading to necrosis.
involve the alveolar socket. Therefore, long-term dental follow-up is necessary. The
Fractures of the Mandible or Maxilla. A fracture involving typical follow-up schedule should include a clinical visit
the base of the mandible or maxilla (see Fig. 13-16F and within 24 to 48 hours after the initial clinical evaluation
G), and often the alveolar process, may or may not involve and treatment, followed by a clinical visit within 2 weeks
the alveolar socket. for removal of the splint. Monthly clinical visits are
planned for the first 6 months and should be followed
INJURIES TO THE GINGIVA OR ORAL MUCOSA up by annual visits for 5 years.3,83,84 The patient should be
Laceration of Gingiva or Oral Mucosa. A shallow or deep informed that future endodontic therapy may be neces-
wound in the mucosa results from a tear and is usually sary, regardless of the severity of injury to the teeth and
produced by a sharp object. supporting structures (Fig. 13-17).7,85-89
Contusion of Gingiva or Mucosa. A bruise is usually pro- The treatment of traumatized primary incisors is com-
duced by impact from a blunt object and results in sub- plicated by the size of the pulp cavity, susceptibility of the
mucosal hemorrhage without a break in the mucosa. developing permanent tooth, and cooperation of the
Abrasion of Gingiva or Oral Mucosa. A superficial wound child. It is also important to note than any type of trau-
produced by rubbing or scraping of the mucosa, leaving matic injury to a primary tooth could result in potential
a raw, bleeding surface, constitutes an abrasion of the sequelae to the permanent tooth. Concerning the per-
gingiva or oral mucosa. manent dentition, the most common developmental dis-
turbances are discoloration of enamel and/or enamel
TREATMENT hypoplasia (46.08%) and eruption disturbances (17.97%)
caused by the traumatic injury in their predecessors. It
After obtaining a thorough history and performing a has not been possible to find an association between the
clinical and radiographic examination, several factors type of injury in primary teeth and sequelae in their suc-
should be considered in the definitive treatment of the cessors.90 Heroic methods designed to maintain the
dentoalveolar injury: primary incisors after trauma should be discouraged.
1. Age of the patient The loss of primary incisors does not require space main-
2. His or her cooperation tenance as growth occurs, regardless of which primary
3. Injury to the primary or permanent dentition and incisors are involved, but loss of primary molars may
stage of root development require space maintenance to prevent mesial drift of the
4. Location and extent of the injury—horizontal and permanent first molar.7,9,85,91 If the primary incisor is lost
proximal superficial (corner) fractures demonstrate before the roots begin to be absorbed (between the ages
a low frequency of pulp necrosis, whereas deep proxi- of 3 and 4 years), eruption of the succedaneous perma-
mal fractures show an increased risk of eventual pulp nent tooth is often delayed. However, this delay usually
necrosis. does not create additional orthodontic problems. If the
5. Residual bone support primary tooth is lost after 25% of the permanent incisor
6. Periodontal health of the remaining teeth root has formed (between the ages of 4 and 5 years),
7. Whether or not there has been a fracture of support- eruption of the permanent successor is often
ing bone accelerated.
8. Vitality of the teeth
9. Whether apical foramina are wide or narrow INJURIES TO HARD DENTAL TISSUE AND PULP
10. Injury to soft tissue In the permanent dentition, crown fractures are associ-
11. Extent of any concomitant head, chest, or abdominal ated with most dental injuries. The most common type
injuries may affect the treatment of the dentoalveolar of injury involves enamel and dentin (45%) with crown
injury and length of time between trauma and fractures. The treatment of crown fractures in the per-
treatment.11,79 manent dentition must initially relieve the pulp’s
Also, the practitioner should determine the amount response to the injury before the final necessary restora-
of time that has passed since the injury occurred and tions are considered.
what storage medium, if any, was used.80,81 Lack of coop- Crown Infractions. Infractions are often overlooked. It
eration on the part of the patient, especially young chil- is important that direct transillumination (directing a
dren and mentally challenged individuals, may require light beam perpendicular to the long axis of the tooth
the use of a general anesthetic or intravenous sedation. from the incisal edge) be performed for adequate evalu-
The periodontal health of the involved and adjoining ation and treatment.92 Infractions predominantly result
teeth must be evaluated for osseous support of the trau- from a direct impact to the enamel, frequently occurring
matized teeth and to determine whether the adjoining on the labial surface of the maxillary incisors. Usually no
teeth can be used for splinting, if indicated. The prog- treatment is indicated for a crown infraction or cracks in
nosis for traumatized teeth is generally better in younger the enamel layer (see Fig. 13-14A). Sealing multiple
patients and in vital teeth with wide apical foramina, infraction lines with unfilled resin and an acid etch tech-
teeth with intact soft tissue, teeth with no root fractures, nique may prevent stains from becoming an aesthetic
A B
FIGURE 13-17 Root resorption is a major common complication associated with dentoalveolar trauma, which if left untreated will result in
loss of the tooth. Resorption resulting from toxic byproducts and bacteria from the necrotic pulp tissue may be seen months to years
after trauma to the tooth. A, Note the various degrees of resorption associated with the maxillary incisors—early external resorption of the
lateral incisor, resorption around a middle third root fracture of the central incisor, and total resorption of the apical root in the other
central incisor. B, Root resorption of a maxillary central incisor is demonstrated in this occlusal radiograph with a patient who was
asymptomatic, without complaints and noted during an initial screening examination. (A, Courtesy Dr. J.A. Wallace, Fox Chapel, Pa;
B, courtesy Dr. Seth Canion, Case Western Reserve University, School of Dental Medicine, Department of Pediatric Dentistry, Cleveland.)
problem. The vitality of the traumatized tooth should be opposing teeth into the fracture site (see Fig. 13-18B and
documented at the time of diagnosis and evaluated ade- C). The risk of pulp necrosis is minimal.
quately by periodic follow-up to monitor the pulpal Fractures without exposure of the pulp from oral
health of the involved tooth. If the tooth does not respond trauma occur more frequently than any other type of
to pulp vitality testing at the time of injury, endodontic crown fracture in the primary and permanent denti-
therapy is not indicated immediately, but the tooth must tions. Exposed dentin usually is sensitive to thermal
be kept under observation. The patient should be changes and mastication. If there is a notable amount of
informed of signs and symptoms that may occur, such as dentin exposed, measures should be taken to do the fol-
pain, swelling, and tooth discoloration. If the patient lowing: (1) seal the dentin tubules from microbial irri-
experiences any of these, further evaluation and poten- tants to prevent ingress of bacteria; and (2) promote
tial treatment may be necessary. The prognosis with secondary dentin deposition by the pulp tissue (Fig.
respect to pulp necrosis is good, provided that concus- 13-19; also see Fig. 13-18D). A calcium hydroxide liner is
sion or subluxation injuries are not overlooked.11 placed over the exposed dentin and the tooth form is
Crown Fractures. For crown fractures that involve the restored with a composite restoration. This traditional
enamel only (see Fig. 13-14B), treatment is limited to technique has been well studied, but current evidence
smoothing of sharp edges or restoration with acid etch suggests that because calcium hydroxide is soluble in
composite (Fig. 13-18A). Because of aesthetic demands, water, the dentinal tubule fluid on surfaces of the
midline symmetry may also be recovered with orthodon- exposed fractured site interferes with the calcium
tic extrusion of the tooth to restore properly balanced hydroxide material, resulting in its dissolution and loss
incisal height. The treatment objectives are to restore the of protective function over time. An alternative treat-
crown’s anatomy and occlusion, thus preventing labial ment uses glass ionomer cement as a liner, which has
protrusion, drifting, tilting, or extrusion of adjacent and proven to be as effective.92 Reattachment of the
A B
C D
FIGURE 13-18 A, Uncomplicated crown fracture of a maxillary central incisor that is confined to enamel only. B, C, Crown fracture limited
to enamel. Treatment is limited to smoothing and a direct composite restoration. The aesthetic direct restoration is shown to demonstrate
the corrected anatomy and occlusion. D, Uncomplicated crown fractures that involve dentin require treatment of the exposed dentin to
manage the possible symptoms associated with thermal change and oral fluid exposure. A dentin-bonding agent was used before
application in the restorative material.
fractured segment using dentin-bonding agents can be contact with human tissue, it appears that the material
performed to restore the tooth and reduce the microle- does the following:
akage around the restoration.11 There is no change in 1. Forms calcium hydroxide (CH) that releases
the bond strength with the use of the dentin-bonding calcium ions for cell attachment and proliferation
agents compared with standard enamel bonding tech- 2. Creates an antibacterial environment by its alkaline
niques.93 No matter which technique is used, the tooth pH
should be evaluated periodically for alterations in pulpal 3. Modulates cytokine production
health. The overall risk for pulp necrosis is minimal, 4. Encourages differentiation and migration of hard
with associated luxation injuries, stage of root develop- tissue–producing cells and
ment, type of treatment, and extent of fracture increas- 5. Forms hydroxyapatite (HA, or carbonated apatite)
ing the risk of pulp necrosis. on the MTA surface and provides a biologic seal
If the pulp tissue is exposed (see Fig. 13-14C), mea- To achieve the best prognosis, the pulp-capping pro-
sures must be taken quickly to attempt to preserve the cedure should be carried out only in teeth with small
vitality of the neurovascular tissue because hemorrhage exposures and those that appear within 24 hours after
from the exposed pulp is usually present. Teeth with pulp injury (Fig. 13-20A and B). Pitt-Ford and Patel65 have
exposure require pulp capping, partial pulpotomy, or compared CH and MTA as pulp-capping agents on
endodontic therapy. The primary aim is to preserve a monkeys’ teeth. Their results showed that most pulps
vital noninflamed pulp surrounded by hard tissue. capped with MTA were free of inflammation and all of
Whichever treatment option is used, careful periodic them showed calcified bridge formation after 5 months.
evaluation is necessary, including clinical examination, In contrast, the pulp of teeth capped with CH showed
vitality testing, and periapical radiographs. If the tooth is the presence of inflammation and significantly less calci-
relatively sound, a pulp-capping procedure with calcium fied bridge formation. MTA promotes dentin bridge for-
hydroxide liner or mineral trioxide aggregate (MTA) mation through differentiation of pulpal cells into
and composite restoration should be performed. MTA is odontoblastic-like cells.94-96 MTA has grown in favor with
a bioactive material that can create an ideal environment clinicians because of its biocompatibility and ability to
for healing. From the time that MTA is placed into direct help maintain pulp vitality.
nal crown fragments, full crown coverage, or laminate

veneers.
Crown-Root Fractures. Crown-root fractures (see Fig.
13-14E and F) account for 5% of traumatic injuries to the
permanent teeth and 2% of injuries to the primary denti-
tion. The treatment options are dependent on the
amount of root remaining. Treatment goals are to pre-
serve the remaining root fragment to support a post and
crown prosthesis, which requires additional periodontal
procedures, such as gingival-alveolar surgery or orth-
odontic measures to expose the retained root segment.
Primary teeth with any type of crown-root fracture
should be extracted and conventional prosthetic-
restorative treatments provided.7,85,98 Emergency treat-
ment should include stabilization of the coronal fragment
FIGURE 13-19 Presentation of a patient following a fall with an to adjacent teeth with an acid etch resin splint.99 In the
uncomplicated crown fracture of the permanent maxillary central permanent dentition, uncomplicated fractures of the
incisor that had a considerable amount of exposed dentin. The enamel, dentin, and cementum depend on the location
tooth did not require root canal therapy and was treated of the fractured segment, which determines the type and
conservatively with an acid-etched composite resin restoration extent of treatment. If the fracture line is above or slightly
and follow-up evaluations. below the cervical margin, the tooth can be restored, as
with a crown fracture. Occasionally, crown-lengthening
procedures are necessary to allow restoration of the
Pulp capping is also indicated in complicated crown margin. If the fracture continues too apically to allow
fractures in immature teeth, in which maintenance of adequate restoration, extraction of the tooth may be
pulp vitality is desirable. Most complicated fractures indicated. If the pulp is involved (complicated), the level
eventually require partial or complete pulpotomy; the of the root fracture determines the treatment. Extraction
latter procedure should be considered a temporary is usually indicated if the coronal segment includes more
treatment and should be followed by pulpectomy when than one third of the clinical root or in cases of vertical
root development is complete.92 A cervical pulpotomy root fractures; otherwise, the tooth may be treated end-
involves removing 2 to 4 mm of pulp tissue subadjacent odontically and restored. When the coronal fragment
to the exposure (i.e., all the coronal pulp), placing a CH compromises one third or less of the clinical root and
or MTA base, and using an acid etch composite for the fracture line extends below the marginal bone level,
restoration. adequate access to provide margins on sound tooth struc-
A cervical pulpotomy is indicated in cases involving ture is necessary. This can be accomplished by extrusion,
immature teeth with incomplete closure of the apex by surgical exposure (gingivectomy or osteotomy) or
because it is not indicated for teeth with concurrent orthodontic elevation of the fracture surface, or by
displacement injuries. CH paste or MTA has been dem- crown-lengthening procedures.92 Surgical procedures
onstrated to promote closure of the apex of the imma- are indicated only in teeth with completed root develop-
ture tooth.7 There have been multiple studies confirming ment and an apical fragment long enough for definitive
MTA’s ability to help promote apex closure and, again, restorative procedures.99 The stability of orthodontic
may be a superior material to CH.94 movements has been evaluated and it was concluded that
Completion of root canal therapy is usually indicated the risk of relapse is always present but can be minimized
by closure of the apex. This closure can be confirmed by by fibrotomy techniques.100 If the tooth is mature and
serial radiographs, usually within 3 to 6 months. Partial, root formation is complete, endodontic treatment is indi-
or Cvek, pulpotomy implies the removal of pulp tissue to cated. If the apex is open, a pulpotomy should be per-
only a depth of 1 to 2 mm. Partial pulpotomy provides formed with a CH or MTA base and should be observed
many advantages when compared with cervical pulpot- through the use of x-rays for closure of the apex, after
omy because there is no necessity for subsequent end- which definitive root canal therapy and permanent res-
odontic therapy and the cell-rich coronal tissue is toration can be initiated. A crown-root fracture of a tooth
preserved (see Fig. 13-20C).97 in a young person may require extraction and placement
If the teeth are mature and fully formed, with notable of a space-maintaining partial denture. Alternative treat-
exposure of the pulp tissue, total pulp removal is indi- ments have been presented in the literature, suggesting
cated (Fig. 13-21). The canals should be completely the retention of the root fragment by the procedures
treated endodontically and filled with gutta-percha to described until the completion of the pubertal growth
prevent post-traumatic complications associated with spurt to preserve the alveolar bone. After that time,
pulp necrosis. Follow-up examinations are necessary to definitive treatment can be accomplished with place-
evaluate all traumatized teeth (with pulp exposure ment of endosseous implants.98
treated conservatively for degenerative pulp necrosis) Root Fractures. Root fractures (see Fig. 13-14G)
and to determine whether definitive root canal therapy account for approximately 6% of cases of dental trauma.101
is necessary. Definitive restoration of crown fractures Root fractures account for approximately 7.7% of the
consists of composite restorations, reattachment of origi- trauma associated with the permanent dentition and
A B
E
FIGURE 13-20 A, Significant crown fracture involving pulp tissue in primary dentition. B, Teeth that have exposure of pulp tissue will
require pulp capping, partial pulpotomy, or endodontic therapy. Ideally, pulp-capping treatment should be initiated within an acute period
of less than 24 hours. C, In teeth that sustain complicated fractures, treatment usually involves a complete pulpectomy. This final
treatment is usually deferred until root development is complete by performing a cervical pulpotomy as a temporary measure. D, A
periapical radiograph demonstrates a complicated crown fracture of the maxillary central and lateral incisors involving exposure of the
pulpal tissue. The involved teeth will require root canal therapy and final restoration of the crowns. E, Once the root canal therapy has
been completed, the teeth should be restored with full crowns. (A, Courtesy Dr. J. Berg, Houston, Tex; D, E, courtesy Dr. Seth Canion,
Case Western Reserve University, School of Dental Medicine, Department of Pediatric Dentistry, Cleveland.)
could possibly damage the permanent tooth. Normal

physiologic resorption of the apical fragment can be
expected (Fig. 13-22A). Leaving a mobile coronal
segment will more likely cause pulp necrosis to develop
and removal is indicated.104
Root fractures of the permanent teeth are most preva-
lent in the maxillary central incisor region in the 11- to
20-year-old age group.104 Studies have shown a survival
rate of up to 80% in root-fractured teeth when treated
appropriately.105
The prognosis of the involved tooth and treatment
indicated are dictated by the level of the fracture along
the horizontal aspect of the root (see Fig. 13-22B and C).
If the fracture is in the apical third of the root and there
is little or no mobility, the prognosis is good and minimal
treatment is indicated.1,3,101,103 Surgical removal of the
root tip can also be considered with the retained segment
sealed.105 If possible, however, the apical segment should
be left to minimize bony resorption. The coronal frag-
ment of the tooth generally remains vital and endodontic
treatment usually is not necessary. If the fracture line is
closest to the gingival crevice, there is a poor chance that
FIGURE 13-21 Endodontic treatment is indicated for mature, fully healing with calcified tissue will occur. The worst prog-
formed teeth with crown fractures that have notable pulp tissue nosis is associated with high root fracture where the
exposure. The canals are filled with gutta-percha to prevent coronal portion is mobile (see Fig. 13-22B) compared
post-traumatic complications associated with pulp necrosis. with apical or midroot fractures (see Fig. 13-22C).104,106
The higher the fracture on the root, the greater the
chance of a communication between the oral cavity and
3.8% in the primary dentition. Careful examination of root fracture line developing, based on the degree of
the supporting soft tissue, alveolar bone, and surround- periodontal disease and bone loss present before the
ing teeth is important in patients with suspected root injury. It is important to evaluate the patient’s oral
fractures. hygiene, especially around the gingival margins, and the
The teeth most commonly traumatized by root frac- periodontal status around the involved tooth, which
tures are the maxillary incisors (75%). Concomitant frac- might eventually dictate treatment. If the fracture occurs
ture of the surrounding alveolar bone is associated with near the cervical margin (see Fig. 13-22D) and significant
40% of teeth involved with root fractures, and additional mobility is present, both the coronal and apical frag-
teeth are traumatized in 45% of cases initially found with ments are extracted or only the coronal portion is
root fractures.102 Careful follow-up care is important for removed, complete endodontic treatment is carried out
patients with root fractures, not only to evaluate the teeth on the retained apical portion, and restoration is com-
that are directly involved but also to evaluate surround- pleted with a crown over a post and core. Alternatively,
ing teeth and alveolar bone, which may demonstrate after removal of the coronal fragment, subsequent orth-
complications over time not obvious at the initial presen- odontic or surgical extrusion of the remaining apical
tation and evaluation of the patient. Horizontal root frac- fragments may be necessary so that the final crown is
tures occur mostly in maxillary central incisors of male even with those of the adjacent teeth.102 Fractures in the
patients. These are fully erupted permanent teeth with middle third of the root have a good prognosis, especially
closed apices and are solidly supported by bone and if there has been minimum displacement of the coronal
periodontium.103 The most common mechanism of portion of the tooth (Fig. 13-23). This type of injury is
injury is a frontal impact on the dentoalveolar structures. usually the most troublesome because splinting is neces-
The clinical examination reveals a slightly extruded sary to prevent migration of the two segments. The seg-
tooth, usually displaced in a lingual direction and clini- ments will usually heal without the need for endodontic
cally difficult to distinguish because of root fracture from therapy. Other treatment options include replacement
luxation injury. A reliable radiographic examination is with endosseous implants.
necessary for a proper diagnosis. Occlusal radiographs The principles for treatment of permanent teeth
are ideal for disclosing fractures in the apical third of include reduction of the displaced coronal fragments
roots, whereas periapical views are better for fractures in and firm immobilization.104 The latter should be per-
the coronal segment.101,104 formed as soon as possible to allow optimal consolidation
Root fractures in primary teeth are uncommon before and repair.101 The stable fixation of teeth with fractured
the completion of root development. Root fractures in roots is essential for good healing and successful treat-
primary teeth without mobility can be preserved and ment. Fixation is usually accomplished by splinting with
should exfoliate normally. If there is mobility or disloca- an acid etch resin splint for at least 2 to 3 months to
tion of the coronal segment, the tooth should be removed ensure sufficient hard tissue consolidation. However, no
without attempts to remove the apical fragments, which studies have established the influence of the length of
D
FIGURE 13-22 A, Occlusal radiograph reveals a root fracture of a primary central incisor. Care was taken during removal of the coronal
segment and the apical segment was not removed to prevent damage to the permanent tooth. B, Root fracture shown in the apical
third. The prognosis for this fracture is good and minimal treatment may be required. C, Root fracture of the coronal third of the root has
a poorer prognosis because of communication with the oral cavity. D, Large cervical restoration that has a higher risk of root fracture.
Treatment may involve removal of the coronal segment and endodontic treatment and restoration with a crown, post, and core system.
the splinting period on fracture healing. The use of rigid, pulp canal obliteration and calcification, external and
orthodontic-based fixation or extensive wiring is contra- internal surface resorption, which occurs in approxi-
indicated because it can result in additional periodontal mately 60% of root fractures 1 year after injury,107 pulp
injury and can affect healing.103 Following stabilization, necrosis, or fracture nonhealing are possible post-
the occlusion should be examined and adjusted to avoid traumatic complications. There is no evidence that defin-
excessive masticatory forces on the affected tooth. Extrac- itively demonstrates that a delay in treatment is associated
tion is indicated for permanent and primary teeth with with an increased incidence of complications; however,
vertical root fractures (Figs. 13-24 and 13-25). treatment within 48 hours is recommended.1 Pulpal
Follow-up examinations are important after the treat- necrosis has been found with displacement of the coronal
ment of root fractures. Radiographic examinations fragment, forceful application of splints, nonsplinting of
should be performed at subsequent visits to evaluate involved teeth, and teeth with incomplete root formation
pulpal and periapical healing. Radiographic findings of at the time of injury.
A B
C D
E
F
FIGURE 13-23 A, Fractures in the middle third of the root have a good prognosis if there has been minimal displacement of the coronal
portion of the tooth. In this patient, there has been significant displacement of the coronal portion, and resorption around the fragmented
segments is noted. B, Orthodontically, the coronal segment was slowly repositioned so that alignment could be obtained. C, Good
alignment of the coronal and apical segments was obtained. D, Endodontic therapy was performed first with a calcium hydroxide paste
in the canal. E, Endodontic treatment was completed with a gutta-percha filling material. F, The tooth 5 years after treatment is
functional, without evidence of internal or external resorption. (Courtesy Dr. J.A. Wallace, Fox Chapel, Pa.)
A B
FIGURE 13-24 A, A traumatized central incisor with full crown coverage continued to be painful for a prolonged period. There was
occasional purulent material that drained from a fistula in the facial mucosa. The infection was controlled with antibiotics but returned
after the antibiotics were discontinued. B, Extraction of the involved tooth revealed a vertical root fracture. (Courtesy Dr. J.A. Wallace, Fox
Chapel, Pa.)
INJURIES TO THE PERIODONTAL TISSUE excessive masticatory forces on the injured tooth. Again,
Of all dental trauma, luxation injuries most commonly with traumatic injury to the teeth, a periodic follow-up
occur in the permanent and primary dentition.106 Caus- evaluation of pulpal health is necessary. Pulp necrosis
ative factors in the permanent dentition include bicycle may develop several weeks or months after injury;
accidents, sports injuries, falls, and fights, whereas falls however, there is a low incidence of adverse pulpal
dominate in the primary dentition.108,109 In both types of sequelae.7,111
dentition, luxation is most commonly seen in the maxil- Subluxation. With damage to the supporting structures
lary central incisor region. The type of luxation injury is of the tooth, bleeding is often associated with sublux-
dependent on the type of force and direction of impact. ation (see Fig. 13-15B). A subluxated tooth is both sensi-
In the primary dentition, intrusions and extrusions com- tive to percussion and mobile, and patients have extreme
prise most injuries, probably because of the resilient masticatory sensitivity. Subluxated teeth tend to involve
nature of the alveolar bone in children of this age, subcutaneous crown fractures.110 Symptomatic
whereas intrusion injuries are notably reduced in the treatment—such as a soft or no-chew diet and, if neces-
permanent dentition. More frequently, two or more sary, occlusal adjustments to remove the involved tooth
teeth are luxated simultaneously, and concomitant crown from any traumatic effects of occlusion—usually allows
or root fractures occur. Diagnosis of the type of luxation the tooth to stabilize. Occasionally, nonrigid splinting to
injury is wholly dependent on clinical and radiographic adjacent teeth is necessary for 7 to 10 days. Concussed
examination. Common sequelae of intrusion injuries are and subluxated teeth have a fairly high reported inci-
pulp canal obliteration, pulp necrosis, internal resorp- dence of pulp complications111,112; therefore, teeth with
tion, external resorption, marginal bone loss, and tran- concussion or subluxation injuries require periodic
sient apical breakdown, each dependent on the type of follow-up evaluations (Fig. 13-26A).
injury, maturity of the affected tooth, and subsequent Intrusive Luxation. Intrusive luxation (see Fig. 13-15C)
treatment intervention.110 of a tooth involves compression of the tooth into the
Concussion. In concussion injuries (see Fig. 13-15A), alveolar socket and through the alveolar bone; this typi-
patients usually have a chief complaint of a tooth that is cally occurs when a child falls and the maxillary incisors
tender to touch. This form of injury primarily involves receive an impact (Fig. 13-26C).* Intrusion of the tooth
the supporting structures of the tooth, with no evidence can range from minimal impaction to complete disap-
of loosening or displacement. The clinical examination pearance within the alveolus and supporting jaw. Signifi-
reveals percussion sensitivity in horizontal and vertical cant damage is done to the periodontal ligament,
directions. No treatment is recommended for concus- resulting in a greater incidence of external root resorp-
sion injuries other than palliative therapy. If symptoms tion, pulp necrosis, and loss of marginal bone. Partial or
develop in the patient, delay of treatment of more than total disappearance of the periodontal ligament space is
1 week does not seem to have any adverse effects on noted in x-rays. A percussion test on the tooth that has
outcome in this group.1 At a minimum, occlusal grinding
of the opposing tooth may be indicated to relieve *References 3, 5, 7, 76, and 108.
A B
FIGURE 13-25 A, The patient reported chewing on a hard piece of raisin bread and had pain associated with the permanent left maxillary
first premolar, which had obviously fractured. B, Extraction of the involved tooth demonstrated a vertical crown-root fracture, which
cannot be repaired.
A B
C D
FIGURE 13-26 A, B, Bleeding around the gingival crevice is commonly noted with damage to the periodontal and supporting tissue of the
tooth in luxation injuries. A tooth that has undergone subluxation is sensitive to percussion and mobile, with patient complaints of
extreme masticatory discomfort. C, D, Intrusive luxation of a tooth can range from minimal impaction to complete disappearance within
the alveolus and supporting jaw.
undergone intrusive luxation produces a dull metallic the alveolar socket. When displacement of the apex has
sound, similar to that of an ankylotic tooth, which is occurred in a position as superior as the nasal cavity,
useful in differentiating the intruded tooth from a tooth hemorrhage from the nares may be seen. No definitive
that is partially erupted. This clinical finding is a result relationship has been found between delay of treatment
of the affected tooth being locked into a firm position in and post-traumatic complications.1 Treatment of teeth
A B
FIGURE 13-27 A, These maxillary central incisors have undergone extrusive luxation during an altercation. The area is irrigated clean of
debris and, with the patient under local anesthetic, the teeth are digitally manipulated into proper position in the alveolar sockets.
B, Maxillary incisors that have laterally luxated and accompanied fracture of the alveolar support structure. This type of fracture requires
digital manipulation to reposition the teeth in proper alignment and reduction of the alveolar fracture with labial and palatal compression
forces. Splints that are placed for stabilization should be left in place for 4 to 6 weeks.
that have undergone intrusive luxation is controversial, space should not be used. If the intruded tooth is facially
and no optimal treatment has been determined.7,112-115 displaced and appears not to have involved the perma-
Recommended treatments include the following7,111,114-117: nent successor, the tooth should be allowed to reerupt
1. The tooth can be allowed to reerupt if the tooth is spontaneously. If, during the eruption phase, the gingiva
immature. becomes infected, the tooth should be removed and anti-
2. Immediate surgical repositioning of the tooth into biotics such as penicillin or clindamycin administered to
its proper place in the arch can be carried out. It prevent damage to the permanent tooth germ7 (see Fig.
has been shown that there is a greater incidence of 13-26).
external root resorption, increased risk of seques- Extrusive Luxation. Extrusive luxation (see Fig. 13-15D)
tration, and marginal bone loss with this technique results in the apex of the tooth being displaced out of
because of additional trauma to the periodontal the alveolar socket with complete rupture or stretching
structures. of the apical neurovascular bundle, severing of the peri-
3. The teeth that have undergone intrusive luxation odontal ligament fibers, and an intact supporting bone
can be splinted to adjacent teeth. usually remaining (see Fig. 13-26B). Radiographically,
4. Low-force orthodontic repositioning of immature the periodontal ligament space is increased. The teeth
and mature teeth that have undergone intrusive appear elongated in a lingual direction, with a dull per-
luxation can be carried out over a period of 3 to 4 cussion sound and evidence of exsanguination around
weeks to allow remodeling of the bone and peri- the gingival crevice. The tooth that is partially displaced
odontal fibers, with endodontic therapy performed out of the alveolar socket should be manipulated digitally
within 2 to 3 weeks to arrest pulp necrosis and into proper position as soon as possible. Treatment
external root resorption, which has been found in should be undertaken as soon as possible within the first
96% of fully formed intruded teeth. Before orth- few hours following injury. Any delay in treatment will
odontic extrusion, the tooth should be slightly alter the prognosis of the involved teeth. Teeth that go
repositioned with the use of extraction forceps. untreated beyond 33 hours have shown an increased
Other clinicians have advocated gingival surgical incidence of pulp necrosis compared with those treated
procedures to provide early access for root canal earlier.1 The tooth should be splinted with a nonrigid
therapy to prevent development of infection. CH material, such as monofilament nylon or thin (28-gauge)
therapy, with its antibacterial properties, has been wire, for 1 to 2 weeks to allow some physiologic move-
recommended to arrest inflammatory root resorp- ment of the involved tooth so that ankylosis may be pre-
tion and promote healing of the adjacent periodon- vented (Fig. 13-27). The fixation prevents the tooth from
tal ligament space. migrating incisally after being repositioned. It is highly
In the primary dentition, the permanent successor probable that the tooth will require endodontic
develops lingual to the primary incisor.9 If the intruded therapy.5,112 Follow-up examinations with radiographic
tooth impinges on the permanent tooth, the primary and vitality evaluation must be performed periodically to
tooth should be extracted immediately and as atraumati- prevent loss of the tooth. The extruded primary tooth
cally as possible to prevent injury to the permanent tooth should be removed to prevent damage to the succedane-
bud. Proper extraction techniques are used to prevent ous tooth.7
further injury of the developing tooth germ. Any instru- Lateral Luxation. A laterally luxated tooth (see Fig.
ment that increases the risk of entering the follicular 13-15E and F) shows a radiographic appearance similar
to that of extruded teeth. In an occlusal exposure, the

0
periodontal ligament space is increased apically when
With Root Resorption

% Permanent Teeth
the apex of the tooth is displaced labially. The crowns are
often displaced lingually, and percussion and mobility
test results are similar to those from intrusions, again
50
because of the locked position in the alveolar socket (see
Fig. 13-27B). Lateral luxation of the tooth is usually
accompanied by comminution or fracture of the alveolar
socket. In lacerations of the gingiva, the tooth can be
forced through the alveolar plate. The tooth and alveolar 100
0 1 hr 2 hr 3 hr 4 hr
bone can typically be manipulated digitally (usually with
Time for the Tooth
force) into proper position, with concurrent compres- A Out of the Mouth
sion forces on labial and palatal bone plates, and splinted
to adjacent stable teeth. If treatment is delayed more
than 48 hours, it is difficult to reposition the tooth manu-
ally.1 Studies have shown that treatment should then be
deferred; the tooth eventually realigns itself or orthodon-
tic intervention is necessary.114 Any large gingival lacera-
tion, which is common with this type of injury, should be
sutured. The tooth should be stabilized for 2 to 8 weeks,
depending on the extent of the displacement.7,112 As with
extrusion injuries, pulp necrosis is prevalent. Endodontic
therapy may be required and follow-up examinations are
necessary.
Avulsion (Exarticulation). A true dental emergency
exists with complete avulsion of the tooth from the alveo-
lar socket (see Fig. 13-15H). Avulsion injuries make up B
about 15% of all traumatic injuries to the permanent
FIGURE 13-28 A, Successful reimplantation is inversely related to
dentition, usually associated with fights, sports, and
the length of time a tooth is out of the socket. Reimplantation of a
MVAs, and 7% to 13% in the primary dentition, with falls
tooth within the first 15 to 20 minutes produces a favorable
against hard objects the primary causative factor.118 The long-term prognosis. B, Avulsed primary teeth should not be
prognosis of the pulp and periodontal tissue is directly reimplanted. The socket site should be inspected, any debris or
related to proper diagnosis and to the action taken at the fragments should be removed, and the area should be irrigated.
scene of the accident, which usually is not performed by Appropriate sutures should be placed for reapproximation of soft
individuals trained in dental techniques.* The most fre- tissue.
quently involved teeth in both dentitions are the maxil-
lary central incisors. Avulsion of these teeth usually
occurs between the ages of 7 and 10 years, when the damage to the attachment apparatus and infection of
permanent incisors are erupting. According to Andreasen, pulpal tissue.83,123 The width and length of the root canal,
the loosely structured periodontal ligaments and resil- stage of root development of the tooth, and type of extra-
ient alveolar bone surrounding erupting teeth provide alveolar storage once the tooth has been avulsed are
minimal resistance, which favors avulsion over other significant factors determining tooth survival. Andreasen
injuries.7 and Hjorting-Hansen122 have observed that after a period
The goal of reimplanting teeth after traumatic avul- of 2 or more years, 90% of teeth reimplanted in less than
sion is to maintain the viability of the cells of the pulp 30 minutes after avulsion exhibit no discernible resorp-
and periodontal ligament, which would assist reattach- tion of roots. In contrast, root resorption was seen in 95%
ment and prevent post-traumatic complications of root of teeth reimplanted after an extraoral period longer
resorption.† The success of reimplantation is inversely than 2 hours. Root resorption has been attributed to
related to how long the tooth is out of the socket (Fig. cemental damage on the external surface of the root,
13-28A). The sooner the tooth is reimplanted, the better with the necrotic pulpal tissue providing a possible
the prognosis. The single most important factor that will source for infection. Reimplanting the tooth within the
affect treatment outcome is speed. Ideally, the avulsed first 15 to 20 minutes prevents the loss of normal peri-
teeth should be replanted within 20 minutes of injury. odontal ligament cells and has a favorable long-term
The longer the periodontal tissue is allowed to dry out, prognosis.124,125
the less opportunity there is for regeneration of the peri- Because time is critical, reimplantation at the site of
odontal fibers within the alveolus and tooth, with loss of injury has the best prognosis.* Most parents and caregiv-
normal physiologic metabolism and morphology of peri- ers have little information regarding avulsion and reim-
odontal ligament cells. Improved prognosis is based on plantation guidelines, so direct instruction is usually
management of inflammation, which is stimulated by required.126
*References 5, 7-9, 73, 76, 86, 112, and 119.

†
References 7, 63, 112, and 120-122. *References 7, 63, 73, 112, and 120-122.
TABLE 13-1 pH and Osmolality of Various Storage Media
Medium pH Osmolality (mOsm/kg)

Saline 7.0 295
Tap water 7.5 12
Saliva 6.3 110–120
Viaspan 7.4 320
Gatorade 3.0 280-360
Milk 6.75 275
Coconut water 6.2 288
Blood plasma 7.2-7.4 290
Hanks’ balanced salt 270-290
solution 7.0
From Hiremath G, Kidiyoor KH: Avulsion and storage media. J Invest Clin
Dent 2:89, 2011.
Telephone instructions to the patient, parent, care-

giver, or supervising personnel should be to inspect the
tooth for debris by holding the tooth by the crown, to
cleanse with saline or milk or simply sucking or spitting
on the tooth, and to place the tooth back into the socket
immediately. After reimplantation, the tooth should be
held in place with light pressure en route to the office
or clinic. If the tooth cannot be replaced, it should be
stored in the buccal vestibule or under the tongue of the
patient unless, because of the extent of injury or the age
and cooperation level of a child, there is a concern that
the tooth may be aspirated or swallowed. The tooth can FIGURE 13-29 Save-A-Tooth emergency tooth-preserving system
then be stored in the mouth of the parent or supervising (3M Health Care, St. Paul, Minn). (From Scuderi GR, McCann PD,
Bruno, PJ: Sports medicine: Principles of primary care, St. Louis,
adult for transportation without adverse consequences.
1997, Mosby.)
If neither option is available, the same effect can be
achieved if the tooth can be stored in milk, saline (1
teaspoon of salt added to 8 ounces of water), or a saliva- of the periodontal ligament. A cell culture medium in a
soaked towel. Storage in tap water has been documented transport container, Viaspan (Belzer UW-CSS, DuPont
to have adverse effects on periodontal healing and is not Pharmaceuticals, Wilmington, Del), claims to be supe-
recommended for cleansing or transportation of avulsed rior to milk with healing results found with HBSS.130 Data
teeth.* Water is the least desirable storage medium have shown that HBSS is able to preserve the vitality of
because of its hypotonic environment, which can cause periodontal ligament fibroblast (PDLF) cells to a greater
cell lysis.124 Milk is considered the best medium because extent when compared with Viaspan and Eagles solution,
of its availability, pH compatibility to vital cells, freedom but clinical relevance has not yet been established.80,81
from bacteria, and function of maintaining the vitality of Approximately 75% of dentoalveolar trauma occurs close
the periodontal ligament cells 3 hours in the postavul- to home or school. Availability of the media in kits at
sion period.128 A comparison of different storage media homes, schools, and day care centers, which have a large
is shown in Table 13-1. A storage medium that has a number of children between the ages of 8 and 12 years,
similar pH and osmolality to those of blood plasma is may be prudent.83 A plan should be developed with the
desired to preserve the periodontal ligament cells.129 staff to handle such an emergency efficiently because
The tooth should never be allowed to dry. Even short time and tissue management are critical to success (Fig.
drying periods can do irreversible damage to the peri- 13-29).
odontal ligament of the avulsed tooth and can cause The primary goal of the emergency visit is to reim-
rapid loss of the tooth through resorption.7,112 Another plant the tooth with a maximal number of vital periodon-
transport medium is a tooth-preserving system known as tal ligament cells that will regenerate and repair the
Hank’s balanced salt solution (HBSS), which is consid- ligamentous attachment of the tooth to bone (Fig. 13-30).
ered to have excellent storage potential while a history Initially, a thorough medical history along with a full
and physical examination is conducted. The advantage history of the accident, is essential, including informa-
of this system is an inner suspension netting and remov- tion about where the tooth was recovered, “dry time,”
able basket that permit gentle washing without crushing and storage media. This information governs treatment
choices. The teeth and traumatized tissue should be
*References 7, 80, 81, 118, and 127. inspected and evaluated. If the patient does not have the
A B
FIGURE 13-30 A, Avulsive trauma of anterior maxilla showing degree of tissue damage, debris, and blood clots. These sites were
examined for fractures and then gently irrigated. B, The avulsed teeth were gently manipulated into position and splinted for 7 to 10 days
with a semirigid acid etch resin splint.
tooth, careful clinical examination must be performed the extent of damage to surrounding structures (e.g., root
to rule out aspiration (see Fig. 13-11), swallowing of the fractures, intrusive luxations). A clinical examination of
tooth (see Fig. 13-10B and C), intrusive luxation, or dis- the socket site is mandatory to ascertain whether it is intact
placement of the tooth in surrounding soft tissue of the and acceptable for replantation of the avulsed tooth. The
head and neck (see Fig. 13-10). Chest, abdominal, pan- socket site is rinsed gently with saline and examined for
oramic, and facial films should be obtained to rule out the presence or absence of alveolar bony wall and the
adverse possibilities. If the tooth has been left at the extent of fracture. The health of the soft tissue of the
scene of the accident, every attempt should be made to socket affects the prognosis of reimplantation and should
retrieve it. be left unaltered. The soft tissue should not be manipu-
The tooth should be evaluated to determine whether lated with instrumentation and the site should be gently
it is of the primary dentition. The root of the tooth irrigated to remove debris and blood clots. However, if a
should be inspected for evidence of resorption or a collapse is evident, a blunt instrument should be inserted
radiograph should be taken of the alveolar bone to locate into the socket carefully in an attempt to reposition the
a succedaneous tooth. Avulsed primary teeth should not fractured piece of bone. If the tooth position is unaccept-
be reimplanted because there is risk of pulp necrosis and able, the tooth should be removed gently and reimplanted
possible interference with the development of succeda- into the correct position. The involved tooth should be
neous teeth (see Fig. 13-29).7,8,63,112 No space problems splinted with a semirigid acid etch resin splint for 7 to 10
will develop in the permanent dentition with premature days. Studies have indicated that rigid splinting of reim-
loss of primary teeth, but eruption often proceeds in a planted teeth increases the extent of root resorption;
labial direction. thus, a minimum of 1 week is sufficient. If there has been
Andreasen7 has proposed that the following condi- a notable concomitant alveolar fracture, a rigid splint
tions be considered before reimplanting a permanent should be used for 3 to 4 weeks.124
tooth: If the tooth is transported to the office or requires
1. The avulsed tooth should be without advanced peri- repositioning, it should be gently cleansed of debris with
odontal disease. saline-soaked gauze or a stream of saline from a syringe
2. The alveolar socket should be reasonably intact to until visible contaminants are removed. To prevent
provide a seat for the avulsed tooth. damage to vital periodontal tissue and cementum, no
3. There should be no orthodontic considerations, effort should be made to scrape the tooth surface or
such as significant crowding of the teeth. sterilize it with solutions before reimplantation. To
4. The extra-alveolar period should be considered. If prevent further damage to the root surface, the tooth
the tooth is reimplanted within 30 minutes of avul- should fit loosely within the alveolus. The tooth should
sion, there is a good chance of successful reimplan- then be manipulated gently into proper position using
tation. For extra-alveolar periods longer than 2 digital pressure. It is not necessary to suction the blood
hours, complications associated with notable root clot from the socket before reimplantation.
resorption increase greatly. The tooth should be splinted and gingival and soft
5. The stage of root development should be assessed. tissue lacerations should be sutured as indicated. The
Survival of the pulp is possible in teeth with incom- traumatized teeth should be removed from the occlusion
plete root formation if reimplantation is accom- and the patient should receive a soft diet for 2 to 3 weeks.
plished within 2 hours after injury. Care should be taken with removal of the splint after 7
If the tooth has been successfully reimplanted before to 10 days because the involved tooth will still be mobile.
evaluation by the dentist, a radiograph should be obtained Splinting longer than 7 to 10 days may promote root
to verify the position within the alveolar socket and assess resorption (Figs. 13-31 and 13-32).7
D
E
FIGURE 13-31 A, This lateral incisor was completely avulsed during an altercation. The tooth was located and the patient was instructed
over the telephone to place the tooth in his mouth and get to the dental clinic as quickly as possible. B, On arrival at the dental clinic, a
radiograph revealed no obvious damage to the supporting bone or surrounding teeth. C, The tooth is gently cleansed of debris with
saline-soaked gauze without scraping or the use of a sterilization solution to prevent damage to the periodontal tissue and cementum.
The tooth is then gently manipulated into the alveolar socket and splinted for 1 week. D, Endodontic therapy is initiated 2 weeks after
reimplantation of the tooth. The canal is first filled with calcium hydroxide paste and treatment is eventually completed with a gutta-
percha filling material. E, The tooth remains functional without evidence of root resorption 5 years after implantation.
Factors that affect healing of the avulsed tooth include succinct and useful guide for treating a patient who sus-
extraoral time, use of suitable storage media, and type tains an avulsion injury.132
and duration of splinting.1,131 Andreasen7 has categorized Healing With a Normal Periodontal Ligament. The
periodontal healing of avulsed teeth into groups based periodontal ligament of the avulsed tooth repairs com-
on histologic evaluation. A useful flow chart for treating pletely. Small areas of resorption on the root surface are
avulsion can be seen in Figure 13-33. This provides a repaired by new cementum deposits, with eventual
In the fully developed jaw, ankylosis of teeth presents

no difficulty. The teeth may be maintained until root
replacement leads to loosening and exfoliation. However,
in younger patients in whom maturation of the alveolar
structures has not occurred, ankylosis may interfere with
the normal growth of the alveolar process. When infraoc-
clusion is diagnosed in these individuals, the tooth should
be extracted to prevent malocclusion.63 Clinically, the
percussion tone is high and may reveal replacement
resorption in the initial phases.
Inflammatory Resorption. The cause of inflammatory
resorption is a communication between surface resorp-
tion and pulp via the dental tubules. Toxic byproducts
and bacteria from the necrotic pulp tissue seep into the
FIGURE 13-32 A comprehensive evaluation of the soft tissue is periodontal tissue and cause an inflammatory reaction.134
imperative during the initial examination because of the nature of Resorption is accelerated and, within a few months, the
force in avulsion injury. This patient not only suffered avulsion of root may be completely resorbed. Inflammatory resorp-
the mandibular lateral incisor but also a complex laceration of the tion is common after reimplantation of the permanent
ventral aspect of the tongue, which was overlooked in the initial incisors in the 6- to 7-year-old child because of wide den-
examination and was discovered on follow-up. tinal tubules, a thin protective cementum layer, or both.
Clinically, the reimplanted tooth is loose, extruded, and
sensitive to percussion, producing a dull sound. Affected
complete regeneration of the periodontal ligament. A reimplanted teeth may undergo replacement and inflam-
normal periodontal space can be seen in a radiograph matory resorption processes simultaneously.
and a normal percussion sound can be elicited. It is Root resorption is the major complication with trau-
important to note that this type of healing is rare with matically avulsed teeth, usually associated with long
tooth avulsion trauma, because trauma to even the inner- extraoral storage times or an unsuitable storage environ-
most layer of the periodontal ligament leads to surface ment at the time of avulsion.124,135 The loss of vitality of
resorption. the periodontal ligament influences the progression of
Healing With Surface Resorption. This is a self-limited resorption of the root surface. Even short drying periods
process that affects superficial localized areas of damage of the avulsed tooth can have an adverse effect on the
to the periodontal ligament. The tooth radiographically periodontal ligament. Unless treated, inflammatory
and clinically appears to be in normal position, eliciting resorption can result in rapid loss of the reimplanted
a normal percussion tone. tooth as early as 3 months after reimplantation. In cases
Healing With Ankylosis (Replacement Resorption). The in which there has been a significant period when the
development of replacement resorption depends on the avulsed tooth has been allowed to dry more than 20
degree of damage to the periodontium at the time of minutes, successful reimplantation of the tooth has been
avulsion and the extent that viable periodontal cells on reported, including regrowth of the periodontal liga-
the root surface are maintained.132 The blood clot in the ment, with the use of Emdogain (Biora, Malmo, Sweden),
damaged periodontal ligament of the avulsed tooth is especially in the 20- to 60-minute drying time period.136,137
organized into granulation tissue, which is replaced by Appropriate endodontic therapy can arrest the resorp-
bone, usually 2 weeks after implantation. The tooth tive process. Treatment is based on the removal of the
undergoes progressive replacement resorption if the source of infection.138 All reimplanted teeth with com-
entire periodontal ligament space is removed before plete root formation should be treated endodontically
replantation or transient replacement resorption if a within 7 to 10 days, prior to splint removal.7,122,139 CH is
limited amount of periodontal ligament space is removed recommended as an interappointment medication
with the avulsion. The tooth becomes ankylosed and the before the placement of gutta-percha because of its anti-
root is gradually replaced by bone. The normal peri- bacterial effects. Controversy exists regarding how long
odontal space is not evident in a radiograph. The areas CH should be used. Hammarstrom et al have claimed
of root resorption can be detected within 2 months of claim that because of the necrotizing effect on the cells
injury, beginning in the apical third of the root, and most repopulating the root surface, the use of CH should be
cases are evident 1 year after reimplantation. The degree contraindicated on damaged root surfaces—for example,
of replacement resorption varies with the age of the avulsion injuries.132 Lengheden et al have studied the
patient (e.g., reimplanted teeth with a damaged peri- prolonged use of CH in avulsed teeth and concluded that
odontal ligament space in younger patients are resorbed because of the relatively high pH of CH , necrosis in
within 3 to 7 years, whereas in older patients, reimplanted growing periodontal healing cells and damaged cells
teeth remained functional for a longer time).133 To mini- occurs and ankylosis develops.140 Other agents that have
mize replacement resorption of avulsed teeth, studies been used to provide a temporary canal-filling material
have used materials placed between the tooth and socket, include an antibiotic-corticosteroid paste (Ledermix,
such as silicone grease and methyl methacrylate, surgical Lederle, Wolfratshausen, Germany) and the hormone
sponge (Gelfoam), fascia, and cutaneous connective calcitonin, both of which help minimize inflammatory
tissue, with limited success.118 root resorption. Andreasen has demonstrated that
FIGURE 13-33 Flow charts of closed apex and open apex avulsion. (From McIntyre JD, Lee JY, Trope M, Vann WF Jr. Permanent tooth
replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 31:137, 2009. )
FIGURE 13-33, cont’d

extraoral root canal procedures and root canal filling resorption. Successful reimplantation requires expedient
materials injure the periodontal ligament, resulting in treatment at the time of the accident and close follow-up
increased ankylosis when compared with nonendodonti- visits every 6 months for at least 3 years and annually for
cally treated avulsed teeth.7 This study recommended as long as possible. If more than 2 hours have elapsed
that endodontic treatment should be initiated 1 to 2 since avulsion of the tooth or if the periodontal ligament
weeks after reimplantation to halt the development of has not been kept moist, there should still be an attempt
inflammatory resorption and allow reformation of peri- to reimplant the tooth, with the patients and parents, if
odontal fibers. However, a recent study has shown that necessary, being made aware of the poor prognosis (Fig.
extraoral endodontic treatment is not detrimental for 13-34).124
avulsed permanent teeth that are replanted after more Many factors, however, still favor replanting such
than 60 minutes of extraoral dry time.141 teeth. First, reliability of failure predictors has not yet
The key to retarding the inflammatory resorption been tested in prospective studies. Second, preservation
process is early initiation of endodontic therapy to elimi- of even resorbing replanted teeth may offer significant
nate a potential bacterial source within the necrotic long-term advantages in preparation for definitive treat-
pulpal tissue. The periodontal ligament space is allowed ment. Also, for psychological reasons, replantation can
to heal and a CH filling material is placed, followed by significantly reduce the anxiety and despair of the injured
the definitive canal filling. Other techniques to over- child and parents. Furthermore, decoronation of a
come the resorptive process include the replacement of resorbing anterior tooth will allow it to serve as a matrix
the apical part of the root with cast Vitallium and ceramic for alveolar bone formation and preserve an otherwise
implants. These procedures do not prevent resorption resorbing alveolar process, thereby leaving an environ-
but prolong the survival time of the reimplanted tooth.118 ment of bone and soft tissue that is optimal for single-
If more than 2 hours elapse before reimplantation can implant insertion or fixed prosthesis. Finally, replantation
be achieved, extraoral endodontic therapy should be and subsequent decoronation, if indicated, appear to be
accomplished141 and the canal should be filled with CH, cost-effective in comparison with nonreplantation com-
which has been shown to be effective in arresting inflam- bined with subsequent repeated prosthetic tooth replace-
matory resorption.7 In teeth with prolonged extra- ments because of vertical alveolar growth of adjacent
alveolar time, application of 2% phosphate-acidulated ridge areas, with eventual definitive implant placement
sodium fluoride (pH, 5.5) for 20 minutes has been shown or a fixed prosthesis.147
experimentally in animal models to slow the replacement Preservation of roots in the alveolar process seemed
resorption to approximately 50%.142,143 Studies have yet to maintain the bone volume, enabling better conditions
to confirm similar results in human teeth. Doxycycline for later implant placement; 41 implants (97.6%) were
has been advocated for root preparation to reduce micro- integrated successfully. Given that patients have finished
organisms in the pulp lumen and increase pulp revascu- growth, with careful treatment planning and timing, the
larization in immature teeth.144 Other agents used to functional and aesthetic outcome of single-tooth implant
protect the root from inflammatory resorptive changes treatment today is excellent and can be recommended
include tetracycline-doxycycline, stannous fluoride, citric for replacing tooth losses after trauma in the anterior
acid, hypochloric acid, formalin, alcohol, diphospho- region of the maxilla.148
nates, and indomethacin solutions.118
Immature teeth with wide open foramina that are INJURIES TO THE SUPPORTING BONE
reimplanted less than 2 hours after avulsion should be Comminution of the Alveolar Bone. Comminution of the
reimplanted and splinted without endodontic therapy alveolar socket (see Fig. 13-16A) is usually associated with
for possible revascularization of the pulp. Radiographic lateral or intrusive luxation injuries. The fractures are
examination should be performed after 2 or 3 weeks and, generally reduced with digital manipulation and the
if root resorption is noted, endodontic therapy should luxation injury is treated. Follow-up for evidence of root
be initiated immediately and CH paste packed into the resorption of the involved teeth is indicated.
root canal to eliminate inflammatory resorption.7 Revas- Fractures of the Alveolar Socket Wall. Alveolar socket
cularization of the root is promoted with a solution of wall injuries (see Fig. 13-16B and C) are frequently seen
1 mg of doxycycline in 20 mL of saline for 5 minutes. in the upper incisor region, usually affecting several
After arresting the resorption and closing the apex, a teeth, and typically are associated with luxation inju-
final endodontic restoration should be completed. ries.149 Generally, there is mobility of the buccal osseous
Tetanus prophylaxis or booster injection should be plate with the involved teeth and evidence of contusion
administered after injury if the last injection was given of the gingiva or mucosa. Lateral extraoral radiographs
more than 5 to 10 years previously. Human tetanus anti- best demonstrate the location of the fractured site.
toxin, 250 units given intramuscularly, is recommended Reduction of the fracture involves simultaneous digital
for dirty wounds untreated for more than 25 hours.145,146 pressure of the coronal aspect of the crown and apex
Antibiotic coverage with penicillin or clindamycin is indi- along the fracture site. After reduction of the fracture,
cated to minimize bacterial activity in the periodontal the occlusion should be checked and the involved teeth
and pulp tissue and twice-daily use of a 0.12% chlorhexi- removed from the forces of traumatic occlusion. Soft
dine rinse for 7 to 10 days is indicated to improve oral tissue lacerations should be sutured and the involved
hygiene and overall oral health. teeth should be in a rigid splint for 4 weeks to allow
The prognosis of reimplanted permanent teeth is osseous healing. Alveolar process fractures with primary
guarded because many teeth are destroyed by root teeth that are not notably displaced or easily
A B
FIGURE 13-34 A, This central incisor was avulsed in a playground accident when the patient was 8 years old. The patient reported that
she put the tooth in her pocket and got to her family dentist after approximately 3 hours, with the tooth still in her pocket. After informing
the family of the poor prognosis, her dentist filled the canal retrograde with amalgam extraorally and replaced the tooth. The tooth
functioned for almost 20 years without difficulty, except discoloration. Mobility of the tooth eventually resulted because of resorption of
the root, requiring extraction. B, A similar case showing root resorption involving a central incisor that had been in function for a number
of years following root canal therapy. The tooth was ultimately extracted because of mobility. (B, Courtesy Dr. Seth Canion, Case
Western Reserve University, School of Dental Medicine, Department of Pediatric Dentistry, Cleveland.)
manipulated back into proper position may not require

splinting because the bone heals quickly in children.
However, splinting of the involved segment may be dif-
ficult in children because of the lack of sufficient tooth
support. The child should maintain a soft diet for 2
weeks, with periodic follow-up examinations required to
monitor pulp health.
Fractures of the Alveolar Process. Fractures of the alveo-
lar process (see Fig. 13-16D and E) are found predomi-
nantly in the anterior teeth and premolar region of older
children.7 These injuries may be isolated or may be seen
in conjunction with other dental and/or facial injuries.
The patient frequently reports that the occlusion has
been changed as the involved segment has shifted from
its original position (Fig. 13-35). The fracture is readily
identified with an intraoral radiograph. FIGURE 13-35 Alveolar process fracture associated with anterior
Treatment involves reduction and immobilization of mandibular teeth. The segment moves as one unit with teeth and
the involved segment and stabilization for 4 weeks to bone. Note the contusion of the gingival and mucosal tissues.
allow osseous healing. Closed reduction of the alveolar
fracture may be accomplished with digital manipulation
of the alveolar and dental segment. Stabilization can be fixation is necessary but, if indicated, the segment can be
accomplished satisfactorily with a rigid acid etch resin wired or a bone plate placed after reestablishment of the
splint or lingual splint (Fig. 13-36). An open reduction proper occlusion is verified. Rigid splinting of the
of the alveolar fracture may be necessary if the alveolar involved teeth or use of an Erich arch bar for 4 weeks
segment is notably displaced or the involved teeth are provides adequate stability for osseous healing (see Fig.
displaced so that the roots are locked over the osseous 13-37).
plate (Fig. 13-37). A vestibular incision is made below the Careful follow-up is mandatory to evaluate pulp necro-
fracture line and a subperiosteal flap is elevated to expose sis and periapical inflammation. These complications are
the fracture site. A no. 1 or 9 periosteal elevator can be rather frequent and are apparently related to the time
used in the fracture line to elevate the segment and place interval between injury and fixation. The best prognosis
the alveolus in proper position. Frequently, no osseous is associated with alveolar fractures treated within 48
hours after injury.1 Teeth splinted within 1 hour after

injury develop pulp necrosis less frequently than teeth
splinted after longer periods.7 Common complications
after treatment include pulp necrosis, pulp obliteration,
root resorption, and loss of supporting bone. A tetanus
booster usually is not indicated unless the wound has
contaminants such as road debris or dirt. Coverage with
penicillin or clindamycin and the use of chlorhexidine
oral rinse are recommended.
Fractures of the Maxilla and Mandible. The management
of maxillary and mandibular fractures (see Fig. 13-16F
and G) is discussed in Chapters 14 and 18.
SPLINTING TECHNIQUES
Splinting provides stabilization of traumatized teeth and
FIGURE 13-36 This segment was digitally manipulated into proper prevents further damage to the pulp and periodontal
occlusion and position. A lingual splint was fabricated to fix the tissue during the healing period, allowing the attach-
involved segment rigidly. ment apparatus time to regenerate.150 It is important that
the splint allow slight flexibility, or physiologic mobility,
to accelerate the healing of periodontally injured teeth.151
The maintenance of oral hygiene and prevention of
infection are important in promoting periodontal
A B
C
FIGURE 13-37 A, Mandibular dentoalveolar fracture following traumatic injury. B, After the segment is out of traumatic occlusion, an Erich
arch bar is used for 4 weeks to stabilize the segment. C, This patient was involved in an accident 5 years before this radiograph, during
which the mandibular incisors and alveolar bone were lingually displaced. The teeth were repositioned digitally without splinting or
removal from traumatic occlusion. The segment healed to a fibrous nonunion, with root resorption of the lateral incisors that required
removal of the entire segment.
healing during stabilization. No portion of the acrylic • It allows slight mobility so that the position of the
composite or wire of the stabilization device should tooth after reimplantation exerts minimal pressure
impinge on the gingival margins of the teeth. Splints that between the root surface and the alveolar bone.
irritate the gingiva and cause gingival inflammation • It is economical and requires minimal specialized
prevent the resolution of the inflammatory response in equipment.
the marginal gingiva. The patient must be able to keep
the gingival tissue as clean as possible, which is difficult Acid Etch Resin Splint
with cap splints, foil splints, and cold-cured acrylic splints. Acid etch resin fixation techniques provide a relatively
Fixation methods used for dental splints may vary with easy, versatile method for stabilization of teeth with effec-
the type of dental trauma; however, in most cases, a splint tive, aesthetic composite resin materials.7,150,153 The labial
of simple design in place for 7 to 10 days is recom- surfaces are cleansed of blood and debris as much as
mended. In cases of root and alveolar bone fractures, possible; the use of a cotton roll or gauze in the vestibule
longer periods of fixation are necessary, usually 2 to 4 and over gingival lacerations assists in keeping the surface
months and 6 weeks, respectively. However, controversy as clean and dry as possible. The teeth are air-dried, and
exists concerning the duration of fixation and post- a 35% phosphoric acid gel is applied to the incisal third
traumatic complications. Studies have shown that the of the traumatized and adjacent teeth, as indicated.154
duration of fixation is unrelated to the success of post- After the gel has been on the surface for approximately
traumatic healing and does not affect any negative 20 seconds, it is removed with a water spray. The teeth
sequelae, and that the period for fixation is wholly depen- are then air-dried to reveal a frosty white surface, signify-
dent on the specific clinical situation presented.111 ing a successful etch. Depending on the composite resin
Erich arch bars, lingual splints, or both, can be used system used, the teeth are stabilized with a band of the
for stabilization of alveolar process fractures if the teeth material along the etch surfaces. The composite resin
within the segment are stable. Arch bar splints are not material is then allowed to cure or is cured using ultravio-
recommended for tooth fixation because the tied wire let light with a light-activated system.
tends to loosen with time and rest on the marginal This type of system provides longer working time and
gingiva, causing mechanical irritation and a site for bac- better control of the material. The occlusion should be
terial deposition. If the teeth are mobile, the supporting checked and the splint altered if it interferes with proper
wires, if positioned apically to the cervical prominence, occlusion. The splint should be smoothed and polished
may have a tendency to elevate the tooth slowly. The for improved patient hygiene and comfort; however, if
Schuchardt splint was developed for the fixation of the teeth are still slightly loose and tender, the polishing
luxated teeth but has proved too rigid and complicated procedure might better be postponed to a later visit.
to construct because it was made with an aluminum-brass This method provides excellent stabilization and
alloy bar 2 mm in diameter. An acrylic cap splint allows the patient to keep the teeth and gingiva clear
cemented to the noninjured teeth has been used in luxa- because the splint is away from the periodontal tissue.155
tion injuries but is also too rigid.150 The procedure is simple and efficient, may not require
Interdental wiring techniques, such as figure-eight anesthesia, is hygienic, and serves as definitive treat-
wiring and loop wiring,73,145 can be used but are techni- ment.156 One disadvantage of the method is that the
cally difficult and troublesome. The patient may have material may fracture because the acrylic is brittle when
difficulty in cleaning around the wires and the wires may exposed to occlusal masticatory forces. It has been sug-
slip apically below the cervical prominence of the tooth gested that other cold-cured resin materials offer greater
and elevate the tooth or damage the cementum surface. stability for prolonged splinting periods (e.g., Sevriton,
The requirements for an acceptable splint are as Ash, Dentsply AG, Milford, Del) of fixation. The material
follows7,114,152: is then removed after the indicated stabilization period
• It is easy to fabricate directly in the mouth, without and the teeth are smoothed with pumice. Care must be
lengthy laboratory procedures. taken during removal of the acrylic material from the
• It can be placed passively without force to the teeth. involved teeth because they will still be fairly mobile after
• It does not contact the gingival tissue and thus the stabilization period and may accidentally be extracted.
cause gingival irritation. A modification of this technique involves the use of a
• It does not interfere with normal occlusion. wire instead of a composite bridge to splint the trauma-
• It is easily cleaned and allows proper oral hygiene. tized teeth154 (Fig. 13-38). The wire should be of proper
• It does not traumatize the teeth or gingiva during stiffness to provide rigid fixation (24 gauge) or semirigid
application. fixation (28 gauge), as indicated by the injury. The etch
• It allows an approach for endodontic therapy. wire composite splint is aesthetic, hygienic, and quick to
• It is easily removed. construct. This technique is useful with missing teeth or
• It provides good aesthetic results. in a mixed dentition in which teeth are not fully erupted
• It does not injure the pulp of the traumatized teeth and the edentulous area has to be spanned (Fig. 13-39A).
or adjacent teeth. Metal bars, nylon lines, fiberglass, polycarbonate, or syn-
• It does not interfere with intraoral radiographic thetic fibers can be used to span the space and fuse with
techniques. the composite material. This type of splint should be
• It allows placement of a rubber dam in all types of used with all types of dentoalveolar trauma, luxation inju-
dentition. ries, root fractures, autotransplantation, and alveolar
• It does not promote root resorption. fractures in which good stabilization can be obtained.
A B
C D
FIGURE 13-38 A, Dentoalveolar fracture involving the maxillary incisors and alveolar bone, requiring a period of rigid fixation for 4 weeks.
The patient did not seek treatment for 24 hours following the trauma. B, Panoramic radiograph reveals the extent of the trauma and
degree of extrusion of the involved teeth. C, The labial incisors of the involved teeth to be used as an abutment are cleansed of blood
and debris. The cotton roll is placed in the vestibule and over the gingival lacerations. The teeth are air-dried and a 35% phosphoric acid
gel is applied to the facial surfaces of the teeth for approximately 20 seconds. The composite resin and rigid wire (24 gauge) are then
introduced and teeth are manipulated into position with digital pressure. D, After the resin has been cured, any excess material is
removed and polished. The occlusion is checked and modified to resolve any potential traumatic occlusion. Lacerations should also be
closed at this time. (Courtesy Dr. Kevin Stanton, New York.)
The only teeth that might not be suitable for this type of be fixed to the teeth with orthodontic brackets and
splint are those with artificial crowns or large fillings square or round stainless steel wires. The wire provides
because they cannot be etched and composite material excellent stabilization and clear gingival margins and
bonded to the surface. interproximal areas to allow hygiene in these areas. A
The wire is cut and modified to lie passively along the radiograph should be obtained following reduction and
facial aspect of the teeth to be splinted. The facial sur- stabilization to verify proper alignment of the teeth and
faces are prepared by the acid etching method described alveolar segments. Cold-cured material may provide
earlier. The wire or line should be placed passively and greater stability but the bond strength may be compro-
the patient asked to bite gently into a bite block of wax mised because of a longer setting time, especially in the
or similar material to force the avulsed tooth gently into presence of traumatized tissues in which field control can
the socket site. The wire is then bonded to the teeth with be difficult. In an emergency room setting, a flowable,
a composite resin restorative material. Light-activated light-cured composite resin and wire are often the most
composite resin systems allow flexibility and control of effective for splinting teeth.
the involved segments. The wire can first be secured to
the anchor teeth with composite resin and activated Semirigid Splint
with the ultraviolet light. The involved teeth can then be If there are no associated alveolar fractures, a semirigid
individually repositioned correctly and bonded to the splint that allows physiologic movement of the trauma-
wire. The occlusion is checked for interferences and the tized tooth is indicated.112 Andreasen7,134 has shown that
composite material is smoothed. A wire splint can also rigid splinting of reimplanted mature and autotransplanted
A B
FIGURE 13-39 A, An acid-etched wire composite splint provides rigid fixation when a 24-gauge wire is used when there are missing teeth
or in a mixed dentition in which the teeth are not fully erupted and the edentulous space has to be maintained. B, To allow physiologic
movement of the involved maxillary central incisors, the teeth are fixed semirigidly with dental floss to the stable abutment teeth. The
teeth are all prepared in the usual fashion with an acid etch technique and the dental floss is secured to the teeth in order from canine to
canine. The involved teeth are usually removed from traumatic occlusion (not required in this case because of the existing anterior open
bite), and the patient receives a soft diet.
immature teeth increases the incidence of root resorp-

tion because of uncontrolled forces on the tooth, peri-
odontal fibers, and lamina dura; there are negative
influences on pulp revascularization and periodontal
ligament healing, with an increased incidence of pulp
necrosis and canal obliteration. The acid etch composite
resin technique with materials such as waxed dental floss,
suture,63 flexible braided orthodontic wire,73 or monofila-
ment nylon line provides stabilization of the traumatized
tooth and allows physiologic movement of the tooth
under function to minimize ankylosis and root resorp-
tion. Various other fixation materials have been evalu-
ated with respect to flexibility. Kevlar (B-W Dental,
Frederiksberg, Denmark) and fiber splints allow more
horizontal movements, with Protemp (Protemp II, Espe,
FIGURE 13-40 Titanium trauma splinting bars. (Courtesy Dr.
Germany) and flexible wire composite splints providing
Andreas Filippi, Department of Oral Surgery, Oral Radiology and
adequate lateral support and vertical flexibility, which Oral Medicine, University of Basel, Basel, Switzerland.)
improve periodontal healing of luxated teeth.157
The involved tooth and two stable adjacent teeth are
acid-etched to provide support (see earlier). A single
strand of 20- to 30-lb test monofilament nylon line is cut commercial splints such as the Anterior and Posterior
to size and secured to the first abutment tooth with a Splint-Grids, Splint-Lock System, and Titanium Splinting
composite resin system. The remaining abutment and Bars. Titanium trauma splinting (TTS) bars have been
traumatized teeth are secured to the nylon line with the advocated by some practitioners for splinting teeth
composite resin system as tension is maintained with because of ease of application with light-cured composite
hemostats on the free end of the nylon line. The resin is resin and removal, better patient compliance with oral
then smoothed and polished after all teeth are secured, hygiene, and fewer patient complaints with alterations in
and the occlusion is verified (see Figs. 13-27 and 13-39).158 masticatory function.4 However, oral hygiene effective-
A radiograph should be obtained to check for proper ness was similar among patients splinted with conven-
root position after splinting. tional wire-composite splints and those splinted with
Single-tooth fixation techniques include endosteal TSS.154,159 The practicality and clinical use of these mate-
(transdental) pin fixation, amalgam splints, and the rials remain to be seen (Fig. 13-40).
Maryland type of etched cast framework, which generally
should be considered unacceptable fixation for most RESTORATION
clinical situations. Unacceptable splints include the self- Following dentoalveolar trauma, the normal form and
curing, circumferential, Essig, arch bar, intracoronal, function of the masticatory system should be restored by
and orthodontic splints. Recommended splints include the restorative dentist. Restorations for crown injuries
the dental floss, suture, resilient, clear resin, Hawley with include composite acid etch buildups, porcelain veneers,
incisal spring, and nylon line splints. Other variations are and full coverage crowns.
FIGURE 13-42 The use of dental implants, especially in the

aesthetic zone of the maxillary anterior teeth, should be
considered as the required reconstruction of patients suffering
dentoalveolar injury. Four implants have been placed in the
maxillary anterior region following traumatic loss of the maxillary
anterior teeth and alveolar bone in this patient.
measures is recommended to prevent damage to the

incisors and dentoalveolar structures.38 Preanesthetic
FIGURE 13-41 Restoration of function following dentoalveolar dental evaluation and the use of mouth protectors in
trauma and loss of teeth can be accomplished with various
patients undergoing tracheal intubation for general
implants or implanted materials, such as autogenous and
anesthetic have been shown to reduce the incidence of
allogeneic graft materials.
dental trauma.42-44 The use of flexible fiberoptic-lighted
stylets or nasopharyngeal airways may help reduce the
risk of dental injury.50 Seat belts, shoulder harnesses, air
Crown-root fractures are usually restored, after end- bags, and padded dashboards in automobiles have been
odontic therapy, with a customized cast core cemented advocated for reducing injuries in MVAs, including facial
into the retained root and coverage with a full crown.7 and dental trauma as the victim hits the steering wheel,
Alveolar process fractures can be malaligned after dashboard, or windshield during impact. Preventive
healing, resulting in malocclusion and occlusal cant. orthodontics should be considered for children with
Orthodontic treatment and leveling of the occlusal plane increased maxillary overjet as a precaution against trau-
with restorations (crowns, veneers) have been shown to matic injury to the exposed teeth.7
be effective.160 The use of intraoral mouthguards has been demon-
With the loss of the dentition, supporting alveolar strated to be an effective means of reducing the degree
bone, or both, various dental implant systems can be and incidence of dentoalveolar trauma associated with
used to support a bridge and restore function.161 If large contact sports.164-173 There is an apparent awareness by
amounts of alveolar bone have been lost, especially if the athletes in high-risk sports for possible dentoalveolar
facial osseous plate has been avulsed, bone grafts may be injuries, but there is considerable lack of the use of
necessary to provide adequate osseous support for the mouthguards by athletes.19 In the United States, partici-
implants (Figs. 13-41 and 13-42). Long-term effects of pation in youth athletic programs continues to increase
dentoalveolar trauma can also include inadequate space by substantial numbers each year, with a greater emphasis
in the dental arch. Orthodontic treatment may be placed on injury prevention and rehabilitation. Studies
required; the use of skeletal orthodontic anchorage have reported that 33% of all dental trauma occurs in
devices have facilitated treatment, with more rapid sporting activities.174,175 In one 10-year study, 31% of cra-
results.162 niomaxillofacial trauma was attributed to sporting activi-
ties.102 In 1960, a joint commission of the Bureau of
MOUTH PROTECTORS Dental Health Education and the American Association
for Health, Physical Education, and Recreation reviewed
The most frequent of all anesthesia-related medicolegal the literature on football injuries and found that when
claims are dental injuries because they often occur from high school football players did not wear face masks or
excessive pressure on the incisors while using a laryngo- mouth protectors, 50% of all their injuries occurred
scope.163 Damage to the incisors and dentoalveolar struc- around the mouth. The committee concluded that most
tures was found to comprise 33% of all anesthetic claims; of these injuries could be prevented by a properly fitted
the use of preanesthetic evaluation and prophylactic mouthguard.172 Even a simple boil and bite mouthguard
when faceguards were mandatory but mouth protectors

BOX 13-1 National Collegiate Athletic Association were seldom worn or accepted on a team basis—indicated
Guideline for Mouthguards that more than one of five injuries to football players
were to the hard and soft tissues of the oral cavity.164,180
The NCAA has mandatory equipment rules, including the use
The NCAA Football Rules Committee recommended the
of mouthguards for selective sports. Various studies of prop-
mandatory use of mouthguards in 1970, and the mouth-
erly fitted mouthguards have indicated that they may reduce
guard rule went into effect with the 1973 football season.
dental injuries and mild traumatic brain injuries (concussions)
when blows to the jaws or head are received.
In the 1970 season, 280 cases of oral injury requiring
The American Dental Association has urged the mandatory treatment were reported. With a mandatory rule for
use of mouthguards for those engaged in athletic activities mouthguard protection in the 1973 season, the reported
that involve body contact and has endorsed their use in sport- number of cases decreased to 55.170
ing activities in which a significant risk of oral injury may occur. Currently, organized football programs at some ele-
When considering the optimal protection for an athlete, it is mentary and junior high schools, and backyard and
important that a thorough medical history be taken and the sandlot football, are the only levels of the sport not
demands of his or her position and sporting activity be covered by mandatory mouthguard rules. If well-accepted
considered. injury figures are conservatively projected, more than
Specific objectives for the use of properly fitted mouth- 200,000 injuries are being prevented annually. The inci-
guards as protective devices in sports are as follows: dence of mouth injuries among football players in 1981
• Properly fitted mouthguards could reduce the potential was between 0.35% and 0.45%.169 Studies have suggested
chipping of tooth enamel surfaces and reduce fractures that the prevalence of dentofacial injuries to football
of teeth, roots, or bones. players is higher than previously recorded. The Academy
• Properly fitted mouthguards could protect the lip and for Sports Dentistry was formed in 1983; it conducts
cheek tissues from being impacted and lacerated against studies on the incidence and prevention of sports inju-
tooth edges. ries, promotes the wearing of mouthguards in more than
• Properly fitted mouthguards could reduce the incidence 40 sports, and encourages the team dentist concept.181
of a fractured jaw caused by a blow delivered to the chin
Enforcement of the mandatory mouthguard rules is
or head.
difficult because many officials report that they cannot
• Properly fitted mouthguards could provide protection to
determine whether a player is using a mouthguard if the
toothless spaces, so support is given to the missing
dentition of the student-athlete.
material is transparent.167 Athletes occasionally are reluc-
Stock, mouth-formed, and custom-fitted mouthguards are tant to use a mouthguard because they believe that the
three types recognized by the American Dental Association. guards are troublesome, prevent adequate breathing and
All need to be fitted properly for maximum protection. Student speaking, cause nausea, are expensive and, overall, are
athletes should be advised about which properly fitted mouth- unaesthetic. There has been an increased use of mouth-
guard is best for them and how it is best maintained to ensure guards with the incorporation of the team’s colors on the
maximum fit and protection for daily practices and game-day guards. The NCAA modified the mouthguard rule for
wear. Medical staff personnel should regularly oversee and the 1990 football season to require that all mouthguards
observe the student athletes and the properly fitted be yellow to facilitate their visualization by the officials
mouthguards. on the playing field. Research at the University of Michi-
To realize fully the benefits of wearing a mouthguard, the gan has revealed that yellow mouth protectors are easier
coach, student athlete, and medical staff need to be educated to detect at various distances than clear mouth protectors
about the protective functions of a mouthguard and the game or none at all.182 It now appears that the mandatory
rules regarding mouthguard use must be enforced. mouthguard rule is not being enforced at the NCAA
division I football level, with an alarming number of
Adapted from National Collegiate Athletic Association: Sports medicine players, especially quarterbacks, not using a mouth pro-
handbook: Guideline 4c: Mouthguards, Indianapolis, 2007, National Col-
legiate Athletic Association. tector or wearing it on the side of their helmet during
the game. Enforcing the use of mouthguards should be
the responsibility of coaches and trainers, not officials or
has been shown to reduce the incidence and severity of referees during games. Compliance should be enforced
orofacial injuries by 50%.176 at all times during practice, when the chance of dental
In 1962, the National Alliance Football Rules Commit- injury is equal to or greater than that found during the
tee required high school football players to use mouth- actual game.
guards and face guards.169 They stated that “each player Currently, mouth protectors are required only in orga-
shall wear an intraoral mouth and tooth protector, which nized football, ice hockey, field hockey, lacrosse, and
includes both an occlusal (protection and separation of boxing matches.183,184 Mouth protectors are recom-
the biting surfaces) and labial (protection of the lip) mended for most sports such as wrestling, rugby, soccer,
portion.”177,178 The most recent National Collegiate Ath- basketball, gymnastics, racquetball, martial arts, skiing,
letic Association (NCAA) guidelines regarding mouth- and weight lifting to minimize tooth injury and support-
guards, revised in August 2007, have defined the use of ing structures through direct or indirect trauma from
“properly fitted mouthguards” (Box 13-1). In 1967, it was falls, collisions, or clenching of the teeth.185 Several
estimated that 25,000 to 50,000 injuries were prevented studies have confirmed the decrease in football and
by the use of intraoral mouth protectors.179 Studies other sports injuries when a mouthguard was worn. The
carried out with the Notre Dame football program— participation of girls and women in competitive athletics
has increased dramatically. The incidence of injuries to ideally be 4 mm because of the stability of EVA (Shore A
female athletes has been found to be similar to that of hardness, 80). A thickness of less than 4 mm has
male athletes involved in the same athletic activity.186 decreased energy absorption potential and more than a
Female athletes should be educated and encouraged by 4-mm thickness has a marginal increase in absorption
coaches and officials to use mouth protectors to prevent potential but less wearer comfort because of the bulki-
dental injury.169 ness of the mouthguard.191,194 However, Duhaime and
A properly constructed and used mouthguard should colleagues195 have reported that it might be possible to
do the following163,175,176: construct a thinner EVA mouthguard that provides pro-
• Hold the lips and cheeks away from the teeth, pre- tection equal to that offered by those currently in use.
venting laceration or bruising. A number of plastic materials have been used for the
• Cushion teeth from direct blows and redistribute construction of mouthguards. Current materials used
the forces. include EVA, polyvinyl acetate–polyethylene copolymer,
• Prevent opposing teeth from coming into excessive polyurethane, polyvinyl chloride, soft acrylics, and
contact. natural rubber. The various materials’ high-energy
• Provide the mandible with resilient support to absorption properties do not necessarily indicate that
absorb impact. the material will provide maximal protection as a
• Provide protection against neck injuries. mouthguard, and some of the absorbed energy may be
• Assist with the prevention of concussion and resul- directly transmitted to the underlying dentoalveolar
tant neurologic injuries. structures.191,194
Mouthguards may be divided into three types: (1)
ready-made or stock protectors; (2) mouth-formed pro- TYPES OF MOUTH PROTECTORS
tectors; and (3) custom-made protectors.* The most Stock Mouth Protectors
desirable qualities of a mouthguard are retention, The stock mouth protector is the simplest and cheapest
comfort, allowance for ease of speech and breathing, type of mouthguard (Fig. 13-43). It is purchased over the
resilient material, and provision of protection for the counter and does not require fitting. These mouthguards
teeth, gingiva, and lips. Mouthguards that are not stock are constructed of latex or silicone and provide minimal
varieties are usually fabricated for the maxillary arch. For protection because they are loose-fitting and can be held
the athlete with a class III malocclusion, the mouthguard in place simply by keeping the teeth together and the
should be manufactured to cover and protect the promi- jaws closed. The stock type of protector is uncomfortable
nent mandibular teeth.168 A properly fitted mouthguard to the participant because it is difficult to breathe
must be protective, comfortable, retentive, resilient, tear- and speak around the mouthguard and it tends to
resistant, odorless, tasteless, inexpensive, and easy to fab- irritate the gingiva and buccal vestibule. There is no
ricate and should not encroach on the airway or interfere evidence that these mouthguards are effective in redis-
with breathing or speech.178 tributing forces of impact, and they may result in soft
For maximal protection, the mouthguard should be tissue injury. Thus, the Academy for Sports Dentistry
designed and constructed according to the following has declared that typical stock mouthguards are not
specifications183,192: acceptable.164,169,183,187-190
• The occlusal surfaces of all teeth are covered for
protection and to prevent possible overeruption of Mouth-Formed Protectors
teeth. The mouth-formed protector is probably the most
• The flanges cover the alveolus and are trimmed popular and universally used mouthguard.164 There are
1
8 inch (2 mm) short of the depth of the buccal two major types of mouth-formed protectors, the shell-
vestibule for maximal retention and to protect the liner type and the thermoplastic type (Fig. 13-44).171,183,189
lip and gingiva.
• The material extends distally to include the second
molars and is relieved for clearance of the frena.
• The material extends lingually no more than 1 4
inch onto the palatal mucosa, tapering at the
margins to prevent lingual bulk, which may inter-
fere with speech and breathing or trigger a gag
reflex.
• The edge of the labial flange should be rounded in
a cross section.
Mouthguards have changed over time from vacuum-
formed mouthguards to two-layer ethylene vinyl acetate
(EVA) mouthguards fabricated on a high-pressure
machine. The EVA mouthguards’ main advantages are
that they fit better and have better protection because of
improved impact absorption.193 The thickness of the
mouthguard at the incisal edge and cusp tips should
*References 164, 169, 172, 183, and 187-191. FIGURE 13-43 Ready-made or stock mouth protector.
A B
FIGURE 13-44 Two major types of mouth-formed protectors, A, Shell-liner mouth-formed protector. B, Thermoplastic mouth-formed
protector. (A, Courtesy Glidewell Laboratories, Newport Beach, Calif.)
Shell-Liner Mouthguard. The shell-liner mouthguard

(see Fig. 13-44A) consists of a preformed outer shell of
latex rubber or plastic that fits loosely around the maxil-
lary teeth. It provides a smooth durable surface and soft
resilient lining that is adapted to the teeth. The tray tends
to be bulky with sharp edges but can be trimmed for
comfort and improved fit in the vestibule. The shell is
then relined with a polymer-monomer soft-curing mate-
rial similar to that used for soft relining of dentures,
self-curing methyl methacrylate, or silicone rubber. The
materials are mixed, placed in the outer shell, and carried
to the mouth to set in 5 to 7 minutes.* The disadvantages
of this type of protector limit its usefulness. Repeated
biting on the relining material causes it to spread and
lose retention of the teeth. The liner can gradually
become hard because it is continually exposed to oral
fluids. The protector tends to be bulky and opens the FIGURE 13-45 Thermoplastic mouthguard showing distortion and
bite if not properly fitted. This type of protector is not hardening of the material. (From Pinkham JR: Pediatric dentistry:
recommended for athletes with orthodontic braces or Infancy through adolescence, ed 3, Philadelphia, 1999, WB
other intraoral appliances. Saunders.)
Thermoplastic Mouthguard. The thermoplastic type of
mouth-formed protector (see Fig. 13-44B) is the most
widely used mouthguard because it is cheap and durable during the molding process. Other advantages include a
and can be resoftened and refitted if it loses retention. low bulk of material and relative ease of fabrication.
The mouthguard is a thermoplastic shell of polyvinyl Disadvantages of the thermoplastic mouthguard include
acetate ethylene that is immersed in boiling water for 30 possible distortion over time and hardening of the mate-
seconds, dipped quickly in cold water, and placed in the rial with continued contact with oral fluids175 (Fig. 13-45).
mouth over the maxillary teeth. Suction develops in the
patient around the mouthguard to mold it into shape Bimaxillary Mouthguard
around the teeth and dentoalveolar structures. The
material is then adapted to the teeth with the fingers. Another type of mouth-formed protector covers both
The vestibule extension can be trimmed and molded for arches and is known as the bimaxillary mouthguard (Fig.
comfortable coverage of the alveolus and soft tissue. The 13-46). The position of the mandible is fixed at a prede-
teeth can be occluded into the material while it is warm termined, relaxed, maximal breathing position that
to provide minimal opening of the closed bite.164,169,189 allows the athlete to maintain adequate ventilation. The
The major advantages over the stock trays are a closer fit mouthguard also rotates the position of the condylar
and greater retention; however, a quality thermoplastic head within the glenoid fossa to help reduce the trans-
mouthguard is technique- sensitive, and care is necessary mission of forces to the glenoid fossa and cranium, which
protects the athlete from concussion-type injuries and
from injuries to the mandibular condyle.176 The anterior
*References 54, 169, 183, 189, and 190. mandibular teeth are also protected from frontal impact.
cleanliness, and retention.196 However, there is no evi-

Custom-Made Mouth Protectors dence that they are more effective in preventing injuries.
The custom-made protector (Fig. 13-47) has the best A study that compared rebound in custom-fabricated
mouthguard qualities when compared with all other mouthguards versus commercial mouthguards has found
types of mouthguards, including retention, protection, that there is greater rebound with all the commercial
taste, lack of odor, comfort, allowance of speech, mouthguards when compared with the custom mouth-
guard.197 A custom-made mouthguard is fabricated in a
laboratory to a stone model made from an alginate
impression of the athlete’s maxillary teeth. A thin
sheet of thermoplastic material, commonly polyvinyl-
polyethylene with a thickness of 116 to 1 8 inch,189 is
adapted to the model to construct a comfortable, indi-
vidualized mouth guard for protection. There is no
excessive bulk, so the athlete can breathe, speak, and be
understood and not have to hold the mouthguard con-
tinually in position with the teeth or cheeks. The interoc-
clusal thickness remains thin and uniform to allow even
occlusion when the athlete bites into the protector.
Excellent retentive properties add to its comfort and do
FIGURE 13-46 Pro Air mouthguard, a bimaxillary mouthguard. not cause the wearer to take the mouthguard out of his
(Courtesy Brain-Pad, Conshohocken, Pa.). or her mouth continually, which would increase the
chances of soiling or misplacing it.164
After the stone model has been made from an alginate
impression, a thin sheet of thermoplastic material is
heated and a vacuum is formed over the model to cover
all the teeth (Fig. 13-48). The vacuum method of adapt-
ing the material produces a guard of uniform thickness
and maximal retention around the natural contours of
the teeth.189 The material is allowed to cool completely
on the model to prevent distortion.
The mouthguard is then trimmed from the palate and
1
8 inch short of the buccal vestibule, with clearance for
the buccal and lingual frena (Fig. 13-49). The edges are
smoothed and rounded with a stone wheel or are placed
on the model and flamed with an alcohol torch and
adapted with the fingers.166,189 The athlete’s name should
be secured to the mouthguard for identification and, if
desired, a strap can be added (Fig. 13-50). The stone
FIGURE 13-47 A custom-made mouth protector. (From Andreasen models are kept by the coach, trainer, or dentist so that
JO, Andreasen FM: Textbook and color atlas of traumatic injuries a replacement mouthguard can be made if necessary.
to the teeth, ed 3, Copenhagen, 1994, Munksgaard.) The disadvantages of the custom-fitted mouthguard are
A B
FIGURE 13-48 A thin sheet of thermoplastic material is heated (A) and vacuum is formed over a stone model of the patient’s teeth (B).
(From Andreasen JO, Andreasen FM: Textbook and color atlas of traumatic injuries to the teeth, ed 3, Copenhagen, 1994, Munksgaard.)
the time and expense involved with management, con- The dentist should be involved in the prevention of
struction, and delivery of the protector. Materials such as sports-related injuries with preseason screenings, avail-
Light Line (LD Caulk [urethane diacrylate], Dentsply) ability for emergency trauma care, and fabrication of
have been used to provide additional comfort because custom-fitted mouthguards.178 Unfortunately, apparently
the material softens intraorally.196 some school officials believe that dentists are willing to
A mouthguard must be easy to fabricate, comfortable, assist with oral protection only if custom-fitted mouth-
able to accommodate the needs of an individual’s denti- guards are used. Regardless of the type of protector used,
tion, durable, easily held in place, and able to provide players will benefit if a dentist is available to offer advice
adequate protection to the teeth, jaws, and cranial struc- on its fit and form and on the health of the player’s
tures. Regardless of which mouthguard is used, the mouth. The thermoplastic variety of mouthguard is rec-
athlete should be instructed to rinse the protector under ommended if it is to be placed or formed by the athlete;
cold tap water, a mouthwash, or 0.2% chlorhexidine however, supervision of the fitting procedure by a dentist
rinse and wash with soap after each use. It should then is recommended. The most desirable protector is the
be stored in a rigid perforated container.189 custom-made mouthguard, fabricated by a dentist from
a thermoplastic material.169 Mouthguards are also recom-
mended for patients who suffer self-inflicted injuries,
such as mental retardation in Lesch-Nyhan syndrome,
comatose patients, and patients in whom dentoalveolar-
intraoral injuries are caused by involuntary movements,
as in Parkinson’s disease. There is sufficient evidence to
suggest that a correctly made mouthguard considerably
reduces the severity of oral injuries. Prevention of dental
trauma requires educational campaigns to broaden the
lay public’s knowledge of emergency management pro-
cedures (Fig. 13-51). The goals of these campaigns
should include the following: (1) raising public aware-
ness; (2) emphasizing the necessity for cooperation
between the emergency and private dental services; and
FIGURE 13-49 The mouthguard should extend to 1
8 inch short of (3) emphasizing the necessity for adequate emergency
the depth of the buccal vestibule, with clearance of the frena. treatment.198
A B
FIGURE 13-50 A, A thermoplastic mouth-formed or custom-made mouthguard may have a strap attached to the helmet. The strap
secures the mouthguard to the facemask and allows the athlete to remove the mouthguard during breaks in competition without
misplacing it or soiling it on the ground. B, Enforcement of a mandatory mouthguard rule is difficult if the mouthguard material is
transparent or has no strap to the helmet.
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CHAPTER
14 Mandibular Fractures
Brian M. Smith
| Atul M. Deshmukh
| H. Dexter Barber
|
Raymond J. Fonseca
OUTLINE
Historical Considerations General Principles of Treatment
History of Treatment Indications For Closed Reduction
Demographics and Epidemiology Indications For Open Reduction
Causes Treatment of Mandibular Fractures
Location of Mandibular Fractures Open Reduction and Fixation Procedures
Facial Fractures Associated With Mandibular Fractures Surgical Approaches
Number of Fractures Per Mandible Rigid Fixation
Nonmaxillofacial Trauma Associated With Mandibular Endoscopic Repair
Fractures Complications of Mandibular Fracture Treatment
Classification of Mandibular Fractures Infection and Teeth in the Line of Fracture
Dictionary Classification Other Complications
Classification by Anatomic Region
Diagnosis of Mandibular Fractures
Patient History
Clinical Examination
Radiologic Examination
HISTORICAL CONSIDERATIONS in an attempt to immobilize fracture segments (Fig.

14-1).
Management of mandibular fractures has continued to Advancements for treatment stagnated, through the
evolve since on of the earliest descriptions in Egyptian nineteenth century. Emphasis remained on some form
literature. The first described case in 1650 bc, discussed of external bandage or wrap occasionally used in con-
the examination, diagnosis, and treatment of mandibu- junction with a bridle wire. Attention was being directed
lar fractures and other surgical complications. Treatment toward the development and improvement of intraoral
options were limited and quite often the condition led and extraoral devices.
to the demise of the patient.1,2 Various techniques were advocated however, most
It was not until the advent of the Hippocratic concept were variations of bandages and external appliances,
for reapproximation and immobilization that manage- extraoral and intraoral appliances, monomaxillary
ment of mandibular fractures was revolutionized. Hip- wiring, including bars, monomaxillary splints, and inter-
pocrates described direct reapproximation of the fracture maxillary wiring and splints, guides or glides, and inter-
segments with the use of circumdental wiress, similar to nal fixation, including wires, plates, and screws. A brief
today’s bridle wire. He advocated wiring of the adjacent overview of these techniques are discussed below.
teeth with external bandaging to immobilize the frac-
ture.3,4 Hippocrates had the insight to realize that reap-
proximation and immobilization are paramount in the HISTORY OF TREATMENT
treatment of mandibular fractures. Bandages and External Appliances
In 1180, a textbook written in Salerno, Italy, described Bandages, first mentioned by Hippocrates,3 gained noto-
the importance of establishing a proper occlusion.5 In riety and acceptance as a standard of care when John
1492, an edition of the book Cirurgia, printed in Lyons, Rhea Barton described his Barton bandage15 (Fig. 14-2).
France, first mentioned the use of maxillomandibular This bandage provided posterior directional forces on
fixation in the treatment of mandibular fractures.6 In the fractured mandible, resulting in deformities such as
1795, Chopart and Desault described the effects of eleva- the “bird face” and malunions.16,17
tor and depressor muscles on mandible fragments.7 External or extraoral appliances also failed to provide
Chopart was also the first to use dental prosthetic devices stable reduction of fractures. These appliances had chin
293
FIGURE 14-1 Chopart and Desault (1795) used

viselike devices to treat mandibular fractures.
of edentulous and partially edentulous mandibular

fractures.
Monomaxillary Wiring, Bars, Arches, And Splints
Originally advocated by Hippocrates,3 and then later sup-
ported in the writings of numerous authors,30-33 mono-
maxillary wiring was popular in the treatment of
mandibular fractures. It was similar in concept to today’s
bridle wire and the Risdon wire of the early 1920s, and
monomaxillary wiring afforded some element of reduc-
tion, but without supplemental fixation, fractures were
inadequately immobilized.
Splints became popular in the middle of the nine-
teenth century and were usually cast of metal and custom-
fitted for the patient. Splints were fabricated with the use
of models made after reduction of the fragments. Some
were cemented to the teeth and others involved sophis-
ticated clamps that would tie buccal and lingual seg-
ments together.17,34-43 The use of monomaxillary wiring,
bars, arches, and splints is limited to fractures containing
stable teeth on both sides of the fracture.
FIGURE 14-2 The Barton bandage, named for John Rhea Barton. Intermaxillary Wiring
Guglielmo Salicetti (William of Saliceto)44 has been
credited with being the first to use intermaxillary
cups and an assortment of straps and external supports fixation. Gilmer,45 also credited with being the first to
that like the bandages, produced an undesirable poste- use this technique, passed wires around individual
rior directional force.18-25 teeth of both arches and then ligated these opposing
wires.
Extraoral and Intraoral Appliances Orthodontic bands and arches were used in patients
A primitive approach combined a rigid splint on the with loose, fractured, or missing teeth. The famous
occlusal surface of the teeth and one on the undersur- American orthodontist Angle46 described many methods
face of the mandible. This viselike device was then used of IMF that used bands and other orthodontic tech-
to apply pressure to the two splints, theoretically immo- niques. A recent study by Cousin revisited this methodol-
bilizing and fixating the fractured segments. Dorrance ogy and noted success using nonwire fixation for IMF.
and Bransfield26 wrote about the multiple disadvantages Sauer47 has described the ligation of an iron wire to
of this method, however, including the inability to gain the teeth with fine ligature wires. However, it was Gilmer48
proper occlusion, its inapplicability for fractures of the who took this idea a step further and fixated full arch
posterior mandible and for bilateral fractures, its promo- bars on both the mandible and maxilla, revolutionizing
tion of drooling, and the lack of immobilization neces- the treatment of fractures.
sary for proper union.
Gunning27 was the first to use a custom-fitted intraoral Open Reduction and Internal Fixation
dental splint for immobilization. He used the splint in Using Sutures
conjunction with an external head appliance, and Historically, mandibular body, ramus, or angle fractures
these splints could also be applied to the maxilla and were treated with closed reduction and intermaxillary
mandible, resulting in IMF (Fig. 14-3). An anterior fixation (IMF). Currently, screw and plate osteosynthesis
space was provided for nourishment.27-29 This basic is standard procedure to stabilize these fractures by open
principle, of using splints for intermaxillary fixation, reduction and fixation.8-10 A fracture of the condyle can
although modified, is still used routinely in the treatment be treated conservatively with IMF, surgically by an open
Mandibular Fractures CHAPTER 14 295
FIGURE 14-3 Thomas Brian Gunning (1840-1889) was the first to use vulcanite in a custom-fitted splint to immobilize mandibular
fragments. He used double arms extraorally for anchorage to a head cap and soft rubber chin support.
A B
FIGURE 14-4 The Thomas principle (1869) presented a

technique of intraoral open reduction with silver wire
osteosynthesis. The spiral springlike termination was
tightened intermittently “until union was secured.”
A, Proximal segment. B, Distal segment.
reduction using a submandibular, preauricular, retroau- iron or silver, was then tightened periodically by creating
ricular, or transparotid approach, or by a transoral pigtails on each end of it (Fig. 14-4). This method was
approach or endoscopically.11-14 hampered by a high incidence of infection.26
Transosseous wires Bone Plates
In the middle of the nineteenth century, Buck and In 1881, Gilmer36 described a method of mandibular
Kinlock have described the use of wire ligature for the fracture fixation that used two heavy rods placed on
immobilization of mandibular fractures.17,49 Using this either side of the fracture and wired together. The rods
method, one would drill a hole on both sides of the were pushed through skin, mucous membranes, and
fracture site and then pass a wire. The wire, which was bone and were wired on both the mouth and skin sides.
Dorrance and Bransfield stated that the earliest refer- The dimensions of biodegradable plates were usually
ence to the use of true bone plates was that of Schede, large compared with miniplates. This would limit their
who, around 1888, used a solid steel plate held by four use in the maxillofacial region. These materials have less
screws.26 During World War I, Kazanjian50 used wire strength, which would limit their use in loaded and func-
sutures through bone fragments and tied the wire to an tional bone, such as the mandible. The stability, strength,
arch bar for fixation. In 1900, Mahé51 used multiple and elasticity of resorbable osteosynthesis have been
plates to secure multiple mandibular fragments after extensively investigated in vitro.63,64 Araujo et al have
applying a monomaxillary splint. A similarity to the reported that elastic stiffness and surgical stability of bio-
plating systems used today can be noted. resorbable plates may change after surgery, however, and
In 1915, Ivy52 attempted the use of Sherman’s steel the reduced stiffness could permit relapse after surgery.64
plates but abandoned the method because of infection Polymer chemists and clinicians continue to evaluate bio-
and necrosis. In 1917, Cole53 used silver plates and screws degradable materials in the hope of developing implants
on each side of the fracture and then silver wires attached with clinical potential equal to that of metallic implants.
to the plates to immobilize the fracture. In 1934, The cases of plate fixation after World War II were
Vorschutz introduced two long screws through the skin sporadic. Before the 1960s, the biomechanical knowl-
into the bone, reduced the fracture, and held the screws edge of internal rigid fixation for the facial skeleton was
in position with the use of a plaster of Paris bandage adapted from the orthopedic literature. In the mid-
(similar to the Joe Hall Morris appliance of today).54 1960s, Luhr65 pursued research in rigid fixation for the
facial skeleton and developed the Vitallium mandibular
Biodegradable Plates and Plating Systems compression plate using glide screw principles. Through-
Internal rigid fixation of the facial skeleton is a reliable out the 1960s, Luhr continued research on rigid fixation
method for obtaining osteosynthesis. Historically, metal- and also contributed the self-threading screw. In the
lic plates and screws have been used to allow for early 1970s, several investigators, including Spiessl,67 studied
passive and active function. To date, titanium plating AO-ASIF principles. They found that adaptation of a
remains the reference standard of mandibular fracture compression plate on the lateral cortex, at the inferior
treatment because of its high biocompatibility, stability55, border of the mandible, gave excellent compression and
resistance to corrosion56,57, and cost-effectiveness (in adaptation at the inferior border but the superior border
comparison to resorbable plating systems).58 However, (tension zone) splayed. Many investigators thought that
these titanium plating systems have certain disadvan- a second tension zone plate would be necessary, whereas
tages, including migration from the original position, others believed that arch bars in tooth-bearing areas were
infection, palpability, and exposure, all which might sufficient to limit tension zone splaying. In 1973, Sch-
require revision surgery, and can cause distortion in mag- mocker and Speissl68 developed the eccentric dynamic
netic resonance imaging (MRI) and computed tomogra- compression plate, which provided compression at the
phy (CT) scanning.59 It may become necessary to remove tension and compression zones of the mandible. When
plates because of stress protection–induced osteopenia the screws closest to the fracture were tightened, the
in the cortex beneath the plate, causing a reduction in fracture line would be placed under compression. When
cortical thickness and shaft caliper. Others have reported the eccentric terminals were tightened, the alveolar
that metallic alloys containing nickel, cobalt, and chro- segment would be reduced.
mium may sensitize the patient and lead to allergic reac- Further development of the this plate fixation tech-
tions. Physicians must take backscatter into consideration nique introduced reconstruction plates. These were also
in patients in whom reconstruction with metallic implants called load-bearing plates because of their rigidity and
has been performed following tumor resection and who application over complex comminuted fractures. Further
will require radiation therapy. The same population will Innovation by Raveh et al introduced a system that
also have artifacts on future scans. allowed the heads of screws to lock into the titanium
Resorbable plating systems or biodegradable fixation plate holes.69-71 The advantage of this system was that the
devices have been used in orthopedics and craniomaxil- vascularity of periosteum was not endangered by plate
lofacial fields for over 25 years.60 These materials not only pressure. In the early 1970s, research was initiated to
reduce the risk of complications and mitigate the need evaluate the use of smaller plating systems. In 1973,
for implant removal, but add the benefit of rigid fixation Michelet et al72 placed bendable monocortical mini-
with biodegradation. Most of the studies included poly- plates to treat mandibular fractures. The advantages of
mers (e.g., poly-l-lactide, polyglycolide, polyglycolic acid, miniplates were their thinness and the fact that they
polylactic acid, and dioxanone). Although reports of the could be placed through intraoral incisions. Also known
use of resorbable plates in the mandible have been sparse, as load-sharing plates, miniplates transferred the path of
a prospective study of 50 fractures has reported success in static compression to one of dynamic compression. Fixa-
achieving union with 2.5-mm resorbable plates and tion to the alveolar ridge allows tensile stress placed on
screws.61 Resorbable plates now consist of amorphous the miniplate to cause an increase in dynamic compres-
molded copolymer of l-lactide–d-lactide and trimethyl- sion and stability.
ene carbonate for malleability and stability.61 Initially, the
load is carried entirely by the resorbable plate and ulti- Edentulous Mandibular Fractures
mately by the healed biological union.62 In 1991, Witten- Treatment of the fractured edentulous jaw began with a
berg et al63 found that poly-l-lactide plates were successful report by Baudens73 (1844), who used circumferential
in areas of low stress and no compression. wiring to reduce and fix the bone. Gunning used splints,
as described earlier.27-29 In 1851, Robert74 used silver wire throughout the world. Work-related accidents, firearms,
passed circumferentially around the mandible with a and pathologic conditions are also causative factors.
needle and tied the wire around a piece of lead that had Reports have shown that on average, more than 75% of
been molded to the edentulous mandible. Gilmer36 mandibular fractures are caused by MVAs and IPV, whereas
(1881) described a gutta-percha or vulcanite splint used 7% are work-related, 7% occur as the result of a fall, 4%
by Black that was maintained by circumferential wires of occur in sports-related accidents, and the remainder have
silver or platinum. Pickerill75 (1913) passed screws into miscellaneous causes. Sports-related maxillofacial inju-
the bone on either side of the fracture and maintained ries were especially evaluated by Roccia et al; of 138
them with a connecting steel bar. Circummandibular patients, 27% sustained a fractured mandible and 6.5%
wiring to maintain a denture splint was often described had dental and alveolar fractures. Sane and Ylipaavalni-
by Ivy and Curtis in the early 1900s.39,40 emi101 studied 8640 accidents that occurred in Finnish
Another technique, described by Partridge41 in 1976, soccer players. They found that 6.4% of the injuries
involves the use of a nylon circumferential strap wrapped occurred in the maxillofacial and dental regions. Of
around the body of the mandible and tightened. Two or these, 81% affected the teeth or alveolar process and
more of these straps are placed on the fracture and tight- 11% were fractures of the mandible and the middle third
ened. This method can be applied only to fractures that of the face. Linn et al89 have reported on 319 patients
have extreme obliquity, but the amount of periosteal treated for sports-related accidents in the Netherlands;
stripping involved may outweigh any potential benefit. 15% of them sustained a mandibular fracture and 5.5%
fractured the mandibular alveolar process, had luxated
teeth, or both.
DEMOGRAPHICS AND EPIDEMIOLOGY Studies of firearm-related mandibular fractures in
civilians are limited. Peleg and Sawatari evaluated 92
CAUSES patients who sustained gunshot wounds to the mandible.
The causes of maxillofacial fractures have changed over In France, Vaillant and Benoist107 evaluated 14 cases of
the past decades and will continue. Different societies bullet wounds of the mandible. The age of the patients
and cultures show different patterns of facial trauma. ranged from 6 to 68 years. Two children were victims of
Varying socioeconomic conditions combined with behav- accidents and the adults were suicide or assault victims.
ioral differences, however, make the aggregate compari- The degree of injury was proportionate to the velocity of
son of mandibular fractures difficult. Obtaining analysis the projectile. Civilian injuries were not as life-threatening
data from various regions can increase the understand- when compared with their high-velocity combat counter-
ing of facial trauma and allow for optimization of treat- parts. Handguns caused 72 injuries, followed by assault
ment.76,77 Demographic information on maxillofacial rifles and shotguns. Their surgical approach involved
injuries has changed with the onset of motor vehicle seat fabrication of an occlusal splint, IMF, aggressive débride-
belt and airbag laws, reduced speed limits, and increas- ment of hard and soft tissues, and immediate reconstruc-
ing urban violence. Many countries, including Brazil, tion with a titanium plate, which they believed could
India, and China, are contributing to this demographic restore the appropriate function and contour of the
data, along with reports from the United States,42,43,78-87 patient.
England,88,89 Germany,90,91 the Netherlands,92,93 and the Dental implants have revolutionized the restorative
Scandinavian countries.94,98 treatment of edentulous patients over the last decade.
The main causes of mandibular fractures worldwide Unfortunately, a sequela of implant placement and
include motor vehicle accidents (MVAs), interpersonal loading is fracture. As implantation procedures have
violence (IPV), falls, and sports-related injuries. Past data become the norm, fractures of the mandible and other
from industrialized or developed nations with large maxillofacial bones are more common. The amount of
numbers of vehicles indicated that multiple mandibular osseous resorption secondary to long-term use of a pros-
fractures were occurring with severe concomitant facial thesis and the higher incidence of metabolic abnormali-
fractures and associated nonmaxillofacial injuries, situa- ties in older adults result in a lower grade of recipient
tions that required extensive treatment. In contrast, bone. Therefore, patient selection is paramount, and
assaults and falls have become the predominant mecha- adhering to good osseointegration principles allow for
nism for facial injuries.99-101 Statistics from smaller devel- better results. Greenstein et al103 have stated several pre-
oping countries have indicated that MVAs remain the disposing factors for mandibular fracture, such as osteo-
most frequent cause. Ogundare et al102 retrospectively porosis (reduction of bone mass), stress at the implant
analyzed mandibular fractures seen in a U.S. urban location, and trauma (tensile forces placed on the bone
setting and found that a striking 79% of 1267 mandibular during mandibular function). Laskin has suggested that
fractures were caused by IPV, whereas Chrcanovic et al103 the degree of mobility or displacement determines ulti-
found that 44% of mandibular fractures were caused by mate treatment; thus, implants that have undergone
MVAs in Brazil. It is important to note, however, that osseointegration and are involved in the line of fracture
local laws and socioeconomic conditions in developed should not be removed.104 Implants that are infected
versus developing countries create mixed results for case should be removed. The use of open reduction and inter-
by case studies. nal fixation (ORIF) should be avoided because of the
Despite the many variables associated with the causes amount of periosteal stripping and the lack of bone in
of mandibular fractures, MVAs and assaults are undoubt- the atrophic mandible. Thus, conservative (closed) treat-
edly the primary causes of mandibular fractures ment of these fractures is the best option.
LOCATION OF MANDIBULAR FRACTURES CLASSIFICATION OF

In the cases evaluated for fracture location, the inci- MANDIBULAR FRACTURES
dences were as follows: angle (30%), condyle (23%),
symphyses (22%), body (18%), ramus (2%), and coro- Mandibular fractures have been classified in several ways,
noid process (1%).105-111 As noted, there are many vari- with the use of terminology that has not been standard-
ables, but generalization fractures that occur in the ized. For example, the term simple fracture has been
symphyses, condyle, and angle do not differ much in defined by Assael and Tucker as “… a complete transec-
incidence, and fractures of the ramus and coronoid tion of the bone with minimal fragmentation of the frac-
process are rare. ture site.”117 Rowe and Killey defined simple fractures as
Individual studies demonstrate how the cause plays a “…linear fractures which are not in communication
role in fracture location. Chrcanovic et al100 have shown with the exterior.”85 Kruger has stated that a simple
that when fractures caused by MVAs are considered, the fracture “… is one in which the overlying integument is
body region is the most common site. When motorcycle intact. The bone has been broken completely but it
accidents are considered, the condyle is the area most is not exposed to air. It may or may not be displaced. It
often affected. When assault is considered, the body may be comminuted.”118 Whitestone and Raley have
demonstrated the highest incidence of fracture. In defined a simple fracture as follows: “…the overlying
another case study, Boole et al have found that assaults mucosa is intact with no potential sources of direct
and fights lead to a higher percentage of angle fractures, communication.”119
whereas MVAs and motorcycle accidents result in more
ramus fractures.107 DICTIONARY CLASSIFICATION
For the sake of this discussion, the following fracture
FACIAL FRACTURES ASSOCIATED WITH terms have been adopted from Dorland’s Illustrated Medical
MANDIBULAR FRACTURES Dictionary120:
Mandibular fractures were the only facial bone fractures 1. Simple or closed: A fracture that does not produce
in an average of 70% of patients. The literature is gener- a wound open to the external environment, whether
ally divided between patients with mandibular and it be through the skin, mucosa, or periodontal
midface fractures and those with mandibular and other membrane
facial bone fractures. Of the patients reported, 15% had 2. Compound or open: A fracture in which an external
another facial bone fracture, along with the fractured wound, involving skin, mucosa, or periodontal
mandible. membrane, communicates with the break in the
bone
NUMBER OF FRACTURES PER MANDIBLE 3. Comminuted: A fracture in which the bone is splin-
Studies on the number of fractures per mandible have tered or crushed
shown remarkable consistency. The number of mandibu- 4. Greenstick: A fracture in which one cortex of the
lar fractures per patient ranged from 1.5 to 1.8. A mean bone is broken, the other cortex being bent
of 53% of patients had unilateral fractures, 37% had two 5. Pathologic: A fracture occurring from mild injury
fractures, and 9% had three fractures. However, many because of preexisting bone disease
authors simply reported single, double, more than two, 6. Multiple: A variety in which there are two or more
or single and multiple, so statistical analysis is impossible. lines of fracture on the same bone not communicat-
It can be concluded that approximately 50% of patients ing with one another
with mandibular fractures have more than one fracture. 7. Impacted: A fracture in which one fragment is firmly
driven into the other
NONMAXILLOFACIAL TRAUMA ASSOCIATED WITH 8. Atrophic: A spontaneous fracture resulting from
MANDIBULAR FRACTURES atrophy of the bone, as in edentulous mandibles
The literature dealing with concomitant nonmaxillofa- 9. Indirect: A fracture at a point distant from the site of
cial injuries associated with mandibular fractures is dif- injury
ficult to interpret with the wide variation in reported 10. Complicated or complex: A fracture in which there
injuries. The incidence of facial injuries occurring in is considerable injury to the adjacent soft tissue or
conjunction with major trauma was shown in several adjacent parts; may be simple or compound
surveys to range from 15% of 1,088 trauma patients in
Liverpool112 to 34% of 87,174 trauma patients in a North CLASSIFICATION BY ANATOMIC REGION
American Database on Trauma.113 In the study of Ellis Mandibular fractures are also classified by the anatomic
et al,110 90% of patients had no other injuries, probably areas involved, as follows: symphysis, body, angle, ramus,
because the cause was primarily assault. Olson et al84 condylar process, coronoid process, and alveolar process.
have reported associated injuries in 46.6% of all patients Dingman and Natvig78 have defined these regions as
treated, most of whom were involved in MVAs. Mulligan follows:
and Mahabir113 have reported associated cervical spine 1. Midline: Fractures between central incisors
injuries in 6.5% of patients, whereas Elahi et al114 noted 2. Parasymphyseal: Fractures occurring within the area
such injuries in only 2.6%. Kapoor and Srivastava115 of the symphysis
noted other (nonfacial) fractures in 40% of patients and 3. Symphysis: Bounded by vertical lines distal to the
Adekeye116 found other fractures in 9% of patients. canine teeth
4. Body: From the distal symphysis to a line coinciding d. Fractures of the angle of the mandible in the
with the alveolar border of the masseter muscle third molar region
(usually including the third molar) e. Fractures of the mandibular ramus between the
5. Angle: Triangular region bounded by the anterior angle of the mandible and sigmoid notch
border of the masseter muscle to the posterosuperior f. Fractures of the coronoid process
attachment of the masseter muscle (usually distal to g. Fractures of the condylar process
the third molar) Shetty et al122 combined six significant injury criteria
6. Ramus: Bounded by the superior aspect of the angle to create the acronym FLOSID, which essentially allowed
to two lines forming an apex at the sigmoid notch for ease of assessment and defined fracture characteris-
7. Condylar process: Area of the condylar process supe- tics. They assessed mandibular fractures using the tax-
rior to the ramus region onomy described and added weighting factors to address
8. Coronoid process: Includes the coronoid process of severity (mandible injury severity score):
the mandible superior to the ramus region 1. Fracture type (F)
9. Alveolar process: The region that would normally a. Incomplete
contain teeth b. Simple
Kazanjian and Converse120 have classified mandibular c. Comminuted
fractures by the presence or absence of serviceable teeth d. Bone defect
in relation to the line of fracture. They thought that their 2. Location of fracture (L)
classification was helpful in determining treatment. a. Left from midline (L1) to condylar head (L8)
Three classes were defined: b. Right from midline (R1) to condylar head (R8)
Class I: Teeth are present on both sides of the fracture line. 3. Nature of occlusion (O)
Class II: Teeth are present on only one side of the a. Normal
fracture line. b. Malocclusion
Class III: The patient is edentulous. c. Edentulous
They thought that class I fractures could be treated 4. Extent of soft tissue damage (S)
by a variety of techniques, using the teeth for mono- a. Closed
maxillary or intermaxillary fixation. Class II fractures, b. Open intraorally
usually involving the condyle-ramus angle or partially c. Open extraorally
edentulous body of the mandible, require intermaxil- d. Open intra and extraorally
lary fixation. Class III fractures require prosthetic tech- e. Soft tissue defect
niques, open reduction methods, or both for 5. Presence of infection (I)
stabilization. a. Yes
Rowe and Killey85 have divided mandibular fractures b. No
into two classes: (1) those not involving basal bone; and 6. Radiographic analysis of interfragmentary displace-
(2) those involving basal bone. The first class primarily ment (D)
is comprised of alveolar process fractures. The second a. Mild
class is divided into single unilateral, double unilateral, b. Moderate
bilateral, and multiple. c. Severe
Kruger118 has classified mandibular fractures into An important classification of mandibular angle and
simple, compound, and comminuted. Kruger and body fractures relates to the direction of the fracture line
Schilli121 took into account many of the aforementioned and the effect of muscle action on the fracture frag-
classifications described and developed four categories ments. Angle fractures may be classified as (1) vertically
of mandibular fractures: favorable or unfavorable or (2) horizontally favorable or
1. Relation to the external environment unfavorable. Figures 14-5 through 14-8 demonstrate the
a. Simple or closed various types.
b. Compound or open In fractures of the angle of the mandible, the muscles
2. Types of fractures attached to the ramus (masseter, temporal, and medial
a. Incomplete pterygoid) displace the proximal segment upward
b. Greenstick and medially when the fractures are vertically and
c. Complete horizontally unfavorable (Fig. 14-9). Conversely, these
d. Comminuted same muscles tend to impact the bone, minimizing
3. Dentition of the jaw with reference to the use of displacement in horizontally and vertically favorable frac-
splints tures. The farther forward the fracture occurs in the body
a. Sufficiently dentulous jaw of the mandible, the more the upward displacement of
b. Edentulous or insufficiently dentulous jaw those muscles is counteracted by the downward pull of
c. Primary and mixed dentition the mylohyoid muscles. In bilateral fractures in the
4. Localization canines areas, the symphysis of the mandible is displaced
a. Fractures of the symphysis region between the inferiorly and posteriorly by the pull of the digastric,
canines geniohyoid, and genioglossus muscles (Fig. 14-10).
b. Fractures of the canine region Condylar fractures are generally classified as extracap-
c. Fractures of the body of the mandible between sular, subcondylar, or intracapsular. Condylar fractures
the canine and angle of the mandible are influenced by location and muscle action. The lateral
Lateral Lateral
pterygoid pterygoid
Medial Medial
pterygoid pterygoid
FIGURE 14-6 Vertically favorable fracture.

FIGURE 14-5 Vertically unfavorable fracture.
Masseter
Medial
pterygoid
Masseter Mylohyoid
FIGURE 14-7 Horizontally favorable fracture. FIGURE 14-8 Horizontally unfavorable fracture.
Lateral pterygoid:
Upper head inserts
into articular disk
and upper part of
condylar head
Lower head inserts Temporalis

into pterygoid fovea
Lateral pterygoid
Medial pterygoid
Digastric
Masseter
Mylohyoid Geniohyoid
FIGURE 14-9 Muscles of mastication, which have a displacing influence on mandibular fractures.
pterygoid muscle has a tendency to cause anterior and because of traction of the lateral pterygoid muscle. The
medial displacement of the condylar head, depending fragments are generally confined within the area of the
on the location, severity of the fracture, and effect of the glenoid fossa. The capsule is torn and the head is outside
supporting capsule (Fig. 14-11). In 1934, Wassmund has the capsule. An open reduction is recommended for this
described five types of condylar fractures.17 Type I is fracture type. Type IV fractures of the condylar head
defined as a fracture of the neck of the condyle, with articulate on, or in a forward position with regard to, the
relatively slight displacement of the head. The angle articular eminence. The type V group consists of vertical
between the head and axis of the ramus varies from 10 or oblique fractures through the head of the condyle,
to 45 degrees. These fractures tend to reduce spontane- and a bone graft is suggested to reconstitute the condylar
ously. Type II fractures produce an angle from 45 to 90 head when considerable displacement of the fragments
degrees, resulting in tearing of the medial portion of the has occurred.17
joint capsule. In type III fractures, the fragments are not As a means of simplifying the classification of high and
in contact and the head is displaced mesially and forward low condylar fractures, Loukota et al have proposed a
three-part system.123 The classification system revolves
around a reference line, which is a linear line that extends
from the posterior border of the condylar neck through
the sigmoid notch to the tangent of the ramus. First, the
diacapitular type describes a fracture through the head
of the condyle, because it may start on the articular
surface and extend outside the capsule. Second, a con-
dylar neck type describes a fracture that is at minimum
over 50% above the reference line. Finally, a condylar
base type refers to a fracture line that runs behind the
mandibular foramen and is at minimum over 50% below
the reference line (Fig. 14-12).
DIAGNOSIS OF MANDIBULAR FRACTURES

PATIENT HISTORY
A thorough history is imperative for the proper diagnosis
of mandibular fractures. The patient’s health history may
reveal preexisting systemic bone disease, neoplasia with
potential metastases, arthritis and related collagen disor-
FIGURE 14-10 Inferior and posterior displacement of the ders, nutritional and metabolic disorders, and endocrine
symphysis of the mandible in bilateral fractures in the canine area. diseases that may cause or be directly related to the
(Anterior three-quarter view

of lateral condyle)
Temporomandibular
joint capsule
Lateral pterygoid
(insertion at
pterygoid fovea) (Medial) (Lateral)
Temporalis
Medial
pterygoid
Genioglossus
Geniohyoid
Mylohyoid
Anterior belly of
digastric
FIGURE 14-11 The lateral pterygoid muscle tends to cause anterior and medial displacement of the condylar head.
A A
A B C
FIGURE 14-12 Classification of condylar fractures. A, High or condylar neck fracture. B, Low or condylar base fracture. C, Diacapitular
fracture. (From Ward Booth P, Eppley BL, Schmelzeisen R: Maxillofacial trauma and esthetic facial reconstruction, ed 2, St. Louis, 2012,
Saunders.)
fractured jaw. The history also reveals significant medical

and psychiatric problems that will influence the manage-
ment of the patient and perhaps even dictate treatment
modalities.
A history of temporomandibular joint (TMJ) dysfunc-
tion can have significant legal and post-treatment rami-
fications. A number of clinicians and radiologists have
experienced problems by not obtaining an adequate
history of previous mandibular trauma or fracture.
The type and direction of traumatic force can be
extremely helpful for the diagnosis. Fractures sustained
in MVAs are usually different from those sustained in
IPVs. Because the magnitude of the force can be much
greater, victims of automobile and motorcycle accidents
tend to have multiple, compound, comminuted man-
dibular fractures, whereas the patient hit by a fist may
sustain a single, simple nondisplaced fracture.
The object that caused the fracture can also influ-
ence the type and number of fractures. A blow from a FIGURE 14-13 Trauma in the form of an anterior blow directly to
broad blunt object (e.g., a two by four piece of wood) the chin can cause bilateral condylar fractures.
may cause several fractures (e.g., symphysis, condyle)
because the impact of the force is sustained throughout
the bone, whereas a smaller, well-defined object (e.g., CLINICAL EXAMINATION
hammer, pipe) may cause a single comminuted fracture
becausethe impact of the force is concentrated in a Initial evaluation is part of the secondary survey when
smaller area. adhering to the Advanced Trauma Life Support (ATLS)
Knowing the direction of force can help the clinician protocol. Stabilization of the airway may require trache-
diagnose concomitant fractures. An anterior blow directly otomy in severe crushing injuries, such as the hallmark
to the chin can result in bilateral condylar fractures (Fig. flail mandible. The mandible should be evaluated after
14-13) and an angled blow to the parasymphysis may the patient is stabilized and more life-threatening inju-
cause a contralateral condylar or angle fracture. A patient ries have been addressed. The signs and symptoms of
with teeth clenched together at the moment of impact is mandibular fractures are as follows.
more likely to have dental and alveolar process fractures Change in Occlusion. Any change in occlusion is highly
than basal bone fractures. Even knowing where the suggestive of mandibular fracture. The clinician should
patient was sitting in an automobile may aid in the diag- ask the patient whether his or her bite feels different. A
nosis of mandibular or other injuries. Chest injuries change in occlusion can result from fractured teeth, frac-
caused by noncollapsible steering wheels, facial fractures tured alveolar process, fractured mandible at any loca-
caused by striking unpadded dashboards, and facial tion, and trauma to the TMJ and muscles of mastication.
lacerations from non–safety glass are a few examples Post-traumatic premature posterior dental contact or an
of predictable injuries that have been eliminated by the anterior open bite may result from bilateral fractures of
use of seat belts and more effective automotive safety the mandibular condyle or angle (Fig. 14-14) and from
engineering.124,125 maxillary fractures with inferior displacement of the
However, certain mandibular fractures or associated

facial fractures result in predictable abnormal mandibu-
lar movements. A classic example is deviation on opening
toward the side of a mandibular condylar fracture.
Because lateral pterygoid muscle function on the unaf-
fected side is not counteracted on the opposite side by
the nonfunctioning lateral pterygoid muscle, deviation
results. Inability to open the mandible may be caused by
the impingement of the coronoid process on the zygo-
matic arch from fractures of the ramus and coronoid
process or from depression of a zygomatic arch fracture.
Inability to close the jaw can be the result of fractures of
the alveolar process, angle, ramus, or symphysis, causing
FIGURE 14-14 Bilateral angle fractures can cause an open bite.
premature dental contact. Lateral mandibular move-
ments may be inhibited by bilateral condylar fractures
and fractures of the ramus with bone displacement.
Change in Facial Contour and Mandibular Arch Form.
Although facial contour may be masked by swelling, the
clinician should examine the face and mandible for
abnormal contours. A flattened appearance of the lateral
aspect of the face may be the result of a fractured body,
angle, or ramus. A deficient mandibular angle can occur
with unfavorable angle fractures in which the proximal
fragment rotates superiorly. A retruded chin can be
caused by bilateral parasymphyseal fractures. The appear-
ance of an elongated face may be the result of bilateral
subcondylar, angle, or body fractures, allowing the ante-
rior mandible to be displaced downward. Facial asym-
FIGURE 14-15 Unilateral open bite may be the result of ipsilateral metry should alert the clinician to the possibility of a
angle and parasymphyseal fractures. mandibular fracture. The same holds true for mandibu-
lar arch form. If there is a deviation from the normal
U-shaped curve of the mandible, fracture should be
suspected.
posterior maxilla. A posterior open bite may occur with Lacerations, Hematoma, and Ecchymosis. Trauma signifi-
fractures of the anterior alveolar process or parasymphy- cant enough to cause loss of skin or mucosal continuity,
seal fractures. A unilateral open bite may occur because or subcutaneous-submucosal bleeding, can result in
of ipsilateral angle and parasymphyseal fractures (Fig. trauma to the underlying mandible. Lacerations should
14-15). A posterior crossbite can result from midline sym- be carefully inspected before closure. The direction and
physeal and condylar fractures, with splaying of the pos- type of fracture may be visualized directly through the
terior mandibular segments. laceration, with the clinician thereby obtaining diagnos-
Retrognathic occlusion is associated with condylar or tic information that might be impossible to ascertain
angle fractures (and forward displaced maxillary frac- clinically or radiographically. The common practice of
tures); prognathic occlusion can occur with effusion of closing facial lacerations before treating underlying frac-
the TMJ joints and with protective forward posturing of tures should be discouraged from diagnostic and treat-
the mandible (also with retropositioning of the maxilla). ment standpoints. The diagnostic sign of ecchymosis in
These are only a few of the many occlusal disharmonies the floor of the mouth indicates a mandibular body or
that can exist, but any change in occlusion has to be symphyseal fracture (Fig. 14-16).
considered the primary diagnostic sign of mandibular Loose Teeth and Crepitation on Palpation. A thorough
fracture. examination of the teeth and supporting bone can help
Anesthesia, Paresthesia, or Dysesthesia of the Lower Lip. diagnose alveolar process, body, and symphyseal frac-
Although changes in sensation in the lower lip and chin tures. A force strong enough to loosen teeth can fracture
may be related to chin and lip lacerations and blunt the underlying bone. Multiple fractured teeth that are
trauma, numbness in the distribution of the inferior firm indicate that the jaws were clenched during trau-
alveolar nerve after trauma is almost pathognomonic of matic insult, thus lessening the effect on the supporting
a fracture distal to the mandibular foramen. Conversely, bone. The clinician should palpate the mandible using
most nondisplaced fractures of the mandibular angle, both hands, with the thumb on the teeth and the fingers
body, and symphysis are not characterized by anesthesia, on the lower border of the mandible. By slowly and care-
so the clinician must not use lip anesthesia as the sole fully placing pressure between the two hands, the clini-
feature in diagnosis. cian can detect crepitation in a fracture. However, this
Abnormal Mandibular Movements. Most patients with a simple diagnostic technique is often overlooked in favor
fractured mandible have limited opening and trismus of extensive (and expensive) radiologic diagnostic
because of guarding of the muscles of mastication. methods.
Dolor, Tumor, Rubor, and Color. Pain, swelling, redness, the TMJ , symphysis (depending on the type of equip-
and localized heat have been noted as signs of inflamma- ment), and dental and alveolar process regions. A sec-
tion since the time of the ancient Greeks. All these find- ondary but important disadvantage is that panoramic
ings are excellent primary signs of trauma and can greatly radiographic equipment is not available in all hospital
increase the index of suspicion for a mandibular radiology departments. In addition, because of the sen-
fracture. sitivity of the panoramic radiographic technique, super-
imposition of structures can lead to interpretation
RADIOLOGIC EXAMINATION errors.127
The lateral oblique view of the mandible can be
The following radiologic studies are helpful in the diag- helpful in the diagnosis of ramus, angle, and posterior
nosis of mandibular fractures: body fractures (Fig. 14-18). The technique is simple and
1. Panoramic radiograph can be done in any radiology department. The condyle
2. Lateral oblique radiograph region is often unclear, as are the premolar and symphy-
3. Posteroanterior radiograph sis regions. The Caldwell posteroanterior (PA) view dem-
4. Occlusal view onstrates any medial or lateral displacement of fractures
5. Periapical view of the ramus, angle, body, and symphysis (Fig. 14-19).
6. Reverse Towne’s view The condylar region is not well demonstrated on this
7. TMJ, including tomograms view, but midline or symphyseal fractures can be well
8. CT—high-resolution spiral or helical CT visualized. The anteroposterior view is occasionally used
The single most informative radiologic study used in for patients who cannot be placed in the supine position;
diagnosing mandibular fractures is the panoramic radio- however, considerable magnification and distortion
graph, showing the entire mandible, including condyles occur with this view. The mandibular occlusal view dem-
(Fig. 14-17).126 The advantages are simplicity of tech- onstrates discrepancies in the medial and lateral position
nique, ability to visualize the entire mandible in one of body fractures and also shows anteroposterior (AP)
radiograph, and generally good detail, but there are
several disadvantages: (1) the technique usually requires
the patient to be upright (machines that allow the patient
to be prone are available), which may make it impractical
in the severely traumatized patient; (2) it is difficult to
appreciate buccal-lingual bone displacement or medial
condylar displacement; and (3) fine detail is lacking in
FIGURE 14-16 Ecchymosis in the floor of the mouth is a significant FIGURE 14-18 The lateral oblique view of the mandible is helpful in
diagnostic sign of a mandibular body or symphyseal fracture. diagnosing ramus, angle, and posterior body fractures.
FIGURE 14-17 Panoramic radiograph, the single most

informative radiograph for the diagnosis of
mandibular fractures.
FIGURE 14-21 The reverse Towne view is most helpful for showing
medial displacement of the condyle and condylar neck fractures.
FIGURE 14-19 The Caldwell posteroanterior view shows medial or

lateral displacement of fractures of the ramus, angle, body, and
symphysis.
FIGURE 14-22 CT scanning is ideal for condylar fractures.
FIGURE 14-20 With the mandibular occlusal view, discrepancies in

the medial and lateral positions of body fractures and
anteroposterior displacement of the symphysis can be shown. diagnosed with plain films and panoramic tomography
(Fig. 14-22).128 With the advent of newer technology,
helical CT (HCT) is faster, more accurate, and less
expensive and delivers decreased radiation exposure as
displacement in the symphysis region (Fig. 14-20). The compared with conventional CT scans. According to
reverse Towne view is ideal for showing medial displace- Roth et al, it also provides enhanced resolution because
ment of condyle and condylar neck fractures (Fig. 14-21). of less motion misregistration. Hence, the trend toward
Transcranial lateral views of the TMJ are helpful in making HCT the current gold standard is underway.128
detecting condylar fractures and anterior displacement In summary, as with most other imaging procedures,
of the condylar head. Periapical dental films show the it is usually optimal to have views of the mandible in two
most detail and can be used for nondisplaced linear planes oriented at 90 degrees to each another. Ideal
fractures of the body and alveolar process and dental imaging includes sections in the axial and coronal planes
trauma. Plain tomograms can be used in an AP and but practical considerations of time, the patient’s condi-
lateral direction when greater detail is necessary. The tion, and cost mandate selectivity. Thus, the history, phys-
traditional CT scan is ideal for condylar fractures that are ical examination, and understanding which structures
difficult to visualize; however, greater expense and radia- are best shown by certain imaging methods dictate the
tion exposure limit its use to cases that cannot be proper radiologic technique.129,130
GENERAL PRINCIPLES OF TREATMENT Teeth are often injured with mandibular fractures
and, although the teeth may not have to be restored
Throughout this text, specific chapters have been devoted immediately, dental knowledge is vitally important for
to preoperative, operative, and postoperative treatment determining which teeth can and should be
of facial fractures. This section presents general princi- maintained.
ples used in the management of mandibular fractures. a. Fractured teeth can become infected and jeopar-
1. The patient’s general physical status should be care- dize bone union; however, an intact tooth in the
fully evaluated and monitored before any consider- line of fracture that is maintaining bone fragments
ation of treating mandibular fractures. can be protected with antibiotic coverage (Fig.
It must be emphasized that any force great enough 14-23).
to cause a fractured mandible is capable of injuring b. A second molar on an otherwise edentulous poste-
other organ systems in the body. This is obvious when rior fracture segment should be maintained to
dealing with massive crush injuries of the face, with prevent superior displacement of the fragment in
concomitant multiorgan system involvement. However, intermaxillary fixation.
it is easy for the clinician to focus on an obvious iso- c. Mandibular canines are the cornerstone of occlu-
lated mandibular fracture without noting a fractured sion and should be maintained at all costs.
cervical spine, subdural hematoma, pneumothorax, d. Some teeth are not critical to restoration and can
cardiac tamponade, or ruptured spleen. The down- be removed when their prognosis is doubtful and
ward spiral to disaster can begin by not following this when maintenance may adversely affect fracture
principle. treatment. For example, a lone mandibular incisor
The literature is replete with case reports of iso- adds little to future bridge or partial denture con-
lated fractures of the mandible in which life- struction; however, a single molar tooth in an oth-
threatening medical conditions became apparent erwise edentulous posterior quadrant can be critical
after treatment was instituted. Post-traumatic throm- to dental rehabilitation.
botic occlusion of the internal carotid artery associ- e. Some fractured teeth cannot be salvaged, no matter
ated with mandibular fractures (and no other apparent how critical they may be. For example, a molar
injuries) was diagnosed 24 hours after injury in one tooth may be split mesially and distally, so recon-
case and 9 hours after injury in another.131 Banna131 struction would be impossible. Maintenance of this
has also reported a case and reviewed the literature tooth during intermaxillary fixation could result in
on post-traumatic thrombotic occlusion of the inter- severe discomfort and perhaps infection.
nal carotid artery after minimal neck trauma. A basal 4. Reestablishment of occlusion is the primary goal in
skull fracture associated with an undisplaced body the treatment of mandibular fractures.
fracture of the mandible became apparent 48 hours Probably because of the mandible’s excellent blood
after injury.132 Gordon et al132 have described a patient supply, nonunion of mandibular fragments is rare, so
with a unilateral body fracture of the mandible who it is apparent that bone fragments do not have to be
had symptoms of a ruptured spleen 5 days after injury in tight approximation to heal. In addition, in most
and 3 days after arch bars had been placed. Bertolami cases, facial aesthetics will not be adversely affected by
and Kaban133 have reported on a case of a 20-year-old slight fragment displacement. However, function can
woman involved in an MVA who sustained a 3-cm chin be seriously compromised when improper treatment
laceration without malocclusion or limitation of man- results in malocclusion. Impressive appearing radio-
dibular movement. After 8 hours, radiographs were graphic bone adaptation should not be the primary
reviewed and showed a nondisplaced fracture of the treatment goal.
angle of the mandible and a fracture of the second 5. With multiple facial fractures, mandibular fractures
cervical vertebra. Minton and Tu134 have noted a case should be treated first.
of bilateral cervical subcutaneous emphysema, pneu- The old adage “inside out and from bottom to top”
mothorax, and pneumomediastinum secondary to a applies to the proper sequence to follow when treating
bilateral fractured mandible without other apparent facial fractures. To build a foundation on which the
injuries. facial bones can be laid, the mandible should be
2. Diagnosis and treatment of mandibular fractures reconstructed first, although with the use of rigid fixa-
should be approached methodically, not with an tion, deviation from this principle can be allowed. All
emergency-type of mentality. intraoral surgery should be done before any extraoral
Patients rarely die of mandibular fractures, so the open reductions or suturing of facial lacerations. Lip
clinician has time to evaluate the nature and extent of and skin wounds that have been meticulously closed
mandibular injuries carefully and thoroughly. Diagno- in an emergency room are often inadvertently, or even
sis on the basis of the history and local physical and necessarily, reopened during the treatment of man-
radiologic examination should be expedited in an dibular fractures. Gross débridement and control of
orderly and efficient manner, and treatment should be hemorrhage should be combined with temporary
instituted in a controlled fashion. However,this is not measures to reapproximate extraoral wounds, thus
to condone prolonged unnecessary delay, which can allowing definitive treatment to be carried out after
increase the potential for infection and nonunion. the intraoral procedures are completed.
3. Dental injuries should be evaluated and treated con- 6. Intermaxillary fixation time should vary according to
currently with treatment of mandibular fractures. the type, location, number, and severity of the
B
FIGURE 14-23 An intact tooth in the line of fracture can be maintained to prevent displacement of the segment.
mandibular fractures, the patient’s age and health, and 8. Nutritional needs should be closely monitored
the method used for reduction and immobilization. postoperatively.
Historically, a period of 6 weeks of intermaxillary Excellent reduction and fixation techniques may
fixation has been used to allow healing to occur. fail in a patient who has undergone notable weight
However, this length of time is only empirical and loss and has a catabolic nutritional status.
should vary with the patient and clinical situation.135 9. Mandibular fractures can be treated by closed
A simple, nondisplaced, greenstick mandibular frac- reduction.
ture in a healthy child would certainly require less With enthusiasm for open reduction and rigid fixa-
intermaxillary fixation time than multiple, grossly tion in the treatment of mandibular fractures, it is
comminuted, compound mandibular fractures in an important to remember that closed reduction tech-
older unhealthy patient.136 With the advent of rigid niques have a long history of success.146,147 Although
fixation techniques, intermaxillary fixation may be open techniques have advantages, such as more exact-
eliminated or maintained with light elastics for short ing bone fragment reapproximation and earlier return
periods. to function by the patient, significant disadvantages
7. Prophylactic antibiotics should be used for compound exist as well. These may subject the patient to pro-
fractures. longed anesthesia, increase the risk of infection and
The benefit of pre- and perioperative antibiotics metal rejection, cause damage to adjacent teeth and
has been extensively analyzed and verified to lower nerves, result in intraoral or extraoral scarring, and
postoperative infection rates. Numerous literature increase hospitalization time and cost. The following
studies have demonstrated the advantages of antibiot- sections present relative indications for open or closed
ics in the management of compound mandibular frac- techniques.
tures; despite the number of new antibiotics, however,
penicillin remains the agent of choice.96,137-140 However, INDICATIONS FOR CLOSED REDUCTION
much debate remains in regard to assessing the effi- Nondisplaced Favorable Fractures. The simplest means
cacy and duration of a postoperative antibiotic possible should be used to reduce and fixate mandibular
regimen.138,141-145 fractures (Fig. 14-24). For the reasons specified earlier,
FIGURE 14-24 Nondisplaced favorable fracture.
B
FIGURE 14-25 Grossly comminuted mandibular fractures.
open reduction can carry an increased risk of morbidity, using closed techniques to establish normal occlusion
so closed techniques should be used for treatment. if without violating integrity.
possible. Fractures Exposed by Significant Loss of Overlying Soft
Grossly Comminuted Fractures. Because of the excellent Tissue. Fracture repair is somewhat dependent on soft
blood supply to the face, small fragments of bones will tissue coverage and vascular supply. Soft tissue coverage
coalesce and heal if the associated periosteum is not should be established by rotational flaps, microvascular
disturbed(Fig. 14-25). Comminuted fractures should be grafts or, if the area is small, secondary granulation.
managed as a so-called bag of bones, with the clinician Wires, screws, and plates may decrease the chance of
C
FIGURE 14-26 Edentulous mandibular fractures. A, Minimal atrophy. B, Moderate atrophy. C, Severe atrophy.
successful bone union by disrupting the covering soft to the clinical presentation. If open reduction is neces-
tissue further. sary, a supplemental bone graft across the fracture site
Edentulous Mandibular Fractures. These fractures (Fig. should be considered in addition to minimal periosteal
14-26) present a special challenge because the inferior stripping. In severely atrophic edentulous ridges, open
alveolar vascular supply to the bone is severely compro- reduction with primary bone grafting may be indicated,
mised, there is little cancellous bone (with associated because proper alignment of the fractured ends of bone
osteoblastic endosteum) for repair, and the fractures may be impossible because of the small cross-sectional
usually occur in older adults, in whom the normal healing diameter of the mandibular body.
potential can be retarded. Open reduction requires strip- Mandibular Fractures in Children With Developing Denti-
ping of the covering periosteum, which further inhibits tion. Open reduction with wires or plates carries the risk
osteogenesis. Closed reduction with the use of a man- of damage to developing tooth buds, which occupy a
dibular prosthesis held in place by circummandibular major portion of the mandible in children (Fig. 14-27).
wires offers a more conservative approach if amendable If open reduction is necessary because of gross
B
FIGURE 14-27 A, Mandibular fracture in a child with developing dentition. B, Treatment with closed reduction and lingual splint.
displacement of the fragments, fine wires should be

placed at the most inferior border of the mandible,
engaging only the cortex. Closed reduction is indicated
with special wiring techniques (continuous loop or
Risdon wire) or fabricated acrylic splints maintained by
circummandibular wiring. A special concern in children
is fractures of the mandibular condyle. Damage to the
condylar growth center can result in retarded growth of
the mandible and facial asymmetry. Intracapsular condy-
lar fractures in children can also lead to ankylosis of the
joint, so early mobilization (after 7 to 10 days of inter-
maxillary fixation) is indicated.
Coronoid Process Fractures. Fractures of the coronoid
process are rarely isolated and are usually simple and
linear, with little displacement, although with extreme
trauma the bone may be displaced into the temporal
fossa. Isolated fractures of the coronoid process cause
trismus and swelling in the region of the zygomatic arch.
There may be swelling in the retromolar area and a
lateral crossbite. Treatment is usually initiated only if the FIGURE 14-28 Condylar fractures can result in ankylosis if they are
occlusion is compromised or if the fractured coronoid improperly treated or go untreated.
process impinges on the zygomatic arch, inhibiting man-
dibular movement.148
Condylar Fractures. Most condylar fractures (Fig. INDICATIONS FOR OPEN REDUCTION
14-28) can and should be treated via closed techniques The indications for open reduction as outlined in the
if the occlusion is not compromised. Early jaw mobiliza- following examples are frequently based on the anatomy
tion and physical therapy are indicated to prevent anky- of the fracture rather than the severity of the injury or
losis or limited jaw movements. This subject is covered the amount of displacement. Control of the edentulous
in detail in Chapter 15. or proximal segment is the overriding factor in selecting
B
FIGURE 14-29 Indication for open reduction. The proximal segment is minimally displaced superiorly, a third molar is in the proximal
segment, and reduction cannot be maintained without intraosseous wires, screws, or plating.
this surgical option. Additional factors such as the neces- If this procedure is not done, any type of suspension
sity of early mobilization or medical considerations wiring, such as that from the frontozygomatic suture area
such as seizure disorders may dictate open reduction to the mandible, would tend to collapse and telescope
treatment. the fractures of the midface and condyles, resulting in a
Displaced Unfavorable Fractures Through the Angle of the foreshortened facial appearance.
Mandible. Open reduction is indicated for this fracture Fractures of an Edentulous Mandible With Severe Displace-
when the proximal fragment is displaced superiorly or ment of the Fracture Fragments. In fractures of an edentu-
medially and reduction cannot be maintained without lous mandible with severe displacement of the fracture
intraosseous wires, screws, or plating (Fig. 14-29). fragments, open reduction should be considered to rees-
Displaced Unfavorable Fractures of the Body or Parasym- tablish continuity of the mandible (Fig. 14-31). The tech-
physeal Region of the Mandible. The mylohyoid, digastric, nique is especially helpful with a nonatrophic mandible
geniohyoid, and genioglossus muscles may further dis- when there are no dentures, so the occlusion is not an
place the fragments (Fig. 14-30). When treated with immediate concern. In this situation, plating of the man-
closed reduction, parasymphyseal fractures tend to open dible without IMF should be a strong possibility. As the
at the inferior border, with the superior aspects of the mandible becomes extremely atrophic, consideration
mandibular segments rotating medially at the point of must be given to the status of blood supply to the bone
fixation. With medial rotation of the body of the man- and the effect of an open surgical procedure on the
dible, the lingual cusps of all premolars and molars move compromised vascularity. Supplemental bone grafts have
out of occlusal contact. If the constriction is not cor- to be considered for extremely atrophic mandibular
rected, masticatory inefficiency and abnormal periodon- fractures.
tal changes occur.149,150 Edentulous Maxilla Opposing a Mandibular Fracture.
Multiple Fractures of the Facial Bones. In multiple frac- When a maxilla opposing a mandibular fracture is eden-
tures of the facial bones, open fixation of the mandibular tulous or contains insufficient teeth to allow intermaxil-
segments provides a stable base for restoration. lary fixation, open reduction should be considered.
Midface Fractures and Displaced Bilateral Condylar Frac- Open reduction with rigid fixation of the mandibular
tures. With midface fractures and displaced bilateral fractures would eliminate the need for IMF. However, if
condylar fractures, one of the condylar fractures should the patient’s condition warrants closed reduction, a
be opened to establish the vertical dimension of the face. prosthesis could be constructed for the maxilla, it could
B
FIGURE 14-30 Displaced unfavorable fractures of the body region frequently require open reduction.
delayed because of head injury or other serious medical

problems so, with time, connective tissue grows between
the bone fragments, inhibiting osteogenesis. When treat-
ment is finally initiated, scar tissue must be removed and
treatment completed via an open approach.
Malunion. When a poor result is obtained after man-
dibular fracture treatment, various types of osteotomies
will have to be done via open surgical approaches to
correct the deficiencies.
Special Systemic Conditions Contraindicating Intermaxil-
lary Fixation. There are situations in which mandibular
functional movement is necessary, and open rigid fixa-
tion techniques can provide that option. For example,
FIGURE 14-31 Edentulous or partially edentulous mandibles that patients with difficult to control seizures, psychiatric or
are not atrophic but are severely displaced should be opened. neurologic problems, compromised pulmonary func-
tions, and eating or gastrointestinal disorders could
benefit from open rigid fixation techniques.
be stabilized with palatal screws or circumzygomatic
wires, and routine IMF could be used to treat the frac-
tured mandible. TREATMENT OF MANDIBULAR FRACTURES
Delay of Treatment and Interposition of Soft Tissue Between Hundreds of techniques are available for treating man-
Noncontacting Displaced Fracture Fragments. When treat- dibular fractures, as noted earlier in the section on
ment has been delayed and soft tissue becomes inter- history. However, state of the art treatment methods are
posed between noncontacting displaced fracture currently limited and well defined. It is important to
fragments, open reduction should be used. There are realize that establishment of occlusion is imperative for
cases in which the treatment of mandibular fractures is the successful treatment of mandibular fractures.
FIGURE 14-32 Ivy loops are effective for certain types of fractures.
FIGURE 14-33 Arch bars are versatile and frequently used in the
treatment of mandibular fractures.
Closed Reduction and Fixation of Dentulous Maxilla Arch Bars. There are a variety of arch bars available for
and Mandible achieving maxillomandibular fixation. Placement of arch
Bridle Wire. Hippocrates was the first to advocate the bars can be a difficult task, depending on the dentition
use of wires for the reduction of mandibular fractures. present and their stability in the traumatized mandible.
His technique of placing a single wire around the teeth Here we discuss placement of arch bars on a full intact
adjacent to the fracture still has its place in modern oral dentition for reasons of simplicity and instruction. Later,
surgery. A simple bridle wire placed around the adjacent we shall discuss the placement of arch bars on some dif-
teeth of a mandibular fracture can temporarily stabilize ferent combinations of tooth loss (edentia).
a flailed mandibular segment. This in itself helps prevent Equipment Needed
further soft tissue damage, aids in protecting the airway, • Local anesthetic
helps alleviate pain from the two segments moving • Arch bars
against each other, and assists in preventing the muscle • 24- and 26-gauge wire
cramping that is associated with unstable segments. • Needle drivers
Equipment Needed Procedure. The first step in placement is measure-
• Local anesthetic ment of the arch bar. The bar is usually placed two teeth
• Needle driver or needle holder proximal from the fracture. The bar is traditionally
• 24- or 26-gauge stainless steel wire placed from a point distal to the first molar to a point
Procedure. After adequate local anesthetic has been distal to the first molar on the opposite side.
administered, the two segments are manually reduced. Wire is the next consideration; 24-gauge wire is recom-
The wire is passed around the necks of the teeth and the mended for the circumdental wires, and 26-gauge wire is
fracture loosely approximated. While manually stabiliz- used for the box wires that provide the maxillomandibu-
ing the fracture, the operator achieves further reduction lar fixation. The first circumdental wires placed are usually
by tightening the wire in a clockwise fashion. In the event on the second premolars. The measured arch bar is then
that the adjacent teeth are loose, decayed, or avulsed, the placed in the loops of the wires and the wires are loosely
operator can use the nearest stable teeth. secured. Wiring then takes place from midline to poste-
Ivy Loops. Ivy loops are a quick and easy way of obtain- rior to avoid excess arch bar in the anterior of the arch.
ing maxillomandibular fixation. The loop is constructed After placement of the circumdental wires and gross
of 24-gauge wire and passed interproximally to two stable reduction of the fractured segments, they are tightened
teeth. The ends of the wire are first brought around to in the same fashion—from midline to posterior (Fig.
the mesial and distal sides of the teeth. The distal wire is 14-33). Some have suggested that the mobile fracture
then delivered under the loop and tightened to the segment should be tightened last, after maxillomandibu-
mesial wire in an apical direction. The loop is then tight- lar fixation. Adaptation of the arch bars to the interdental
ened to adapt it into the interproximal space. spaces helps maximize tooth to arch bar contact and helps
Maxillomandibular fixation between Ivy loops can prevent loosening of the arch bar. The box wires are
then be achieved by various methods. A smaller gauge placed and occlusion is obtained. The circumdental wires
wire can be passed through the loops and tightened. To are tightened and the rosettes are formed. Box wires are
obtain adequate fixation with this method, the loops then fully tightened and maxillomandibular fixation is
should be short enough that they do not overlap and achieved. The goal is to have proper occlusion before
create an unstable fixation. Another method involves complete tightening of interdental wires.
passing a smaller gauge wire around the lugs created by The Erich arch bar and, occasionally, eyelet (Ivy loop)
the loops (Fig. 14-32). and continuous loop (Stout) wiring are used for
intermaxillary fixation. Other modalities more rarely • IMF screws

used are the Risdon wire and intermaxillary fixation • Screwdrivers
screws.151 • Needle drivers
Risdon Wire. Use of a Risdon wire can be advantageous Procedure. This procedure can be performed under
when treating primary and early mixed dentition. Often, local anesthetic or, if the patient cannot tolerate it, under
because of the anatomy of the teeth at this stage of devel- IV sedation or general anesthetic. The mucosa just
opment, the design of conventional arch bars does not medial to the canine region is injected with local anes-
allow for secure maxillomandibular fixation. There are thetic in the upper and lower dentitions. Next, the self-
two separate methods for using the Risdon wire, one tapping IMF screw, 8 to 12 mm in length, is inserted in
continuous cable used on the entire arch or two separate the bone in a transmucosal fashion. Alternatively, the
cables joined at the midline of the arch. mucosa overlying the site can be incised with a no. 15
A 24- or 26-gauge wire is passed around the distalmost blade and pilot holes can be drilled to facilitate insertion.
strong tooth, leaving both ends on the buccal side. The Close attention should be paid to the location of the
wire is then twisted to create a cable, which is fastened mental nerves and root apices to avoid inadvertent
in the same manner to the contralateral distalmost strong iatrogenic injury. Next, IMF is obtained using 24-gauge
tooth.152 Alternatively, a separate 24- or 26-gauge wire can wires.
be twisted around both distal strong teeth and the two The disadvantages of IMF screws are the lack of tension
separately twisted strands can then be crossed at the band effect and interference with internal fixation plates.
midline and twisted around each other.119 Then, as noted Therefore, we recommend their use only in minimally
earlier, a circumdental wire is passed above and below displaced fractures.
the twisted cable to ligate each tooth independently. A The screws can be removed under local anesthetic in
small rosette is formed and elastics are used to create the office. Usually, the mucosa around the screw will
maxillomandibular fixation (Fig. 14-34). grow to cover the head of the screws, necessitating an
Intermaxillary Fixation Screws. The application of arch incision and a minimal amount of dissection to retrieve
bars and insertion of wires in the interdental spaces them.
increase the chance of accidental skin puncture, hence
increasing the chance of transmission of HIV and viral Partially Edentulous Mandible
hepatitis. The use of cortical bone screw fixation for the If the patient is partially edentulous, a preexisting
treatment of mandibular fractures was first described by partial denture can be wired to either jaw using
Karlis and Glickman.150 The advantages of these inter- circummandibular or circumzygomatic wiring tech-
maxillary fixation screws are as follows: niques. If no prosthesis is available, impressions can be
1. Ease of application taken and acrylic blocks can be fabricated, incorporated
2. Decreased operating time hence diminished overall with an arch wire, and applied to the remaining teeth.
cost. The acrylic prosthesis is wired to the mandible with cir-
3. Decreased risk of disease of transmission. cummandibular wires.
4. No impingement of cervical gingiva
Equipment Needed Edentulous Mandible
• Local anesthetic If the patient is completely edentulous, dentures can be
• 24-gauge wire wired to the jaws using circummandibular and circumzy-
gomatic wires or, in the case of a maxillary denture,
palatal screw fixation can be done to hold the denture
(Fig. 14-35). Another method of fixation consists of
placing intermaxillary fixation screws through the
FIGURE 14-35 A palatal screw can be used to hold the splint or

FIGURE 14-34 Risdon wire. denture in place.
preexisting denture to stabilize it and then place the dentulous or edentulous patients, it is most valuable in
patient in intermaxillary fixations. the following situations: (1) in edentulous cases, to main-
If dentures are not available, impressions are taken of tain space where bone is missing because of severe
the jaws and acrylic base plates are processed and used trauma or resection; (2) in severely comminuted frac-
as dentures. An arch bar can also be processed into the tures; and (3) when intermaxillary or rigid fixation
dentures or holes can be placed into the flange of the
denture for intermaxillary wires. Prosthetic incisor teeth
can be removed for existing dentures, and space can be
made in the acrylic to allow food intake (Gunning splint)
(Figs. 14-36 to 14-38).
A technique that should probably be considered as
semiclosed (or semiopen) is the biphasic pin fixation
(Roger Anderson or Joe Hall Morris appliance) tech-
nique. In this approach, pins are placed on either side
of the fracture site and, after fracture reduction, an exter-
nal appliance, followed by an acrylic bar, is placed to
maintain the bone fragments in their proper position
(Figs. 14-39 and 14-40). A variation of this technique, in
which a monophasic appliance is used, has been dis-
cussed.153,154 Although this technique can be used for
FIGURE 14-38 Gunning splint used for edentulous mandibular

fractures.
FIGURE 14-39 The biphasic pin fixation technique is very useful in

fractures for which there is comminution or infection.
fractures.

fractures.
FIGURE 14-40 Biphasic pin fixation technique.
cannot be used. A more detailed discussion of managing of patients, the nerve passed above the inferior border
edentulous patients with fractures is presented in of the mandible proximally to where the facial artery
Chapter 30. crossed the inferior border. In 19% of patients, the nerve
took a downward course, with the lowest being 1 cm
OPEN REDUCTION AND below the inferior border. Whether anterior or posterior
to the facial artery, all branches of the nerve innervated
FIXATION PROCEDURES the depressors of the lower lip, past the inferior border
of the mandible. Those branches remaining below the
Just as there are a multitude of techniques for closed inferior border distal to the facial artery innervated the
reduction and fixation, there are also many methods platysma muscle. The marginal mandibular branch con-
of open reduction and types of orthopedic hardware sisted of two branches in 62% and one branch in 21% of
available for establishing bone approximation. As patients, 8% had three branches, and 3% had three or
noted, open reduction should be used in specific situa- more branches.
tions because of the morbidity attendant with open The dissection to bone is carried through the deep
procedures. cervical fascia by the surgeon, carefully using a nerve
stimulator. The dissection is continued beneath the fascia
SURGICAL APPROACHES to the inferior border of the mandible. The submandibu-
Before operating on a mandibular fracture, the surgeon lar gland and its capsule will become evident, and the
should include the angle of the mouth in the operating lower pole of the parotid may be encountered. The dis-
field to monitor facial nerve activity and ensure that the section is carried to the masseter muscle, with the surgeon
anesthesiologist has not paralyzed the patient for an taking care to retract the nerve fibers superiorly. Once
extended period of time. Factors used to establish the the muscle is encountered, it is sharply divided at the
location of incision include fracture location, skin lines, inferior border to expose the bone. The muscle, perios-
and nerve position. teum, and soft tissue are retracted superiorly to expose
the body, ramus, and fracture site. If facial vessels cannot
Submandibular Approach be retracted successfully, they may be divided and ligated.
The submandibular approach was first described in 1934 Typically, the submandibular lymph node can be identi-
by Risdon.155 The skin incision is 4 to 5 cm in length, fied adjacent to the facial vessels. Exposure can be
2 cm below the angle of the mandible. Optimally, the increased and closure enhanced by dissecting the medial
skin incision should be positioned in an existing skin pterygoid and stylomandibular ligaments from the infe-
crease to hide the scar and should be made at right rior and posterior borders. Further exposure can be
angles to the skin surface (Fig. 14-41). The subcutaneous obtained by distracting the angle and inferior border
fat and superficial fascia are dissected to reach the pla- with a wire or bone forceps. The submandibular gland
tysma muscle. The platysma is sharply dissected to reach and its capsule are usually located just inferior to the
the superficial layer of the deep cervical fascia. The mar- inferior border of the mandible. The parotid gland is
ginal mandibular branch of the facial nerve lies just deep generally posterior to the ramus but may wrap around
to this layer, so it is important to know its course. Dingman the inferior angle. The capsules of both should be
and Grabb155 dissected out the nerve in 100 cases. In 81% avoided during dissection. Disruption of gland paren-
chyma may lead to sialoceles or salivary fistulas.
Retromandibular Approach
Hinds and Girotti156 first described the retromandibular
approach in 1967. This approach was basically a variation
of the submandibular approach except the incision was
approximately 3 cm above the submandibular incision.
The incision is also described by curving behind the
angle of the mandible. The incision is made to encounter
the parotid, masseteric, and deep cervical fascia (Fig.
14-42). The dissection is then extended anteriorly
through the deep cervical fascia with the surgeon using
nerve stimulation. The incision to bone through the mas-
seter muscle is usually between the marginal mandibular
and buccal branches of the facial nerve. The muscle and
periosteum are incised over the angle instead of the
inferior border. The soft tissue and nerve fibers are then
Preauricular retracted superiorly. This incision gives superior access
to the ramus and subcondylar region of the mandible.
Preauricular Approach
Submandibular
This allows for exposure of the TMJ and is easily extended
to allow access to temporal anatomy. The incision com-
FIGURE 14-41 Submandibular and preauricular incisions. monly encounters the superficial temporal vessels, which
inferior attachment of the ear and cheek. Care should

be taken not to extend the incision inferiorly because it
might encounter the facial nerve as it enters the poste-
rior border of the parotid gland. The incision and
dissection should extend just superficial to the perichon-
drium. If this plane is followed, it is unlikely that the
temporal vessels will be encountered and retracted
anteriorly. The dissection is carried anteriorly until the
temporal fascia is encountered at the superior portion of
the incision. Care should be taken not to perforate into
Masseter
muscle
the internal auditory canal as it courses anteromedially.
The superficial temporal fascia is continuous with the
Marginal subcutaneous musculoaponeurotic system above the
mandibular zygomatic arch and extends superiorly to the galea.
branch of VII The undersurface of this layer is where the superficial
temporal vessels, auriculotemporal nerve, and facial
Periosteal nerve are found. All these layers should be retracted
incision anteriorly with the soft tissue flap. The facial nerve has
Skin incision been described as crossing the zygomatic arch 0.8 to
3.5 cm (mean, 2 cm) anterior to the concavity of the
FIGURE 14-42 Retromandibular incision. The Risdon approach
auditory canal. A total of 50% have been found to cross
illustrates the relationship of the marginal mandibular branch of
the facial nerve (VII) to the inferior border of the mandible and
at a point less than 2 cm. The distance from the auditory
periosteal incision (dotted line). concavity and lateral articular tubercle is also 2 cm (1.6
to 2.5 cm) and should be the anteriormost point of dis-
section needed for access.
The temporal fascia divides 2 cm above the zygomatic
arch and is an extension of the parotidomasseteric fascia.
P1 The lateral layer is contiguous with the lateral perios-
E teum and the deep layer is contiguous with the medial
periosteum. Between these two layers is fat, temporal
I vessels, and the zygomaticotemporal branch of the maxil-
lary nerve. A sharp incision is made through the perios-
P2 teum 2 to 3 cm anterior to the skin incision. The
periosteum, vessels, and nerves are then retracted ante-
riorly. The temporal and zygomatic branches of the facial
nerve lie within the lateral periosteum-fascia layer. This
dissection is carried anteriorly to the lateral eminence,
exposing the joint capsule. Fracture location dictates
PA
whether the capsule is opened.
Endaural Approach
The endaural incision is started in the skin crease between
the anterior helical cartilage and tissue, extended down-
R
ward in the cleft between the tragus and helix and inward
approximately 5 mm along the roof of the auditory
canal. As the incision deepens, it is carried anteriorly
through the tragal cartilage. After the tragal cartilage is
FIGURE 14-43 Preauricular incision. Surgical approaches to the released, the incision is deepened along the auricular
posterior mandible and temporomandibular joint. E, Endaural cartilage, similar to the preauricular approach described
approach; I, inverted hockey stick approach; P1, P2, preauricular earlier.
approach; PA, postauricular approach; R, Risdon approach.
Intraoral Access
Symphysis and Parasymphysis. Anterior mandibular
fractures may be accessed via intraoral incisions. First,
can be avoided by incising along the preauricular the incision region is infiltrated with local anesthetic and
cartilage. vasoconstrictors. The lip is retracted and a curvilinear
The incision is made sharply in the preauricular folds, incision is made perpendicular to the mucosal surface.
approximately 2.5 to 3.5 cm in length, as described by It is important to carry the incision out into the lip,
Thoma157 and Rowe158 (Fig. 14-43; see Fig. 14-41). The leaving at least 1 cm of mucosa attached to the gingiva.
preauricular fold is identified by pushing the ear and The mentalis muscle, now visible, should be incised
tragus forward. The incision extends at a 45-degree angle perpendicular to bone, leaving a flap of muscle attached
to the zygoma, from the superior aspect of the ear to the to bone for closure. The dissection is carried
subperiosteally to identify the mental neurovascular telescoping. In this case, the wire must be placed
bundle, approximately midway between the alveolar through both segments of bone, which may be millime-
ridge and inferior border, below the second premolar or ters away from the buccal fracture line. However, if the
slightly anterior. The fracture site is identified and fracture is perpendicular to the buccal surface of the
reduced. The surgical site is closed in layers. The men- mandible, wire should be placed in a figure-eight fashion
talis muscle is secured to the remaining pedicle with to cradle the lower border and to bring the two edges of
interrupted sutures while an assistant reduces the wound the fracture together.
with finger pressure from below. The mucosa is then
closed and an adhesive bandage is applied to the chin to RIGID FIXATION
support the mentalis muscle and thus prevent Although the subject of rigid fixation is discussed thor-
drooping. oughly elsewhere in this text, a short summary of the
Body, Angle, and Ramus. After administration of ade- principles and techniques is included here for complete-
quate local anesthetic and vasoconstrictors, the cheek is ness. Jones and Van Sickels162 reported on this subject
retracted laterally. The mucosa is incised to the bone with and presented a thorough literature review.
the blade positioned perpendicular to the bone to avoid The use of bone screws and compression plates for the
the mental nerve. The incision is made approximately treatment of mandibular fractures is derived from con-
5 mm from the mucogingival junction to allow adequate cepts developed in orthopedic surgery. Currently, tita-
mobile tissue for closure. The proximal portion of the nium and bioabsorbable osteosynthesis systems are
incision should be carried along the external oblique available for rigid fixation. Essentially, three goals are
ridge, only as high as the mandibular occlusal plane. desired—anatomic reduction, fracture fragment com-
Extending the incision higher predisposes the buccal fat pression, and rigid immobilization. Anatomic reduction
pad to prolapsing onto the surgical field. The anterior is thought to promote primary bone repair, resulting in
surface of the ramus can then be exposed by stripping direct lamellar bone formation in medullary bone
the buccinator and temporal tendon with a notched without a cartilaginous phase. In cortical bone, longitu-
angled retractor and periosteal elevator. Once the coro- dinal growth of capillaries and osteogenic cells across the
noid is exposed, a curved Kocher clamp can be applied, fracture line occurs by way of tunnels.
which will act as a self-retaining retractor. Dissection in Compression plating requires absolute stability for
this manner, subperiosteally, keeps the buccal fat pad out bone healing. In contrast, locking plates function as
of the field. The masseter muscle can then be elevated internal fixators with multiple anchor points. Greiwe and
with periosteal elevators and J strippers. The entire ramus Archdeacon have explained that “this type of fixed-angle
and subcondylar region can now be exposed with the device converts axial loads across the bone to compres-
placement of Bauer retractors in the sigmoid and ante- sive forces across fracture sites, minimizing gap length
gonial notches. The masseter can also be retracted with and strain.”163
the placement of LeVasseur-Merrill retractors. The primary goal of a bone plate should be to provide
maximum stability in the bone fracture region with a
Wire Osteosynthesis minimum amount of implanted material. The eccentric
Historically, open techniques were performed through a dynamic compression plates with eccentrically positioned
skin incision or laceration, and wires were generally holes create compression across a fracture. The screws
used to maintain the fracture fragments. With the placed at an angle in the holes tend to converge as they
advent of modern orthognathic surgery, intraoral open are tightened, bringing the bone fragments together.
surgical approaches have become the standard and, Locking plates are designed to be slightly convex, so that
although wire osteosynthesis is still widely used in the when they are tightened on the buccal surface of the
United States, techniques developed in Europe that use bone, compression occurs on the lingual surface. In
bone plates and screws for rigid fixation have become addition, this method was designed to minimize biologic
widely accepted here. Wires may be simpler to place and damage, thereby promoting earlier callus formation. The
usually will maintain the bone fragments and prevent plates are held with monocortical screws (these present
bone displacement by muscle pull until healing occurs. less danger to nerve vessels and tooth roots) or bicortical
However, wires lack rigidity, directional control, and screws (enhanced stability). Tapped screw holes allow
surface to bone surface contact area to maintain rigidity maximal contact between the screw and bone surface
under function, so IMF must be used. On the other area. Self-tapping screws are more easily applied.
hand, with screw or plate rigid fixation, IMF is usually A disadvantage of traditional compression plates is
unnecessary.159-162 that the plate must be perfectly adapted to the underly-
Wire osteosynthesis is most commonly used for angle ing bone to achieve the desired result. Hence, the com-
fractures at the superior border of the mandible; the pression of the undersurface of the plate to the cortical
wire is placed via an intraoral approach. Concomitant bone has been shown to disrupt the underlying cortical
removal of an impacted third molar allows excellent blood supply, which results in bone resorption.164,165 To
access and easy placement of the wire. Parasymphyseal overcome this, the concept of a locking bone plate was
or midsymphyseal fractures are also often reduced and introduced. In this technique, the screws are locked to
fixed, with wire osteosynthesis placed via an intraoral the plate to allow stable fixation without compression of
approach. The wire is positioned beneath the teeth, the plate against the bone.166
inferior alveolar canal, and mental foramen. As noted, In an experimental study, Söderholm et al have shown
fractures in this area are often oblique, causing greater potential for stability with locking screw-plate
systems.167 This system allows for a minimum number of

screws to be placed without the need for a perfect adapta- COMPLICATIONS OF MANDIBULAR
tion of the plate against the bony surface. Another advan- FRACTURE TREATMENT
tage of this system is that the screw is unlikely to loosen
from the bone because it is screwed into the plate.165 Complications following the treatment of mandibular
Studies have shown infection rates varying from 3.6% to fractures are rare. Orthopedic evidence supports the
28%.168-174 avoidance of fracture contamination. Intraoral flora,
Lag screws have been described for use in oblique however, offer a unique risk in the management of man-
fractures. A lag screw has threads on half the shaft, with dibular fractures. Any surgical intervention, open or
the portion below the head being smooth so that it will closed, can theoretically lead to direct wound contamina-
not engage. This allows the inner segment to be com- tion. From a literature review and our experience, it
pressed against the outer segment. The lag screw tech- appears that the most common complication is infection
nique is accomplished by preparing the outer segment’s or osteomyelitis. Reported cases also mention hematoma
drill hole slightly larger than the thread diameter. This or psuedoaneurysm formation and auditory canal hem-
is called the gliding hole. The threads only engage the orrhage.198,199 Contributing factors seem to be preopera-
inner segment and compress it against the outer segment. tive, perioperative, and postoperative oral hygiene,
This technique of bone fixation is stable enough so that presence of teeth in the line of fracture, alcoholic or
maxillomandibular fixation is not needed. Typically, two metabolic disturbances, prolonged time before treat-
to three screws are placed to prevent rotational forces, ment, patient poor compliance or noncompliance, dis-
and the screws must diverge at a minimum of 7%. placement of fracture fragments, and probably iatrogenic
Of paramount importance to many of these systems is causes via open fixation procedures.200-202 Edwards et al161
the concept of a tension band across the mandible. have found a strong relationship between the severity of
Because of muscle actions, different areas of the man- the mandibular fracture and the complication rate.
dible are under different forces at the same time (e.g.,
compression, tension, or neutral). Metal plates posi- INFECTION AND TEETH IN THE LINE OF FRACTURE
tioned over areas of maximal tension allow equal With variations of incidence of mandibular fractures,
distribution of forces over the fracture surface, eliminat- evaluation of infections must also be evaluated on the
ing displacement by muscle action. As expected, these basis of the region and socioeconomic conditions of the
sophisticated techniques are not without difficulty, as dis- population served. Khan,202 in a study from Harare, Zim-
cussed in the following section on complications. babwe, has reported a 22.5% preoperative incidence of
Although anatomic reduction, compression, rigid infection associated with facial fractures and a postopera-
fixation, tension bands, and various metal appliances are tive infection rate of 18%. Abiose,203 in a study from
important in the treatment of difficult to manage long Ibadan, Nigeria, has reported a preoperative infection
bone fractures, it has not been shown that these same rate of 56.25%, but thought that the infection “did not
approaches are vital to the treatment of mandibular frac- necessarily accompany delay nor unduly complicate
tures. Perhaps the one overriding value of these tech- definitive treatment.” From a historical standpoint, it is
niques is the elimination or decreased duration of IMF. interesting to compare current results regarding infec-
Whether the advantages of this technology outweigh its tion with those reported by Chambers and Scully204 in an
disadvantages has yet to be proven. article written about mandibular fracture treatment in
India during World War II. Of 124 patients treated for
ENDOSCOPIC REPAIR mandibular fractures, 46% had teeth extracted from the
line of fracture and 44% had postoperative infections
Medical uses of endoscopy date back to the era of Hip- and delayed union.
pocrates. With the advent of the flexible endoscope and Kelly and Harrigan,76 although admitting that “a
fiberoptics, endoscopic techniques have revolutionized a certain percentage of patients treated were lost in
number of approaches in the surgical field. The endo- follow-up,” reported that 66 cases (2.3%) of a total of
scopic approach to the treatment of abdominal and 3329 fractures (including ramus, coronoid, and condyle)
gynecologic disorders has been well established.172 Initial required a surgical extraoral procedure, necessitating
applications in craniomaxillofacial surgery were for aes- drainage, or sequestrectomy or saucerization. The most
thetic procedures, such as the brow-lifting procedure and common organisms isolated were Staphylococcus (60%),
forehead recontouring.175-177 Uses were expanded within Streptococcus (20%), and others (14%), including two
the field to treat orbital wall fractures,178-183 distraction cases of Actinomyces and one of Klebsiella infection. Cul-
osteogenesis,180,181 zygoma fractures,186,187 frontal sinus tures were apparently not done for anaerobes. In a
fractures,188-190 cranial synostosis,191,192 and subcondylar limited study, Rajasuo et al found that most anaerobe
fractures.193-197 By using the endoscopic technique, the specimens (Actinomyces, Campylobacter, and Lactobacillus
risk of damage to the facial nerve and visible scarring is spp.) were associated with third molar involvement.205
minimized. For our purposes here, the endoscopic tech- In a review of 909 cases of mandibular fractures from
nique is mostly used for the repair of subcondylar frac- Cape Town, South Africa, Melmed and Koonin,206 found
tures (discussed elsewhere in this text), but it can also be 85 cases of sepsis and 4 cases in which osteomyelitis devel-
used for the repair of high ramus fractures. The surgical oped. Of the 85 sepsis cases, 4 occurred with open reduc-
approach is via a transoral sagittal splitlike incision or an tion, 5 were caused by a tooth in the line of fracture, 8
extraoral submandibular incision. resulted from the application or removal of
Gunning-type splints, 25 resulted from very poor teeth, of injury that are significantly mobile, have root exposure
and 43 (50%) were caused, the authors believed, by a in markedly distracted fractures, or interfere with reduc-
delay of more than 48 hours in seeking treatment after tion or fixation of the fracture were extracted. These
injury. Interestingly, Smith207 has demonstrated that selection criteria are perhaps more stringent than
there was no increase in the incidence of wound dehis- those to which most clinicians would subscribe. Marker
cence, wound infection, or delayed union in patients et al210 have demonstrated a 3.5% incidence of infection
who had delayed osteosynthesis from 2 to 11 days after when closed reduction was used in patients in whom a
injury. completely or partially impacted third molar was in the
Olson et al,84 in their analysis of 580 cases of fractured line of fracture. They postulated that the infection
mandible, found that 156 (26.9%) had some type of rate was low compared with that with rigid fixation
complication, including infection, respiratory disorders, because patients were not allowed to move their jaws
neurologic problems, delayed healing, and nonunion. immediately.
They said that “Complications are the most common in In a study of 26 mandibular fractures, Chan et al211 has
the vehicular-accident victim who has sustained multiple reported that 8 developed complications, including soft
injuries. The patient who sustains only mandibular frac- tissue infections, osteomyelitis, malunion, and nonunion.
ture with or without facial laceration, seldom experi- A common feature in all these cases was infection of
ences complications.” teeth in the line of fracture and poor compliance or
In one of the few prospective studies in the literature, noncompliance with the treatment plan. The results of
James et al81 evaluated 253 consecutive patients with 422 their literature review and retrospective study are pre-
mandibular fractures and found a postoperative infec- sented in Table 14-1.
tion rate of 6.95% (16 of 230 fractures with sufficient In a study by Ellis in a sample of 402 patients,173 a
follow-up). There were 261 teeth directly associated with postoperative complication rate of 19% was found in the
mandibular fractures, 39% of which were extracted at the group containing teeth in the line of fracture and a com-
time of treatment. The postoperative infection rate had plication rate of 15.8% in fractures not containing teeth
no bearing on whether the tooth in the line of fracture in the line of fracture (p = NS [not significant]). For
was extracted or not. They used antibiotic therapy rou- those fractures associated with a tooth, when the tooth
tinely for all patients with compound fractures. Of these was retained, the incidence of infection was 19.5%. When
patients, 46 did not continue taking antibiotics after hos- the tooth was removed, the incidence was 19.0%.174 In a
pital discharge and, in 4, postoperative infection devel- similar study, Malanchuk and Kopchak observed that
oped. Of the 177 fractures that required an open noncarious teeth in the line of fracture could not be
reduction, 12 (6.78%) became infected. Of the 12 infec- considered a predisposing factor for the development of
tions, 6 were associated with angle fractures in which the infection.212
tooth in the line of fracture was extracted at the time of Roed-Petersen and Andreasen213 found that there was
surgery. In contrast to the study of Olson et al,84 most of much less pulp necrosis in teeth involved in the fracture
their infected fractures were related to injuries involving site when the fracture was treated within 48 hours (15%
IPV. The authors’ data supported the concept that
healthy teeth in the line of fracture do not increase the
incidence of infection and, in many cases, their aid to
stabilization outweighed the consideration of infection.
It is interesting that aerobic and anaerobic organisms TABLE 14-1 Studies of Mandibular Fractures Involving
were obtained from cultures of specimens from the 16 Teeth
patients with postoperative infections, with alpha- Teeth in Infection, Incidence of
hemolytic streptococci and Bacteroides organisms found No. of Fracture Delayed, Complications
most often. Most of the organisms cultured were sensitive Study Patients Line Nonunion (%)
to penicillin. Neal and 519 260 87 32
Two studies have shown remarkably similar results. Wagner
Amaratunga135 found an infection rate of approximately Kahnberg — 185 14* 13
5%, with or without teeth in the line of fracture (191
Wilkie 250 190 — 8
patients, 226 fractures). Schneider and Stern208 found
complications, including delayed union, infection, and Zallen and 643 64 36* 50 (without
odontalgia, in 5% of patients who had teeth in the line Curry antibiotics)
of fracture (157 patients, 199 fractures). Bernstein and 6 (with
McClurg41 studied 156 consecutive patients with fractures antibiotics)
of the mandible and found that in 20 patients (12.82%), Ridell 84 — 20* 4.2
infections developed; 4 of the infections were related to Roed- 1 110 27* 25
teeth in the line of fracture. Prophylactic antibiotics did Peterson
not seem to affect the incidence of infection. Kromer 113* 60 32 53
Chuong and Donoff209 found little difference in the Chan et al 26 26 8 30
incidence of infection when comparing the retention of
*Data modified from statistics presented in cited references.
teeth in the line of fracture with the extraction of teeth Data from Chan DM, Demuth RJ, Miller SH, Jastak JT: Management of
in the fracture site (14% versus 11%, respectively). mandibular fracture in unreliable patient populations. Ann Plast Surg
However, they were careful to note that teeth in the line 13:298, 1984.
versus 37% for those treated later). A study by Kamboozia individual systems and postoperative complication rates
and Punnia-Moorthy214 evaluated the dental complica- when the fracture area remains constant. These studies
tions associated with the teeth in the line of mandibular involved the use of two dynamic compression miniplates
fractures. They demonstrated a statistically significant (31 fractures), the AO reconstruction plate (52 frac-
increase in the incidence of nonvitality of teeth adjacent tures),221 two 2.4-mm dynamic compression plates (65
to and in the line of a fracture when open reduction and fractures),222 and two noncompression plates (69 frac-
internal fixation were performed as opposed to IMF. tures)223 in the treatment of mandibular angle fractures.
All the fractures were treated with open reduction and
Factors Affecting Incidence of Infection and internal fixation only, using AO-ASIF principles.
Other Complications The lowest infection rate, 7.5%, was seen in the frac-
Closed Versus Open Reduction. Factors regarding the tures treated with the AO reconstruction plate and the
location and degree of severity (see earlier) can dictate highest rate, 32%, was found in the 2.4-mm dynamic
treatment modality. Earlier reports have noted that surgi- compression miniplates. The dynamic compression
cal experience, along with patient history (e.g., substance plates and the noncompression plates each had an
abuse, excessive alcohol consumption) can have a signifi- infection rate around 25%. Interestingly, it was noted
cant affect on treatment outcome with either approach. that in the group of fractures treated with the 2.4-mm
Passeri et al215 have reported a 13% incidence of infec- dynamic compression plates, the mandibles that had
tion when using nonrigid fixation on 99 angle fractures fixation screw holes tapped had a lower incidence of
in 96 patients. They thought that the high incidence of infection than those that were untapped—29% and
infection was secondary to the patient population studied 40%, respectively. It can therefore be concluded that
and a 3- to 4-day delay in treatment. smaller plates have an increased rate of infection, possi-
Lamphier et al216 have reviewed 594 mandibular frac- bly because of a lack of providing absolute rigidity. In
tures and compared the complications associated with this series of articles, only the AO reconstruction plate
open and closed treatment over a 4-year period. In an was found to provide a predictably low incidence of
urban setting, they found that closed reduction offered complications.
a lower incidence of postoperative morbidity when com- Ellis also examined the outcomes of two 1.0-mm mini-
pared with open reduction techniques. Their results plates versus a single larger, stronger 1.25-mm plate in
showed a 3.2% infection rate in the closed reduction treatment of mandibular symphysis and body fractures.218
group versus 9.1% in the open reduction group. One of the most notable results showed an increased
In a retrospective review of 100 fractures in 56 patients, incidence of wound dehiscence and plate exposure in
Moore et al82 have found a postoperative infection rate the two-plate group, 6%, versus the single-plate group
of 9.8% in those managed with open reduction com- with 4%. However, the single-plate technique showed an
pared with a rate of 8.9% in those treated by closed 11% rate of postoperative infection compared with a 7%
reduction. There were too few cases to generalize on the infection rate with the two-plate technique.
effect of teeth in the line of fracture. Surprisingly, nine Danda has compared postoperative complications in
patients (16.1%) had soft tissue infection. a randomized study of treatment with two noncompres-
Terris et al217 have retrospectively evaluated 183 frac- sion miniplates versus a single noncompression mini-
tures in 112 patients for the incidence of major complica- plate in patients with mandibular angle fractures. No
tions, including infection, when comparing open significant advantage was seen in the use of two mini-
reduction with plate osteosynthesis, open reduction with plates over a single plate.224
wire osteosynthesis, and closed reduction. Results of this With the advent of the locking screw-plate system,
study demonstrated a statistically significant difference in infection rates as low as 3.6% have been cited in the lit-
the rate of infection and other major complications erature, confirming the advantages associated with this
between plate osteosynthesis and the other two forms of system.225
treatment. The incidence of infection was not significant Antibiotics. Larsen and Nielsen95 have cited studies
when wire osteosynthesis was compared with closed showing infection in 36 of 104 patients with mandibular
reduction. However, a significant difference was found fractures before the use of antibiotics, a 19% incidence
when the frequencies of other complications (malocclu- of infection in a partially preantibiotic period (1943 to
sion, delayed union, and inadequate fixation) were mea- 1953), and a current infection rate of 0%. Their study of
sured and compared between these two groups. 229 patients showed a 0.4% incidence of infection. They
Leach and Truelson218 have reported similar findings attributed their low infection rate to early treatment,
when comparing plate osteosynthesis with traditional thorough wound cleaning before treatment of com-
methods (intermaxillary fixation, wire osteosynthesis, pound fractures, and prophylactic antibiotics.
and external fixation). They reported a 30% incidence In a prospective randomized study (64 patients) of
of infection in the plating group, as opposed to 13% in antibiotic usage for the treatment of fractures with teeth
the traditional group. in the line of fracture, Zallen and Curry139 have found a
Different Rigid Fixation Techniques and Systems. Rigid complication rate of 6.25% in patients who received anti-
fixation techniques, as noted, can be categorized into biotic coverage compared with a complication rate of
two groups, locking and nonlocking. Ellis et al219-223 have 50.33% in those who did not.
studied the effects of different plating systems and tech- Limchayseng138 has studied 158 mandibular angle
niques on mandibular angle fractures; these studies fractures and found infection, despite postoperative anti-
provide us with information on the performance of biotics, in 25% of patients in whom third molars were
retained in the line of fracture. In this study, however, and one case of inadequate reduction and fixation of the
86% of the third molars were removed before fracture angle were noted. In all cases, union progressed in 4 to
reduction and fixation. A higher infection rate was also 5 weeks.
reported when fractures were moderately or grossly dis- Freihofer and Sailer229 found a complication rate of
placed. Fractures treated by rigid fixation showed a 7% in 148 patients with 178 wiring sites approached
higher incidence of infection (28%) than those managed intraorally, combined with 4 weeks of intermaxillary fixa-
with open reduction with superior border wire fixation tion. Complications included occlusal abnormalities
(6%); however, fractures with more displacement tended (3%), delayed bone union (3%), pseudarthrosis (0.5%),
to be treated with rigid fixation. and osteomyelitis of the fracture site (0.5%).
Current studies, however, question the actual benefit Wire Osteosynthesis Versus Rigid Fixation. In an exten-
of prophylactic antibiotics. Kyzas has reviewed 31 studies sive review, Theriot et al230 found the reported infection
of more than 5000 patients, and ultimately argued that rate to be variable when comparing wire osteosynthesis
the “overall evidence for the use of prophylactic antibiot- with bone plate osteosynthesis in the treatment of man-
ics is poor.”199 In a prospective, randomized, double-blind dibular fractures. The range was between 0.5% and
clinical study, Abubaker and Rollert have found no 14.7% for wire osteosynthesis, with European studies
advantage in the use of postoperative oral antibiotics for having the lowest rate of infection (1.1% via an extra-
the treatment of uncomplicated mandibular fractures.225 oral approach and 0.5% via an intraoral approach). In
Lovato and Wagner,141 in a retrospective study of 150 the United States, the authors reported infection rates
patients, that approximately 10% of those in the extended from 6.6% to a high of 14.7% when wire osteosynthesis
antibiotic group developed an infection whereas 13% of was used in a limited number of patients. The data
patients became infected in the perioperative group. derived from this review have shown an initial high rate
Extraoral Versus Intraoral Surgery. With the advent of of infection associated with bone plate osteosynthesis,
trocar and cannula systems, extended extraoral incisions decreasing as the researchers became more proficient
have been minimized to small stab incisions. Over a with the technique. They also cited studies on the inci-
7-year period, Mehra and Murad treated 98 fractures dence of infection with bone plates—3 of 11 patients
with an intraoral or transoral approach and 65 fractures infected (27%), 5 of 26 patients infected (19.2%), and
with an extraoral approach.226 Interestingly, the results 25 infections in 171 patients (14.6%).156 They also
showed a similar post-perative complication rate of reported on other results, a 3.8% infection rate in a
infection between the two modalities, 2% and 1.5% series of 183 patients and a 3.5% infection rate using
respectively. compression plate osteosynthesis. In their own prospec-
Wagner et al227 have studied the morbidity associated tive study of 75 patients with 126 mandibular fractures,
with extraoral open reduction (82 patients, 100 frac- they reported infections in 4 of 34 patients with 52 frac-
tures) and found a complication rate of 13%, including tures treated by bone plate osteosynthesis and two infec-
a wound or bone infection rate of 10%. They found that tions in 41 patients with 74 fractures treated by wire
67 fractures were associated with teeth and, in 32 cases, osteosynthesis.
the teeth were removed before reduction. The group Using AO-ASIF and osteo systems, Tu and Tenhul-
with teeth in the line of fracture had 9 of the total of 13 zen231 have reported removing the plates in 11.4% of
postoperative complications, including three wound patients because of complications when using the
infections and six infected fractures that required Champy system for mandibular fractures (183 cases).
sequestrectomies. Becker232 has reported infection (3.8%), malunion
Kerr228 has analyzed 755 facial fractures and noted (0.5%), nonunion (0.5%), and the need for occlusal
post-treatment infection in three mid-face fractures and equilibration (4.8%) while using the Champy system. In
13 mandibular fractures. Of these 13, nine involved 50 cases, Cawood233 found infection in 6% and malocclu-
extraoral open reduction and lower border wiring. In sion in 8%.
seven of the nine cases, the offending organism was Souyris et al234 have reported a 12-year study using
Staphylococcus pyogenes, and the onset was within 4 to 10 cobalt-chromium alloy (Vitallium) plates with bicortical
days after treatment. The cases were treated with incision self-tapping screws placed along the inferior border of
and drainage, without removal of the wire. It was sug- the mandible. Postoperative infections occurred in 14.5%
gested that this indicated that the infection had not of patients (25 of 171), 20 additional patients required
involved the fracture itself but was a superficial wound removal of the plates because of the late development
infection introduced at the time of operation. (months to years) of an inflammatory reaction, and 15%
Chuong and Donoff209 have evaluated their mandibu- of patients had occlusal discrepancies managed by occlu-
lar fracture cases treated via an intraoral approach. Of sal equilibration. Using Vitallium cobalt-chromium plates
372 fractures, 161 were treated by open reduction via an with bicortical self-tapping screws, Luhr64 has reported
intraoral approach and 23 involved removal of an an infection rate of 5.7% (105 patients) for extraoral
impacted or partially erupted third molar and placement placement and 3.2% (255 patients) for intraoral
of an intraoral upper border wire. Three body fractures placement.
in edentulous portions of the mandible and five symphy- In a retrospective analysis, Terris et al217 have mea-
seal fractures were treated by intraoral wire fixation. Four sured the frequency of major complications (e.g., infec-
complications were seen in the 31 fractures (12.9%) tion, malocclusion, hematoma, inadequate fixation)
treated by the intraoral approach. Two cases of dehis- between plate and wire osteosynthesis. Their study dem-
cence of the angle, one case of infection of the symphysis, onstrated a significant difference between the two groups,
30.6% and 10.3%, respectively. Infection was the most and one was in the symphysis. Seven patients had open
frequently reported complication. They failed to mention reduction and four had preoperative or postoperative
any incidence of postoperative nerve injury or deficit. In infection. Two nonunions occurred in the angle and one
their retrospective study Leach and Truelson have noted occurred in the body. Moore et al82 found a nonunion
that rigid internal fixation is associated with a significant rate of 1.8% in 56 patients with 100 mandibular fractures.
difference in the rate of nerve injury, infection, operative The nonunion occurred in a 74-year-old patient with
time, and cost when compared with traditional methods.218 bilateral fractures of an atrophic edentulous mandible.
They also noted that significantly fewer patients in the Bernstein and McClurg41 have reported delayed union in
rigid fixation group returned for at least 6 weeks of 5 of 156 patients with mandibular fractures. The diagno-
follow-up. sis was made by eliciting pain when the fracture site was
Ellis has prospectively reviewed three treatment torqued; treatment consisted of additional IMF time. In
methods over a 12-year period235: (1) nonrigid fixation a study from Sweden, Heimdahl and Nordenram94 found
that included 5 to 6 weeks of maxillomandibular fixation; two patients with osteitis and osteomyelitis, causing severe
(2) nonrigid but functionally stable fixation using a bone loss and pseudarthrosis, in 100 patients. They
single miniplate; and (3) rigid fixation using two mini- believed that abuse of alcohol or narcotics, or both,
plates. Of 60 patients treated with nonrigid fixation, 32 resulted in uncooperativeness on the part of patients
complained of neurosensory deficit and 9 had a wound (23%) and contributed to the nonunion. Chuong and
problem (e.g., cellulitis, purulence, dehiscence). Of 62 Donoff209 defined delayed union as mobility of the frac-
patients treated with one miniplate (nonrigid), 37 com- ture site after 5 weeks of treatment with maxillomandibu-
plained of neurosensory deficit and 2 had a wound lar fixation. Using this rather strict criterion, they found
problem. Of 63 patients treated with two miniplates that delayed union occurred in 12 of 372 mandibular
(rigid), 31 complained of neurosensory deficit and 14 fractures(3.1%). No cases of nonunion were reported.
had a wound problem. The outcomes showed that the Haug and Schwimmer237 have reported 32 cases of fibrous
use of a single miniplate generated fewer complications union in 714 patients. They concluded that age, race,
comparatively. gender, mechanism of injury, and noncompliance with
antibiotic therapy were not factors contributing to
formation of a fibrous union. They determined that self-
OTHER COMPLICATIONS abusive habits (e.g., alcohol and drug abuse), inadequate
Delayed Healing and Nonunion immobilization, location of the fracture, teeth in the line
Delayed healing and nonunion of the mandible are rare of fracture, and postoperative infections all contributed
and occur as a result of violation of the treatment goals to the development of a fibrous union.
outlined in the previous section. By definition, a non-
union is the lack of osseous union by two or more frac- Delayed Healing and Nonunion Related
ture segments after the usual healing period. Infection to Fixation Techniques
is the greatest factor, but severity of the injury, inade- Bochlogyros238 has reviewed German studies, compiled
quate reduction, lack of fracture stability, uncooperative the nonunion cases, and categorized them by treatment
patients, alcoholism, and metabolic and nutritional defi- method: (1) closed reduction and intermaxillary fixa-
ciencies all play a major role in prolonged healing. tion; (2) interosseous wiring; and (3) stable compression
Kelly and Harrigan76 have reported 34 nonunions of plate fixation. The results are shown in Tables 14-2 to
the mandible of 3338 mandibular fractures (1%). Infec- 14-4. It was found that the factors predisposing to non-
tion accounted for the greatest number of nonunions, union are delay in treatment, inadequate immobiliza-
and lack of cooperation by the patient (e.g., removal of tion, and osteomyelitis of the fracture site before and
IMF) was second. The most common site of a nonunion after surgery.
was in the body of the mandible. Bui et al236 have noted
that one subject released maxillomandibular fixation
multiple times during the course of treatment; this TABLE 14-2 Incidence of Nonunion of Fractures of the
patient subsequently developed an infection and skewed Mandible After Closed Reduction and Intermaxillary Fixation
their complication rate from 6.2% to 8.2%. In the same Study (year) No. Of Patients Nonunion
study, they reviewed 49 patients with mandibular frac- Wassmund (1943) 1500 2 (0.1%)
tures that were accessed through intraoral exposure and
Köle (1956) 655 (0.6%)
reduction using a 2.0-mm, eight-hole strut plate. Although
the study had limited participants, an extraordinary Herrmann et al (1960) 556 8 (1.4%)
result showed absolutely no nonunion or malunion.237 Paschke and Berz (1961) 385 5 (1.3%)
On the other hand, Melmed and Koonin206 had 20 Müller (1967) 2258 17 (0.8%)
cases of nonunion resulting from 909 fractures of the Trauner (1973) 530 4 (0.8%)
mandible (2.2%). They believed that alcoholism, delay Claudi and Spiessl (1975) 68 1 (1.5%)
in seeking treatment, and carious teeth contribute to the
Mathog and Boies (1976) 577 14 (2.4%)
problems of management and complications. The pro-
spective study of James et al81 showed delayed union (no Krüger (1982) 104 1 (0.96%)
clinically evident union after 8 weeks) in 9 of 253 patients Bochlogyros (1985) 529 3 (0.6%)
(3.5%) and nonunion in 3 patients (1%). Of the delayed From Bochlogyros PN: Non-union of fractures of the mandible. J Maxil-
unions, four were in the angle, four were in the body, lofac Surg 13:189, 1985.
hemostasis. Citing an extensive literature review on

TABLE 14-3 Incidence of Nonunion of the Mandible After alcohol and its relationship to mandibular fractures,
Interosseous Wiring Adele et al242 have carried out a retrospective study on
Study (year) No. of Patients Nonunion 401 patients with fractures of the body of the mandible.
Edgerton and Hill (1952) 434 18 (4.5%) The most notable variable related to delayed healing was
Plumpton and Crawford (1955) 30 1 (3%)
the frequency of alcohol abuse. They stated that “… the
frequency of patients with alcohol problems and psycho-
Freihofer and Sailer (1975) 148 (178 fr.) 1 (0.5%)
social handicaps is reported high in most studies on jaw
Schegg et al (1975) 450 2 (0.5%) fractures.” The patients in the delayed healing group
Bochlogyros (1985) 139 1 (0.7%) were more frequently intoxicated by alcohol at the time
From Bochlogyros PN: Non-union of fractures of the mandible. J Maxil- of trauma and at the first visit. As a group, they were
lofac Surg 13:189, 1985. much less likely to keep appointments and were more
apt to remove their own maxillomandibular fixations.
Eid et al243 have found that complications were more
likely to occur in the presence of an alcoholic state, poor
TABLE 14-4 Incidence of Nonunion of the Mandible After oral hygiene, and uncooperativeness. In an analysis of
Stable Compression Plate Fixation 352 patients with 589 fractures, Passeri et al244 reported
Study (year) No. of Patients Nonunion a statistically significant relationship between chronic
Schmitz et al (1975) 220 2 (0.9%) substance abuse and postoperative complications. They
Scharf and Reuter (1975) 82 1 (1.2%)
reported a 6.2% rate of complications in patients with no
history of substance abuse and a complication rate of
Bochlogyros (1985) 78 3 (3.9%)
15.5% for chronic alcohol abusers, 19.2% for non-IV
From Bochlogyros PN: Non-union of fractures of the mandible. J Maxil- drug abusers, and 30% for IV drug abusers. In another
lofac Surg 13:189, 1985. study of 472 patients presenting with 699 mandibular
fractures, Serena-Gomez and Passeri found an 8.5% com-
plication rate in non–substance abusers, 17% for alcohol
Facial Widening abusers, 14% for non-IV drug abusers, and 37.5% for IV
Ellis and Tharanon239 have noted this complication in drug abusers.245 The correlation between substance abuse
case reports. The use of rigid fixation in mandibular and postsurgical complications can be attributed to physi-
fractures can cause facial widening if the device is not ologic alterations and patient behavior.
correctly placed. The type of mandibular fracture that is Recognizing the delayed healing problem in alcohol-
most prone to this complication is a symphyseal fracture ics, Cannell and Boyd246 set up a specific treatment pro-
associated with condylar fractures and poor dentition. In tocol especially for the vagrant alcoholic patient. These
symphyseal fractures, muscle pull from the tongue and patients were kept in the hospital for 1 month or longer.
suprahyoids can cause lateral flaring of the mandibular Open reduction was avoided, if possible, and additional
angles and lingual tipping of the buccal segments. The fixation was used (metal cap splints, when possible).
buccal fracture line at the symphysis remains intact, but When open reduction was necessary, a minimal amount
the lingual cortex is separated. Increased flaring is seen of periosteum was reflected and heavy antibiotic cover-
when bilateral subcondylar fractures are also present. In age was instituted. Despite all their precautions, infection
this case, the buccal segments are flail segments, and of fractures or wounds occurred in 12 of 16 patients in
precise reduction is paramount. Flaring is also caused by the series. In 8 of these, rigid fixation was used after
tightening of the maxillomandibular fixation wires. The thorough cleansing of open fracture sites, removal of
authors have suggested a simple solution. Providing pres- teeth in fracture lines, and strict attention to aftercare.
sure in a medial direction to the gonial angles during The authors noted that the accumulation of hepatic fat
reduction and fixation can help alleviate the chance of may lead to diffusion of fatty emboli capable of impairing
a facial width complication. local blood supply. They believed that the quality of the
In a similar study, Cillo and Ellis have found that mandibular bone was poor and that movement of the
approximately 25% of patients with double unilateral fracture sites because of noncompliance was the most
mandibular fractures show gonial flaring on the affected likely precursor of infection. They also speculated about
side.240 It was noted that patients with posterior occlusion secondary osteoporosis, osteomalacia, and vitamin defi-
had the most favorable outcome. ciency in the undernourished alcoholic. Perhaps the
subject is best summed up by Heimdahl and Nordenram,
Alcoholism, Substance Abuse, Immunosuppression, who concluded that the “treatment of these patients is
and Delayed Healing … not only surgical but very much social.”94
Alcohol abuse and mandibular fractures are closely inter- Numerous studies have documented that substance
related in regard to cause and the increased incidence abuse and medically compromised patients have an
of complications.207,241 Recovery is compromised in an increased risk of developing a postoperative complica-
alcoholic because of the suppression of T cell counts and tions following treatment. Human immunodeficiency
a delayed response in cell migration, adhesion, and virus (HIV) infection causes a decline in the CD4 (T
signal transduction.242 Also, chronic alcohol consump- helper cell) count, resulting in impaired immunity.
tion reduces protein production, which negatively affects Martinez-Gimeno et al247 and Schmidt et al248 have
platelet counts and aggregation, leading to improper reported a higher overall postoperative infection rate
with HIV-positive patients. However, controversy still minimally displaced fracture of the condyle on the
remains as to whether the HIV-positive patient is at same side. Recovery was complete 2 months after
increased risk of developing a postoperative infection. surgery.
With HIV, variables include antiretroviral medications, Schmidseder and Scheunemann251 have reported on
virulence of the HIV strain, and the fact that a relatively nerve injury following condylar neck fractures. They
intact immune system may still be present. It is essential found post-traumatic neurologic complications in 8 of
to obtain an accurate history of the patient’s past oppor- 237 fractures. One case involved the chorda tympani,
tunistic infections and CD4 count as a means of better with unilateral loss of taste in the tongue. One case
assessing patient vulnerability for negative treatment involved the facial nerve, resulting in total paresis. Five
outcomes.201 cases involved the auriculotemporal nerve and, in two of
the cases, Frey’s syndrome developed. One case involved
Nerve Disorders the buccal branch of cranial nerve VIII and occurred 7
The most commonly injured nerve associated with man- days after a condyle was grossly medially displaced. Most
dibular fractures is the inferior alveolar nerve and its of these cases improved over time.
branches—mylohyoid, dental branches, incisive branch
and, especially, the mental nerve. Rarely, other branches SUMMARY
of the mandibular nerve may be injured, such as the
masseteric (condylar fractures), buccal (intraoral lacera- From this review, it is apparent that infection is the most
tions associated with angle or body fractures), auriculo- common type of complication arising from the treatment
temporal (condylar fractures), and lingual (intraoral of mandibular fractures. Although the incidence varies,
lacerations) nerves. The prominent sign of inferior alve- it appears to range from 5% to 10% (average). Preopera-
olar nerve deficit is numbness or other sensory changes tive oral sepsis, with grossly carious and periodontally
in the lower lip and chin. involved teeth, contributes to the problem and, unless
A rare but impressive nerve deficit is that associated diseased teeth are important for reduction and fixation
with the marginal mandibular branch of the facial nerve. of the fracture, they should be removed. Inadequate
The telltale motor dysfunction of the musculature of the immobilization of the fracture segments and prolonged
face or lips can result from trauma in the region of the delay in treatment also contribute to infection.
condyle, ramus, and angle of the mandible and from Although it would be expected that open reduction
lacerations affecting the facial nerve, particularly the dis- would contribute to infection, this relationship is not
tribution of the marginal mandibular branch. Most of evident in a review of the literature. In addition, there
the sensory and motor functions of these nerves will appears to be little difference between the infection rates
improve and return to normal with time because they are of intraoral and extraoral open reduction procedures.
a consequence of compression or stretching; however, Rigid fixation techniques are initially seen to result in
lacerations or nerve tissue loss produced by grossly dis- a higher complication rate, but as surgeons become
placed fracture fragments, soft tissue loss, or gunshot more proficient with the procedures, complication rates
wounds can result in permanent deficits. fall. Delayed union results from infection, lack of frac-
There are a few studies of sensory nerve deficit associ- ture stability, noncompliance, and alcoholism. Nonunion
ated with mandibular fractures. Renzi et al have prospec- is extremely rare.
tively reviewed 97 patients with 103 facial fractures. It is evident that alcohol abuse plays a major role in the
Reportedly, presurgical trigmeninal nerve impairment cause of mandibular fractures and results in a higher rate
was higher when fractures were associated with direct of complications following treatment. This higher com-
nerve involvement (100%) and dislocated fractures plication rate can be attributed immunosuppression as
(84%) as opposed to nondisplaced fractures (47%). well as noncompliance because of impaired judgement.
After 12 months, residual hypoesthesia was noted only There are few studies on the incidence of permanent
with 6 mandibular fractures, which were associated with nerve damage associated with mandibular fractures to
direct nerve involvement. Moore et al82 (56 patients, 100 allow any definitive conclusions to be reached. More
fractures) have reported an incidence of mental nerve controlled prospective studies on the various methods of
paresthesia of 1.89% and facial nerve damage of 1.8%. reduction and fixation of mandibular fractures are neces-
It is not known whether the deficit was permanent. sary to establish clinical protocols.
Larsen and Nielsen95 have reported permanent sensory
disturbances in the area of the mental nerve following ACKNOWLEDGMENT
mandibular fracture in 19 patients, corresponding to 8%
of 229 patients evaluated. The authors wish to thank Dr. Ramin Bahram and
Milford and Loizeaux249 have reviewed the literature Dr. Keith Silverstein for their previous contributions to
on false aneurysms and partial facial paralysis secondary this chapter.
to mandibular fractures. They also noted one case of
facial paralysis following a fracture of the mandibular
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1980. lofac Surg 20:297, 1992.
248. Ellis E 3rd: A prospective study of 3 treatment methods for iso- 262. Schmidt B, Kearns G, Perrot D, Kaban L: Infection following treat-
lated fractures of the mandibular angle. J Oral Maxillofac Surg ment of mandibular fractures in human immunodeficiency virus
68:2743, 2010. seropositive patients. J Oral Maxillofac Surg 53:1134, 1995.
249. Bui P, Demian N, Beetar P: Infection rate in mandibular angle 263. Renzi G, Carboni A, Perugini M, et al: Posttraumatic trigeminal
fractures treated with a 2.0-mm 8-hole curved strut plate. J Oral nerve impairment: a prospective analysis of recovery patterns in
Maxillofac Surg 67:804, 2009. a series of 103 consecutive facial fractures. J Oral Maxillofac Surg
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of 27 patients. J Oral Maxillofac Surg 52:832, 1994. 264. Milford ML, Loizeaux AD: Facial paralysis secondary to mandibu-
251. Bochlogyros PN: Non-union of fractures of the mandible. J Maxil- lar fracture: report of case. J Oral Surg 30:605, 1972.
lofac Surg 13:189, 1985. 265. Rapids AD, Brock DO: Delayed facial paralysis after a condylar
252. Ellis E 3rd, Tharanon W: Facial width problems associated with fracture. Br J Oral Surg 14:220, 1977.
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CHAPTER
Traumatic Injuries to the
15 Mandibular Condyle
David M. Yates
| John R. Zuniga
| Michael F. Zide
OUTLINE
Condylar Neck Region Biomechanics Complications of Condylar Fracture Treatment
Classification of Temporomandibular Joint Fractures Condylar Fractures in Children
Strasbourg Osteosynthesis Research Group Physical Therapy for Condylar Fractures
Classification for Management of Subcondylar Fractures
Radiographic Evaluation Condylar Fractures
Mandibular Condylar Fractures
Indications for Reduction
Treatment
Reduction of the Condyle for Access
T
he literature suggests that condylar fractures (subcondylar) fractures (25%).10 In isolated condylar
account for 17.5% to 52 % of all mandibular frac- fractures, the degree of malocclusion increases as the
tures. In most condylar fractures, direct force to fracture moves distally. Malocclusion was present in only
the distal mandible sequentially shocks the joint area 12% of intracapsular fractures, 31 % of condylar neck
proximally.1-5 fractures, and 57% of subcondylar fractures.9
CONDYLAR NECK REGION BIOMECHANICS CLASSIFICATION OF

Multiple factors create condylar head displacement, TEMPOROMANDIBULAR JOINT FRACTURES
including direction, magnitude, and the point of
maximum force.6 Stability of the occlusion and jaw posi- Temporomandibular joint (TMJ) classification schemes
tion (open versus closed) during the traumatic insult tend to be complex, difficult to use, and clinically irrel-
affect condylar displacement. Little or no displacement evant in treatment plan development.11 There are many
occurs in occlusion with adequate molar support; signifi- variables to consider, including intracapsular versus
cant condylar displacement may occur with the mouth extracapsular fractures, condylar fracture location (high,
open, exposing condylar vulnerability.7 medium, or low), age of the patient, age of the fracture,
Surgeons commonly overlook condylar fractures.8 dislocation of the condyle, simple versus comminuted,
Subtle signs may mask diagnosis. On the other hand, type of joint capsule injury, amount of occlusal support,
patients may deform significantly. Patients may occlude ramus height shortening, and degree of fracture angula-
prematurely on the ipsilateral side and open posteriorly tion (displacement).12,13
on the contralateral side (Fig. 15-1). They will deviate Condylar displacement and ramus shortening are
toward the fracture side on opening because of disruption useful determinants. Patients with displaced condylar
of lateral pterygoid forces.9 Patients with bilateral condy- fractures of 10 degrees or more, together with ramus
lar fractures characteristically occlude posteriorly and height shortening of 2 mm or more, benefit from open
open the anterior occlusion symmetrically (Fig. 15-2). reduction internal fixation. This is true despite the
Subtle findings may include limited mouth opening, level of condylar fracture.10,13-17,24 The literature is con-
limited mandibular movements, and preauricular pain. flicted concerning the indications for fracture repair
According to a review by Zachariades et al,6 72% of based solely on condylar displacement; however,
condylar fractures are associated with concomitant man- increased degrees of condylar displacement correspond
dibular fractures, usually parasymphyseal (Fig. 15-3). to increased joint dysfunction and pain.19,20
Body fractures prevail with bilateral condylar fractures, Two helpful classification systems are reviewed here.
except in children. The first is an anatomic classification scheme that evalu-
Concomitant facial fractures predominate with more ates condylar displacement, condylar fracture location
proximal condylar fractures. The forces generated to (diacapitular, neck, or base), and ramus height shorten-
yield coexistent facial fractures produce diacapitular ing. The second is a treatment algorithm aimed at sub-
(intracapsular) fractures (75%) and condylar base condylar fractures.
331
C
FIGURE 15-1 Classic condylar fracture occlusion—premature occlusion of dentition on ipsilateral side of fracture, posterior open bite on
contralateral side of fracture. (From Fonseca RJ, Turvey TA, Marciani RD: Oral and maxillofacial surgery, ed 2, St. Louis, 2009, Saunders)
FIGURE 15-2 Bilateral condylar fracture. (From Zuniga

B
Zide Bilateral condylar fractures.)
STRASBOURG OSTEOSYNTHESIS • Diacapitular fracture (through the head of the condyle).

RESEARCH GROUP The fracture line starts in the condylar head and may
This system was developed to simplify the categorization extend outside of the capsule.
of condylar fractures based on anatomic and clinical sig- • Fracture of the condylar neck. More than half of the frac-
nificance (Fig. 15-4).10,18,21,22 It may be stated as follows: ture is superior to an imaginary line extending from
Traumatic Injuries to the Mandibular Condyle CHAPTER 15 333
FIGURE 15-3 Condylar fracture patterns.
the most inferior portion of the sigmoid notch per- RADIOGRAPHIC EVALUATION OF
pendicular to the tangent of the ramus (line A). CONDYLAR FRACTURES
• Fracture of the condylar base. More than half of the frac-
ture is inferior to line A. Various views may be used to evaluate these fracture.18,23,25
• Displacement. Minimal displacement is defined as dis- These include the standardized Towne’s radiograph,
placement less than 10 degrees or ramus height short- anterior posterior dimension (coronal position), Panorex,
ening 2 mm or less. Moderate displacement is defined and medial lateral dimension (sagittal position).
as displacement of 10 to 45 degrees. Severe displace- For the measurement of condylar process displace-
ment is defined as displacement of 45 degrees or more. ment,23,25 coronal displacement is evaluated with Towne’s
Displacement refers to fracture line status. Dislocation radiograph (Fig 15-5A) and sagittal displacement with a
refers to the luxation grade of the condylar head.21 panoramic radiograph.
To evaluate the loss of ramus height,18,23,25 a panoramic
CLASSIFICATION FOR MANAGEMENT OF radiograph is used. The measurement technique is as
SUBCONDYLAR FRACTURES follows (see Fig. 15-5B):
This system uses two proven indications, ramus height • Line drawn between gonial angles across Panorex
shortening and condylar displacement (coronal or sagit- • Perpendicular lines to most superior aspect of con-
tal plane), for open reduction and internal fixation dylar heads
(ORIF) and attempts to provide corresponding treat- • The difference between the nonfractured and frac-
ment guidelines.14,23,24 tured side equals the change in ramus height.
• Class 1 fractures. Minimally displaced leads to closed
reduction; ramus height shortening less than 2 mm;
degree of fracture displacement less than 10 degrees. MANDIBULAR CONDYLAR FRACTURES
• Class 2 fractures. Moderately displaced leads to ORIF;
ramus height shortening 2 to 15 mm; degree of frac- INDICATIONS FOR REDUCTION
ture displacement 10 to 45 degrees. There has been much disagreement about whether frac-
• Class 3 fractures. Severely displaced leads to ORIF; tures should be treated open or closed. Social inequities,
ramus height shortening more than 15 mm; degree of reimbursement quandaries, and surgical schedules guide
fracture displacement more than 45 degrees. choices when objective beneficial conclusions are hazy.
C
FIGURE 15-4 A, Diacapitular fracture. B, Condylar neck fracture. C, Condylar base fracture.
Opening a condyle fracture is no simple task for the reveals that patients with ramus height shortening of
inexperienced or unaided; hence, a surgeon will acqui- 2 mm or more and condylar displacement of more than
esce to an acceptable result, acquired with minimal surgi- 45 degrees (severely displaced) benefit from ORIF
cal intervention. Reflecting their history and experience, regardless of fracture level or type of fixation per-
there are centers where all condylar fractures are treated formed.27,28 Patients in the open treatment group had
closed and a few where the vast majority are opened.26 less pain, discomfort, malocclusions, and greater range
Currently, without universal standards and indications, of motion in all parameters.14,18,26 The data are inconclu-
fractures are mostly opened on a case by case basis. sive concerning indications for fracture repair based
There are certain situations that are almost always solely on moderate condylar displacement (10 to 45
perceived as absolute indications for ORIF of condylar degrees); however, the degree of condylar displacement
fractures. Conversely, there are also clear indications for correlates directly with condylar dysfunction and long-
treating some condylar fractures with closed reduction. term pain.19
These are listed in Box 15-1. The quandary, then, is how Ellis, in 2009,29 retrospectively reviewed 332 patient
to treat the remaining condylar fractures that fall in cases with unilateral extracapsular condylar fractures to
between the absolute indications for ORIF and the clear determine when open treatment of condylar process
indications for closed reduction (CR). fractures would be meritorious. This study did not isolate
Recent prospective randomized studies have com- fracture type or displacement of the condylar head. It
pared CR with ORIF. Both CR and ORIF have been was concluded that only a patient who develops a maloc-
shown to be acceptable. Conclusive evidence, however, clusion after release from maxillomandibular fixation
L
A B
FIGURE 15-5 A, Condylar displacement. B, Loss of ramus height. (From Bhagol A, Singh V, Kumar I, Verma A: Prospective evaluation of
a new classification system for the management of mandibular subcondylar fractures. J Oral Maxillofac Surg 69:1159–1165, 2011.)
(MMF) need be considered for open reduction. In this

BOX 15-1 Indications for Open Reduction study, only 1 of 332 patients developed a postoperative
malocclusion.
ABSOLUTE INDICATIONS A recent prospective, double-center study by Kokem-
• Condylar displacement into middle cranial fossa ueller et al26 has compared endoscope-assisted transoral
• Invasion by foreign body reduction and internal fixation with CR. Inclusion crite-
• Lateral extracapsular displacement of condyle ria included unilateral condyle fractures exhibiting at
• Malocclusion not amenable to closed reduction (e.g., func- least one of the following characteristics: more than 30
tional reduction of ramus height) degrees of displacement, severe functional impairment
STRONG EVIDENCE FOR OPEN REDUCTION (open bite or malocclusion), severe pain on movement,
• Bilateral condylar fractures or vertical ramus shortening; high condylar fractures
• Gross condylar displacement > 45 degrees (severely were excluded. Results revealed that the ORIF group was
displaced) more symptom-free, with less malocclusion. The dura-
• Anatomic reduction of ramus height ≥ 2 mm tion of MMF was shorter in the ORIF group compared
• Condylar fractures with an unstable base (associated with the CR group.
midface fractures) Regardless of whether a surgical or nonsurgical treat-
• Unstable occlusion (e.g., periodontal disease, less than ment plan is pursued, postoperative rehabilitation is an
three teeth per quadrant) essential component to orthopedic success. Restoration
• Condylar fractures for which adequate physiotherapy is of maximal incisal opening (MIO) of at least 40 mm, full
impossible excursive movements, and proper occlusion are laudable
MIXED EVIDENCE FOR OPEN REDUCTION goals, achievable only with persistent rehabilitation and
• Moderate condylar displacement, 10 to 45 degrees monitoring.
WHEN TO TREAT WITH CLOSED REDUCTION TREATMENT
• Nondisplaced or incomplete fractures Surgical Versus Nonsurgical Treatment
• Isolated intracapsular fractures
• Condylar fractures in children (except for absolute The surgical goals enumerated decades ago by Walker
indications) include the following five features20,33:
• Reproducible occlusion without dropback or with dropback 1. Pain-free mouth opening, with an interincisal distance
that returns to midline on release of posterior force beyond 40 mm
• Medical illness or injury that inhibits ability to receive 2. Good movement of the jaw in all excursive movements
extended general anesthesia 3. Preinjury occlusion of teeth
4. Stable TMJs
Material adapted from references 14, 18, 19, 29, 30, 31, and 32. 5. Good facial and jaw symmetry
ORIF and CR patients benefit from early mobilization

and extensive rehabilitation, generally over a period of 6 BOX 15-2 Rehabilitation in Patients Treated by Closed or
to 12 weeks.34 Immediately after the traumatic injury, Open Reduction
tissues are not yet tethered down by scar formation. Early
OCCLUSAL GUIDANCE*
mobilization of the joint after injury reduces permanent
• Place arch bars
joint hypomobility.35,36 Rehabilitation with a target
• Class 2 elastics on ipsilateral side of fracture
maximal incisal opening reaching more than 40 mm • Have patient discontinue guiding elastics 24 hours prior
before 12 weeks is fundamental and ideal before 6 weeks. to clinic appointment. If occlusion stable and opens sym-
Once an MIO of more than 40 mm is reached, it should metrically, there is no need to continue with elastic
be maintained during the next few months while the soft guidance.
and bony tissues are maturing. • Remove arch bars during 6- to 12-wk period postopera-
In clinical practice, joint rehabilitation consists of tively after rehabilitation goals are achieved.
scheduled patient exercises to increase opening and
range of motion. Early on, opening exercises alone are FUNCTIONAL EXERCISE: REHABILITATION TARGETS
• Maximal incisal opening > 40 mm
probably sufficient. Patients should be given arbitrary
• Lateral excursive movements > 10 mm
achievable goals. For example, ibuprofen or aspirin, heat
• Protrusive excursive movements > 12 mm
and massage for 1 minute, and then opening three times • Full use of TMJ throughout the day (diet as indicated by
daily before meals, as wide as possible, 30 times. Measure- pain and coexisting injuries)
ments encourage progress. • Close supervision by surgeon to evaluate occlusion, adjust
Active (the patient does the work) and passive (bite regimen as necessary
sticks, external forces) all have their place. Usually, we
recommend active physiotherapy during the first 6 weeks, *If malocclusion is present.
especially if other fractures are present, and only passive Adapted from Palmieri C, Ellis E, Throckmorton G: Mandibular motion
forms when obstacles are encountered (Box 15-2). after closed and open treatment of unilateral mandibular condylar process
fractures. J Oral Maxillofac Surg 57:764–775, 1999.
Surgical Approaches to the Condylar and
Subcondylar Regions above the inferior border of the mandible. The facial
All open approaches have three common aspects to their vein is just deep to the platysma.
success: Surgical Technique
1. The ramus must be distracted. Exposure. The corners of the mouth and lower lip are
2. The proximal condyle must be controlled and manip- exposed anteriorly and the entire ear, posteriorly.
ulated. Incision. Using arch bars and elastics or wires prior to
3. The fracture must be anatomically reduced and plated facial incision, place the patient in MMF. These are 1.5
with more than one screw on the proximal segment. to 2 cm below the inferior border of the mandible in or
Submandibular Approach. This is also known as the parallel to a skin crease. In patients with ramus height
Risdon approach.12,37-42 shortening, place the incision 1.5 to 2 cm below where
Indications. These include axial anchor screw fixation. the anticipated reduced mandible would be. The initial
Advantages. These include the ability to distract the incision is placed to the depth of the platysma, with
mandibular ramus and direct access of the gonial angle. extensive undermining in all directions.
Disadvantages. These include limited surgical site Dissection. See Figure 15-8.
exposure (the incision is distant from the fracture), dif- • Through the platysma. Undermine and sharply dissect,
ficult to reduce medially displaced condyles, and plate being careful to stay superficial to the superficial layer
and screw fixation restricted without a transfacial trocar. of the deep cervical fascia.
Pertinent Anatomy • From the platysma to pterygomasseteric sling. Make a small
Marginal Mandibular Branch of the Facial Nerve. Poste- incision through the superficial layer of the deep cer-
rior to the facial artery, the marginal branch passes infe- vical fascia at the level of the skin incision (1.5 to 2 cm
rior to the border of the mandible in 19% to 56% of inferior to the mandible). The facial artery and vein
specimens studied (Fig. 15-6).37,38 The maximum inferior may be retracted anteriorly or divided and ligated if
extent of the mandibular branch is 1.2 cm below the necessary. Continue the dissection superiorly until the
mandible. Anterior to the facial artery, the marginal pterygomasseteric sling is encountered.
branch passes inferior to the border of the mandible in • Division of the pterygomasseteric sling. The use of a nerve
0% to 6% of specimens studied. It passes immediately stimulator is necessary through this portion of the
deep to the superficial layer of the deep cervical fascia, dissection, with the absence of muscle relaxants, to
which is immediately deep to the platysma, and superfi- identify the branches of the facial nerve. Sharply incise
cial to the facial vessels. the pterygomasseteric sling with a scalpel along the
Facial Artery and Vein. This passes through or along inferior border of the mandible. Use a periosteal ele-
the superficial surface of the submandibular gland and vator to expose the ramus up to the level of the TMJ
approximates the inferior border of the mandible just capsule and coronoid process. A sigmoid notch retrac-
anterior to the pterygomasseteric sling (Fig. 15-7). The tor is helpful in fully exposing the ramus.
artery then rounds the inferior border of the mandible Osteosynthesis: Axial Anchor Screw
and becomes superficial to the mandible. Generally, the Visibility and Reduction. Distract the distal segment using
anterior facial vein runs posterior to the facial artery ligature wire at the gonial angle (see Fig. 15-9). Use a
FIGURE 15-6 Facial nerve. (From Patton K, Thibodeau G: Anatomy and physiology, ed 7, St. Louis, 2012, Mosby.)
Zygomatic
arch
Masseter
muscle
Mandible
VII
VII
FV Free
artery
Pterygoid
FIGURE 15-7 Exposure of the facial artery vein and cranial nerve
muscle
VII. (From Ellis E III, Zide MF: Surgical approaches to the facial
skeleton, ed 2, Philadelphia, 2006, Lippincott Williams & Wilkins, p Salivary
169.) gland
FIGURE 15-8 Anatomic landmarks of submandibular dissection.

1/3
1/3
1/3
15-20mm
15mm
B C
FIGURE 15-9 Direct fixation using lag screw technique. (B from Krenkel C: Biomechanics and osteosynthesis of condylar neck fractures of
the mandible. Carol Stream, Ill, 1994, Quintessence.)
sigmoid notch retractor and condylar neck retractor to segment an additional 1 to 2 cm. Measure length and
reflect soft tissues. Stabilize and reduce the proximal place and tighten titanium screw with biconcave washer.
segment using a curved hemostat. Indirect Fixation. This alternative method is indicated
Direct Fixation. Place a groove in the lateral cortex when the proximal condylar fragment is difficult to
approximately 1 cm anterior to the posterior border and reduce (Fig. 15-10). First, place the positioning screw
1.5 to 2 cm inferior to the fracture line (see Fig. 15-9). A into the proximal segment. Then reduce the proximal
centering instrument is used to place the screw hole; a segment using a biomechanically advantageous screw.
2-mm drill is used to drill the pilot hole to the fracture Place a groove through the lateral cortex to the fracture
line. The drill guide is placed and a 1.5-mm drill is used line. Lock the screw into place using a two-hole miniplate
to penetrate beyond the fracture line into the proximal locked against the proximal screw shaft.
A B
C
FIGURE 15-10 Indirect fixation using lag screw technique. (From Krenkel C: Biomechanics and osteosynthesis of condylar neck fractures
of the mandible. Carol Stream, Ill, 1994, Quintessence, pp 104–105.)
Closure
• Pterygomasseteric sling. Suture together the masseter there is best access to the fracture site; there is no need
and medial pterygoid using interrupted resorbable for a transfacial trocar; the facial scar is less noticeable
sutures. than with a submandibular incision; it is effective in
• Platysma. Suture using resorbable sutures in a running patients with edema; and there is access for an osteotomy
fashion. if required to reach the condyle.
• Subcutaneous tissue. Use resorbable sutures. Disadvantages. The facial scar is more noticeable
• Skin. Use nonresorbable suture material. than with a preauricular incision.
Retromandibular Approach Pertinent Anatomy
Indications. This is used for any fracture that is large Facial Nerve. See the Preauricular section for further
enough to be reduced and stabilized by ORIF using discussion of the facial nerve. However, between the
plates and screws.37,38 superior and inferior divisions of the facial nerve, the
Advantages. These include the following: there is a posterior ramus of the mandible can be safely accessed
short distance between the incision and the fracture site; (Fig. 15-11).

RV
FIGURE 15-11 Superior and inferior divisions of facial nerve. Facial

nerves—superior division (*) and inferior division (+). RV,
Retromandibular vein. (From Ellis E III, Zide MF: Surgical FIGURE 15-12 Exposure of ramus. (From Ellis E III, Zide MF:
approaches to the facial skeleton, ed 2, Philadelphia, 2006, Surgical approaches to the facial skeleton, ed 2, Philadelphia,
Lippincott Williams & Wilkins, p 171.) 2006, Lippincott Williams & Wilkins, p 179.)
Retromandibular Vein. This is formed deep to the neck

of the mandible from the superficial temporal vein and
maxillary vein (see Fig. 15-11), superficial to the external
carotid and crossed by the facial nerve.
Surgical Technique
Exposure. Anteriorly, this should be at the corner of
the mouth and lower lip and posteriorly, at the entire ear.
Incision. Place the incision 0.5 cm below the earlobe
and carry inferiorly for 3 to 3.5 cm. Place it just posterior
*
to the posterior border of the mandible. Incise to the
depth of the scant platysma overlying the superficial mus-
culoaponeurotic system (SMAS) and the parotid capsule.
Undermine extensively in all directions for maximal
exposure. RV
Dissection
• Dissection to the pterygomasseteric sling. Sharply incise the
platysma, underlying SMAS, and parotid capsule (Figs.
15-12 and 15-13). Continue the dissection bluntly in
the substance of the parotid parallel to the expected
direction of the facial nerve. Carry the dissection to FIGURE 15-13 Position of facial nerve. (From Ellis E III, Zide MF:
the periosteum of the posterior border of the man- Surgical approaches to the facial skeleton, ed 2, Philadelphia,
dible, avoiding injury to the branches of the facial 2006, Lippincott Williams & Wilkins, p 179.)
nerve and retromandibular vein. The use of a nerve
stimulator is necessary through this portion of the
dissection, with the absence of muscle relaxants, to Osteosynthesis
identify the branches of the facial nerve. • Distract the proximal fragment inferiorly using an
• Division of the pterygomasseteric sling. To divide the ptery- Allis clamp (Fig. 15-14). Place the hole superior to
gomasseteric sling, sharply incise, starting as superi- fracture line in the second screw hole from the top of
orly and posteriorly on the ramus as possible. Carry the plate.37
the incision around the gonial angle as far anteriorly • Place 24-gauge wire through the inferior hole of the
and inferiorly as possible. Use a periosteal elevator to plate. Distract the condylar head inferiorly to enable
expose the ramus and condylar area. Use a sigmoid the placement of a drill hole in the superior hole of
notch retractor to maintain exposure of the ramus. It the plate, and apply a screw.
is helpful to distract the mandible inferiorly to expose • Drill and place the screws in the inferior holes in the
the condylar process fracture fully. distal segment.
FIGURE 15-14 Double miniplate technique. (From Krenkel C: FIGURE 15-15 Rhytidectomy incision. (From Ellis E III, Zide MF:
Biomechanics and osteosynthesis of condylar neck fractures of Surgical approaches to the facial skeleton, ed 2, Philadelphia,
the mandible. Carol Stream, Ill, 1994, Quintessence, p 57.) 2006, Lippincott Williams & Wilkins, p 189.)
Closure. For the pterygomasseteric sling, suture

together the masseter and medial pterygoid using inter-
rupted resorbable sutures. For the parotid capsule, pla-
tysma, and SMAS layer, use slowly resorbable horizontal
mattress sutures in a running fashion. This step is vital
for avoiding a salivary fistula. For subcutaneous tissue,
use resorbable sutures and, for the skin, use nonresorb-
able sutures.
Rhytidectomy Approach. This uses the same access as
that of the retromandibular approach, with better cos-
mesis.30,38 This approach must be drained with closed
suction drainage postoperatively (Figs. 15-15 and 15-16).
Transmasseteric-Anteroparotid Approach.
Indications. This is done to provide access to high and
low subcondylar and ramus fractures.43-46
Advantages. These include quick and direct access to
fracture sites for direct plating and screw fixation, with
excellent exposure and the ability to distract mandibular
ramus because of access to the gonial angle, and has the
best access of all the approaches.
Disadvantages. There is a visible scar that is more
noticeable than with the other approaches and there is FIGURE 15-16 Drain placement. (From Ellis E III, Zide MF: Surgical
potential damage to the facial nerve. approaches to the facial skeleton, ed 2, Philadelphia, 2006,
Pertinent Anatomy Lippincott Williams & Wilkins, 189)
Marginal Mandibular and Buccal Branches of the Facial
Nerve. Posterior to the facial artery, the marginal man-
dibular branch is above the inferior border of the man- layer, masseter superficial and deep bellies, and perios-
dible in 44% to 81% of specimens studied.43-45 There is a teum of the mandible.
single buccal branch of the facial nerve in 85% of speci- Surgical Technique:
mens studied, which is inferior to the parotid duct. In Exposure. Anteriorly, this is at the border of the mouth
15% of cases, there are two branches, one above and one and lower lip and lateral nose and cheek; posteriorly, the
below the parotid duct. Both are immediately deep to entire ear. The patient is in wire MMF for the entire
the SMAS layer of the parotidomasseteric fascia. procedure.
Layers of the Parotidomasseteric Region. These are the Incision. Draw a line from the bottom of the earlobe
skin, subcutaneous fat, parotidomasseteric fascia–SMAS at the posterior border of the ramus to the gonial angle.
FIGURE 15-17 Transmasseteric incision. (From Zuniga Unilateral

condylar fracture: Transmasseteric approach)
Divide the distance of this line into thirds. Draw a line

the same distance as above, anteriorly along the inferior
border of the mandible from the gonial angle forward.
Divide this distance into thirds.
Make the incision at the line connecting the intersec- FIGURE 15-18 Division of the masseter. (From Zuniga Unilateral
tions of the last third on the posterior ramus line and the Condylar Fracture: Transmasseteric Approach)
first third on the inferior border line, the intersection
closest to the gonial angle in each direction (Fig. 15-17).
The initial incision is to the depth of the parotidomas- Identify the proximal fracture or margin by visualiza-
seteric fascia (SMAS). Then, there is extensive subcuta- tion, palpation, or distraction of the mandible inferiorly
neous undermining in all directions to allow for maximal using a Kocher clamp. Directly engaging the angle of the
exposure. mandible through the access provided earlier can be
Dissection to the Pterygomasseteric Sling. Undermine the helpful. Strip the lateral and inferior portions of the
parotidomasseteric fascia (SMAS) in the horizontal direc- proximal segment of the fracture and place an Obwege-
tion (parallel to the facial nerves). The use of a nerve ser retractor on the proximal lateral surface above the
stimulator is necessary through this portion of the dissec- fracture junction.
tion, with the absence of muscle relaxants, to identify the Osteosynthesis. Engage the angle of the mandible
branches of the facial nerve. through the access provided earlier using a Kocher
If no facial nerve branches are identified by testing or clamp. One individual should displace the mandible
visualization, then sharply incise and expose the pterygo- inferiorly while the operating surgeon positions the prox-
masseteric sling. If the facial nerve is identified by testing imal segment to the correct position.
or visualization and unavoidable in the horizontal Once the proximal segment is positioned properly,
approach, bluntly dissect through the parotidomasse- release the inferiorly displaced mandible. Repeat until
teric fascia (SMAS) in the vertical direction to displace the fracture is reduced. Generally, the reduction is self-
the facial nerve(s) away in the superior or inferior retaining, without the need for lateral or superior com-
direction. pression or manipulation during the stabilization and
Division of the Masseteric Sling. Bluntly dissect (using osteosynthesis phase so the Kocher clamp can be removed
hemostats or scissors) in a vertical plane, with access to assist in further visualization of the osteosynthesis.
through the masseter muscle until the mandible is identi- Place the plates (variable, straight, H, U, X, modified
fied (Fig. 15-18). The direction of dissection is parallel Y-shaped) (Fig. 15-19) and screws with direct visualiza-
to the masseter muscle fibers. Avoid sharp dissection to tion. This rarely requires a trocar except in a very high
reduce bleeding and injury to the facial nerve. Once the subcondylar fracture or limited access to the proximal
mandible is identified, place two or three Obwegeser segment’s most superior hole(s).
(towed-in) retractors on the mandible and retract to Closure. No closure of the periosteum or masseter
enhance the exposure of the lateral mandible at the muscle sling is necessary. Suture the parotidomasseteric
ramus–midbody section. fascia (SMAS) using slowly resorbable sutures in running
Exposure of the Mandible and Fracture. Use a periosteal fashion (necessary to avoid salivary fistula). Suture the
elevator to strip the masseter muscle and periosteum to subcutaneous tissue using resorbable sutures. Suture the
expose the angle of the mandible first and then the skin using nonresorbable sutures.
lateral mandible along the ascending ramus. Identify the Preauricular Approach.
sigmoid notch and place a retractor (e.g., channel retrac- Indications. These include wire fixation of a high,
tor) in the sigmoid notch for orientation. Finally, expose anteromedially displaced proximal fragment.37,38
the posterior ramus of the mandible superiorly to the Advantages. This provides access to the superiormost
fracture site. portion of the joint.
Blood Vessels. These include the superficial temporal

artery, lateral and posterior to the condylar head and
neck. It runs within the temporoparietal fascia accompa-
nied by the auriculotemporal nerve. As it crosses over the
zygomatic arch, a temporal branch is given off, which
frequently causes bleeding when using the preauricular
approach. The retromandibular vein is formed from the
maxillary and superficial temporal veins. It travels just
posterior to the mandibular ramus and is superficial to
the external carotid and deep to the facial nerve.
Nerves. The main trunk of the facial nerve is 2 cm
deep to the skin at the middle of the anterior border of
the mastoid process. The temporal branches are the
most susceptible to injury; 8 to 35 mm (average, 20 mm)
is the range of distances from the anteriormost portion
of the bony external auditory canal (EAC) to where the
upper trunk crosses zygomatic arch, under the surface of
the temporoparietal (superficial layer of temporalis
fascia) fascia. Avoid by incising within 8 mm of the EAC
and dissecting beyond the temporoparietal fascia and
periosteum of the zygomatic arch.
Trigeminal Nerve: Auriculotemporal Nerve. This courses
FIGURE 15-19 Fixation with Y plate. (From Zuniga Unilateral laterally behind the condylar neck and supplies skin in
Condylar Fracture: Transmasseteric Approach.) the temporal and preauricular regions, EAC, and tym-
panic membrane. It is almost invariably injured when
using the preauricular approach. Avoid by dissecting
TB VII close to the cartilaginous portion of the external auditory
meatus.
STA ATN Layers of the Temporal Region. These include the skin,
subcutaneous fat, temporoparietal fascia (i.e., superficial
temporal fascia or suprazygomatic SMAS). Extension of
the galea is continuous with the SMAS. The superficial
AE
temporal vessels run along the superficial surface. The
EAC facial nerve branches run along the deep surface. The
C superficial and deep layers of the temporalis fascia invest
the fascia of the temporalis muscle. The superficial layer
attaches to the lateral aspect of the zygomatic arch. The
deep layer attaches to the medial aspect of zygomatic
arch. The superficial temporal fat pad is between the
superficial and deep layers of the temporalis fascia and
usually contains a large vein.
Surgical Technique
FIGURE 15-20 Anatomic landmarks. (From Ellis E III, Zide MF: Exposure. Expose the entire ear and lateral canthus of
Surgical approaches to the facial skeleton, ed 2, Philadelphia, the eye.
2006, Lippincott Williams & Wilkins.) Incision. This is made in the skin fold along the entire
length of the ear. It extends superiorly to the top of the
helix and may include the anterior extension. Incise to
Disadvantages. This is not indicated for placement of the depth of the superficial layer of the temporalis fascia.
the plate and screw fixation. There is no access to the Dissection to the Joint Capsule. Dissect along the ante-
angle of the mandible to distract the ramus inferiorly; rior portion of the external auditory cartilage to avoid
towel clip placed transcutaneously may be a reasonable damage to the superficial temporal vessels and auriculo-
substitute. Limited ramus exposure makes osteosynthesis temporal nerve above the zygomatic arch and the parotid
plate placement extremely difficult. This results in more below the zygomatic arch (Figs. 15-21 and 15-22). Above
proximal segment stripping, leading to an increased risk the zygomatic arch, bluntly dissect approximately 1.5
of necrosis. to 2 cm anteriorly at the level of the superficial layer of
Pertinent Anatomy. See Figure 15-20. the temporalis fascia. Below the zygomatic arch, bluntly
Ginglymoarthrodial Joint. This allows for rotation and dissect parallel to and along the external auditory
translation. The capsular ligament surrounds the condy- cartilage.
lar head, superiorly attaches to the temporal bone, and Incise the superficial layer of the temporalis fascia
inferiorly attaches to the condylar neck. For the collat- just anterior to the tragus at the zygoma, continuing in
eral discal ligaments, attach the articular disc to the con- the anterior superior direction. Carry the dissection
dylar head. along the posterior side of the superficial layer of the
VII
FIGURE 15-23 Disadvantages of endoscope-assisted intraoral

approach. (From Zuniga Endoscope repair)
The use of a nerve stimulator is necessary through this

portion of the dissection, with the absence of muscle
FIGURE 15-21 Dissection to joint capsule. relaxants, to identify the branches of the facial nerve.
Exposing the Superior Joint Space. Distract the condyle
inferiorly and sharply dissect along the posterior slope of
the articular eminence until the joint space unites with
the retrodiscal tissues.
Exposing the Inferior Joint Space. Incise the disc along
the lateral recess of the superior joint space. This allows
exposure to the inferior joint space.
Closure
• Inferior joint space. Use slow resorbing or permanent
suture material to reconnect the lateral disc attach-
ments (medial) to the joint capsule (lateral).
• Superior joint space. Use slow resorbing sutures to attach
the remnants of the TMJ capsule from the zygomatic
arch to the remainder of the joint capsule.
• Subcutaneous tissues. Close using resorbable sutures.
• Skin. We recommend monocryl subcuticular sutures
with a pressure dressing.
Intraoral Approach
Indications. This approach is indicated for low sub-
condylar fractures.26,35,38,42,47-50 Axial anchor screws or
miniplate fixation may be used.
Advantages. A visible scar avoided and damage to the
facial nerve is minimized.
FIGURE 15-22 Exposing the joint. (From Ellis E III, Zide MF: Disadvantages
Surgical approaches to the facial skeleton, ed 2, Philadelphia, Intraoral Approach without Endoscope. There is limited
2006, Lippincott Williams & Wilkins, p 203.) access, the poorest access of all the approaches, it is dif-
ficult to ascertain the adequacy of reduction and fixation,
and there is a high rate of complications.
temporalis fascia to the zygoma; then incise and reflect Endoscope-Assisted Intraoral Approach. This is more
the periosteum laterally. Carry the incision of the poste- time-consuming, with a steep learning curve, poor visibil-
riormost portion of the dissected superficial layer of the ity of the posterior ramus, and difficulty in reducing
temporalis fascia inferiorly, parallel to the original skin certain fracture types (Fig. 15-23).
incision. Reflect and further dissect the subperiosteal Pertinent Anatomy. This is an anatomically safe
flap anteriorly until the entire TMJ capsule is revealed. approach, with minimal risks.
FIGURE 15-24 Intraoral axial anchor screw. (From Krenkel C:

Biomechanics and osteosynthesis of condylar neck fractures of
the mandible. Carol Stream, Ill, 1994, Quintessence, p 113.)
Surgical Technique
Incision. Incise at the anterior border of the ramus,
extending to the lower buccal sulcus. This is similar to
the surgical approach for a sagittal split osteotomy.51 The FIGURE 15-25 Axial anchor screw. (From Krenkel C: Biomechanics
incision is made through the periosteum. and osteosynthesis of condylar neck fractures of the mandible.
Dissection and Exposure. Use a notch retractor to Carol Stream, Ill, 1994, Quintessence, p 114.)
reflect soft tissues so the sigmoid notch can be visualized.
Strip the masseter and temporalis muscles using a sub-
periosteal dissection. If inferior distraction of the ramus
is needed, perform transcutaneously with a towel clamp.
Osteosynthesis: Miniplate and Screw Fixation
• Preauricular transcutaneous trocar insertion. Insert the
drill and screwdriver through a trocar incision with
the first drill hole placed in the proximal fragment.
Insert the screw and plate via a transoral incision.
• Other screws and drill holes are placed through a
trocar incision.
Osteosynthesis: Axial Anchor Screw. Position the screw
just superior and parallel to the occlusal plane, superior
to the mandibular foramen. Place the groove in the
medial cortex approximately 1.5 to 2 cm anterior to the
fracture line (Figs. 15-24 and 15-25).
A centering instrument is used to place the screw hole.
A 2-mm drill is used to drill the pilot hole to the fracture
line. A drill guide is placed and a 1.5-mm drill is used to
penetrate beyond the fracture line into the proximal
segment an additional 1 to 2 mm. Measure length and
place and tighten a titanium screw with a biconcave
washer.
Endoscope-Assisted Osteosynthesis. Advantages over tra-
ditional screw plate intraoral approaches include being
able to access high condylar fractures, no extraoral trocar
site needed, there is much better visualization and assur-
ance of proper reduction, and fewer reported complica- FIGURE 15-26 Endoscope through intraoral incision.
tions.26,49,50 Equipment needed includes angled drills, a
30-degree angled 4-mm endoscope, screwdrivers, and
special illuminating hooks and retractors (Figs. 15-26 and Closure
15-27). • Oral mucosa. Resorbable sutures
Insert the endoscope through a transoral or subman- • Skin. If trocar site is present, nonresorbable sutures
dibular incision and identify the fracture fragments. Use Osteosynthesis of the Mandibular Condyle. The primary
one or two four-hole miniplates to fixate the fracture, goals of fracture reduction are to restore ramus
depending on dislocation grade of fracture, fragment height and correct angular displacement. A number
stability after reduction, and amount of space available. of approaches and dedicated instruments have been
FIGURE 15-27 Endoscope through submandibular incision.
suggested for ORIF. A comparative study evaluating and 2-mm lag screws12,39,42 (see Figs. 15-9, 15-10,
osteosynthesis via the lag screw, miniplate, or Kirschner 15-24, and 15-25.)
wire has noted that all techniques are acceptable, with Finally, endoscopic exposure and fixation may reduce
precise repositioning of the condylar head at 90%. facial scars, but so far is more time-consuming than direct
However, shortening of the ramus more than 5 mm was fracture approaches for any plating method.50
found to occur more frequently in the miniplate group
than in the lag screw group (p < .05).36 REDUCTION OF THE CONDYLE FOR ACCESS
• Kirschner wires. Thick wires and pins, used before Access and reduction of medially dislocated condylar
the advent of miniplates, are required for at least heads is difficult and stressful to the uninitiated and
14 days of MMF. This method is obsolete because inexperienced. Distraction of the mandibular ramus
decreased range of motion and dysfunction com- inferiorly on the fractured side must forcefully counter-
monly occurred.42 act unopposed muscle pull of the pterygomasseteric sling
• Miniplate systems. This is a common osteosynthesis superiorly. After the superior ramus is opened, guiding
technique, with significant drawbacks, such as plate instruments position the proximally dislocated fracture
fractures (up to 35 %), screw loosening, and plate segment (Fig. 15-28). Ideally, periosteum should be pre-
bending.36,52,53 served on the anterior and medial condylar segments,
An elegant study by Throckmorton and Dechow which retains lateral pterygoid vascularity.12
has determined that the greatest amount of
tensile strain exists in the anterior and lateral por- Inferior Distraction of the Ramus
tions of the condyle.54 Therefore, a double mini- A 0.5-mm retaining wire may be threaded through a
plate method is more successful (no plate fracture, bicortical drill hole and fed into a 6-mm Silastic tube to
bending, or screw loosening) and can withstand protect soft tissue during traction. This technique is
significantly greater loads than other methods, effective in the submandibular approach.12
such as a single miniplate or minidynamic compres- Ellis and Zide insert a bicortical screw in the gonial
sion plate system.52,55 Obviously, patients with more angle and wrap a 24-gauge traction wire securely around
oblique, comminuted, and smaller fracture seg- the head of the bone screw. An 18-gauge needle is intro-
ments and those with unsupported posterior occlu- duced retrograde through the skin below the mandibu-
sion are most at risk for ORIF plate failures. In this lar angle into the surgical field. The ends of the traction
group of patients, prolonging the nonchewing diet wire are pushed into the 18-gauge needle and then
and restoring molar occlusion is encouraged. pulled atraumatically out the needle hole. After needle
• Axial anchor screw. This is generally approached removal, inferior force on the wire twister distracts the
through a submandibular or intraoral incision. The ramus inferiorly37 (Fig. 15-29).
technique restores vertical ramus height and may Transcutaneous ramus distraction with a towel clamp
result in less resorption than miniplate systems.36 may also be performed. It is usually indicated when per-
This affordable indirect technique reduces butt to forming an intraoral, preauricular, or transmasseter
butt condylar neck fractures with biconcave washers approach.
B C
FIGURE 15-28 A-C, Guiding instruments position the proximally dislocated fracture segment. (From Krenkel C: Biomechanics and
osteosynthesis of condylar neck fractures of the mandible. Carol Stream, Ill, 1994, Quintessence, pp 84-85.)
Difficult Proximal Condylar Dislocations COMPLICATIONS OF CONDYLAR

To reposition with a wire extension (Fig. 15-30), use a FRACTURE TREATMENT
fine twist drill at a low-speed handpiece (at 1000 rpm) to
drill a hole 2 mm anterior to the distal border of the The most frequent complications after ORIF or CR are
medially dislocated proximal segment. A 0.3-mm wire malocclusion, hypomobility (8% to 10%), ankylosis
approximately 50 cm long is threaded through the hole. (0.2% to 0.4 %), asymmetry, dysfunction or degenera-
A vascular clamp secures the wire. The condyle is then tion, and iatrogenic injury.13
reduced with inferior traction and a repositioning fork. Malocclusion. This is often implied secondary to
Alternatively, an axial repositioning screw (≈27 to improper treatment, such as inadequate use of occlusal
30 mm) may be inserted within the exposed fractured guidance or closed reduction when open reduction is
surface of the proximal fragment at an angle of 1 to 3 indicated.13 However, this is disingenuous because maloc-
degrees to the dorsal border of the fragment. After clusion or centric relation discrepancies are common
reduction, the repositioning screw may be removed or secondary to displaced fractures treated with CR methods.
retained secondarily anchored in the ramus (see Fig Older patients (>50 years) with preexisting locked-in
15-10). occlusion and definitive wear facets often complain of
Our preferred technique is to drill a screw hole. A occlusal disharmony, even after proper physiotherapy.
screw is inserted in the hole through the second hole of Patients presenting with displaced fractures, ramus
the plate and the plate and screw are used to manipulate shortening, and early objective malocclusion will often
the condylar head into position. When that is not enough, have persistent centric relation discrepancies when
another traction location is selected or a preauricular treated in a closed fashion. Malocclusion is also common
incision is opened.12 when patients have prolonged hospitalizations, other
B C
FIGURE 15-29 Inferior distraction using bicortical screw and 24-gauge wire. (From Ellis E III, Zide MF: Surgical approaches to the facial
skeleton, ed 2, Philadelphia, 2006, Lippincott Williams & Wilkins, p 180.)
complex injuries, or any medical limitation to adaptive Asymmetry. In children, approximately 25% of condy-
physiotherapy. lar fractures will produce some facial asymmetry, whether
Mandibular Hypomobility. This is related to delayed it is hypoplasia or hyperplasia.57 In adults, deviation on
physiotherapy of the joint and has been shown to increase opening has been noted in up to 50% of individuals fol-
the longer the patient is subjected to MMF.56 Children lowing fracture of the condyle.13
are more susceptible to hypomobility, as are those sub- Dysfunction or Degeneration. All injured joints are more
jected to high-energy injuries with capsular disruption. susceptible to arthritis, and the TMJ is no different. Risk
Ankylosis. In children, ankylosis is related to severe factors include increased age, displaced condyle, longer
meniscal disruption with inappropriate physiotherapy.57 periods of MMF, and hypomobility secondary to capsular
In adults, ankylosis usually results from a widened man- or meniscal injuries.13
dible, which leads to superior lateral displacement of the Condylar Resorption. This is somewhat avoidable by
condyle. This may be mitigated by proper reduction of limiting the total denudation of the blood supply and
the fractures restricting mandibular widening.58 proper anatomic reduction. However, difficult cases may
In summary, with closed reduction, early postsurgical

malocclusions may not be completely corrected. If the
easy open reduction period of 3 weeks is over, full range
of mobility is a better goal. Re-creation of presurgical
proper occlusion may be wishful. Occlusal disharmonies
may merit late correction with orthognathic surgery.
They are not correctable by physiotherapy alone after 8
weeks.
Frustration during the execution of open techniques
must be avoided. The surgeon should plan proper
choices beforehand if, perhaps, the mental picture of his
or her finished surgery must be adjusted to the reality of
the situation. It is worse to place a single screw in an
obliquely fractured proximal segment than to let the
segment go free, and it is worse to remove a displaced
condylar head than to leave it in situ or fixate it properly
as a free graft.
Arthritic noises and painful sequelae may develop
after trauma to the joint and capsular components any-
where in the body. The TMJ is no different.
CONDYLAR FRACTURES IN CHILDREN

FIGURE 15-30 Repositioning with wire extension. (From Krenkel C:
Biomechanics and osteosynthesis of condylar neck fractures of Condylar fractures are the most common facial fracture
the mandible. Carol Stream, Ill, 1994, Quintessence) in children.60 Condylar fractures may also result in sig-
nificant functional deformities and facial asymmetry
when improperly diagnosed or treated in children who
are still undergoing significant facial growth.3 Intracap-
sular crush injuries in children younger than 3 years have
demand replacement of the condylar head as a free bone been demonstrated to retard growth on the affected
graft. side.61-63 Lund has found that 30% of children with con-
Iatrogenic Injury. Following surgical repair of condylar dylar fractures are more likely to have excessive growth
fractures, up to 15% of patients may experience transient on the fractured side.64
facial nerve weakness; however, permanent injury is Because mandibular growth continues throughout
rare.13 the teenage years, most appropriately managed fractures
Chronic Pain. This occurs more commonly when con- remodel the condylar stump closer to its original form
dylar fractures are treated with closed reduction.* inversely with increasing age at the time of injury.51 The
More patients will have superior results when the younger the child, the more complete the remodel-
surgeon correctly judges a proper path through the coming.6,65,66 As skeletal growth ceases, so does its regenera-
plexity of condylar fracture variables. Without proper tive capacity; only functional remodeling is possible in
physiotherapy, marginal results will be the norm. Even adults. Therefore, condylar fractures in children are
with proper physiotherapy, there will be patients with late managed conservatively and are rarely opened.30
malocclusions and arthritis. These patients may lead to Rehabilitation and restoration of MIO, excursive
us questioning whether the results might have improved movements, and occlusion are the most important factors
with a different surgical or nonsurgical plan. for proper fracture management in children. No studies
Open reduction is now an accepted modality that have demonstrated any benefit of ORIF over CR of con-
should be considered during the first 3 weeks after frac- dylar fractures in children. In recent reviews, over 53%
ture. Patients should be informed that a closed reduction to 56% of respondents reported significant long-term
might not be fully therapeutic. Reduced swelling and TMJ complaints (most were minor). Results were inde-
reassessment present opportunities. pendent of whether surgical or conservative treatment
Nevertheless, use of open reduction techniques was carried out.51,67
implies that no single technique is applicable to all Children younger than 15 years should be mobilized
patients. A surgeon may become aware of this during the early and managed with a soft painless diet.51,61,68 Guiding
delayed open reduction of a small condylar fragment in maxillomandibular elastics may aid in reestablishing
an older patient with a malocclusion. We have noted proper occlusion when an open bite is present. There is
worse complications in patients who have been properly no confirmed benefit to any period of MMF.
planned with open reduction than with closed reduction. The absolute indications for open reduction in chil-
However, execution of the selected process became cor- dren are the same as those for adults and include the
rupted through patient noncompliance or surgical following: (1) displacement into the middle cranial fossa;
errors. (2) impossibility of obtaining adequate occlusion by CR;
(3) lateral extracapsular displacement of the condyle;
*References 14, 16, 18, 31, and 59. and (4) invasion by a foreign body.30
A B
FIGURE 15-31 Manual therapy techniques. (Courtesy Julie DeVahl.)
A B
FIGURE 15-32 Active range of motion exercises. (Courtesy Julie DeVahl.)
to prepare it for successive stretching with passive and/

PHYSICAL THERAPY FOR or active movements. Persistent pain in some patients
CONDYLAR FRACTURES may be managed with transcutaneous electrical nerve
stimulation.
When the fracture site is stable and the patient is cleared To restore mandibular range of motion, accessory
for active motion, the physical therapist will examine the motions of the TMJ must be addressed. Manual therapy
patient to quantify impairments and identify functional techniques include joint distraction for general mobil-
limitations. Typical postimmobilization findings include ity, anterior glide to restore translation during mand
pain with mandibular movement, decreased range of ibular depression greater than 20 to 25 mm and
motion in all planes, soft tissue adhesions, and decreased protrusion, and lateral or medial glides to restore
muscle strength and endurance. In addition to mandibu- lateral deviation required for chewing (Fig. 15-31). Soft
lar mobility, cervical mobility and posture are examined tissue massage and myofascial release are used for soft
and deficits addressed in the rehabilitation program. tissue adhesions.
Patients are frequently anxious and fearful of movement Following manual therapy, the patient is taught to
following traumatic injury and surgery, so patient educa- perform active range of motion exercises. Visual feed-
tion and cooperative goal setting are key to a successful back with a mirror is critical to enable the patient to
recovery. perform early exercises properly. A tongue depressor can
Pain experienced during initial attempts at active and be used to facilitate straight opening and symmetrical
passive movement normally decreases with successive lateral deviation (Fig. 15-32). When the fracture site is
attempts at motion. However, pain may inhibit the healed enough to handle stress, active-assisted opening
patient’s willingness to move, so the application of is performed by the patient by placing her or his thumbs
adjunctive modalities is helpful during the initial stages on the maxillary canines and/or premolars and the
of rehabilitation. Moist heat prior to range of motion middle fingers on the central mandibular incisors (Fig.
exercises, followed by cold packs after exercise, can be 15-33). The patient uses a prying open motion to facili-
demonstrated in the clinic and continued as a home tate movement. The same technique can be used with
intervention. In the presence of capsular fibrosis, ultra- sustained passive stretching at end range of motion
sound can provide deep heating of the connective tissue during later stages of rehabilitation.
Muscle strengthening and endurance can be facili-

tated with progressive diet instructions. The patient is
encouraged to chew on both sides of the mouth equally.
In addition, isometric exercises can be performed in
a progressive manner. The physical therapist demon-
strates the amount of pressure to be applied manually
to restrict mandibular movement in various planes and
the patient performs the exercises as a home program
(Fig. 15-34A-C).
When the patient demonstrates good control without
pain, the exercises are repeated with 1 to 2 cm of man-
dibular depression (see Fig. 15-34D). Dynamic strength-
ening of the mandibular elevators can be performed by
biting on surgical tubing with progressive wall thick-
nesses repetitively or with sustained holds.
FIGURE 15-33 Active-assisted opening by patient. (Courtesy Julie
DeVahl.)
A B
C D
FIGURE 15-34 Muscle strengthening and endurance therapy. (Courtesy Julie DeVahl.)
ACKNOWLEDGMENT 23. Bhagol A, Singh V, Kumar I, Verma A. Prospective evaluation of a

new classification system for the management of mandibular sub-
condylar fractures. J Oral Maxillofac Surg 69:1159–1165, 2011.
We would like to acknowledge the contributions of Ms. 24. Loukota RA, Neff A, Rasse M. Technical note: Nomenclature/clas-
Julie DeVahl, Assistant Professor, University of Texas sification of fractures of the mandibular condylar head. Br J Oral
Southwestern School of Health, Dallas, Southwestern Maxillofac Surg 2010. 48:477–478.
Allied Health Services School, Department of Physical 25. Palmieri C, Ellis E, Throckmorton G. Mandibular motion after
closed and open treatment of unilateral mandibular condylar
Therapy, for her recommendations on the physical process fractures. J Oral Maxillofac Surg 57:764–775, 1999.
therapy management of condylar fractures. 26. Kokemueller H, Konstantinovic VS, Barth E-L, et al: Endoscope-
assisted transoral reduction and internal fixation versus closed
treatment of mandibular condylar process fractures—a prospective
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CHAPTER
Fractures of the Zygomatic Complex
16 and Arch
Edward Ellis, III
OUTLINE
Anatomy Internal Orbital Reconstruction
Terminology and Fracture Patterns Intrasinus Approach to the Orbital Floor
Classification of Zygomaticomaxillary Complex Fractures Patients Treated for Zygomaticomaxillary Complex Fractures
Diagnosis of Zygomaticomaxillary Complex Fractures Zygomatic Arch Fractures
Clinical Examination Complications
Radiologic Evaluation Periorbital Incision Problems
Treatment of Zygomaticomaxillary Complex Fractures Infraorbital Nerve Disorders
Determining Whether the Zygoma Has Been Properly Implant Extrusion, Displacement, and Infection
Reduced Persistent Diplopia
Need for Fixation Enophthalmos
Need for Internal Orbital Reconstruction Blindness
Principles in the Treatment of Zygomaticomaxillary Complex Retrobulbar and Intraorbital Hemorrhage
Fractures Malunion of the Zygoma
Surgical Approaches to Zygomaticomaxillary Complex
Fractures
Reduction Techniques
Fixation Techniques
If excuses are needed for the writing of the present paper, they cause of the injuries sustained is greatly affected by the
are to be found in the comparatively common occurrence of the nature of the population in these studies; in the former
fracture discussed, in the extreme scarcity of mention of it or studies, the populations were from industrialized areas
its treatment in surgical literature, and in the fact that even with high rates of unemployment, in which interpersonal
well-known pathologic museums do not contain a single violence is very high.
example. Modern textbooks of surgery and fractures deal with In zygomatic fractures caused by altercations, the left
fractures of the malar-zygomatic compound so sparingly that zygoma is most commonly affected,* presumably because
one must be content with a few stray references or a paragraph of the greater incidence of right-handed individuals. This
on maxillary fractures or be guided by a terse sentence or two predilection disappears in unilateral fractures caused by
covering this subject. MVAs. Bilateral fractures of the zygoma are uncommon
H.D. Gillies, T.P. Kilner, and D. Stone, 19271 and account for approximately 4% of 2067 cases of zygo-
matic fracture in a 10-year review by Ellis et al.26 Bilateral
Zygomatic fractures are common facial injuries, repre- fractures in that study were more commonly the result of
senting the most common facial fracture2-14 or the second MVAs than altercations, indicating that the trauma
in frequency after nasal fractures.3,15-17 The high inci- inflicted in MVAs is more severe than that inflicted in
dence of these fractures probably relates to the zygoma’s altercations.
prominent position within the facial skeleton, which fre- Because the gross shape of the face is influenced
quently exposes it to traumatic forces. The incidence, largely by the underlying osseous structure, the zygoma
cause, age, and gender predilection of zygomatic injuries plays an important role in facial contour. Disruption of
vary, depending largely on the social, economic, political, zygomatic position also has great functional significance
and educational status of the population studied. Most because it causes impairment of ocular and mandibular
studies indicate a male predilection, with a ratio of function. Therefore, for cosmetic and functional reasons,
approximately 4 : 1 over females.18-27 Most authors also it is imperative that zygomatic injuries be properly and
agree that the peak incidence of such injuries occurs fully diagnosed and adequately treated.
around the second and third decades of life.28,29 The
causes of zygomatic injury in some studies are mostly
altercations, whereas in others, motor vehicle accidents
(MVAs) account for a more substantial number.30,30a The *References 12, 18, 20, 21, 24-26, and 30.
354
Fractures of the Zygomatic Complex and Arch CHAPTER 16 355
ANATOMY runs laterally from the infraorbital rim to the undersur-

face of the zygomaticomaxillary buttress. It forms the
The zygoma, a major buttress of the facial skeleton, is the superolateral aspect and part of the superoanterior
principal structure of the lateral midface. A thick strong aspect of the maxillary sinus. The zygoma also has a
bone, the zygoma is roughly quadrilateral in shape, with narrow weak articulation with the zygomatic crest of the
an outer convex (cheek) surface and an inner concave greater wing of the sphenoid bone at the lateral aspect
(temporal) surface. The convexity on the outer surface of the inferior orbital fissure (Fig. 16-3A). It forms a
of the zygomatic body forms the point of greatest promi- major portion of the lateral aspect and floor of the orbit.
nence of the cheek. Therefore, the zygoma plays a major The frontal process is thick and triangular in cross
role in facial contour. section, with facial, orbital, and temporal surfaces.
The zygoma is roughly the equivalent of a four-sided Because of its thickness, it is a frequent site for wire or
pyramid (Fig. 16-1). It has temporal, orbital, maxillary, bone-plate fixation following fracture. The temporal
and frontal processes, and articulates with four bones— process is flat and projects posteriorly to articulate with
the frontal, sphenoid, maxillary, and temporal (Fig. the zygomatic process of the temporal bone; the combi-
16-2). The body of the zygoma extensively articulates nation of the two makes up the zygomatic arch. The
with the maxilla along the anterior maxilla and along the zygomaticotemporal articulation is a thin delicate con-
orbital floor (see Fig. 16-2B). The suture between these nection, which fractures frequently and with minimal
two bones lies just lateral to the infraorbital foramen and force.
The zygoma provides an origin to a major portion of
the masseter muscle along the body and temporal
process. In addition, the temporal fascia attaches along
the arch and posterolateral edge of the temporal process.
The zygoma also provides attachments for the temporal
and zygomatic muscles. The strong infraorbital and
lateral orbital rims provide protection to the orbital
contents.
TERMINOLOGY AND FRACTURE PATTERNS

The malar bone represents a strong bone on fragile supports,
and it is for this reason that, though the body of the bone is
rarely broken, the four processes—frontal, orbital, maxillary,
and zygomatic—are frequent sites of fracture.
H.D. Gillies, T.P. Kilner, and D. Stone, 19271
The fracture pattern of any bone depends on several

factors, including the direction and magnitude of the
force. Fracture lines thus created pass through the areas
of greatest weakness of a bone or between bones. Because
FIGURE 16-1 The disarticulated zygoma has four processes—the of the strong buttressing nature of the zygoma and the
frontal, temporal, orbital, and maxillary—and constitutes the lateral thin bones surrounding it, most injuries involving the
portion of the orbit. zygoma are accompanied by disruption of adjacent
FIGURE 16-2 Anatomic position of the

zygoma. A, Lateral skull demonstrating its
articulation with the temporal, frontal, and
maxillary bones. B, Frontal skull
demonstrating its articulation with the
maxillary, frontal, and sphenoid bones.
The hatch marks demonstrate the extent
of the maxillary sinus. Note that the
zygoma forms the superolateral aspect of
A B the sinus.
FIGURE 16-3 Common fracture pattern in A

ZMC injury. A, Frontal view of skull showing
fracture medial to a zygomaticomaxillary
suture and along a zygomaticosphenoid
suture within orbit. B, Oblique frontal view of
skull showing fractures through a
frontozygomatic suture and posterior to a
zygomaticotemporal suture. C, Temporal
view of skull showing fractures extending
from the inferior orbital fissure superiorly
through the zygomaticosphenoid suture and
inferiorly through the zygomatic buttress of
the maxilla. D, Inferior skull showing a triple
fracture through the zygomatic arch. Note
that the orbital floor, medial orbital wall, and
zygomaticomaxillary buttress are frequently C D
comminuted in addition to the fracture
patterns described.
articulating bones. This disruption occurs because when zygoma and adjacent bones from isolated zygomatic arch
a force is applied to the body of the zygoma, it is distrib- fractures, and they are used when this distinction is
uted through its four processes to the adjacent articulat- necessary.
ing bones, many of which are weaker than the zygoma. The inferior orbital fissure is the key to remembering
Although the zygomatic bone is involved, it is rare to have the usual lines of ZMC fractures. Three lines of fracture
an isolated fracture of the zygoma in which the fracture extend from the inferior orbital fissure in an anterome-
lines are completely within this bone or through only the dial, superolateral, and inferior direction (see Fig. 16-3).
sutures surrounding it. One fracture extends from the inferior orbital fissure
Zygomatic or malar fractures are the terms commonly anteromedially along the orbital floor, mostly through
used to describe fractures that involve the lateral third of the orbital process of the maxilla toward the infraorbital
the middle face. Because of the impure nature of zygo- rim. The orbital floor and medial wall are often com-
matic fractures, other terms have been adopted in minuted, creating multiple lines of fracture within the
describing such fractures. Zygomaticomaxillary complex, internal orbit. The infraorbital canal is usually crossed by
zygomaticomaxillary compound,31 zygomatico-orbital,26 zygo- the fracture line(s) because the fracture frequently
matic complex,32,33 malar, trimalar, and tripod fractures are extends through the infraorbital rim to the facial surface
terms that have been used to describe the clinical entity of the maxilla, above or even slightly medial to the infra-
of fractures involving the zygoma and adjacent bones. orbital foramen. The fracture extends from the infraor-
The latter two terms are misnomers because the zygoma bital rim in the maxilla laterally and inferiorly under the
has not three but four processes, and their use should be zygomatic buttress of the maxilla. Comminution of the
condemned. Zygomatic, zygomatic complex, or zygomat- infraorbital rim and bone along the anterior and lateral
icomaxillary complex (ZMC) are perhaps the most com- maxilla is common, with frequent involvement of the
monly used. They are used throughout this chapter infraorbital foramen. Therefore, the fracture rarely
because the zygoma is the major bone involved in such involves the zygomatic bone along the orbital floor and
fractures and for the sake of simplicity. The term zygo- the anterior and lateral aspects of the face. The fracture
matic or ZMC helps distinguish fractures that involve the lines are mostly within the maxilla.
A second line of fracture from the inferior orbital is true for many other aspects of surgery, it is extremely
fissure runs inferiorly through the posterior (infratem- rare to find two patients who have exactly the same
poral) aspect of the maxilla and joins the fracture from condition.
the anterior aspect of the maxilla, under the zygomatico- In 1990, Manson et al40 published a classification of
maxillary buttress (see Fig. 16-3C). midfacial fractures that was based on the amount of
The third line of fracture extends superiorly from the energy dissipated by the facial bones secondary to the
inferior orbital fissure along the lateral orbital wall pos- traumatic force. Their classification of high-, moderate-,
terior to the rim, usually separating the zygomaticosphe- or low-energy fractures was based on findings on com-
noid suture (see Fig. 16-3A and C). Extending superiorly, puted tomography (CT) scans. High-energy fractures
laterally, and anteriorly toward the lateral orbital rim, the had extreme displacement, comminution of the articula-
fracture frequently separates the frontozygomatic suture tions, and segmentation of the bones. They noted that
at the lateral orbital rim. However, the fracture through these required extensive exposure and fixation for a sat-
the lateral orbital rim is occasionally superior or inferior isfactory outcome. On the other hand, lower energy frac-
to the frontozygomatic suture. tures were characterized by displacement but without
A ZMC fracture that follows this pattern usually has comminution of bony articulations. They noted that
one additional fracture line through the zygomatic arch. these could be treated by less aggressive means. Using
Because the point of least resistance to fracture is not at preoperative CT findings may be the most useful way to
the zygomaticotemporal suture, but approximately decide how much intervention may be required before
1.5 cm more posteriorly, the point of fracture when a surgery.
single fracture exists is usually in the approximate middle It behooves clinicians to evaluate each case individu-
of the zygomatic arch, in the zygomatic process of the ally. Whether they choose to prescribe treatment based
temporal bone. Frequently, however, three fracture lines on the experience of others for a given class of fracture
exist through the arch, producing two free segments is their choice; however, with proper surgical manage-
when the fractures are complete (see Fig. 16-3D). These ment, the nature of the treatment should depend more
segments can be displaced by associated muscle pull or on the preoperative imaging analysis and surgical find-
may be pushed medially into the infratemporal fossa. ings than on statistical prescription.
Often, the fractures are incomplete, or greenstick, frac-
tures, producing a medial or lateral warping of the zygo-
matic arch without notable upward or downward DIAGNOSIS OF ZYGOMATICOMAXILLARY
displacement. COMPLEX FRACTURES
This description is for the common or usual ZMC
fracture. However, the variability of these fractures is In a typical case, diagnosis may be made at sight once the
great because of the differences in magnitude and direc- characteristic appearance has been fully recognized. A peculiar
tion of force, amount of soft tissue covering the zygoma, facies is present, due chiefly to a certain flatness of contour
and density of the adjacent bones. Frequently, the lines and an absence of expression on the affected side.
of fracture are in locations different from those described H.D. Gillies, T.P. Kilner, and D. Stone, 19271
earlier. Using radiographs to summarize the course of
fracture lines in 100 isolated zygomatic injuries, Meyer et The diagnosis of zygomatic fractures is primarily based
al11 have found fractures in the body of the zygoma in on clinical and radiologic examination, although the
almost 40% of cases, compared with the more common history frequently raises a strong suggestion of the pos-
medial location along the anterior maxillary surface. sibility that a fracture may exist and gives an indication
Single or multiple lines of fracture (i.e., comminution) about the nature, direction, and force of the blow. It
may exist. Gross displacement may occur, or no displace- should be stressed that the clinical examination is fre-
ment at all. Because of the infinite number of possible quently difficult to perform adequately because of the
variations, one must assess each zygomatic fracture inde- nature of the patient’s mental state and/or the amount
pendently and determine the extent and location of the of facial edema and pain. The swelling may conceal facial
fractures present. deformity that appears only after the swelling has sub-
sided. If the examination can be performed immediately
following the injury and before the onset of edema, more
CLASSIFICATION OF information can be obtained from the clinical examina-
ZYGOMATICOMAXILLARY tions. Because there are no sensitive indicators of zygo-
COMPLEX FRACTURES matic fractures (e.g., those that the teeth provide in
maxillary or mandibular fractures), and because the con-
It is probably fair to say that classification of zygomatic comitant soft tissue edema and contusion that frequently
fractures according to the individual who tries to describe accompany zygomatic injuries can obscure clinical exam-
them. The result has been a confusing array of classifica- ination, the use of imaging and clinical findings is impor-
tion systems that try to describe the anatomic position of tant in the diagnosis of ZMC fractures.
the displaced bone or to classify fractures using position
and criteria for postreduction stability.6,22,33-39 Whether a CLINICAL EXAMINATION
patient receives better treatment from being classified After the clinician has ascertained the neurologic status
into one system or another is doubtful, and one should of a patient with suspected ZMC fracture, the first prior-
not dwell on the many classification systems available. As ity is determination of the visual status of the involved
eye. A thorough ocular and funduscopic examination

should be performed, with complete documentation of
the findings. Ocular injuries, such as vitreous hemor-
rhage, hyphema, globe laceration, severance of the optic
nerve, and corneal abrasions, were found in 4% of
patients with midfacial trauma by Turvey12 and in 5% of
zygomaticoorbital fractures by Livingston et al.41 Oph-
thalmologic consultation was deemed necessary in
approximately 5% of 2067 cases of zygomaticoorbital
injuries reported by Ellis et al.26 Ioannides et al42 found
significant ocular and adnexal injuries in 26% of orbital
fractures. Al-Qurainy et al43 prospectively performed
ophthalmologic examinations in 363 patients who had
sustained midfacial fractures. Minor or transient eye inju-
ries, such as corneal abrasion, chemosis, mild impair- FIGURE 16-4 Method of assessing posterior displacement of the
ment of accommodation and visual acuity, and orbital ZMC from behind the patient. The clinician should firmly depress
emphysema, were found in 63% of patients. Moderate the fingers into the edematous soft tissue while palpating along
injuries, such as enophthalmos, conjunctival abrasion, infraorbital areas.
traumatic pupillary changes, iridodialysis, lens damage,
macular edema, and moderate to severe impairment of
accommodation and visual acuity, were noted in 16% of
patients. Severe ophthalmic disorders, such as gross pro- opposed to palpating along the lateral aspect. When frac-
ptosis, retrobulbar hemorrhage, corneal laceration, tures are present, palpation frequently is accompanied
hyphema, angle recession, severe reduction or loss of by exquisite tenderness. The body of the zygoma and
vision, visual field loss, choroidal tear involving the zygomatic arch are best palpated with two or three fingers
macula, and optic nerve injuries, were found in 12% of in a circular motion, with the surgeon comparing this
patients. One third of all patients with comminuted ZMC palpation with that of the opposite side. The zygomatic
fractures suffered a severe ocular disorder. Therefore, if buttress of the maxilla is palpated intraorally with one
the clinician discovers any significant or questionable finger, and hematoma or irregularities are sought.
findings in patients with midfacial fractures, ophthalmo-
logic consultation should be obtained. Signs and Symptoms
Examination of the zygoma involves inspection and Several signs and symptoms accompany zygomatic frac-
palpation. Inspection is performed from the frontal, tures. The presence and magnitude of their severity
lateral, superior, and inferior views. One should note greatly depend on the extent and type of zygomatic
symmetry, pupillary levels, presence of orbital edema and injury. For example, facial flattening is more pronounced
subconjunctival ecchymosis, and anterior and lateral pro- in injuries in which the zygomatic body has been greatly
jection of the zygomatic bodies. The most useful method displaced, as opposed to those in which the body has not
for evaluating the position of the body of the zygoma is been displaced. Similarly, zygomatic arch fractures may
from the superior view. The patient can be placed in a be expected to produce less ocular disruption than ZMC
recumbent position or recline in a chair. The surgeon fractures. The following signs and symptoms can accom-
inspects from a superior position, evaluating how the pany zygomatic fractures and therefore should be
zygomatic bodies project anteriorly and laterally to the evaluated.
supraorbital rims, comparing one side with the other. Periorbital Ecchymosis and Edema. Edema and bleeding
The surgeon should lay his or her index finger below the into the loose connective tissue of the eyelids and peri-
infraorbital margins, along the zygomatic bodies, press- orbital areas is the most common sign following fracture
ing into the edematous tissue to palpate and reduce the of the orbital rim.45,46 Swelling, often massive, may be
visual effect of edema simultaneously when performing present and is most dramatic in the periorbital tissue,
this examination (Fig. 16-4).44 The superior view is also where the eyelids may be swollen closed. The ecchymosis
helpful for evaluating possible depression of the zygo- may be in the inferior lid and infraorbital area only or
matic arches. One should not forget to perform an intra- around the entire orbital rim.
oral examination, because zygomatic fractures are often Flattening of the Malar Prominence. A characteristic sign
accompanied by ecchymosis in the superior buccal sulcus and striking feature of zygomatic injury is a flattening of
and maxillary dentoalveolar fractures. the normal prominence in the malar area. An especially
Palpation should be systematic and thorough, and one common finding in ZMC injuries, this flattening is
side should be compared with the other. The orbital rims reported in 70% to 86% of cases,22,26,29 especially those in
are palpated first. The surgeon palpates the infraorbital which distraction of the frontozygomatic suture and
rims with the index finger, moving the finger rhythmi- medial rotation and/or comminution have occurred. If
cally from side to side along the rim. The lateral orbital edema is present, flattening may be difficult to discern
rims are palpated with the index finger and thumb. One soon after injury; however, one can usually gain an appre-
should also use the index finger along the inner aspect ciation of this sign by depressing the index fingers into
of the lateral orbital rim because fractures may frequently the soft tissue of the zygomatic areas and comparing one
be detected by palpating inside the orbital rim, as side with the other from above the patient (see Fig. 16-4).
Flattening over the Zygomatic Arch. A characteristic

indentation or loss of the normal convex curvature in the
temporal area accompanies fractures of the zygomatic
arch. Visual and digital comparison with the opposite
side is extremely helpful for detection of depressions of
the zygomatic arch.
Pain. Severe pain is normally not a feature of zygo-
matic injuries unless the fractured segment is mobile.
Patients do, however, complain of discomfort associated
with the attendant bruising. Palpation of the fracture
sites also elicits a painful response.
Ecchymosis of the Maxillary Buccal Sulcus. An important
sign of zygomatic or maxillary fracture is ecchymosis in
the maxillary buccal sulcus. Ecchymosis may occur even
with a small disruption of the anterior or lateral maxilla
and should be sought in patients with suspected zygo-
matic fractures.
Deformity at the Zygomatic Buttress of the Maxilla. Intra-
oral palpation of the anterior and lateral aspects of the
maxilla frequently reveals irregularities of the normally
smooth contour, especially in the area of the zygomatic
buttress of the maxilla. Crepitation from comminuted
fragments of bone is also frequently palpable. If no ten- FIGURE 16-5 Depressed zygomatic arch impinging on the
derness is experienced during this maneuver, the chances temporal muscle and/or coronoid process, limiting mandibular
are that no fracture exists. The absence of pain makes a excursions.
zygomatic fracture unlikely, but its presence does not
establish one because the pain can be a result of soft
tissue injury and/or maxillary fracture.
Deformity of the Orbital Margin. Fractures running
through the orbital rim often result in a gap, or step
deformity, if displacement has occurred. This finding is
frequently noted at the infraorbital and lateral orbital
rims when zygomatic fractures are present.45,46 These
areas may also be tender to touch.
Trismus. Limitation of mouth opening frequently
accompanies zygomatic injuries and is present in approx-
imately one third of cases.26,46,47 This condition occurs
with an even higher incidence in isolated fractures of the
zygomatic arch (45%). The reason often cited for post-
fracture trismus is impingement of the translating coro-
noid process of the mandible on the displaced zygomatic
fragments. Whether this contact actually occurs in most
cases is doubtful, because the amount of displacement
necessary for producing actual mechanical interference FIGURE 16-6 Typical fracture extends along or through the
is great. A more likely explanation is muscle spasm sec- infraorbital groove or canal along the orbital floor and frequently
ondary to impingement by the displaced fragments, espe- across the infraorbital foramen on the facial surface of the maxilla.
cially on the temporal muscle (Fig. 16-5). An associated The orbital floor medial wall is frequently comminuted, with
finding is deviation of the mandible toward the fractured multiple lines of fracture crossing the infraorbital neurovascular
side when the mouth is opened. bundle.
Abnormal Nerve Sensibility. An important symptom,
present in approximately 50% to 90% of ZMC injuries,
is impaired sensation of the infraorbital nerve.22,26,45-52 results in multiple fragments of bone strung together by
Infraorbital nerve paresthesia is more common in frac- the infraorbital neurovascular bundle. When the line of
tures that are displaced than those that are not. It is fracture is lateral to the infraorbital groove and foramen
difficult to differentiate true anesthesia from the altered (less common), the infraorbital nerve is spared. Disrup-
sensation of swollen edematous tissue but, as the swelling tion of the infraorbital nerve causes anesthesia of the
decreases, infraorbital nerve anesthesia becomes appar- lower eyelid, upper lip, and lateral aspect of the nose.
ent. Infraorbital anesthesia occurs when the fracture A related symptom may be altered sensitivity of the
through the orbital floor and/or the anterior maxilla maxillary teeth and gingiva.53 When this altered sensitiv-
causes tearing, shearing, or compression of the infraor- ity is present, the clinician should suspect a disruption of
bital nerve along its canal or foramen (Fig. 16-6). Fre- the infraorbital nerve within its canal, where the middle
quently, the entire orbital floor is comminuted, which and anterior superior alveolar nerves take origin.
Epistaxis. Whenever the sinus mucosa is disrupted,

hemorrhage into the sinus is possible. Most fractures
through the sinus wall that have had even a minor
amount of displacement tear the lining mucosa, produc-
ing internal bleeding. Because the maxillary sinus drains
into the nose via the middle meatus, unilateral hemor-
rhage from the nose is possible and occurs in approxi-
mately 30% to 50% of ZMC injuries.26,46
Subconjunctival Ecchymoses. Subconjunctival hemor-
rhage, a frequent finding in zygomatic fractures, is
present in 50% to 70% of cases.26,46 It may accompany
even a hairline crack through the orbital rim if the peri-
osteum has been torn. Its absence does not exclude an
orbital rim fracture because if no disruption of the peri- FIGURE 16-7 Inferior displacement of the zygoma results in
osteum has occurred, bleeding can accumulate in a sub- depression of the lateral canthus and pupil because of depression
periosteal location and may not be visible under the of the suspensory ligaments that attach to the lateral orbital
(Whitnall’s) tubercle.
conjunctiva. When present, subconjunctival ecchymoses
usually have no posterior limit and will be bright red
because of the ability of oxygen to diffuse through the
conjunctiva to the collection of blood. is important to distinguish between them. Monocular
Crepitation from Air Emphysema. Fracture through a diplopia, or blurring of vision through one eye with the
sinus wall with tearing of the lining mucosa allows air to other closed, requires the immediate attention of an oph-
escape into the facial soft tissue if the pressure within the thalmologist, because it usually indicates a detached lens,
sinus is greater than that within the tissue. The soft tissue hyphema, or other traumatic injury to the globe. Binocu-
of the periorbital area, especially the eyelids, is prone to lar diplopia, in which the blurring of vision occurs only
inflation with air because of its loose areolar nature. when the patient looks through both eyes simultaneously,
When inflation occurs, one can palpate crepitation, indi- is common and occurs in approximately 10% to 40% of
cating subcutaneous emphysema. Crepitation is most zygomatic injuries.* Al-Qurainy et al65 have found that the
easily appreciated by alternatively rolling two fingers severity of diplopia is associated with the severity of midfa-
gently over the tissue, which produces a characteristic cial injuries. Almost 30% of patients with comminuted
crackling sensation. It is an uncommon finding following fractures of the ZMC experienced diplopia, 22% of
zygomatic fractures, but the potential for air emphysema patients with noncomminuted displaced ZMC fractures
is constant. When present, however, crepitation can be had diplopia, and only 8% of patients with minimally dis-
alarming to the patient. The emphysema disappears placed or nondisplaced ZMC fractures had diplopia. Bin-
spontaneously in 2 to 4 days without treatment. The sig- ocular diplopia that develops following trauma can be the
nificance of emphysema is the potential for infection result of soft tissue (muscle or periorbital) entrapment,
through the communication between the sinus and the neuromuscular injury, intraorbital or intramuscular
soft tissue. hematoma or edema, or a change in orbital shape, with
Displacement of the Palpebral Fissure. The lateral palpe- displacement of the globe causing a muscle imbalance.
bral ligament is attached to the zygomatic portion of the Enophthalmos and globe ptosis associated with marked
orbital rim. Displacement of the zygoma carries the pal- displacement of the globe can also cause diplopia.
pebral attachment with it and thus produces a dramatic A useful point in differentiating the cause of diplopia
visual deformity. When the zygoma is displaced in an is the finding that general edema of the orbit usually
inferior direction, the lateral palpebral ligament is also causes diplopia in the extremes of upward and downward
depressed, causing a downward slope to the fissure (anti- gaze. Almost complete lack of eye movement in one
mongoloid slant) (Fig. 16-7). Because the orbital septum direction is present with mechanical interference or neu-
is attached to the infraorbital rim, inferior or posterior romuscular injury, most commonly muscle entrapment.
displacement of the inferior orbital rim causes depres- The diagnosis of diplopia can be difficult in the early
sion of the lower eyelid, giving it a shortened appear- stages of an injury, when severe edema of the orbit and
ance.54 This depression may cause more sclera to be eyelids is present. Diplopia of edema or hemorrhagic
exposed below the iris and an apparent ectropion. origin should resolve in a few days, whereas diplopia
Unequal Pupillary Levels. With the disruption of the caused by entrapment of orbital tissue does not.
orbital floor and lateral aspect of the orbit that frequently One can determine the presence of entrapment of
accompanies zygomatic fractures, loss of osseous support orbital contents by the fracture through the orbital floor
for the orbital contents and displacement of Tenon’s with a forced duction test. Small forceps are used to grasp
capsule and the suspensory ligaments of the globe permit the tendon of the inferior rectus through the conjunctiva
depression of the globe.55 This displacement is mani- of the inferior fornix and the globe is manipulated
fested clinically as unequal pupillary levels, with the through its entire range of motion (Fig. 16-8). Inability
involved pupil at a level lower than that of the normal to rotate the globe superiorly signifies entrapment of the
side (see Fig. 16-7). muscles in the orbital floor. This test should differentiate
Diplopia. Diplopia is the name given to the symptom of
blurred vision. Two varieties of diplopia exist; it *References 15, 22, 26, 34, 35, 46, and 56-64.
FIGURE 16-8 The forced duction test determines whether there is a physical impediment to ocular motility. A, Grasping of the inferior
rectus muscle. B, Clinical photograph. (From Ward Booth P, Eppley BL, Schmelzeisen R: Maxillofacial trauma and esthetic facial
reconstruction, ed 2, WB Saunders, St. Louis, 2012.)
between entrapment of orbital contents and paralysis as can be obtained with CT is much greater than that which
a result of neuromuscular injury or edema. The test can be obtained from a series of plain films. CT accu-
should be performed routinely in those who cannot rately identifies lines of fracture, position and displace-
rotate the globe into an upward gaze. ment of the ZMC, and status of the zygomatic arch (Fig.
Enophthalmos. If the zygomatic injury has produced an 16-9). CT scans are especially helpful in that they allow
increase in orbital volume, usually by lateral and inferior a complete assessment of the status of the orbital floor
displacement of the zygoma and/or disruption of the and walls and the depth to which one must dissect to
inferior, medial, and/or lateral orbital walls, or has reach stable bone. CT has eliminated the question about
resulted in a decrease in orbital soft tissue volume by her- whether the orbit should be explored. With the accurate
niation of orbital soft tissue, enophthalmos can result. image of the internal orbit provided by CT, one can make
This diagnosis is difficult to make acutely unless the a decision regarding the necessity for internal orbital
enophthalmos is severe because adjacent soft tissue edema reconstruction before surgery.
always produces a relative enophthalmos. After the swell- The status of the orbital soft tissue can also be
ing has dissipated, enophthalmos becomes more obvious assessed because of the great contrast provided by CT.
and is frequently associated with ptosis of the globe. The Comparison of globe projection from one side with the
clinical manifestations of enophthalmos are accentuation other helps identify enophthalmos in unilateral inju-
of the sulcus of the upper lid and narrowing of the palpe- ries.66,67,70,71 Also, CT scans allow identification of associ-
bral fissure, causing pseudoptosis of the upper lid. The ated craniofacial injuries.72 For ZMC injuries, it is
anterior projection of the globe as viewed from above is optimal to obtain axial and coronal high-resolution
reduced on the side of injury. Zygomatic fractures are scans. The axial scan is extremely helpful in evaluating
associated with enophthalmos in approximately 5% of the medial and lateral orbital walls, and the coronal
cases before treatment.22,26,46 If enophthalmos is present scan defines the extent of injury to the orbital floor
during the initial examination, it is likely that a great (see Fig. 16-9). Reformatted coronal views (from axial
increase in bony orbital volume has occurred.66,67 scans) are not as helpful but may be necessary if the
patient cannot be properly positioned because of
RADIOLOGIC EVALUATION injury. Three-dimensional CT scans offer no additional
Nothing is more valuable to the surgeon in determining the information beyond what is already present in two-
extent of injury and the position of the fragments—both before dimensional scans but are useful to understand the dis-
and after operation—than a good skiagram. placement and fracture patterns.73,74
H.D. Gillies, T.P. Kilner, and D. Stone, 19271
By 1992, CT essentially supplanted other radiologic TREATMENT OF ZYGOMATICOMAXILLARY

methods in the assessment of patients with midfacial inju- COMPLEX FRACTURES
ries.68 Two-dimensional CT is now considered the best
and most useful means of radiologic assessment of the The methods of treating a fractured malar bone recom-
injured facial skeleton.69 The amount of information that mended by the various writers who have reported
A B
C D
E F
FIGURE 16-9 A-D, CT scans showing exquisite detail of a patient without a ZMC fracture demonstrating normal anatomy. A, Coronal CT
scan through the medial orbital rim. One should be alert to the possibility of fractures in this area. If lateral displacement of the medial
orbital rim goes unnoticed, proper alignment of the infraorbital rim will cause the ZMC to be laterally displaced. B, Coronal CT scan just
posterior to the globe. The coronal scan is particularly useful for assessing the status of the medial wall and floor of the orbit. One should
carefully compare the size of the orbits and the contour of the floor and walls. The coronal scan is also extremely useful for assessing the
position of the malar eminence. One can follow the contour of the malar eminence inferiorly along the zygomaticomaxillary buttress. ZMC
fractures have disruption of this area and the malar eminence often rotates inferomedially into the maxillary sinus. C, Axial CT scan at the
level of the midglobe. This allows assessment of the medial wall, lateral wall, and lateral orbital rim, and the position of the globes in
relation to the bony orbit and one another. Note that the lateral orbital wall is fairly straight in its course. ZMC fractures usually show
displacement of the zygoma in relation to the greater wing of the sphenoid within the lateral portion of the orbit. Many ZMC fractures
associated with significant orbital floor and medial wall fractures show fractures of the medial wall in this view, with the orbital contents
herniating into the top of the maxillary sinus and ethmoids. D, Axial CT scan just below the infraorbital rim, at the level of the zygomatic
arch. This view is useful for showing the status of the zygomatic arch, projection of the malar eminences, and fractures along the
infratemporal surface of the ZMC. If scans are taken with the head properly positioned so that similar cuts are made bilaterally, one
should compare the right and left sides for symmetry. E and F, Coronal CT scans of the orbit showing a common location of orbital floor
and medial wall fractures. Note the increase in orbital volume that accompanies these injuries. Fracture defects may be small and have
little orbital tissue herniating into the sinuses. Many defects associated with ZMC fractures are larger than the one shown. Examination of
several cuts identifies the posterior extent of the fracture, allowing the surgeon to determine preoperatively how far posteriorly to dissect
and the size of material necessary for reconstructing the defect.
architecture. If a comminuted ZMC is not treated for

TABLE 16-1 Reported Incidence of Zygomatic Fractures several days following injury, an excellent reduction may
Not Requiring Surgical Treatment be compromised by the soft tissue scarring and change
Percentage Not in morphology that occur between the time of injury and
Study Sample Size Requiring Surgery fracture repair. Optimally, fractures are treated before
Carlson and Märtensson, 144 16 the onset of edema from the traumatic incident. In prac-
196945 tice, however, such timing of treatment is rarely possible.
Wiesenbaugh, 197046 71 21 When edema is moderate to severe, postponement of
Lund, 197128 62 42
surgery for several days makes thorough examination
and surgical treatment reliable and much easier tasks.
Melmed, 197219 270 43
Therefore, postponement of the decision to operate
Pozatek et al, 197376 85 9 until facial edema resolves is recommended when the
Haidar, 197718 108 43 necessity for intervention is questionable. This approach
Larsen and Thomsen, 137 16 may be used in fractures that are minimally displaced,
197822 when radiographic examination of the internal orbit
Afzelius and Rosén, 197913 214 16 shows no major defects. However, if the radiographic
Adekeye, 198023 337 47 findings are so dramatic that intervention is definitely
necessary, it may be advantageous to perform the surgery
Balle et al, 198229 105 25
regardless of the facial edema present, because the final
Pospisil and Fernando, 117 37 soft tissue contour may be superior to that which may
198477
occur when surgery is postponed. If the surgeon decides
Fischer-Brandies and 97 12 not to intervene, the patient should be observed for 2 to
Dielert, 198425 3 weeks and a soft diet should be prescribed.
Foo, 198424 77 30 One should always remember that if a force is suffi-
Ellis et al, 198526 2067 23 cient to produce a fracture of the zygoma, it is also suf-
Kristensen and Tveterås, 74 49 ficient to produce intracranial injuries. ZMC fractures
198627 are not life-threatening injuries and should not be given
Kaastad and Freng, 198978 251 9 priority over more acute problems. Treatment need not
be hastened if the neurologic state of the patient is in
Covington et al, 199479 259 29
question because zygomatic fractures can be satisfacto-
rily treated in several days, after the facial edema has
resolved.
Another important consideration in deciding whether
to intervene is the status of the opposite eye. If the patient
cases include simple digital manipulation under general has diminished vision in the eye on the side opposite the
anesthesia, external manipulation by means of a cow- fracture for any reason, one may decide not to treat the
horn dental forceps grasping the edges of the bone, displaced ZMC fracture associated with the only normally
traction and elevation by means of wire or heavy bone functioning eye. Although the risk to vision is minimal
elevators passed through small local external incisions, when ZMC fractures are treated, loss of sight in the only
and elevation via incision in the mucosa of the gingival functioning eye would be a catastrophe. Therefore, the
sulcus at the canine fossa. patient must be educated so that an informed decision
can be made.
Our technique, which has now been used successfully in a If intervention is deemed necessary, proper treatment,
number of cases, differs from those mentioned. as for any displaced fracture, requires reduction and, if
H.D. Gillies, T.P. Kilner, and D. Stone, 19271 necessary, fixation. Because closed reduction using exter-
nal manipulation is impossible, all reduction techniques
Since Duverney75 first described the fractured zygoma, are operative procedures (i.e., open) in the sense that
numerous methods have been suggested for treating it. the skin or mucosal surfaces are violated.
These range from nonintervention and observation to One must be aware that ZMC fractures can result from
open reduction and internal fixation (ORIF). Because high- and low-energy injuries.40 Those resulting from
many fractures are nondisplaced or minimally displaced, altercations seem to be more linear in character and
intervention is not always necessary. Studies have shown displaced en bloc (Fig. 16-10). These fractures can fre-
that between 9% and 50% of ZMC fractures do not quently be treated with limited exposure, simple reduc-
require operative treatment (Table 16-1). tion, and simple methods of fixation, if necessary.
The decision to intervene should be based on signs, Conversely, high-energy injuries, such as those sustained
symptoms, and functional impairment. The decision in MVAs, produce more comminution, especially of the
need not be made hastily because ZMC fractures are not adjacent bones, where the ZMC abuts, and are much less
emergencies and treatment can be delayed, if necessary. amenable to simple methods of treatment (Fig. 16-11).
However, during the first week following trauma, the soft These fractures usually require extended open reduction
tissue undergoes changes consistent with the usual and rigid fixation techniques. The surgeon must there-
sequence of wound healing. The form that they will ulti- fore be aware of the nature and extent of the injury as
mately take depends on the underlying bony treatment is planned.
A B
FIGURE 16-10 CT scans of a low-energy ZMC fracture. A, Coronal scan shows rotation of the ZMC around the zygomaticofrontal suture
downward and medially into the maxillary sinus. Note the difference in the position of the malar eminence from one side to the other and
the disruption and displacement of the zygomaticomaxillary buttress. However, note that the fracture through the orbital floor is
noncomminuted. B, Axial scan of the same patient shows posterior displacement of the malar eminence and rotation of the posterior
(infratemporal) surface of the ZMC medially into the maxillary sinus. This fracture was treated by open reduction via an intraoral approach
and fixation with a single bone plate applied along the zygomaticomaxillary buttress. The orbit was not entered.
A B
C D
FIGURE 16-11 CT scans of a high-energy ZMC fracture. A, Coronal scan of the posterior orbit showing disruption of the orbital floor and
lateral wall. Note also the comminution of the malar eminence and zygomaticomaxillary buttress. B, Axial scan at the level of the
midglobe showing comminution of the lateral orbital wall (sphenozygomatic suture) and notable posterior displacement of the lateral
orbital rim. C, Axial scan at the level of the zygomatic arch showing severe displacement of the malar eminence posteriorly into maxillary
sinus. Note also the degree of comminution and bowing of the zygomatic arch. D, Axial scan at the level of the malar eminence showing
severe posterior and medial displacement of the ZMC. This fracture was treated by open reduction using intraoral, coronal, and lower
eyelid approaches. Several bone plates were used for fixation and the orbital floor and walls were reconstructed with bone grafts.
Because of the ZMC’s difficult anatomic details, and

because there are no sensitive clues to accurate and
stable reduction, some surgeons have suggested that
Axis of each ZMC fracture be treated aggressively, with ORIF of
Rotation at least two of its four major processes.17,81-85 Dingman
and Natvig,81 for example, have stated that “While closed
reduction techniques are popular and attractive in
the management of fractures in this region, the experi-
enced surgeon will be quick to see, in many cases, the
limitations that closed methods impose.” The main con-
troversies in the treatment of ZMC fractures are the
following:
1. Should surgical exposure of the zygoma in two or
ZMC three locations routinely be performed to deter-
Displacement mine whether the reduction has been adequate?
2. Should fixation devices be routinely applied?
3. Does the internal orbit require reconstruction?
It is noteworthy that the most common treatment
errors that lead to poor results also center on these same
topics.
DETERMINING WHETHER THE ZYGOMA HAS BEEN

FIGURE 16-12 The ZMC can rotate inferiorly and medially, even PROPERLY REDUCED
when reduced at the frontozygomatic and infraorbital areas.
There should be no doubt that observation of the frac-
ture in three of its four processes will allow the surgeon
Many methods are available for the reduction and to determine the postreduction position accurately.
fixation of zygomatic fractures, which indicates that no Karlan and Cassisi80 have shown this to be true in a clini-
one technique is always superior to the others. Few if any cal review of their patients. The question therefore
procedures are always satisfactory for every type of zygo- becomes whether this is always necessary. Recommenda-
matic fracture, so the surgeon’s judgment and ability to tions in the literature for reduction of ZMC fractures
apply a satisfactory modality to a given fracture are the range from closed reduction techniques78-79 to three- or
deciding factors in whether the patient receives appro- four-point surgical exposure.89-92 Incisions used to expose
priate treatment. It should be stressed that satisfactory the lateral orbital, infraorbital, and zygomaticomaxillary
results can be achieved using a number of techniques. It buttress (intraorally) areas not only take time but also
is not so much the actual technique, but the proper have the potential to produce complications of their
application of principles, that produces satisfactory own, regardless of the zygomatic fracture for which they
results. are being used (see later, “Complications”).
The fractured zygoma is perhaps the least understood In several cases, however, surgical exposure becomes
and most frequently mistreated facial fracture. Much of helpful. First, when preoperative signs and symptoms
the difficulty in treating these fractures stems from the and/or radiographs indicate the need for internal orbital
complex and multiple anatomic relationships that the reconstruction, it is prudent to gain access to the infra-
zygoma maintains within the facial skeleton. The most orbital rim and orbital floor before elevation of the
common mistake made in clinical practice is to assume zygoma. Second, if surgery must be performed while
that the ZMC will be in its proper position if the infraor- excessive facial edema is present, surgical exposure to
bital and lateral orbital rims have been reduced. One determine the position of the ZMC is helpful. Third, if
must remember that the fractured ZMC has four major one cannot determine whether the reduction has been
processes that articulate with adjacent bones. Only when adequate during the surgery, exposure will provide the
three are properly positioned can one be sure of an necessary verification. Fourth, surgical exposure is
accurate reduction. It may be more helpful to think of helpful if fixation devices are deemed necessary from the
the zygoma as a four-legged chair. If three of the four preoperative assessment of the fracture. Thus, the use of
legs are on the floor, the other must also be on the floor. surgical exposure depends on the circumstances and
On the other hand, if two legs are on the floor, two may experience of the surgeon; however, given these exam-
also be off the floor. Therefore, reducing orbital rim ples, it will be frequently performed. If there is any doubt
fractures (two legs of the chair) does not guarantee that about the postreduction ZMC position, one should verify
the entire complex has been properly reduced, because it with exposure, remembering that even though the
the zygoma can rotate inferiorly and medially (Fig. orbital rims are reduced, the body of the zygoma can be
16-12). In this case, fractures through the zygomatic but- rotated medially. Exposure and exploration of other
tress of the maxilla and zygomatic arch are left improp- areas help determine when the zygoma has been prop-
erly aligned,80 producing a flattened appearance to the erly reduced. Fractures at the zygomatic arch and inter-
face in the area in which the body of the zygoma nor- nal orbit along the greater wing of the sphenoid (Fig.
mally gives soft tissue support. 16-13A) are sensitive indicators of ZMC position.
A B
FIGURE 16-13 Anatomic areas for determining the proper reduction of ZMC fracture. A, Rotation of the ZMC in the vertical axis is most
easily determined by its alignment with the greater wing of the sphenoid along the internal orbit (straight arrow). B, The
zygomaticomaxillary buttress provides a sensitive indicator of malar projection.
However, exposure of the zygomaticomaxillary buttress NEED FOR FIXATION

(intraorally; see Fig. 16-13B) provides one of the most One of the most controversial topics in maxillofacial
valuable clues about the adequacy of ZMC position, if it surgery is the amount of fixation necessary to prevent
is not severely comminuted. With this exposure, one will postreduction displacement of the fractured ZMC.93-95
also have excellent exposure of the infraorbital rim. It Some have noted that reduction, by itself, does not
should be realized that a reciprocal relationship exists produce adequate stability of the fractured zygoma,
between malar projection and facial width. If the zygo- claiming that the downward pull of the masseter muscle
matic arch is bowed laterally, the malar eminence is will cause a medial rotation of the zygomatic body before
posteriorly displaced (Fig. 16-14). Reduction of ZMC healing.* Albright and McFarland96 went so far as to
fractures should ensure that the malar eminence is prop- recommend intermaxillary immobilization following
erly projected anteriorly and, if the zygomatic arch is fracture reduction to help reduce the pull of the mas-
reconstructed, the procedure is done by keeping it flat. seter muscle on the repositioned ZMC. The masseter
If the surgeon has navigation and/or intraoperative muscle has often been implicated as a primary cause of
CT scanning available, the amount of surgical interven- postreduction displacement of the fractured ZMC. It was
tion can often be minimized. Either of these tools can assumed to be capable of exerting sufficient inferiorly
assess the position of the ZMC and internal orbital floor directed force on the fractured ZMC to cause movement,
reconstructions in the operating room. Thus, one can even after surgical insertion of fixation devices. However,
often use a more limited exposure, reduce the fracture, this contention has never been proven. There is no
and determine whether the ZMC is in proper position. evidence in the literature that postreduction displace-
Another important point that should be stressed in ment of a ZMC fracture has occurred in patients. Previ-
the treatment of ZMC fractures is the status of the medial ous clinical studies simply evaluated patients clinically
orbital rim. Occasionally, a unilateral nasal-orbital- and radiographically months after surgery and noted an
ethmoid fracture occurs on the side of the ZMC occasional patient with poor ZMC position. It was
fracture, displacing the medial portion of the infraorbital assumed that because the fractures were simply elevated,
rim laterally. This portion of bone may seem to be very or perhaps stabilized with wire fixation, postsurgical dis-
stable and the fact that it is malpositioned may go unno- placement had occurred. Therefore, recommendations
ticed. If the ZMC is reduced into apposition with this for fixation have varied from none to the placement of
laterally displaced fragment of infraorbital rim, the ZMC three or four bone plates at different locations around
will be laterally positioned, increasing orbital volume and the fractured ZMC.
widening the face (Fig. 16-15). Because a unilateral nasal- Ellis and Kittidumkerng99 have reviewed a series of
orbital-ethmoid fracture may be difficult to diagnose isolated ZMC fractures treated by different approaches
clinically, preoperative CT scans are the best diagnostic and fixation schemes, both immediately and several weeks
tool (see Fig. 16-9A). Therefore, one should always search after repair, and found no evidence of postreduction
for fractures of the medial orbital rims when assessing
preoperative scans. *References 9, 80, 81, 84, and 96-98.
A
B
C D
E F
FIGURE 16-14 A, The reciprocal relationship between facial width and malar projection is demonstrated. Note that the normal contour of
the zygomatic arch is straight, not curved. If the zygomatic arch is reconstructed with a bow, the malar eminence will lack anterior
projection. Frontal (B) and submental (C) views of a patient who had open reduction and internal fixation of a right ZMC fracture 2 years
previously. Note the increase in facial width and the decrease in malar projection. Also note the enophthalmos of the right globe. D, Axial
CT scan showing lateral bowing of the zygomatic arch and the posterior position of the frontal process of the zygoma. One can see that
the medial orbital wall was also inadequately reconstructed when the contour is compared with the opposite orbit. Coronal CT scan of
the anterior (E) and posterior (F) orbit showing inadequate orbital reconstruction (arrow). The bone grafts in the anterior orbit do not
maintain normal orbital shape. The grafts also did not extend far enough posteriorly. Note the great increase in orbital volume.
instability in any patient. Based on their experience and Thier study compared masseter muscle force in 10 male
the data generated from their study, various methods can control subjects with that in 10 male patients who had
be used successfully to stabilize ZMC fractures. These sustained unilateral ZMC fractures. The calculation of
range from reduction without fixation to reduction with muscle force was based on measured bite force, electro-
three- or four-point fixation using bone plates. myograms, and radiographic determination of muscle
Such a diversity of treatment options should not be vectors. It was found that the masseter muscle developed
surprising, given the results of a study by Dal Santo et al.95 notably less force in patients with ZMC fractures than in
TABLE 16-2 Reported Incidence of the Need for Fixation

in Addition to Reduction
Percentage
Sample Requiring
Study Size* Fixation
Mansfield, 194857 149 38
Nysingh, 196015 200 60
Knight and North, 196135 120 40
Fryer et al, 1969104 196 40
Wiesenbaugh, 197046 75 13
Lund, 197128 26 17
Melmed, 197219 131 21
Pozatek et al, 197376 77 58
Matsunaga et al, 19779 147 100
Haidar, 197718 84 77
Larsen and Thomsen, 197822 137 24
Hoyt, 1979107 11 27
Laufer et al, 1976112 70 18
Adekeye, 198023 179 23
FIGURE 16-15 This patient was treated for a left ZMC fracture.
Balle et al, 198229 79 29
Note lateral displacement of the ZMC and slight telecanthus on
the left. This patient had an undiagnosed left nasal-orbital-ethmoid Foo, 198424 43 25
fracture, with lateral displacement of the frontal process of the Pospisil and Fernando, 198477 74 39
maxilla. The left ZMC fracture was reduced to this bone, resulting Fischer-Brandies and Dielert, 198425 81 51
in lateral displacement of the ZMC. Ellis et al, 198526 1521 30
Champy et al, 1985108 1030 79
Champy et al, 1986111 695 77
control subjects. Following fracture, masseter muscle Kristensen and Tveterås, 198627 37 30
force slowly increased, but at 4 weeks after surgery, most
Kaastad and Freng, 198978 251 55
patients were still well below control levels. The results
of that study cast doubt on the role of the masseter Ogden, 199186 105 8
muscle in postreduction displacement of the fractured Zingg et al, 199187 813 82
ZMC and indicate that potentially minimum amounts of Zingg et al, 199288 1025 78
fixation are required for such injuries. Covington et al, 199479 259 88
Most have disagreed with the concept that fixation
*Only those cases that were surgically treated in these studies are included
should be routinely applied following reduction of zygo- in this table.
matic fractures.* These surgeons applied fixation to
zygomatic fractures only where indicated. The indica-
tions for the application of fixation seem to vary with the
surgeon and type of fracture, so the incidence of fixation buttress* or, more commonly, at the frontozygomatic
application varies widely in the literature (8% to 100%) area.† Champy et al111 used a single bone plate at the fron-
(Table 16-2). tozygomatic area in 342 isolated ZMC fractures and found
The efficacy of using simple elevation (without fixa- that only 6 (1.8%) had an unsatisfactory result. Tarabi-
tion) when indicated has been demonstrated by Larsen chi100 treated 17 consecutive low-velocity ZMC fractures
and Thomsen.22 They reexamined 87 patients several by a transoral open reduction and internal bone-plate
months to years after elevation of their fractures by the fixation of the zygomaticomaxillary buttress, with excel-
Gillies temporal approach and found only 2 patients with lent results in all but 2 patients, who had comminution of
residual deformity. Similarly, Fischer-Brandies and the orbital rim. Covington et al79 were able to stabilize
Dielert25 reexamined 41 cases of zygomatic fracture 30% to 40% of ZMC fractures by one-point fixation. Ellis
treated with elevation using a hook and found no postsur- and Kittidumkerng99 were able to use one-point fixation
gical displacement. Several other studies in the literature in 31% of ZMC fractures reported in their study. Similar
have used ZMC repositioning without fixation, with good results were shown by Shumrick et al.114
results,29,78-79 verifying that fixation requirements are less An important point regarding the stability of ZMC
than advocated by some. Fixation with one bone plate has fracture reduction is the state of the fracture ends. Where
been advocated by several surgeons in a certain percent- the osseous processes are not comminuted, the fracture
age of ZMC fractures, either at the zygomaticomaxillary is more likely to remain stable without fixation devices.
*References 95, 99, 100, 112 and 113.

†
*References 8, 13, 15, 22-29, 33, 61, 78, 88, 79, 95, and 99-111. References 52, 88, 79, 89, 108, 109.
However, when comminution of the fragments has the internal orbit is made. The surgeon can then decide
occurred, instability usually results and fixation devices whether it is necessary to reconstruct the orbital walls
become necessary. Thus, comminuted fractures behave (Fig. 16-16).
differently from linear fractures. If there is any question
about the stability of a reduced zygomatic fracture, it is
prudent to apply fixation. PRINCIPLES IN THE TREATMENT OF
ZYGOMATICOMAXILLARY COMPLEX FRACTURES
NEED FOR INTERNAL ORBITAL RECONSTRUCTION In the treatment of any ZMC fracture that requires surgi-
By definition, the orbital floor is fractured in ZMC frac- cal intervention, consideration should be given to each
tures. However, the magnitude and extent of orbital floor of several steps in a sequential and orderly manner (Box
disruption vary from a linear crack to fragmentation of 16-1).
the entire floor and medial and lateral walls. Many, Prophylactic Antibiotics. The incidence of infection fol-
perhaps most, low-energy ZMC fractures do not have her- lowing ZMC fracture or fracture reduction is extremely
niation of periorbital contents into the sinus with entrap- low; however, such an infection is difficult to discern
ment of ocular muscles or enophthalmos. However, these because many surgeons routinely use prophylactic
problems do occur in a certain percentage of cases. antibiotics. This practice also makes it difficult to deter-
Davies115 noted significant orbital floor disruption in mine the effectiveness of antibiotics in preventing infec-
47% of patients with zygomatic fractures. Sacks and tion of these fractures. Because the maxillary sinus is
Friedland116 noted this complication in two thirds of involved, ZMC fractures can be considered compound,
ZMC fractures. Crewe117 noted notable disruption in and prophylactic antibiotics are probably appropriate,
most zygomatic fractures. Crumley and Leibsohn64 noted especially given the fact that the orbital contents are also
that 39% of zygomatic fractures had comminuted frac- frequently violated. The choice of antibiotics should
tures of the orbital floor. The need for orbital floor cover routine sinus bacteria (e.g., ampicillin, amoxicillin,
reconstruction to support the periorbital tissue was neces- clindamycin, cephalosporin).
sary in two of three cases of orbital floor exploration Anesthesia. For isolated ZMC fractures, general anes-
performed by Pozatek et al76 and Wiesenbaugh.46 Ellis thesia with oral intubation is helpful. The anesthesiolo-
et al26 found it necessary to place implants in one of three gist or anesthetist should be positioned so that the
cases on exploration of the orbital floor. The orbital floor surgeon has access to the side of the fracture and head
and walls were reconstructed in 44% of isolated ZMC of the table. It is very important to have complete access
fractures in a study by Ellis and Kittidumkerng.99 A similar to the top of the patient’s head for visual comparison of
study by Shumrick et al found the necessity to reconstruct one side with the other. (Reduction of isolated zygomatic
the internal orbit in only 30% of ZMC fractures.114 arch fractures can be performed with the patient under
Although some surgeons believe that so-called explo- local anesthetic, with or without sedation when the
ration of the internal orbit should be performed rou- patient is cooperative, and an intraoral or a percutane-
tinely when operating on ZMC fractures,* most do not. ous approach is used.)
These surgeons would argue that exploration of the orbit Clinical Examination and Forced Duction Test. Following
should depend on preoperative and intraoperative find- induction of general anesthesia, the surgeon should take
ings. Fortunately, CT scans have eliminated the debate the opportunity to examine the patient more carefully.
about when an orbit should be explored. It is now pos- With the patient under anesthesia, the surgeon has more
sible to obtain an accurate assessment of the status of the freedom in the examination and can use more digital
internal orbit before surgery so that adequate treatment force than is possible with the patient awake. This exami-
can be proscribed and planned.114,118 If comminution of nation can help confirm previous diagnoses and may
the orbital floor and walls and/or prolapse of orbital soft reveal new information. It is very important to look at the
tissue into the maxillary and ethmoid sinuses is noted, or patient from the superior view and to visualize both
if orbital volume has increased from blowout of the floor zygomas simultaneously. Unless the swelling is marked,
and walls, reconstruction should be performed.119,120 one should be able to determine an asymmetry. Laying
Using similar criteria in the preoperative CT scans, Reddy the index finger across the infraorbital area or on the
and Ellis were able to classify patients successfully into malar prominence should help discern the asymmetry
those who required and those who did not require inter- (see Fig. 16-4). A forced duction test should also be per-
nal orbital reconstruction.118 They showed that in those formed at this time (see Fig. 16-8).
who were determined not to need internal orbital recon- Protection of the Globe. The cornea must be protected
struction, good radiographic and clinical results were from inadvertent trauma. Of the several ways of provid-
obtained. ing this protection, perhaps the simplest is placement of
With the availability of intraoperative CT scanning in a scleral shell (corneal shield) after application of an
some operating rooms, the question about whether to ophthalmic ointment (Fig. 16-17A). Temporary tarsor-
reconstruct the internal orbit in those patients in whom rhaphy can also be used by suturing the dermal surfaces
the preoperative CT scan does not show gross disruption of the upper and lower eyelids together with 5-0 nylon
can be answered in the operating room. After the ZMC sutures (see Fig. 16-17B and C).
has been reduced, a scan is taken and an assessment of Antiseptic Preparation. The type of preparation neces-
sary depends largely on the type of approach(es) that are
anticipated. It is good practice, however, to prepare the
*References 17, 85, 92, 102-111, 113, 113a, 112. forehead, both periorbital areas and cheeks to the level
10.00mm/div 10.00mm/div
A 10.00mm/div
B 10.00mm/div
C D
FIGURE 16-16 Use of intraoperative CT scanning. A, B, Preoperative three-dimensional CT scans show a moderately displaced right ZMC
fracture. Note the lateral displacement of zygomatic arch and posterior displacement of malar eminence. C, D, Preoperative coronal CT
scans show fractures of the orbital floor.
E F
G H
FIGURE 16-16, cont’d The ZMC fracture was exposed using maxillary vestibular (E) and upper eyelid approaches (F). G, The ZMC was
reduced using a Carroll-Girard screw. H, An intraoperative CT scan was then obtained to determine whether the reduction of the ZMC
was adequate and to determine whether internal orbital reconstruction was necessary.
continued
I J 10.00mm/div
10.00mm/div
K
L
FIGURE 16-16, cont’d I, J, Intraoperative three-dimensional reconstructions demonstrated good reduction of the ZMC. Coronal (K) and
sagittal (L) images of the orbit indicated that the orbital floor was in good position, so no internal orbital reconstruction was deemed
necessary.
M N
O 10.00mm/div
P 10.00mm/div
FIGURE 16-16, cont’d The ZMC was stabilized with bone plates across the zygomaticomaxillary buttress (M) and frontozyomatic suture
areas (N) and the incisions closed. O, P, Q, Postoperative CT scans demonstrate good position of the ZMC and orbital floor (R,S,T).
continued
10.00mm/div
Q R
10.00mm/div
S T
of the mouth, and both sides of the preauricular area.

Such preparation allows comparison of the affected side BOX 16-1 Steps in Surgically Treating a
with the opposite side during surgery. Another useful Zygomaticomaxillary Complex Fracture
suggestion is always to prepare the mouth with throat
pack and antiseptic rinse, because an oral approach to 1. Prophylactic antibiotics
the sinus and/or zygoma is frequently useful. If the pre- 2. Anesthesia
operative clinical and radiographic examinations suggest 3. Clinical examination and forced duction test
that a coronal approach may be necessary, the hair and 4. Protection of the globe
5. Antiseptic preparation
ears are prepared and draped.
6. Reduction of the fracture
Reduction of the Fracture. The fracture should be
7. Assessment of reduction
reduced by whatever means the surgeon deems appropri-
8. Determination of necessity for fixation
ate (techniques described later). 9. Application of fixation device
Assessment of Reduction. The most important step in 10. Internal orbital reconstruction
the management of ZMC fractures is to determine at the 11. Assessment of ocular motility
table whether the fracture has been properly reduced. 12. Bone graft extraorbital osseous defects
The success or failure of reduction will be obvious for 13. Soft tissue resuspension
those who have opened the fracture at three sites. If 14. Postsurgical ocular examinations
exposure at three sites has not been performed, the 15. Postsurgical images
orbital margins are the areas that should be palpated first
B C
FIGURE 16-17 A, Scleral shell used for ocular protection. B, C, Technique of temporary tarsorrhaphy.
to determine reduction. If reduction has been satisfac- the reduction will be stable by itself or needs some form
tory, these margins will be smooth and continuous. This of fixation. If constant reduction force is necessary for
finding by itself, however, is inadequate verification that maintaining ZMC position, the ZMC should be stabilized
the zygoma is properly positioned. Although the zygo- with some form of fixation device(s). If the zygomatic
maticofrontal suture area provides the strongest pillar of position is deemed appropriate and does not require
the zygoma, it is one of the worst indicators of proper constant application of reduction force, one should press
reduction of the entire complex, even when surgically with moderate pressure on the malar eminence with the
exposed and evaluated directly. One should also palpate fingers and see whether displacement results. If it does
in the maxillary vestibule. If there is any flatness still not, fixation devices may be unnecessary. Many minimally
visible, the zygoma has not been properly elevated. If displaced cases are stable after they have been reduced.
there is any doubt about proper reduction, exposure is However, if there is any doubt about postreduction stabil-
mandatory. In this case, an incision in the maxillary ves- ity, the application of fixation devices is prudent.
tibule offers excellent exposure of the zygomaticomaxil- Application of a Fixation Device. The methods of stabiliz-
lary buttress and the infraorbital rim. ing the fractured ZMC vary with the imagination and
For surgeons who have navigation or intraoperative CT experience of the surgeon. General principles are
scanning available, assessment of the reduction is rela- involved, however (see later).
tively easy.Determination of the Necessity for Fixation. The Internal Orbital Reconstruction. When indicated, recon-
second most important step in surgically treating zygo- struction should be carried out after repositioning and
matic fractures (following determination of whether the stabilizing the ZMC fracture. In such cases, the orbital
reduction has been satisfactory) is determining whether floor and walls should be exposed before elevation of the
A B
FIGURE 16-18 A, Anterior maxillary wall defect after reduction and fixation of a ZMC fracture. B, Bone graft placed over the area of
defect.
ZMC so that the open orbital rim can also serve as a guide results in facial asymmetry and provides traction on the
to reduction. However, it is unwise at this point to try to lower eyelid, causing ectropion. Yaremchuk and Kim122
free any trapped tissue, because elevation of the zygoma have confirmed this hypothesis and found a 20% inci-
may separate bone fragments and make this maneuver dence of scleral show when the facial soft tissue was not
much easier following reduction. Assessment of the mag- resuspended but no scleral show when the tissue was
nitude of the defect to be reconstructed is made follow- resuspended. Thus, for fractures in which the soft tissue
ing reduction, because the actual defect will then be was completely stripped from the bone, sutures should
revealed (techniques described later). be passed through the deep surface of the soft tissue of
In minimally displaced cases in which no ocular signs the cheek and secured to structures such as the orbital
of entrapment or enophthalmos are noted preopera- rim and temporal fascia to raise them into their proper
tively, and in which the fracture is treated by simple location on the underlying bone (Fig. 16-19; see also Fig.
reduction, internal orbital exploration and/or recon- 16-25F).
struction is unnecessary unless a postreduction forced Postsurgical Ocular Examination. The pupillary reflexes
duction test produces positive findings (rare). In most of should be monitored postoperatively and the fundus
these cases, reduction of the zygoma results in adequate examined periodically. Visual acuity must also be checked.
alignment of the orbital floor.33,114,118 However, one Because of surgical edema, binocular diplopia will
should never avoid reconstructing the internal orbit for probably be present, depending on the surgical
fear of causing harm to orbital tissue. This occurrence is procedure.
extremely rare. For those surgeons who have intraopera- Postsurgical Images. Postoperative images should be
tive CT scanning capability, the status of the internal obtained whenever the patient is stable. Axial and coronal
orbit after reduction of the ZMC is known and the deci- CT scans are recommended to assess adequacy of reduc-
sion about the need for internal orbital reconstruction tion and internal orbital reconstruction, if performed.
can be made during the surgery.
Assessment of Ocular Motility. Another forced duction
test should be performed at the end of all active treat- SURGICAL APPROACHES TO
ment, with the possible exception of suturing, to verify ZYGOMATICOMAXILLARY COMPLEX FRACTURES
that the treatment did not create entrapment of orbital Many techniques have been advocated for reducing and
contents (see Fig. 16-8). stabilizing ZMC fractures. These approaches will be
Bone Graft for Extraorbital Osseous Defects. Consider- described after a discussion of the surgical approaches
ation should be given to grafting areas of missing bone used to gain access to the ZMC. Techniques of orbital
along the anterior maxilla and zygomaticomaxillary but- exploration and reconstruction will then be presented.
tress. Even though bone plate fixation may provide sta- A standard series of approaches has been used exten-
bilization of the ZMC by spanning such defects, it is sively for approaching the fractured ZMC and orbit.
unclear how long bone plates will provide such stability. Existing lacerations are often used for this purpose. In
Reconstruction of the skeleton with bone grafts prevents the absence of lacerations, properly placed incisions
soft tissue prolapse from the cheek into the maxillary offer excellent access, with minimal morbidity and
sinus and promotes osseous union across the defect, pro- scarring.
viding long-term stability (Fig. 16-18). Protection of the cornea during operative procedures
Soft Tissue Resuspension. In 1991, Phillips et al121 is mandatory in all operations in the vicinity of the orbit.
described a method of soft tissue suspension of infraor- If one is operating on the dermal side of the eyelids to
bital and malar soft tissues before closing incisions after approach the orbital rim and/or orbital floor, a tempo-
treating midfacial fractures. They hypothesized that rary tarsorrhaphy (see Fig. 16-17B and C) or scleral shell
these soft tissues droop if not resuspended; the drooping (see Fig. 16-17A) may be used after application of a bland
A B
FIGURE 16-19 A, Appearance of malar soft tissue before resuspension. Note the 3-0 polyglycolic acid suture, which enters through the
subciliary incision and passes through the periosteum and malar soft tissue. It is shown without being tied. B, Appearance of the malar
soft tissue after the suture has been pulled superiorly. Note the elevation of the malar soft tissue mass and the support provided to the
lower eyelid. This suture can be tied to one of the screws in a bone plate on the lateral orbital rim, through a hole through the orbital rim,
or through the temporal fascia.
eye ointment.123 These are simply removed at the com- the midface—for example, with a unilateral ZMC
pletion of the operation. fracture—the incision can be made on one side only,
Diluted epinephrine solutions are used before inci- leaving the other side intact. Submucosal injection of a
sion for two reasons. The first is the hemostasis that they vasoconstrictor can reduce the amount of hemorrhage
provide. The second is to separate the tissue before inci- during incision and dissection. The incision is usually
sion intentionally. This latter use becomes important placed approximately 3 to 5 mm superior to the muco-
when one operates on the thin eyelids. The solutions can gingival junction. The incision extends as far posteriorly
be used to cause the tissue to balloon out, facilitating as necessary to provide exposure, usually to the first
incision. One must remember, however, to mark the line molar tooth, and traverses mucosa, submucosa, facial
of incision before injecting the solution into the eyelids, muscles, and periosteum. Periosteal elevators are used to
because the tissue will be distorted and a perceptible elevate the tissue in the subperiosteal plane. Almost no
crease may disappear following injection. anatomic hazards exist except the infraorbital neurovas-
cular bundle above and the posterosuperior alveolar
Maxillary Vestibular Approach vessels along the posterior maxilla, which infrequently
The maxillary vestibular is one of the most useful cause bleeding. The entire anterior face of the zygoma
approaches for open treatment of ZMC fractures. Access can be easily exposed. Fractures through the infraorbital
to the entire facial surface of the midfacial skeleton— rim, anterior maxilla, and zygomaticomaxillary buttress
from the zygomatic arch to the infraorbital rim to the can easily be identified and treated (see Fig. 16-18).
frontal process of the maxilla—can be achieved in a rela- Restitution of the nasolabial muscles should be per-
tively safe manner through this approach. Its greatest formed as three uniform steps during closure of the
advantage is the hidden intraoral scar that results. This maxillary vestibular incision. The first step involves iden-
approach is also relatively rapid and simple, and compli- tification and resetting of the alar bases, the second
cations are few. involves eversion of the tubercle and vermilion, and the
Technique. The length of the incision and amount of third involves closure of the mucosa. To help control the
subperiosteal dissection depend on the area of interest width of the alar base, an alar cinch suture is placed
and extent of surgery. If one is interested in only half of before suturing the lip. A V-Y advancement closure of the
A B
FIGURE 16-20 Supraorbital eyebrow approach to frontozygomatic suture. A, Most of incision is within the confines of the eyebrow.
B, Exposure of the fracture.
maxillary vestibular incision is recommended where the prevent cutting hair shafts, which also may retard the
incision has been placed across the base of the nose and growth of eyebrow hair. The incision is made to the
subperiosteal dissection of the tissue along the piriform depth of the periosteum in one stroke and, after minimal
aperture has occurred. When closing the horizontal inci- undermining, another incision through the periosteum
sion, one should begin in the posterior and work anteri- completes the sharp dissection.
orly with running resorbable sutures (3-0 chromic catgut) Two sharp periosteal elevators are used to expose the
through the mucosa, submucosa, musculature, and lateral orbital rim on the lateral, medial (intraorbital),
periosteum. The superior aspect of the incision is gradu- and posterior (temporal) surfaces. The fracture is usually
ally advanced toward the midline by passing the needle located at the inferior extent of the wound; this location
anteriorly in the lower margin of the incision as com- necessitates wide undermining of the periosteum to
pared with the upper margin. This maneuver, in addition allow the tissue to be retracted inferiorly to provide
to the V-Y closure, helps lengthen the relaxed muscula- better access to the fracture (see Fig. 16-20B). It should
ture so that it reattaches in its proper position. be noted that if one stays in the subperiosteal space,
there is almost no chance of damaging vital structures.
Supraorbital Eyebrow Approach The incision is closed in two layers, the periosteum and
A popular approach used to gain access to the lateral skin.
orbital rim is the eyebrow incision (Fig. 16-20). No
important neurovascular structures of any significance Upper Eyelid Approach
are at risk when this approach is used, and it provides The upper eyelid approach to the superolateral orbital
simple and rapid access to the frontozygomatic area. rim is also called the upper blepharoplasty, upper eyelid
Because the incision is made almost entirely within the crease, and supratarsal fold approach. In this approach,
confines of the eyebrow, the scar is usually imperceptible. a natural skin crease in the upper eyelid is used to make
However, the scar will not be hidden in those who have the incision (Fig. 16-21A). The advantage to this approach
no eyebrows extending laterally along the orbital margin. is the inconspicuous scar it creates, rendering it one of
In this case, another incision is indicated. An additional the best approaches to the region of the superolateral
disadvantage of this approach is that it does not afford a orbital complex.
great amount of surgical access. Technique. If the tissue is edematous, the skin sur-
Technique. Before incising the skin, the surgeon rounding the opposite orbit can be used to obtain an
should palpate the lateral orbital rim to reveal the loca- appreciation of the direction of the creases. If a lid crease
tion of the fracture site. It is usually in the frontozygo- is not readily detectable, a curvilinear incision along the
matic suture area, which is at the interolateral aspect of area of the supratarsal fold that trails off laterally over
the eyebrow. However, the fracture may be more inferi- the lateral orbital rim works well. The incision should be
orly positioned, and in that case the incision may need similar in location and shape to the superior incision in
to be placed a given amount below the eyebrow. a blepharoplasty. However, the incision may be extended
The surgeon supports the skin over the orbital rim farther laterally as necessary for surgical access. The inci-
using two fingers and a 2-cm incision is made. It should sion should begin at least 10 mm superior to the upper
be stressed that there is no reason to shave the eyebrow lid margin and be 6 mm above the lateral canthus as it
before incision because the hair may not grow back. The extends laterally. The incision is through both the skin
incision should be parallel to the hair of the eyebrow to and orbicularis oculi muscle. The surgeon develops a
A B
FIGURE 16-21 Supratarsal fold approach to the lateral orbital rim. A, Location of incision. B, Dissection into the medial orbit.
skin-muscle flap superiorly, laterally and, if necessary,

medially, using scissor dissection in a plane deep to the
orbicularis oculi muscle. The dissection is carried over
the orbital rim, exposing periosteum. The skin-muscle
flap is retracted until the area of interest is exposed. The
periosteum is divided 2 to 3 mm posterior to the orbital
rim with a scalpel. Periosteal elevators are used to perform
subperiosteal dissection of the orbit and orbital rims (see
Fig. 16-21B). The wound is closed in two layers, perios-
teum and then skin and muscle.
Lower Eyelid Approaches
Several approaches to the orbit through the skin surface
of the lower eyelid have been described. They differ in
the level at which the skin incision is made and level of
dissection to the infraorbital rim. The subtarsal approach
is one of the more frequently used approaches for access
to the infraorbital rim and orbital floor. The subtarsal
incision is made in a natural skin crease at or below the
level of the tarsus, approximately half the distance
between the lash margin and orbital rim (Fig. 16-22). It
extends laterally and inferiorly, similar to the skin creases. FIGURE 16-22 Incisions used to expose the infraorbital rim and
The main advantages of the subtarsal approach are the orbital floor—subciliary (or blepharoplasty) incision (dashed line)
following: (1) it is relatively easy; (2) the incision is placed and subtarsal incision (dotted line).
in a natural skin crease so that the scar is imperceptible;
and (3) it is associated with minimal complications. It has
few disadvantages. Dissection Technique for the Subciliary or Subtarsal
The subciliary approach, also called the infraciliary Approach. After the skin has been incised, the surgeon
approach, or blepharoplasty, has been favored by a has three options. The first is to dissect between the skin
number of U.S. surgeons over the past 20 years. The skin and muscle until the orbital rim is reached, at which
incision is made approximately 2 mm inferior to the gray point another incision through muscle and periosteum
line of the lower eyelid, along the entire length of the lid to bone is made (Fig. 16-23A). The second option is to
(see Fig. 16-22). The incision may be extended laterally incise through muscle at the same level as the skin inci-
approximately 1 to 1.5 cm in a natural crease inferior to sion and dissect down just anterior to the orbital septum
the lateral canthal ligament. The main advantage to this to the orbital rim (see Fig. 16-23B). The third option is
incision is the imperceptible scar that it creates. The a combination of these, in which subcutaneous dissec-
disadvantages are the following: (1) the procedure is tion toward the rim proceeds for a few millimeters and
technically difficult for the novice; and (2) a higher risk is followed by incision through the muscle at a lower
of postoperative ectropion exists.109,124-128 level, producing a stepped incision, with dissection then
A B C
FIGURE 16-23 Cross-sectional anatomy of the dissection through the eyelid for the subtarsal (or subciliary) incision. A, Skin flap elevated
from the orbicularis oculi muscle to just below the level of the infraorbital rim. An incision through the orbicularis oculi muscle and
periosteum is then made. B, Skin-muscle flap dissected from the orbital septum to just below the level of the infraorbital rim, where an
incision is then made through the periosteum. C, Three to 4 mm of skin are undermined before dissection through the orbicularis oculi
muscle to the orbital septum, which is then followed inferiorly. The incision is then made through the periosteum.
following the orbital septum to the rim (see Fig. subciliary incision can also be used to expose the lateral
16-23C).129 Fine scissors are useful during the dissection orbital rim. When the incision is used for this purpose,
to the infraorbital rim no matter which option is chosen, lateral extension of the skin incision for 0.5 to 1 cm and
with the surgeon using a spreading motion. wide subperiosteal dissection permit the necessary access
Although advocated by a number of surgeons, each to the lateral aspect of the orbit, up to and including the
option has advantages and disadvantages. The first frontozygomatic suture.131 In the process of subperiosteal
option, in which the surgeon makes a subcutaneous dis- dissection, the lateral palpebral ligament and suspensory
section producing a skin flap to the level of the rim, ligaments are stripped from the orbital tubercle of the
leaves an extremely thin skin flap. It is a technically dif- zygoma. This stripping presents no apparent problem if
ficult flap to elevate, and accidental buttonhole dehis- the injury is acute and the periosteal tissue is securely
cence can occur. A further problem that may occasionally sutured at the completion of the operative procedure.
be seen is a slight darkening of the skin in this area fol- This technique is not recommended for the inexperi-
lowing healing. Presumably, the thin skin flap becomes enced surgeon because it can be fraught with difficulties
avascular and acts essentially as a skin graft. An increase in access and postoperative swelling. Properly performed,
in the incidence of ectropion has also been noted, as however, it is an excellent method for simultaneously
opposed to when the dissection is made deep to the exposing the infraorbital and frontozygomatic areas, and
orbicularis oculi.126 Entropion, lash problems, and skin healing produces an imperceptible scar. Exposure of the
necrosis have occasionally been experienced after the lateral orbital rim via a subtarsal incision is not recom-
skin-only flap.77 The second option, in which the dissec- mended because the lateral portion of the incision is
tion is made between muscle and orbital septum, is tech- usually some distance inferior to the orbital rim.
nically less difficult. Care must be taken, however, because Closure should be in at least two layers, the perios-
the thin orbital septum can be easily violated, resulting teum and skin. Attempting to suture the orbicularis oculi
in periorbital fat herniating into the wound. The skin is difficult and of little value. The running subcuticular
and muscle flap, however, presumably maintains a better suture is an excellent suture for the thin skin of the
blood supply and pigmentation of the lower lid has not eyelid.
been a finding.130 The third technique, in which a layered
dissection is used, is probably the simplest of the three Transconjunctival Approach
and prevents the disadvantages of the others. An added The transconjunctival approach, also called the inferior
advantage of leaving a 4- to 5-mm strip of muscle attached fornix approach, was originally described by Bourguet in
to the lower tarsus is that if it remains functional, it may 1928.132 Two basic transconjunctival incisions have since
help maintain the position of the lower eyelid on the been described, the preseptal and retroseptal approaches,
globe. which vary in the relationship of the orbital septum to
With any of these techniques, the incision through the the path of dissection (Fig. 16-24). Tenzel and Miller133
periosteum should be placed 3 to 4 mm below the orbital have developed the transconjunctival retroseptal incision
rim to prevent insertion of the orbital septum along the and Tessier134 elaborated on the transconjunctival prese-
orbital margin. Subperiosteal dissection exposes the ptal incision (see Fig. 16-24B). The retroseptal approach
floor and medial and lateral walls of the orbit. The is more direct than the preseptal approach and is easier
A B
C D
FIGURE 16-24 Transconjunctival incisions. A, Retroseptal approach. B, Preseptal approach. C, Initial full-thickness incision through the
lateral canthus. D, Inferior cantholysis performed to release the lower eyelid.
continued
to perform (see Fig. 16-24A). Converse et al135 have through in a horizontal (lateral) direction (see Fig.
added a lateral canthotomy to the transconjunctival ret- 16-24C). With eversion of the lid margin by the traction
roseptal incision for improved lateral exposure. The suture, the scissors are directed inferiorly to transect the
advantage of the transconjunctival approaches is that inferior portion of the lateral canthal tendon (inferior
they produce superior cosmetic results when compared cantholysis; see Fig. 16-24D). When transection is com-
with any other commonly used incision because the scar pleted, the eyelid will fall away freely. The scissors are
is hidden behind the lower lid. Other advantages are the then used to undermine the palpebral conjunctiva just
following: (1) these techniques are rapid; and (2) no skin below the tarsus. The conjunctiva can be undermined
or muscle dissection is necessary. In a study by Wray medially to the lacrimal punctum. One beak of the scis-
et al,126 in which the transconjunctival approach was used sors is brought out of the pocket and the conjunctiva and
for orbital floor and rim fractures, lateral canthotomy lower lid retractors are incised (see Fig. 16-24E). A suture
was necessary for improving access in 56% of approaches. can be passed through the incised conjunctiva in the
Technique for Retroseptal Transconjunctival Approach fornix and used to retract the tissue superiorly. Blunt
Combined With Lateral Canthotomy. In any transconjuncti- dissection toward the orbital rim is performed with scis-
val approach, the cornea must be protected. Because a sors while the lower eyelid is being retracted anteriorly.
tarsorrhaphy is precluded, a corneal shell should be With retraction of the globe and retraction of the lower
placed to protect the globe (see Fig. 16-17A). The lower eyelid, an incision is made with a scalpel through the
eyelid is everted by two traction sutures placed through periorbita, just posterior to the orbital rim (see Fig.
the tarsal plate. The surgeon performs a lateral can- 16-24F). A broad malleable retractor should be placed as
thotomy as the initial step by inserting one end of sharp soon as feasible to protect the globe and confine the
iris scissors into the lateral palpebral fissure and cutting periorbital fat. Subperiosteal dissection of the orbital
E F
G
FIGURE 16-24, cont’d E, Conjunctival incision. F, Cross-sectional anatomy of the dissection. G, Canthotomy closure in two layers.
contents can then proceed. To facilitate retraction of the Al-Kayat and Bramley,137 is an extremely useful incision
lower eyelid, the periosteum can be dissected anteriorly for surgery of the zygoma and arch. Although it may
over the orbital rim and a few millimeters onto the face initially appear as a radical approach to the management
of the maxilla. of zygomatic fractures, it provides excellent access to the
The periosteum may be difficult to close; some sur- orbits, zygomatic bodies, and zygomatic arches, with
geons do not attempt closure of this layer.136 The trans- almost no complications.138 It is an extremely useful inci-
conjunctival incision is closed with the use of running 6-0 sion if there is comminution of the supraorbital and
gut sutures; the inferior limb of the lateral canthal tendon lateral orbital rims, and zygomatic body and arch. The
and tarsal plate is sutured to the inner aspect of the scar produced is hidden within the hairline and is there-
lateral orbital rim using 4-0 slowly resorbing or nonre- fore invisible.
sorbing sutures (see Fig. 16-24G). Placement of these Technique. In contrast with the earlier practice of
sutures is critical to adapting the lower eyelid to the globe extensive shaving of the head before incision, shaving the
properly. The surgeon should pass the suture along the hair from the operative field is unnecessary, other than
medial side of the lateral rim of the orbit, attempting to for surgical convenience. A 2-cm strip of hair can be
pass it through the superior portion of the lateral canthal removed in the immediate area of the incision and the
tendon, which is still attached to the lateral orbital tuber- adjacent hair prepped. If the hair is long, it can be tied
cle. The small skin incision at the lateral canthus is closed off in clumps with sterile elastics (once prepped) to mini-
with 6-0 sutures. mize the annoyance of loose hair in the operative field
during the procedure. The drapes can be sutured or
Coronal Approach stapled to the scalp, covering the posterior scalp and
The coronal, or bifrontal, flap, modified to include some confining this hair. For bilateral procedures, a strip
of the advantages of the modified preauricular flap of across the superior aspect of the head is shaved.
In placing the incision, two factors should be borne canthopexy is performed by drilling a hole through the
in mind. The first is the hairline of the patient, not just lateral orbital rim just below the frontozygomatic suture
the present but the anticipated future hairline. In males, for the passing of the suture. The suture can be secured
minor recession of the hairline with age may make the to the temporal fascia or tied to the bone plate or wire
scar visible if it is placed just behind the hairline. There- in the zygoma at the frontozygomatic suture area. The
fore, the incision should be placed along a line extend- periosteum over the zygomatic arch is difficult to close,
ing from one preauricular area to the other, several and passing the suture may damage the temporal branch
centimeters behind the hairline (Fig. 16-25A). The inci- of the facial nerve. Instead, closure of the incised tempo-
sion can even be made farther posteriorly if necessary, ral fascia is performed (see Fig. 16-25F). The scalp inci-
without a significant reduction in access to the operative sion is closed in two layers with the use of 2-0 sutures
field. The second factor that should be considered is the through the galea and sutures or staples on the skin
amount of inferior access required for the procedure. surface. The use of a flat suction drain is optional. The
Usually, the coronal incision may extend inferiorly to the skin sutures or staples are removed in 7 to 10 days.
level of the anterior border of the helix. If necessary, the
coronal incision can be extended inferiorly to the level
of the lobe of the ear, providing improved access at the REDUCTION TECHNIQUES
inferior portion of the wound when necessary for zygo- Temporal Approach
matic arch and infraorbital exposure. An approach that has been popular through the years
The incision is made with a no. 10 blade through skin, for reduction of ZMC and zygomatic arch fractures is the
subcutaneous tissue, and galea. At this point, the surgeon temporal approach. First described by Gillies et al in
encounters a plane of loose areolar connective tissue 19271 for use in zygomatic arch fractures, this approach
overlying the pericranium (see Fig. 16-25B). The flap has proven versatility for zygomatic arch and ZMC frac-
margin can be rapidly and easily lifted and dissected tures. One of its greatest advantages is that it allows the
from the pericranium within this plane. On incision, the application of great amounts of controlled force to dis-
anterior and posterior wound margins are elevated for 1 impact even the most difficult zygomatic fractures. It is,
to 2 cm to allow for the application of hemostatic clips therefore, especially useful in late treatment of a frac-
(Raney clips), which prevent continuous bleeding from ture, when partial consolidation has already occurred.
the vascular scalp throughout the procedure. Little hem- The Gillies temporal approach is also a quick and simple
orrhage should be encountered throughout the remain- method, rarely requiring more than 15 to 20 minutes
der of the procedure, although small vessels running unless fixation techniques are necessary.81 The temporal
through the pericranium from the skull may require approach is associated with few complications. Although
cauterization. The anterior flap is elevated from the peri- the middle temporal veins may be encountered during
cranium with finger dissection or the use of a blunt instrumentation,139 the hemorrhage encountered is
periosteal elevator. Along the lateral aspect of the skull, rarely of any consequence.
the temporal fascia becomes visible where it inserts into Some have noted that this technique should be
the pericranium, with the plane of dissection superficial reserved for zygomatic arch fractures only, being ineffec-
to it. Once the flap has been elevated to within approxi- tive for displaced or rotated zygomatic body fractures.36,76
mately 2 cm of the body of the zygoma and zygomatic An overwhelming majority of surgeons, however, dis-
arch, these structures can usually be seen through the agree with this presumption and use the Gillies temporal
covering fascia. The superficial layer of temporal fascia approach as the main method for reducing zygomatic
is incised approximately 2 cm superior to the zygomatic fractures.*
arch, beginning at the root of the zygomatic arch and Technique. A 3- × 3-cm area of hair is shaved approxi-
continuing anteriorly and superiorly (see Fig. 16-25C). mately 2.5 cm above and 2.5 cm anterior to the helix of
On incision of the superficial layer of temporal fascia, a the ear. It is unnecessary to isolate the area completely
layer of fat and areolar tissue is encountered (see Fig. from adjacent hair. A cotton pellet is placed within the
16-25D). Further dissection inferiorly at this level pro- external auditory canal to prevent blood from entering
vides safe access to the zygomatic arch. From the root of during surgery. Frequently, the bifurcation of the super-
the zygomatic arch, a periosteal incision is then made ficial temporal artery is visible once the area has been
along the superior aspect of the arch and it is exposed shaven and serves as an excellent landmark for incision.
subperiosteally (see Fig. 16-25E). The pericranium is now A 2.5-cm incision is made through the skin and subcuta-
incised across the forehead and down along the lateral neous tissue at an angle running from anterosuperior to
orbital rim. The periosteal incision at the lateral rim is posteroinferior in the area previously shaved. This inci-
connected to that over the zygomatic arch. Periosteal sion can usually be placed superior to the bifurcation of
elevation then exposes the frontozygomatic fracture line the superficial temporal artery, between—and thereby
and is continued around the lateral orbital rim into the avoiding—both branches. The incision is carried down
orbit. The infraorbital rim can also be visualized to some through skin and subcutaneous tissue until the white
extent with wide undermining. If access to the infraor- glistening surface of the temporalis fascia is visualized
bital area is necessary, the zygomatic arch and body (Fig. 16-26A). This incision can usually be performed
should be thoroughly dissected before exposing the
infraorbital areas to relax the tissue.
After fracture reduction and fixation have been *References 13, 15, 18, 19, 22, 24, 26, 28, 29, 33, 35, 81, 101, 102, 106,
accomplished, the wound is closed in layers. A lateral and 140-142.
Skin
Subcutaneous CT
Galea aponeurosis
Subapon. areolar tissue Scalp
Periosteum
Skull
Ant. auricular m.
Skin incision
Temporalis m.; temporal fascia

Incision through outer layer of temp. fascia
temporal br. of VII
Inner layer of temp. fascia
Zygomatic arch
Zygomatic br. VII
Parotid gland
Masseter m.
Ramus of mandible
B
Temporal Temporal fascia (TF)

fascia Outer
inner Layers of TF
Fatty tissue
Zygomatic Zygomatic arch
arch Skin flap
Outer layer of TF
Periosteum
D
C
Temporalis m.
Zygomatic
arch F
E
FIGURE 16-25 Coronal incision for exposure of ZMC fracture. A, Location of incision. The incision should be placed well behind the
hairline. B, Anatomic layers of scalp and temporal area. C, Dissection of the flap anteriorly above the pericranium and temporal fascia. A
second incision is made through the superficial layer of temporalis fascia and pericranium above the supraorbital rim. D, Anatomic layer
of dissection through the superficial layer of temporalis fascia. Note that the temporal branch of the facial nerve is retracted laterally,
protected by dissection in this plane. E, Subperiosteal dissection of the lateral orbit and zygomatic arch. F, Superficial layer of temporalis
fascia is suspended by suturing it in a higher position than originally incised.
A B,C
D E
F G
FIGURE 16-26 Gillies temporal approach to elevation of the zygoma. A, Initial incision to the level of the temporalis fascia. B, Second
incision through the temporalis fascia to the underlying muscle. Note the muscle, which usually bulges out slightly through the incision.
C, A flat periosteal elevator is inserted deep to the temporalis fascia (between the fascia and the muscle) and is swept anteriorly and
posteriorly because it is advanced inferiorly. In this manner, the deep surface of the temporalis fascia is freed from the temporalis muscle.
The periosteal elevator is advanced inferiorly until the medial surface of the zygomatic arch and temporal surface of the zygomatic body
are identified. It is then withdrawn and the Rowe zygomatic elevator (D) is inserted in this same plane (E). When the handle of the Rowe
elevator is allowed to contact the skin, the depth of the blade beneath the zygoma can be determined. F, Two hands are used to elevate
the zygoma. The working end of the elevator should be on the temporal surface of the zygomatic body for initial elevation. G, Gillies
approach.
with one stroke of the scalpel. At this level, one should approximately the same length. With this feature, the
be above the point where the temporalis fascia splits into surgeon can be constantly aware of the depth of insertion
two layers, one attaching laterally and one medially to of the working blade by collapsing the hinge between the
the zygomatic arch. It is important that the incision be two arms and seeing where the external handle lies in
above this point of bifurcation so that the elevator can relation to the zygoma (see Fig. 16-26E).
be easily placed medial to the zygomatic arch. If the inci- Once the Rowe zygomatic elevator is in position at the
sion is below the layer of temporal fascia bifurcation, the proper depth, the external handle is elevated as the
elevator will be placed within the space above the arch other handle stabilizes the working blade position. Firm
and medial placement will be difficult. anterior, superior, and lateral elevation is applied to the
After exposure of the temporal fascia has been com- body of the zygoma in cases of ZMC fractures or to the
pleted, a second, deeper incision is carefully made the arch in cases of arch fractures (see Fig. 16-26F and G).
full length of the skin incision through the fascia (see During elevation, an assistant must palpate the frontozy-
Fig. 16-26B). At this point, one should see the underlying gomatic and infraorbital areas while steadying the head
temporalis muscle bulge through the incision. If this is against the elevator’s pull. An audible crunch or crack
not seen, the possibility of the incision being placed too usually accompanies the elevation. If strong resistance is
low and into the space above the arch should be sus- felt, one must consider that the zygoma is greatly
pected. In this case, the incision should be deepened impacted, in which case more force may be necessary, or
until the temporal muscle is visible. Remember that the that the tip of the elevator may have been placed too far
temporalis muscle is the key structure in this dissection. medially through the temporal muscle. In the latter case,
A flat instrument, such as a large Freer elevator or the one may be applying elevation to the coronoid process
broad end of a no. 9 periosteal elevator, is then inserted or medial aspect of the ramus of the mandible. Once the
between the temporalis muscle and temporalis fascia body of the zygoma has been elevated, the instrument’s
(see Fig. 16-26, C). The instrument is swept back and working blade should be swept posteriorly and laterally,
forth as the tip is moved inferiorly until the medial aspect reducing or ironing out any zygomatic arch fractures.
of the zygomatic arch and infratemporal surface of the The surgeon must then verify that any steps at the osseous
body of the zygoma are felt. The instrument should glide zygomatic processes have been eliminated. Once verifica-
freely in this plane because there is no dense attachment tion of adequate reduction and resistance to displace-
between the temporal muscle and temporal fascia. It may ment has been accomplished, the elevator is withdrawn
be difficult, however, to pass the instrument medially to and the incision is closed in one or two layers.
the zygomatic arch if medial displacement has occurred,
especially in areas of fracture. In this case, the tip of the Buccal Sulcus Approach
instrument must be pressed medially until the medial Another popular technique for the reduction of zygo-
aspect of the zygomatic arch is reached. The entire extent matic fractures is the approach through the maxillary
of the arch and zygomatic body should be palpated with buccal sulcus. Keen published an article on this tech-
the instrument to determine the location and extent of nique in 1909143 and it is favorably used by many surgeons
fractures. Bimanual palpation with one hand placed today.36,144 The major advantage, as in most intraoral
externally over the soft tissue of the side of the face is approaches, is the prevention of any external scar. The
frequently helpful. buccal sulcus approach can be used for both ZMC and
The periosteal elevator is removed and a flat instru- zygomatic arch fractures. Although the use of this
ment of sufficient rigidity is inserted into this same plane approach for elevation has several laudable attributes,
to reduce the fracture. Originally, a Bristow elevator was unstable fractures may require external incisions for the
used and it was necessary to use the superior margin of application of stable methods of fixation.
the wound and adjacent skull as a fulcrum to obtain the Keen Technique. A small incision (≈1 cm) is made in
leverage necessary for reducing the fracture. It was neces- the mucobuccal fold, just beneath the zygomatic buttress
sary to place gauze under the instrument at the point of of the maxilla. The incision can be made from anterior
fulcrum to prevent bruising the scalp. Although this to posterior or from medial to lateral and should extend
instrument can still be used, it should be used with care through mucosa, submucosa, and any buccinator muscle
because damage to the cranium has occurred.143 An inge- fibers. The sharp end of a no. 9 periosteal elevator or
nious instrument that has since been designed for zygo- curved Freer elevator is inserted into the incision. Using
matic elevation, and allows one to exert large amounts a side to side sweeping motion, the surgeon makes
of controlled force without using the skull as a fulcrum, contact with the infratemporal surface of the maxilla,
is the Rowe zygomatic elevator (see Fig. 16-26D). It has zygoma, and zygomatic arch and dissects the soft tissue
a flat blade on its working end for insertion medial to in a supraperiosteal manner. A heavier instrument can
the zygomatic arch and body. It has two handles for then be inserted behind the infratemporal surface of the
grasping during use. The first handle is in a direct line zygoma and, using superior, lateral, and anterior force,
with the working end and is used primarily for stabiliza- the surgeon reduces the bone (Fig. 16-27A). The use of
tion. The second handle is on the external lifting lever, one hand over the side of the face to assist in the reduc-
which is in turn attached to the area of the stabilizing tion procedure is extremely helpful. One should take
handle. When the stabilizing handle is kept in one posi- care to avoid using the anterior maxilla as a point of
tion and the lifting handle is activated, the working blade fulcrum.
can generate large amounts of force beneath a zygoma. Several different instruments can be used to accom-
The instrument was designed so that the two arms are plish this maneuver, including those designed specifically
A B C
FIGURE 16-27 Intraoral approach to reduction of the ZMC and arch. A, Suitable elevator inserted on the temporal surface of the
zygomatic body for elevation. B, Dental extraction forceps used in a manner similar to that for the Rowe zygomatic elevator. C, Flat
instrument used to reduce a depressed zygomatic arch.
for this purpose, such as the Monks or Cushing (joker) of the ramus through the mucosa and submucosa. The
elevator. However, any suitable instrument of sufficient incision is not made down to the bone but to the depth
rigidity with a bend on the end to engage the infratem- at which the temporal muscle inserts on the ramus. The
poral surface of the zygoma can be used. A right angle wound is deepened superiorly, following the lateral
retractor, bone hook, large Kelly hemostat, or urethral aspect of the temporal muscle with blunt dissection. This
sound are satisfactory instruments for this purpose. route of dissection will bring the instrument (or finger)
Another instrument that can be used successfully through between the temporal muscle and zygomatic arch, which
the buccal sulcus approach is a simple dental extraction should be readily palpable. The buccal fat pad will prob-
forceps (see Fig. 16-27B). It is used in a manner similar ably be encountered but is of no concern. A flat-bladed
to a Rowe zygomatic elevator in that the hinge portion heavy elevator is inserted into this pocket, with the
of the forceps is the stabilizing handle and one of the surgeon taking care to ensure its proper placement
forceps handles is the elevating handle. The other forceps lateral to the coronoid process, and the arch is elevated
handle becomes the working end and engages the pos- while the surgeon palpates extraorally along the arch
terior aspect of the zygoma. Controlled force can be (see Fig. 16-27C). The wound is closed in one layer.
easily applied in this manner.
A flat instrument, such as a Seldin retractor, can then Elevation from Eyebrow Approach
be used to follow the medial surface of the zygomatic In the United States, a popular technique for the eleva-
arch and elevate it laterally, if necessary. This same tion of zygomatic fractures is the eyebrow incision
approach is used on isolated zygomatic arch fractures. It (described earlier).17,81,76,147 The advantage to this tech-
must be stressed that when the temporal surface of the nique is that the fracture at the orbital rim is visualized
zygomatic body is followed laterally, one must stay close directly and fixation of the fracture at this point can be
to bone or the instrument may become placed on the undertaken through the same incision, when necessary.
medial side of the coronoid process. Although some cli- The disadvantage is that it is difficult to generate a
nicians think that the intraoral approach cannot be used large amount of force, especially in the superior
effectively for zygomatic arch fractures,81,145 this has not direction.9,36,102
been the experience of all. The incision in the mucobuc- Technique. Once exposure of the fracture at the fron-
cal fold does not have to be sutured. tozygomatic area of the lateral orbital rim has been
accomplished, a heavy instrument is inserted posteriorly
Lateral Coronoid Approach to the zygoma along its temporal surface. The instrument
In 1977, Quinn146 described a lateral coronoid approach is then used to lift the zygoma anteriorly, laterally, and
for the reduction of zygomatic arch fractures. This superiorly while one hand palpates along the infraorbital
approach is not useful for fractures of the ZMC but is a rim and body of the zygoma (Fig. 16-28A). Useful instru-
simple method for isolated fractures of the arch. A 3- to ments for this purpose are the Dingman zygomatic eleva-
4-cm intraoral incision is made along the anterior border tor, urethral sound, or even large Kelly hemostat. The
A B
FIGURE 16-28 Elevation of ZMC from the eyebrow approach. A, Dingman zygomatic elevator is placed along the temporal surface of the
zygoma for anterior, lateral, and superior elevation. B, Elevator is used to reduce the zygomatic arch fracture.
arch can also be approached from this exposure and area of application of the point of the hook on the back
reduced (see Fig. 16-28B). of the zygoma, ensuring that the hook has not slipped
into the inferior orbital fissure, which can cause venous
Percutaneous Approach hemorrhage that might result in ocular injury. Strong
A direct route to elevation of the depressed zygoma is traction in any direction can then be applied to reduce
through the skin surface of the face overlying the zygoma. a displaced zygoma (see Fig. 16-29C).
This approach has been used extensively worldwide. The A large bone screw, such as the Carroll-Girard screw,
advantage to the technique is that one can produce is another instrument that has been used with some fre-
forces anteriorly, laterally, and superiorly in a direct quency for elevating zygomas (Fig. 16-30). It resembles
manner, without having to negotiate adjacent structures an elongated corkscrew with a T bar handle and contains
with the instruments. The major disadvantage is a scar threads on its working end. This screw can be threaded
on the face in a very noticeable location. However, in into the body of the zygoma following placement of a
practice, scarring is more a theoretical than real disad- hole and can then be used as a handle to reduce the
vantage because the incision sites are rarely visible 2 to 3 displaced zygoma (see Fig. 16-30B). An advantage to its
weeks after surgery. use is that one can control the ZMC position in all three
Technique. The percutaneous approach is probably planes of space.
the simplest of all techniques because no soft tissue dis- Any of these instruments (and probably others) are
section is necessary. Several instruments can be used to helpful when the clinician uses the transcutaneous
elevate the zygoma. The bone hook, introduced by Stroh- approach to the zygoma. The possible application of one
meyer in 1844,148 has probably been the most widely used or two monofilament sutures is all that is necessary to
instrument and is advocated by many (Fig. 16-29A).* The care for the wounds created by their use.
point of the hook is simply inserted through the soft
tissue of the malar area at a point just inferior and pos- FIXATION TECHNIQUES
terior to the prominence of the zygoma so that it engages The application of plate and screw fixation techniques
the infratemporal aspect (see Fig. 16-29B). Poswillo152 to ZMC fractures has replaced all the older techniques
draws two intersecting lines on the face to determine the of fixation. There is no better method of providing stable
proper location for application of the bone hook. The fixation to an unstable ZMC fracture than to secure it
first is a vertical line dropped from the lateral canthus of rigidly internally with bone plates and screws. The obvious
the eye. The second is a horizontal line drawn laterally advantage to bone plates is that stabilization in three
from the ala of the nose. A small stab incision is made at planes of space can be provided, even across areas of
the point of intersection of these lines and the hook is comminution or bone loss.
inserted. The hook is then rotated to engage the tempo- Each case must be individualized, because the fixation
ral surface of the zygoma. One must be cognizant of the requirements differ greatly from one fracture to the
next. Some fractures may require no fixation; others may
*References 25, 103, 104, 109, 110, 149-153. require three or four bone plates. When plate and screw
A B
C
FIGURE 16-29 Elevation of the ZMC with a bone hook. A, Bone hook. B, Anterior and lateral traction with the use of a percutaneous
bone hook. C, Clinical photograph of the use of a bone hook. The dotted lines on the face represent those discussed in the text. Note
finger placement at the infraorbital rim during elevation to detect reduction.
fixation is used, there are general principles of its appli- the bone plate be adequately secured to each frag-
cation for ZMC fractures. ment. At least two screws are necessary for stabiliz-
1. Use self-threading bone screws. The thin bones of ing a bone plate to a bone fragment.
the midface lend themselves to the application of 4. Avoid important anatomic structures. One should
self-threading screws. It has been shown that self- position bone plates so that the screws do not
threading screws have more holding power in thin impale structures, such as the tooth roots and infra-
bones than when the holes are tapped.154-157 orbital nerve. If the fracture through the zygomati-
2. Use hardware that will not scatter postoperative CT comaxillary buttress is low, one should select an L-,
scans. Titanium plates and screws have the advan- a T-, or Y-shaped bone plate so that both of the
tage of not causing scatter in CT scans. Vitallium lower screws are positioned horizontally in the alve-
causes more scatter, so if it is selected, smaller plates olar process. The use of straight plate in this case
and screws should be used to minimize CT might cause the lower screw to impale a tooth root
artifacts.158-161 (Fig. 16-31).
3. Place at least two screws through the plate on each 5. Use as thin a plate as possible in the periorbital
side of the fracture. The three-dimensional stability areas. The skin overlying the orbital rims is very
provided by plate and screw fixation demands that thin and becomes more so over time. If a bone
A B
FIGURE 16-30 Elevation of the ZMC with a bone screw inserted percutaneously. A, Carroll-Girard bone screw. B, Use of a bone screw.
and adjacent bones are comminuted, it will be nec-

essary to apply additional bone plates in additional
areas. One can determine how much fixation is
necessary by forcefully trying to displace the repo-
sitioned ZMC during surgery. This maneuver is
especially easy if a Carroll-Girard screw has been
inserted. If the ZMC is stable against the applica-
tion of moderate force, it is unlikely that postreduc-
tion displacement will occur and no more fixation
is necessary. If there is some mobility after the appli-
cation of a bone plate, another plate may be
necessary.
7. If concomitant fractures of other midfacial bones
exist, it will be necessary to apply fixation devices
more liberally. For example, if the maxillary alveo-
lus, hemimaxilla, or complete maxilla is unstable,
a bone plate at the zygomaticomaxillary buttress
FIGURE 16-31 Vertical placement of two holes below the fracture
at the zygomaticomaxillary buttress can jeopardize the tooth roots
will no longer be able to provide the primary means
(right). In such cases, an L, T, or Y plate may avoid the tooth
of support for the repositioned ZMC. In such cases,
roots. primary fixation of the frontozygomatic area will be
necessary. It is imperative that the dentition be
placed into maxillomandibular fixation before
plate must be placed along the orbital rim, it should bone plates are applied when concomitant maxil-
be extremely thin to prevent visibility and reduce lary fractures are present.
palpability. This is especially true of the infraorbital 8. In areas of comminution or bone loss, span the gap
rim. If possible, one may wish to avoid placing bone with the bone plate. Comminution of fractures
plates in this location unless absolutely necessary. through the zygomaticomaxillary buttress and
6. Place as many bone plates in as many locations as infraorbital rim is common. If small bone frag-
necessary to ensure stability. Many fractures can be ments are missing, it is imperative that the gap be
adequately stabilized with a single bone plate maintained by the bone plate; otherwise, the ZMC
applied at the frontozygomatic area* or at the zygo- will be malpositioned. When the gaps are more
maticomaxillary buttress95,99,100,113 (see earlier). than a few millimeters, bone grafts can be attached
However, when the articulations between the ZMC to the bone plate or laid (and stabilized) over the
bone plate to promote osseous healing across the
*References 52, 88, 79, 89, 108, 109, 111, and 161. defect.
scans. Studies have shown that the CT scan allows pre-

dictable determination preoperatively of whether the
orbital floor and/or walls require reconstruction.114,118
This information permits more comprehensive preop-
erative planning of the surgery and avoids unnecessary
orbital exploration. The availability of intraoperative CT
scanning in some operating rooms will also affect the
decision about when internal orbital reconstruction is
necessary.
Intrasinus Approach to the Orbital Floor
The antral approach to the orbital floor historically has
been predicated on the ability to realign the orbital floor
without making external incisions when the orbital floor
has been depressed but there is no herniation of soft
tissue through the periorbita. Packing the sinus with
gauze or a balloon to provide support to the orbital floor
for 2 weeks was thought to allow healing to take place.45,168-
172
In practice, however, this technique is rarely possible
and should not be used as the routine approach to the
orbital floor.
More recently, surgeons have begun to use an endo-
scope for evaluating and reconstructing the orbital
floor.173-178 Approaching the orbital floor through a bone
window in the lateral maxilla allows the insertion of an
FIGURE 16-32 Patient 8 months after treatment of a left ZMC
fracture. Note the deepening of the supratarsal fold, a hallmark of
endoscope to examine the status of the floor and, if
enophthalmos. The slightly inferior position of the globe is also necessary, reconstruct it by insertion of a material, such
evident. as bone, metallic mesh, or porous polyethylene into the
orbital defect.
INTERNAL ORBITAL RECONSTRUCTION External Approach to the Internal Orbit
In the treatment of ZMC fractures, internal orbital recon- Reconstruction of the orbital floor is performed through
struction is a supplementary procedure that is frequently a lower eyelid approach (subciliary, subtarsal, or trans-
but not always indicated. When indicated, internal orbital conjunctival). Using any of the approaches to the infra-
reconstruction is a vital component of treating ZMC frac- orbital rim and internal orbit (see earlier), the surgeon
tures (Fig. 16-32). The complications of ZMC fractures gently elevates the periorbita along the floor of the orbit.
that are most difficult to correct secondarily are those of It must be remembered that the orbital floor is inferior
the orbit. When internal orbital reconstruction is not to the level of the rim, so when the periorbita is elevated,
performed when indicated, or is performed inadequately one must be careful to follow the contour of the rim or
(see Fig. 16-14), postsurgical enophthalmos can result. perforation of the periorbita will occur. The subperior-
Postsurgical enophthalmos is one of the most distress- bital dissection should extend beyond the full length of
ing complications after treatment of ZMC fractures. It the access incision in the skin. Comminution of the infra-
usually results if the orbital floor and walls have not been orbital rim is commonly present. It is always easier to
reconstructed when indicated or have been inadequately dissect the periorbita from sound bone toward the frac-
reconstructed.88,91,162-167 Studies have shown that posttrau- tured areas. Protection of the periorbita and globe is
matic enophthalmos is most commonly caused by an facilitated after dissection by placement of a malleable
increase in the size of the bony orbit.66,67 Lateral position- retractor. The area of disrupted orbit may be a narrow
ing of the ZMC is one of the most effective methods for crack along the floor, usually along the infraorbital
increasing orbital volume because of the cross-sectional groove, or severely comminuted floor and walls. When
area of the orbit at the level of the displaced ZMC. comminuted, it becomes difficult to dissect the perior-
However, concomitant fractures of the orbital floor and/ bita from the thin bone spicules. One must continue
or medial wall are common with ZMC fractures and can dissection posteriorly along the orbital floor and medial
also increase orbital volume.147 wall until sound bone is found. Thus, dissection far pos-
Any patient with presurgical enophthalmos should be terior to the globe is usually necessary. Areas of perior-
suspected of having orbital disruption but traumatic bital fat dehiscence through the periorbita into the
edema may mask the problem, making clinical examina- maxillary or ethmoid sinuses must be gently freed. Small
tion difficult. CT has made preoperative assessment of bone spicules can be removed if free from soft tissue
the status of the bony orbit possible, with a great degree attachments.
of accuracy. In reviewing treatment of ZMC fractures For fractures in which the defect is a narrow linear
over a 10-year period, Covington et al79 found a reduc- groove, no reconstruction is usually necessary. When a
tion in orbital exploration from 90% in 1985 to 30% in larger defect is noted and the periorbita has been dis-
1989 because of the increasing use of preoperative CT rupted, reconstruction of the internal orbit is necessary
A B
D
C
FIGURE 16-33 A, Right ZMC fracture with comminution of the orbital floor and medial wall. B, After reduction and internal fixation of the
ZMC fracture, the internal orbit is reconstructed with a graft or implant that completely bridges the defect or comminuted area.
C, Stabilization of the graft or implant is performed with a lag screw or by other means. D, Reconstruction of the left orbital floor and
medial wall with the use of calvarial bone grafts secured with lag screws.
for preventing enophthalmos and ptosis of the globe surface of the opposite maxilla, and the buccal or lingual
(Fig. 16-33). cortex of the mandible have also been used with good
success. From 1980 to 2000, the calvarium became one
Materials Used for Orbital Reconstruction of the primary donor sites.180-182 When bone is used, it
A number of materials have been used to reconstruct the should be borne in mind that some resorption will even-
internal orbit, including autologous bone, autologous tually take place, so adequate volume should be trans-
cartilage, allogeneic bone and cartilage, methyl methac- planted to offset this eventuality. Although the use of
rylate, silicone polymer, polyurethane, aluminum oxide allogeneic bone and cartilage is less common, it may have
ceramic, Teflon (polytetrafluoroethylene polymer), merit.183 The possibility of infection from the open sinus
gelatin film (Gelfilm), Supramid, polyethylene, polyvinyl does not seem to be a problem with bone.
sponge, polydioxanone plates, polyglactin mesh or plates, Although autologous grafts may appear to be ideal,
polylactide plates, porous polyethylene, lyophilized dura, there is associated donor site morbidity and increased
and metal sheets or mesh (Potter and Ellis have written operative time involved in graft harvesting and carving.
a comprehensive review179). Furthermore, calvarial bone grafts are difficult to shape
Bone has been used extensively for many years with and are brittle. These factors led to the development and
excellent results and is often chosen when the orbital acceptance of alloplastic substitutes for use in orbital
defect is large. Autologous bone can be obtained from a reconstruction. Criticism directed at the use of alloplastic
number of donor sites. Historically, the most common materials cites the complications of infection, extrusion,
source was the iliac crest. However, split ribs, the anterior and implant displacement. There have been reports of
late complications developing with implanted silicone posterior edge unsupported. To ensure proper
that have necessitated its removal as long as 18 years placement, dissection back toward the orbital apex
postoperatively.184-194 Morrison et al195 have reviewed 311 is necessary for establishing the posterior extent of
cases of silicone implants placed over a 20-year period the defect. If it is impossible to establish a sound
and found that at least 13% required removal for one posterior margin, the posterior edge of the material
reason or another. However, when used in small defects must be well supported laterally and medially. Alter-
and properly stabilized, silicone, Teflon, and other allo- natively the material can be cantilevered to adja-
plasts have proven useful. Porous polyethylene has cent sound bone with the use of plate and screw
become popular in recent years for orbital reconstruc- fixation.209
tion. It comes in various thicknesses, is easy to bend, and 2. The thickness of the implant or transplant. The
maintains its shape. Another advantage is that it offers thickness of the implant or transplant is usually
sufficient rigidity to confine the orbital contents and can determined by the flexibility of the material. If flex-
be stabilized easily with plate and/or screw fixation.196 ible, a thicker piece is necessary for reconstructing
A major advantage to bone, cartilage, and bioresorb- a large defect without allowing sagging of the peri-
able products, such as gelatin film and polydioxanone or orbital soft tissue into the sinus.
polyglactin plates, when compared with alloplastic 3. The volume of the implant or transplant. More
implants, is that not only are they able to provide the bulk can be implanted if there is notable preopera-
necessary support to orbital tissue, but they are also tive enophthalmos present. Most surgeons advocate
incorporated or replaced in the body, minimizing the the placement of more volume of implant or trans-
chance of late reactions. Gelfilm has been shown to plant than considered necessary for reestablishing
undergo slow degradation over a 10-week period, with the former position of the floor and walls. The
bone bridging occurring simultaneously in orbital floor added bulk should be posterior to the axis of the
defects created in adult rhesus monkeys.197 Unfortu- globe to displace it anteriorly. When bone is used,
nately, many of the biodegradable products are not stiff more than necessary is placed because remodeling
enough to be useful in large orbital defects.198-202 In such and resorption will minimize its size (≈20% to
cases, bone, porous polyethylene, or metallic implants 30%).182 The volume necessary is difficult to predict;
should be considered. however, postsurgical exophthalmos is rare.
Metallic mesh has become popular for orbital recon- 4. Tension-free placement of the implant or trans-
struction in recent years.203-208 Even though metallic mesh plant. The implant or transplant must be passive
is exposed to open sinuses, it is rare to have to remove when inserted into the wound. In other words, there
any because of infection. Advantages of the use of metal- should be no tendency for an implant to buckle or
lic mesh are that it can be made to conform to the for its edges to curl up or down, or for the implant
desired contours, it is stiff enough to maintain adequate to migrate when placed. If any of these occurs, the
support of the periorbital tissue, and it is extremely thin. pocket is too small or the implant too large.
Also, it is readily visible on postoperative CT scans. 5. Stabilization of the implant or transplant. The
implant or transplant must be fashioned so that it
Principles of Orbital Implant and cannot be displaced or must be secured with
Transplant Placement sutures, wires, or bone screws (see Fig. 16-33C).
Because the objective of orbital reconstruction is to Usually, orbital implants migrate anteriorly. This
support the periorbital soft tissue and partition the max- tendency is probably because the implant is improp-
illary or ethmoid sinuses from the orbit, any of the mate- erly sized and placed under tension. The implant
rials discussed will suffice. The decision is usually based should not extend over the infraorbital rim. It
on the availability of the products, preference of the usually can be placed so that its anterior end is
surgeon and, most importantly, size of the defect. When behind the rim, with the rim acting as a physical
the defect is large, autologous bone, porous polyethylene impediment to anterior migration (see Figure
sheets, and metallic mesh are the materials of choice. 16-33, C). Stabilization with bone screws and/or
The use of other materials, when the defect is large, bone plates will prevent migration.210
necessitates a very large or thick implant, which would 6. Careful closure of the wound. The periorbita must
be difficult to stabilize along the minimal osseous be carefully closed with resorbable sutures. This
margins. Alloplastic implants, such as silicone and Teflon, closure is extremely important because it ensures the
should be reserved for smaller defects. No matter which proper positioning of the orbital septum and helps
material is used, however, certain principles should be adapt the tissue over the implant or transplant.
kept in mind.
1. The size of the implant or transplant. As large an
implant or transplant as necessary for covering the PATIENTS TREATED FOR ZYGOMATICOMAXILLARY
entire defect should be used. The implant or trans- COMPLEX FRACTURES
plant must be of sufficient size to be supported It should be obvious from the earlier discussion and
along most margins by sound bone. Before the review of the literature that all ZMC fractures do not have
placement of any implant or graft, one must be to be treated in the same manner. Some require less
certain that its posterior edge is resting on sound surgical exposure and fixation than others.* The use of
bone. Perhaps the most common error in place-
ment of an implant or transplant is leaving the *References 78, 87, 89, 99, 113, 114, and 118.
A B
C D
E F
FIGURE 16-34 A, Patient sustained severe (high-energy) right ZMC and internal orbital fractures. B, Axial CT scan through the zygomatic
arch shows retrusion of the entire ZMC and fracture of the arch at the junction with the articular eminence of the temporal bone. C, Axial
CT scan showing posterior displacement of the ZMC. D, Coronal CT scan behind the globe showing disruption of the floor. E, Coronal
exposure demonstrating reconstruction of the zygomatic arch and bone plate at the frontozygomatic suture area. F, After stabilizing the
ZMC in position, a large orbital floor defect is present, with only the infraorbital nerve spanning it.
preoperative CT scans has allowed more accurate plan- infraorbital rim and internal orbit, and lateral orbital rim
ning of treatment by identifying the severity of the inju- (Fig. 16-34). In many such cases, the zygomatic arch may
ries. Those that are severely displaced or segmented also require exposure. The decision to use a coronal
and/or have comminuted articulations usually require approach is based on the amount of displacement of the
extensive internal orbital reconstruction. An aggressive ZMC posteriorly and laterally and on comminution of
approach to such fractures should be taken and should the arch.211,212 If the other articulations located more
expose at least the zygomaticomaxillary buttress, anteriorly appear to be significantly comminuted,
G H
I J
K L
FIGURE 16-34, cont’d G, Orbital floor reconstruction bone plate used to span the defect. Autologous bone was placed on top of the
plate. H, After repositioning the ZMC, a large defect of the lateral maxillary wall is present. Bone plates were used to span the defect.
I, Bone grafts used to reconstruct the lateral maxillary wall. J, Resuspension of facial soft tissue performed before closure. This
photograph shows resuspension of the outer layer of the temporalis fascia. K, Postoperative axial CT scans showing repositioning of the
ZMC and reconstruction of the zygomatic arch (L).
exposure and reconstruction of the arch provide another determines this position mainly through palpation of the
point for reduction and stabilization. articulations, visual assessment of malar projection, and/
Fractures that do not require internal orbital recon- or intraoperative CT scanning and/or navigation. Occa-
struction (as determined by the preoperative or intraop- sionally, an audible crunch will be heard and palpated
erative CT scans) and whose articulations are not when the ZMC is elevated into position. The most impor-
comminuted (as determined from the preoperative CT tant step is to ensure that the ZMC is properly positioned.
scan) can be treated less aggressively.99,114,118 In such With minimal edema, the proper position is often easily
cases, the treatment algorithm presented in Figure 16-35 ascertained by palpating the malar eminences bilater-
can be used. The first step is to elevate the ZMC into what ally.44 If the surgeon is unsure of the ZMC position, it is
is thought to be the proper position. The surgeon mandatory that exposure be performed to examine
M N
O P
Q R
FIGURE 16-34, cont’d M, Alignment of the zygomaticosphenoid suture. N, Postoperative coronal CT scans show reconstruction of the
orbital floor with metal plate and bone graft just posterior to the globe and, more posteriorly, in the orbit (O). Frontal (P), right (Q), and
left (R) lateral photographs of patient 18 months after surgery.
Reduce Fx
Reduced Unsure of redn

Transoral open redn
and stable and/or unstable
STOP Unsure of redn
Open redn
Reduced but unstable
FZ and lat orbit
Bone plate ZM buttress Bone plate FZ area

FIGURE 16-35 Treatment algorithm for ZMC fracture without the need for internal orbital reconstruction.
A B
C D
E F
FIGURE 16-36 Patient with low-energy ZMC fracture treated with reduction using a Carroll-Girard screw without fixation. A, Frontal and
inferior (B) views of the patient before surgery. Note the significant contour deficit present. C, Axial CT scan at the level of the midglobe
shows displacement of the lateral orbital rim and disruption of the lateral orbital wall. D, Axial CT scan at the level of the zygomatic
arch shows medial rotation of the posterior (infratemporal) surface of the ZMC into the maxillary sinus. E, Coronal scan posterior to the
globe shows notable displacement of the ZMC, but minimal comminution of the orbital floor. After reduction, the position of the ZMC was
thought to be satisfactory, and the ZMC did not displace to digital pressure. No exposure or fixation was therefore applied. CT scans
taken after surgery showed satisfactory reduction of the fracture. F, Postoperative axial CT scan at the level of the midglobe shows good
alignment of the lateral orbital wall.
continued
alignment with adjacent articulations. If one is satisfied can be performed easily. The use of this approach as an
with the position of the ZMC and it is firm in its position, initial point of exposure is predicated on the basis of the
as determined by the surgeon attempting to displace it, following: (1) the scar is hidden; (2) the access for reduc-
no fixation is required and no further surgery is neces- tion is good; and (3) if fixation is necessary, a bone plate
sary (Fig. 16-36). If the ZMC can be positioned properly placed on the zygomaticomaxillary buttress provides the
but must be held in position, it must be stabilized. best mechanical method of preventing postsurgical dis-
In either of these cases, exposure of the zygomatico- placement in isolated ZMC fractures. After exposure of
maxillary buttress via the maxillary vestibular approach the entire face of the anterior maxilla and zygoma, a
G H
I J
K L
FIGURE 16-36, cont’d G, Postoperative axial CT scan at the level of the zygomatic arch shows satisfactory reduction. H, Postoperative
axial CT scan just below the infraorbital rim shows good position of the malar eminence. I, Postoperative coronal CT scan at the
posterior surface of the right globe shows satisfactory reduction of the fractures through the lateral orbital wall and floor. J, Coronal CT
taken behind the right globe shows a satisfactory contour of the right zygomaticomaxillary buttress and maintenance of the contour of
the orbital contents. Frontal (K) and inferior (L) views of patient 5 weeks later showing good symmetry.
broad surface area is visible for assessing alignment of after this one point of fixation, no further surgery is
the infraorbital rim and zygomaticomaxillary buttress. necessary (Fig. 16-37).
Because the ZMC is often comminuted, there will usually If the adequacy of reduction is still uncertain after
be an area in which the fractured zygomaticomaxillary exposure of the zygomaticomaxillary buttress, or if stabil-
buttress can be aligned with the alveolar process. If the ity is not adequate even after placement of a bone plate
ZMC is found to be reduced and stable, no further on the zygomaticomaxillary buttress (unlikely), exposure
surgery is necessary. If the zygomaticomaxillary buttress of the frontozygomatic area is performed. The surgeon
can be aligned but rotates medially into the maxillary exposes the frontozygomatic area using an approach
sinus when not supported, a single bone plate is placed through the upper eyelid—an upper blepharoplasty inci-
at the zygomaticomaxillary buttress. If the ZMC is stable sion. Although a lateral brow approach can also be used,
A B
C D
E
F
G H
FIGURE 16-37 Patient with low-energy ZMC fracture treated by reduction using Carroll-Girard screw and bone plate fixation along the
zygomaticomaxillay buttress. A, Frontal and inferior (B) views of patient with left ZMC fracture. C, Axial CT scan at midglobe level shows
minimum displacement of the lateral orbital rim. D, Axial CT scan just below the infraorbital rim shows posteromedial displacement of the
malar eminence. Note that the fractures are not comminuted. E, Coronal CT scan showing noncomminuted orbital floor and walls. The
patient underwent reduction with a Carroll-Girard screw, but the malar eminence kept rotating inferomedially into the maxillary sinus.
Transoral open reduction and internal fixation with a single bone plate was performed, producing stability of the ZMC. F, Postoperative
radiography showing symmetry obtained and location of the bone plate. G, Frontal and inferior (H) views of patient 4 months after
surgery.
the exposure provided is considerably less than with an occasional yet interesting finding has also been some
upper eyelid approach unless the incision is extended visual disturbances, such as diplopia, occurring early
below the eyebrow. However, this extension often results after injury and subconjunctival ecchymosis.8,96
in a noticeable scar that crosses the resting skin tension The necessity for treatment of these injuries is based
lines. Alignment of the fracture through the frontozygo- on clinical detection of cosmetic or functional distur-
matic area and along the inside of the lateral orbital wall bances. In the study by Ellis et al,26 20% of zygomatic arch
(sphenozygomatic suture area), when combined with fractures were not treated. However, other studies have
alignment of the zygomaticomaxillary buttress, provides shown a variable ratio of treated versus nontreated zygo-
excellent assessment of reduction. Whether placement matic arch fractures.20
of fixation devices across the frontozygomatic fracture Reduction of these fractures can be simply accom-
area is necessary is based on the ability to move the ZMC plished by any of the techniques already described for
using the Carroll-Girard screw. If necessary, the type and ZMC fractures. A percutaneous bone hook, the Gillies
amount of fixation are at the discretion of the surgeon. temporal approach, and an intraoral approach all are
Because this area is readily palpable, very thin devices acceptable techniques. The need for stabilizing zygo-
should be used. Thin bone plates or a transosseous wire matic arch fractures varies with the location of the
may be all that is necessary when combined with a plate injury, number of fractures, and displacement of the
at the zygomaticomaxillary buttress. If the reduction and segments. Ellis et al26 have found that 10 of 126 (7.3%)
stability are judged to be adequate, no further surgery is isolated zygomatic arch fractures treated in their
necessary. study required fixation. Others have reported that
If one is still unsure of the reduction (unlikely for a almost every zygomatic arch fracture is stable, once
low- or medium-energy injury), the infraorbital rim is elevated.35,36,76
exposed via an approach through the lower eyelid. The Stabilization of depressed zygomatic arch fractures has
infraorbital rim can be aligned and, if necessary, stabi- been achieved in a number of ingenious ways. Usually,
lized with fixation devices. However, fixation devices in the use of percutaneous circumferential wires or heavy
this area should be avoided unless absolutely necessary sutures passed around the arch with an aneurysm needle
because of the thinness of the overlying tissue and the or Mayo trocar and tied to an external object has served
tendency for scar formation between the tissue of the this purpose well (Fig. 16-39). Plastic oral airways,213
lower eyelid and hardware. If fixation hardware is deemed metal eye shields,214 short pieces of endotracheal
necessary, the thinnest possible device should be used. tubing,215 and orthopedic finger splints216,217 all have
been used as the external devices. The passing of an awl
ZYGOMATIC ARCH FRACTURES and tightening of wires in this region of the face may be
expected to damage branches of the facial nerve but this
Fractures of the zygomatic arch are usually the result of complication has not been reported. Some have placed
fractures of the entire ZMC. However, isolated fractures materials such as gauze and balloons between the zygo-
of the arch without other injuries do occur when a force matic arch and lateral aspect of the mandible through
is applied directly from the lateral aspect of the head. an intraoral approach81; however, this approach is usually
The incidence of these injuries varies, but usually iso- unnecessary.
lated zygomatic arch fractures constitute fewer than 10% Occasionally, the zygomatic arch requires ORIF. Frac-
of zygomatic injuries.26 However, others have noted tures that are in several segments or that are grossly
higher incidences, possibly related to the nature of the displaced are candidates for this form of treatment. The
population.12,36,76 Conceivably, many isolated zygomatic zygomatic arch can be safely approached from a coronal
arch fractures may go unnoticed by the patient or are incision. Once the arch has been identified by subperi-
deemed of insufficient significance to seek treatment. osteal dissection, it can be manually repositioned and
Isolated zygomatic arch fractures characteristically stabilized. Long, thin bone plates are used to maintain
result in a V-shaped indentation of the lateral aspect of the normal arch morphology. When plates are used, one
the face, with the apex deep toward the sigmoid notch should be cognizant of the normal flat configuration of
(Fig. 16-38). There may be only one definite line of frac- the zygomatic arch. Bone plate fixation that provides too
ture, with bending or greenstick fractures in two other much curvature to the arch results in a noticeable cos-
areas to produce a W-type configuration of the arch and metic deformity. Although the zygomatic arch is called
a V-shaped cosmetic deformity. Occasionally, three defi- an arch, in reality it is not all that curved.
nite lines of fracture producing two free segments occur. Following reduction of zygomatic arch fractures, one
In this case, the normal convexity of the temporal area must protect the side of the head from injury. The force
is lost. Flattening of the side of the face was noted in 57% of the weight of the head resting on a pillow is sufficient
of isolated zygomatic arch fractures in a study by Ellis to displace even a properly reduced fracture. Many mate-
et al.26 rials are available that can be taped to the side of the
Accompanying zygomatic arch fractures may be head to protect the zygomatic arch following reduction.
trismus as a result of impingement of the fractured Commonly used and readily available materials that can
segment on the temporal muscle (see Fig. 16-38A). This be formed and applied for this purpose are paper cups,
finding was noted in 45% of 166 isolated zygomatic arch metal eye patches, aluminum finger splints bent in a
fractures by Ellis et al26 and in 67% of those in Knight staple configuration,218 and a number of others (Fig.
and North’s series.35 The patient may have difficulty in 16-40). Ideally, they should be left in place for 2 to 3
shifting the mandible toward the injured side. An weeks.
A B
C D
FIGURE 16-38 Reduction of a zygomatic arch fracture via the intraoral route. A, Preoperative photographs of the patient showing limited
mandibular opening and a flattening over the left zygomatic arch (B). C, Preoperative intraoral tangential radiograph showing medial
displacement of zygomatic arch fragments. D, Urethral sound inserted via a small incision in the maxillary vestibule. The instrument is
placed medial to the zygomatic arch and the area of the displaced fracture is elevated while the other hand palpates along the arch (E).
continued
E F
G H,I
FIGURE 16-38, cont’d F, Postoperative radiograph showing reduction. G, Immediately postoperatively, patient has regained mobility of the
mandible. H, Metal and gauze eye patches can be used to protect the reduced arch for several days (I).
large, at which point wound care and resuturing may be

COMPLICATIONS necessary.
One problem that may accompany any incision to gain
PERIORBITAL INCISION PROBLEMS access to the infraorbital rim and internal orbit is a verti-
Several complications can result from the incisions cal shortening of the lower lid following healing (Fig.
described earlier for approaching the infraorbital rim 16-41). This shortening probably occurs as a result of
and orbital floor and walls. Minor complications, such scarring between the tarsal plate and periosteum, short-
as dehiscence, hematoma or seroma formation, and ening the orbital septum. To help prevent this, superior
lymphedema, are more bothersome than difficult to support of the lower lid for several days (or until gross
handle. Hematomas and seromas, when large, can be edema has resolved) following surgery is beneficial. The
decompressed with a needle and syringe. Lymphedema most direct method of achieving this support is through
subsides with time, especially if the lower lid is sup- the use of a Frost suture, in which a suture is placed
ported in its proper position. Dehiscence of a wound through the dermal surface of the lower lid just inferior
may require nothing more than observation unless it is to the gray line and is taped to the forehead (Fig. 16-42).
A B
FIGURE 16-39 One method of stabilizing a reduced zygomatic arch fracture. A, A large curved needle or an awl is used to pass heavy
suture or fine wires around the zygomatic arch. B, The wires are then secured to a stable object, such as a tongue blade and aluminum
finger splints, until healing has occurred.
A FIGURE 16-41 Patient 7 weeks after treatment of a right ZMC

fracture through the transconjunctival approach with lateral
canthotomy. Note 1 mm of scleral show.
B
FIGURE 16-40 Methods of protecting a reduced zygomatic arch
fracture. This can be easily accomplished by using an oral airway
(A), aluminum finger splint material (B), or other suitable object
that can be taped over the area for several days.
FIGURE 16-42 Frost suture placed through the skin of the lower lid
and taped to the forehead to provide support to the lower lid.
A B
FIGURE 16-43 A, Patient 8 weeks after treatment of a left ZMC fracture through the transconjunctival approach with lateral canthotomy.
Note 3 mm of scleral show, entropion, and the unnatural appearance of the lateral canthus, with the lid not touching the globe. B, Six
weeks after surgical correction.
This technique closes the eye, supports the lower lid, aids on after the onset of traumatic edema develop more
in the dissipation of lid edema, and allows one to examine complications. They found that ectropion developed in
the globe and vision by simply removing the tape from 3 of 16 patients (18.8%) after a subciliary incision with
the forehead and opening the eyelids. skin-muscle dissection to approach the orbit. However,
Postsurgical deformities of the lower eyelid are dis- the ectropion was permanent in only one patient. Anto-
tressing problems, although most cases are self-limited. nyshyn et al181 have found a scleral show frequency of
Ectropion, or an outward curl to the lower eyelid, is clas- 16.6% with this same approach. Appling et al227 have
sified as mild when there is only slight lifting of the lid compared a subciliary incision with skin-muscle dissec-
from the globe. Moderate ectropion is associated with tion with transconjunctival approaches to the orbit and
lifting of the lid from the globe and a shortening of the noted a 12% rate of transient ectropion and a 28% rate
vertical height of the lower eyelid. Severe ectropion is a of permanent scleral show after the subciliary approach.
combination of shortening of the eyelid and true ever- No transient ectropion and only a 3% incidence of per-
sion of the eyelid, not just a lifting away. Mild and moder- manent scleral show were found with the transconjunc-
ate ectropion usually resolve with the passage of time and tival approach.
with gentle massage of the lid. Severe ectropion may
require surgical correction. Entropion, or an inward curl INFRAORBITAL NERVE DISORDERS
of the lower eyelid, occurs less commonly but is more Occasionally, a patient who has had treatment of a zygo-
distressing because of the irritation of the eyelashes on matic fracture will complain that the upper teeth, espe-
the globe. Entropion that does not resolve spontaneously cially the anteriors, feel numb or different, and even
may require surgical correction (Fig. 16-43). painful to heat, cold, or light touch. De Man and Bax,52
The incidence of ectropion or scleral show reported in a study of 273 isolated ZMC fractures, found that 80%
for subciliary incisions with skin and muscle dissection suffered from dysesthesia on admission. Nordgaard49
varies considerably.125,126,219-221 Heckler et al130 have found sensory disturbance in 96% of 100 patients imme-
reported a 6% temporary incidence after a skin-muscle diately after fracture. Jungell and Lindqvist51 found that
approach to the orbital floor. Manson et al and Dufresne 81% of patients with ZMC fractures had paresthesia of
et al222-224 have noted a 10% incidence of temporary the infraorbital nerve. The figure was even higher (94%)
ectropion or scleral show using a skin-muscle flap to in those who required surgical treatment. Most patients
approach the orbit. They noted that with time, sufficient had regeneration, but 42% of patients had some degree
resolution occurred that patients did not request correc- of persisting sensory disturbance. Only 12% of patients
tive surgery. Wray et al126 have compared the incidence had total loss of sensation. Similar statistics have been
of ectropion following subciliary exposure of orbital frac- reported by Altonen et al,20 who observed that 42% of
tures with the conjunctival approach and found an patients had some permanent changes and 10% had
extremely high incidence of postoperative vertical lid marked deficits. Zachariades et al228 have found that 27%
shortening in the former. After subciliary incisions, ectro- of their patients have alteration of infraorbital sensation
pion developed in 19 of 45 eyelids, 15 of which were 6 months after ZMC fractures. Additionally, they found
transient and 4 of which required operative intervention. that inpatients who did not undergo surgery because of
A prospective study by Lacy and Pospisil225 has reported minimum or no displacement, all recovered sensation.
on 55 skin-muscle dissections through the eyelid to An interesting finding with nerve deficits after ZMC
perform surgery for zygomatico-orbital trauma. Ectro- fractures has been that fewer deficits remain in patients
pion occurred in 18% of their cases, being transient in treated with rigid fixation of their fractures. Champy
all but two. They again noted an increased incidence in et al,111 de Man and Bax,52 Zingg et al,87,88 and Taicher et
older patients and in those with edematous lids during al229 have stated that reduction and fixation are impor-
surgery. Bähr et al226 have confirmed that orbits operated tant factors in the recovery from sensory disturbances of
A B
FIGURE 16-44 Patient who had a silicone implant used to reconstruct his orbital floor 13 months previously. A, For the past several
months, he had intermittent swelling and drainage from this sinus tract. B, At surgery, the implant was found to be surrounded by
chronic inflammatory tissue and was removed. The sinus tract was excised to gain access to the orbital floor. He had no further
problems following implant removal.
the infraorbital nerve. They maintain that fixation of the Polley and Ringler232 have reviewed 230 Teflon implants
fracture line by a miniplate, mainly in the frontozygo- used on the orbital floor over a 20-year period and found
matic area, achieves the fastest recovery rate of neurosen- only one postoperative infection that necessitated
sory dysfunction. The proposed method whereby implant removal. There were no other complications.
recovery improves is that improved stability prevents con- The implants were not routinely sutured to the orbital
tinued compression on the nerve after reduction. floor in their series. Similarly, Morrison et al195 have
Tajima53 has indicated that full recovery should occur reviewed 311 cases of silicone implants placed over a
within 5 months. Jungell and Lindqvist51 have found that 20-year period and found that at least 13% required
most recovery occurs early, within the first 2 weeks. removal for one reason or another.
However, Lund28 has noted sensory disturbances in Particularly distressing are the occasional occurrences
almost 50% of patients more than 2 years after their of acute foreign body reactions to silicone191 and Teflon190
injuries. In cases of persistent dysesthesia, anesthetiza- orbital floor implants many years after implantation. It
tion of the superior alveolar nerves by local infiltration may be that slight trauma to the implant precipitates this
should be attempted. If symptoms are not alleviated, the reaction, because one of the patients reported was sub-
clinician should suspect a disruption of the infraorbital jected to a blow to the orbit that preceded the acute
nerve within its canal where the middle and anterior reaction. In these subjects, implant removal and at least
superior alveolar nerves take origin, with possible partial removal of the inflammatory tissue allowed reso-
neuroma formation. Surgical exploration may be neces- lution of the process. Other series have shown complica-
sary when the altered sensation is bothersome to the tion rates ranging from 3% to 15% with the use of
patient. alloplasts other than Teflon.233-238 When the implants
become displaced or extruded, they should be removed
IMPLANT EXTRUSION, DISPLACEMENT, (Fig. 16-44). It is usually not necessary to place another
AND INFECTION at the time of surgery; however, if enophthalmos or ptosis
The possible risks that always exist when an alloplastic occurs, reconstruction of the internal orbit can be under-
material is used are infection, displacement, and extru- taken secondarily.
sion of the implant. Infection usually occurs early and
may result in the need for implant removal. These com- PERSISTENT DIPLOPIA
plications are uncommon but do occasionally occur. Aar- Binocular diplopia present initially after zygomatic frac-
onowitz et al230 have reported a 3.9% early complication ture is generally a result of edema or hematoma of one
rate (within 1 month of surgery) when Teflon implants or more extraocular muscles or their nerves and intraor-
were used to reconstruct the orbital floor. These compli- bital edema or hematoma. In these cases, resolution of
cations consisted of infections and improper placement diplopia following fracture treatment (if necessary)
of the implant, necessitating removal in all cases. They usually occurs spontaneously within 5 to 7 days.49,239 Occa-
also found a 2.8% late complication rate, which included sionally, muscle entrapment is the cause of diplopia but
one patient with a cutaneous antral fistula. Correlation such entrapment should be apparent with the use of a
criteria were established to determine whether any pre- forced duction test.
operative or intraoperative findings correlated with the Persistent diplopia occurs in a small percentage of
complication rate. The only positive correlation was an patients after what appears to be appropriate treatment,
association between the concomitant use of antral packs ranging from 3% to 15% in reported series. The cause
and implants. Therefore, they recommended that this of persistent diplopia is not known, but it has been
application be avoided. The association between antral thought to result from scar contracture and adhesions in
packs and implants has also been noted by Spira.231 ocular muscles or between them and other structures.
Neural injuries from the trauma or from surgery may also placed along the axis of the globe only shifts the globe
produce persistent diplopia. It should be pointed out to the opposite side.
that few of these patients complain of their diplopia, and Several materials have been used to decrease orbital
blurring of vision may be found only in upward and volume, such as glass beads,243-245 silicone sheets or
lateral gaze. If the diplopia is bothersome, the patient sponges,246-249 Teflon beads,250 cartilage grafts,251-253 porous
should be referred to an ophthalmologist for evaluation polyethylene sheets,185 hydroxylapatite,254,255 and metallic
and possible treatment with exercises and/or surgery. mesh or plates.203,205 The advantage of using nonresorb-
ing materials is that they maintain their bulk within the
orbit; however, extrusion, migration, and infection are
ENOPHTHALMOS always possible. The implant or bone may need to be
Enophthalmos may be present, even after what appeared placed in several locations within the orbit to affect the
to be proper treatment at the time of the operation. Few anterior projection of the globe; therefore, access to
patients are aware of enophthalmos and it therefore almost the entire circumference of the orbit is often
seldom presents a clinical problem unless severe. The necessary. Usually, the orbital floor, medial wall, or pos-
incidence of enophthalmos varies considerably from one terolateral wall of the orbit requires an implant or graft
report to the next, depending on how much globe retru- posterior to the axis of the globe.131
sion is considered to represent enophthalmos. The usual
figure is low, reported between 5% and 12%.27,29,64
However, Altonen et al20 have noted enophthalmos in BLINDNESS
41% of patients. The reason for this high incidence prob- Reduced vision and blindness have occasionally been
ably stems from the 26% incidence of slight enophthal- reported after the treatment of zygomatic fractures.
mos in their series. If one takes away the 26% who had Ord256 has reported that the incidence of postoperative
slight enophthalmos, the figure becomes a more under- retrobulbar hemorrhage and blindness following treat-
standable 15%. In a comprehensive study of patients ment of zygomatic fractures is 0.3%. Blindness has also
treated for complex orbital fractures, Antonyshyn et al181 been reported in patients following internal orbital
have noted moderate enophthalmos, characterized by reconstruction.186,257-261 These complications are extremely
more than 3 mm of difference in projection from the rare occurrences, but they have devastating consequences.
uninjured globe, in 3 of 49 patients, and severe enoph- There are several causes of reduced vision following
thalmos (more than 4 mm of difference) in 4 patients. trauma or fracture repair. Direct damage to the optic
Thus, 14% of their complex orbital injuries had some nerve from displacement of a fracture segment or from
degree of enophthalmos. a fractured optic canal is rare but possible.4,262-265 Post-
Enophthalmos has been thought to be caused by a mortem investigations, however, have demonstrated that
decrease in volume of the orbital contents, increase in injury to the optic nerve resulting from optic canal frac-
volume of the bony orbit, loss of ligament support, scar tures is rarely the result of osseous compression, lacera-
contracture, or combination of these. The most popular tion of the nerve, or hemorrhage into the nerve itself.
theories of the mechanism of enophthalmos have been More often, hemorrhage into the optic sheath or contu-
bony orbit enlargement and fat atrophy. A study by sion of the nerve results in edema and compression.266,267
Manson et al,67 which evaluated patients demonstrating The injury may lead to secondary compression of the
post-traumatic enophthalmos using quantitative CT, vascular supply to the nerve where the nerve sheath is
found that an increase in bony orbital volume was present fixed to its bony surroundings. Another cause of blind-
in these cases. Others have demonstrated similar find- ness following zygomatic fracture or fracture repair is
ings.66,240 The study by Manson et al, however, did not retrobulbar hemorrhage.
find loss of soft tissue volume within the orbit, which A major question that must be answered when blind-
could signify fat atrophy. It is probably unusual to have ness follows fracture repair is to determine what caused
great losses of orbital soft tissue volume unless infection the blindness—the trauma or the surgery. The answer is
has occurred, producing post-traumatic fibrosis and important from a surgical standpoint and obviously of
atrophy of the periorbital fat. Thus, post-traumatic interest from a medicolegal standpoint. Unfortunately,
enophthalmos is usually caused by an increase in bony one cannot always know the answer. If the patient was
orbital volume (Fig. 16-45; see also Fig. 16-14). Even after blind before surgery, the answer is obvious. However,
restoration of the orbital rims and floor at the time of most cases of blindness associated with zygomatic frac-
surgery, defects located posteriorly along the medial tures have followed surgical intervention. It might there-
and/or lateral walls are common and frequently over- fore be concluded that blindness occurring after surgical
looked, and are probably the main reason for postopera- intervention, which was not present before, is a result of
tive enophthalmos.63,241,242 the surgery. However, there have been reports in which
Enophthalmos is difficult to correct secondarily; blindness occurred days following injury, even when no
however, improvement is possible. The goal of surgery is surgery had been performed.268,269 Spontaneous retrobul-
to reduce orbital volume by reconstructing the internal bar hemorrhage has also been noted following fracture
orbit and, if necessary, placing a space-occupying mate- but before fracture repair.270,271 Thus, if the fracture had
rial behind the globe, thus displacing the globe anteri- been treated, it might have been thought to be respon-
orly (see Fig. 16-45). A space-occupying material placed sible for the blindness. Unfortunately, there is no ideal
in front of the globe worsens the enophthalmos and that method of sorting out these problems.
A B
C D
E
FIGURE 16-45 A, Clinical appearance 9 months after surgical correction of a left ZMC fracture (and facial lacerations). Note 3 to 4 mm of
enophthalmos. B, Coronal CT scan showing large, untreated orbital floor and medial wall fractures. C, Intraoperative photograph of the
left medial orbital wall exposed using the coronal approach. A porous polyethylene sheet was used to cover the entire medial orbital wall
defect. Note that the sheet was stabilized with a bone screw. The sheet extended down to the orbital floor, covering that defect. D,
Intraoperative photograph of the floor of the left orbital floor showing a sheet of polyethylene from the medial wall, covering a defect in
the orbital floor. A second sheet of porous polyethylene was used along the floor and medial wall to occupy a space posterior to the
globe to help correct the enophthalmos. E, Patient 6 months after surgery showing marked improvement, but slight residual
enophthalmos remains.
be the limit for survival and recovery, although Rowe33

RETROBULBAR AND has indicated that 15 to 20 minutes is a more accurate
INTRAORBITAL HEMORRHAGE figure.
Intraorbital and retrobulbar hemorrhage can occur from An ophthalmologist should be summoned immedi-
the traumatic event or the surgery to repair the fractured ately while orbital decompression is instituted. If one has
zygoma. Reduced vision and blindness resulting from placed an antral pack, this should be immediately
orbital hemorrhage have been reported in several cases removed. Orbital decompression can then be performed
of zygomatic fracture and fracture repair.* The cause of by a variety of approaches. If a transantral approach to
the reduced vision and blindness in these cases is unclear, reduce or fix the fractured zygoma has already been
but many have thought that these complications were a used, this approach can be used to decompress the orbit.
result of retinal artery occlusion. The occlusion of the The orbital floor should be carefully but quickly removed
retinal artery may be secondary to direct compression of and the periorbita incised if it has not already been
the artery, sufficient stretching until the artery goes into disrupted. This incision should provide an avenue for
spasm, or both. One explanation for the mechanism the escape of accumulated blood and cause an immedi-
whereby stretching of the retinal artery is possible is that ate increase in orbital volume. Careful and gentle suc-
when hemorrhage into or around the muscle cone tioning by means of thin polyethylene tubing inserted
occurs, the eye protrudes. Because the muscles are fixed into the periorbital tissue may also find pockets of
posteriorly to the tendinous ring, they are stretched hemorrhage.
along with the nerves and vessels of the globe. Another If one has made an incision at the infraorbital rim for
explanation for the reduced vision has been offered by fracture reduction, it should immediately be reopened.
Hayreh,278 who postulated that increased intraocular If no blood is encountered below the periorbita, the
pressure reduces the perfusion of the anterior head of periorbita should be incised if it has not already been
the optic nerve in a progressive manner. Whatever the lacerated from the injury, and blood should be evacu-
mechanism, the increase in intraorbital pressure from ated. Careful blunt dissection through the periorbital
hemorrhage causes changes that can lead to blindness if tissue and dissection through the muscular septum
not halted. between the lateral and inferior rectus muscles allows the
The signs and symptoms of retrobulbar hematoma intramuscular cone to be drained. Aspiration with a short
include a tense proptosis (exophthalmos), periorbital piece of polyethylene tubing may help find areas of
swelling that may be in the process of increasing in size, sequestered blood.33
retroorbital pain, dilation of the pupil, and ophthalmo- If no periorbital incisions were made during fracture
plegia. Hueston and Heinze279 have stated that “retrobul- reduction and/or fixation, a 2-cm inferior lid incision
bar hemorrhage is not an emergency, total blindness is.” should immediately be made. In contrast to the usual
If the process becomes static at this point, and if vision approach to the infraorbital rim, however, incision
and retinal circulation are maintained, observation is through the orbital septum is desirable when one is surgi-
indicated.256,280 Fortunately, the vast majority of retrobul- cally decompressing the orbit. Blunt scissors should be
bar and intraorbital hemorrhages do not progress to inserted within the wound along the inferior aspect of
produce visual impairment281,282 and, when they do, most the orbital floor and spread to evacuate accumulated
produce only transient and/or partial loss of vision.283 blood. Dissection into the muscular cone, as just
Most ophthalmologists do not treat retrobulbar hemor- described, may also be necessary.
rhages or treat them conservatively with the application If any of these measures are not successful, as indi-
of ice, sedatives, bed rest, and/or diuretics, such as intra- cated by the expulsion of fresh hemorrhage and the
venous mannitol. Observation for signs of visual impair- beginning of relief of proptosis, access to the superolat-
ment, however, is warranted. Gradual absorption of the eral aspect of the orbit should be provided. This can be
hemorrhage occurs and full range of motion usually rapidly and safely achieved via an eyebrow approach with
returns in several weeks but cases have been reported in dissection through the periorbita.285,286 Decompression
which blindness occurred days after surgery because of via a lateral canthotomy and small curvilinear incisions
the development of the hematoma.186,276 above and below the lateral canthus have also been
When the point is reached that the optic nerve or advocated.186,287
retinal artery becomes involved, the pupil becomes fixed Decompression of the globe by perforating the ante-
and nonreactive to light. Funduscopic examination may rior chamber of the eye has been suggested to be an
reveal a pale edematous fundus, with blurring of the disc effective treatment for managing retrobulbar hemor-
margins. The classic sign of arterial occlusion or spasm, rhage249,288; however, many surgeons doubt its effective-
the macula appearing as a bright red (cherry red) spot, ness.280,281 In any case, it is not recommended as an
is infrequently observed in reported cases.284 These find- emergency measure by nonophthalmologists.
ings, associated with visual loss, constitute and should be Other measures that should be used in conjunction
considered a medical emergency because permanent loss with the aforementioned are the following: control of the
of vision will occur in several minutes if the orbit is not systemic blood pressure, if high; bed rest; possible use of
immediately decompressed. Hueston and Heinze279 have diuretics (e.g., IV mannitol, 200 mL of a 20% solution;
claimed that survival of the optic nerve head is at stake 500 mg of acetazolamide [Diamox] IV); and high doses
in this situation and 60 minutes of ischemia appears to of systemic steroids (e.g., dexamethasone, 3 mg/kg ini-
tially and then 2 mg/kg every 6 hours). Ophthalmologic
*
References 6, 256, 265, 270, and 272-277. follow-up is mandatory.
eyebrow, inferior lid, and intraoral. Another approach

MALUNION OF THE ZYGOMA that greatly facilitates zygomatic osteotomy is the coronal
Malunion of the zygoma can be the result of improper approach used in conjunction with subciliary and intra-
reduction, improper fixation, or nonintervention when oral approaches (see earlier, “Coronal Approach”). With
surgery was indicated. The last situation happens occa- this approach, the zygoma can be totally freed from all
sionally when the patient’s medical condition precludes external soft tissue attachments, facilitating osteotomy
early operative intervention, treatment is not sought by and repositioning. Although there may be concern that
the patient, or the patient declines surgery until later. the zygoma will resorb or become infected after extensive
The signs and symptoms are the same as those seen in a stripping of soft tissue, this is a rare occurrence in cranio-
patient with a fresh zygomatic fracture, including flatten- facial surgery, in which large segments of osseous tissue
ing of the malar prominence, enophthalmos, altered are completely stripped from their soft tissue attach-
pupillary level, and limitation of mandibular motion. ments and replanted.289 If the old fracture site is visible, it
When confronted with this problem, one has two can be used as the line of osteotomy. However, the frac-
treatment alternatives—camouflaging the defect with an ture along the orbital floor should be used only if it does
implant or transplant or repositioning the malpositioned not extend too far posteriorly toward the orbital apex. A
bone. The advantages and disadvantages of a malar sharp osteotome, thin bur, or saw can be used to perform
implant or transplant and osteotomy should be under- the necessary bony incisions. Care is taken to protect the
stood. In cases of malunion, when minor deformity is infraorbital neurovascular bundle within its groove along
present and limited to flattening of the malar eminence, the orbital floor and at its exit from the infraorbital
with little orbital involvement, a subperiosteal implant or foramen on the anterior surface of the maxilla. Care is
transplant can be inserted to restore normal facial form. also taken to protect the orbital contents.
Another situation in which an implant or transplant is The most difficult osteotomy to make is that extend-
useful is when the zygoma is so comminuted that it ing from the inferior orbital fissure, along the temporal
cannot be mobilized and repositioned in one piece. surface of the maxilla to the zygomatic buttress area of
Many implant or transplant techniques and materials are the maxilla. This osteotomy is greatly facilitated by the
available for this purpose. There are advantages and disuse of the hemicoronal flap, which permits access to this
advantages to the use of any material, and several have difficult area. A sharp osteotome can be easily inserted
been used for malar augmentation. Bone has been less from the temporal approach into the inferior orbital
frequently used than alloplastics because of the difficulty fissure and can be used to create a fracture down the
in contouring bone and the unpredictable amounts of infratemporal aspect of the maxilla. The osteotomy along
resorption that may occur. Most surgeons use silicone or the anterior maxillary wall can be extended inferolater-
porous polyethylene implants in a subperiosteal location. ally until it meets the posterior osteotomy at the zygo-
The implant techniques described are beyond the scope matic buttress of the maxilla. Some also use an intraoral
of this chapter. If necessary, a coronoidectomy can be approach in the maxillary vestibule to help complete this
performed, along with implantation to improve the osteotomy. This is a helpful optional incision because it
range of mandibular motion. may be necessary to place bone grafts into the zygomatic
When concomitant functional deficits are present buttress area, especially if nonrigid forms of fixation are
along with cosmetic deformity, zygomatic osteotomy applied along the orbital rims. Before mobilization, the
should be considered because it will correct both prob- zygomatic osteotomies should be carefully checked to
lems simultaneously. If zygomatic refracture or osteot- verify that all osseous incisions have been completed. If
omy is selected as the appropriate treatment modality, mobilization is attempted while some bony areas are still
preoperative CT is warranted. The areas of fracture, posi- intact, aberrant fractures may occur.
tion of the globe, orbital volume and shape, and defects After the zygoma has been mobilized, it is reposi-
in the orbital floor or walls should be thoroughly inves- tioned. If the malunion was long-standing, it may be
tigated. Restoring a severely malpositioned zygoma to its necessary to excise bone in some areas in which callus
proper position following malunion and simultaneously and new bone have formed to permit proper reduction.
correcting existing orbital defects is a difficult and chal- The lateral orbital rim may need to have some bone
lenging undertaking. The ZMC must usually be refrac- subtracted for proper repositioning; however, this is not
tured or, more appropriately, osteotomized to allow always the case. The most accurate method of reposition-
repositioning. Fixation is always necessary, and restora- ing involves the use of intraoperative navigation to help
tion of normal globe position may require internal the surgeon place the zygoma into the most symmetrical
orbital reconstruction of the bony orbit. Several tech- location, as determined by preoperative computer plan-
niques for zygomatic osteotomy have been used in the ning. The zygoma is best stabilized with bone plates at
past and all can produce good results with proper atten- the frontozygomatic and possibly infraorbital areas. If
tion to detail. However, preoperative planning and intra- necessary, bone grafts are inserted into bony voids (Fig.
operative repositioning are the most important steps. 16-46). The internal orbit is reconstructed as described
Software for computer planning and intraoperative earlier, with care being taken to correct defects in the
navigation have greatly improved outcomes for such lateral wall of the orbit. When the zygoma has been com-
malunions. minuted by trauma, it may be necessary to onlay graft or
Various soft tissue access incisions allow visualization implant over the malar prominence to reestablish normal
of the osseous anatomy for osteotomy. Some surgeons contour. The zygomatic arch can be reconstructed with
refracture the ZMC using standard incisions, such as the a strip of cranial bone or rib.
FIGURE 16-46 Osteotomy to reposition the

malaligned ZMC. In most cases, the old
fracture site is visible and may serve as the
osteotomy site. Left, Note the medial Graft
rotation of the right zygomaticomaxillary
buttress into the maxillary sinus. Right,
Following repositioning and stabilization, it is
usually necessary to bone-graft the area of
the zygomatic buttress of the maxilla to
rotate the body of the zygoma outward and
upward. Internal orbital reconstruction may
also be necessary.
17. Schultz RC: Facial injuries, Chicago, 1977, Year Book.

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5. Schuchardt K, Schwenzer N, Rottke B, Lentrodt J: [Causes, fre- 23. Adekeye EO: Fracture of the zygomatic complex in Nigerian
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Gesichtschir 11:1, 1966. 24. Foo GC: Fractures of the zygomatic-malar complex: A retrospec-
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CHAPTER
Diagnosis and Treatment of
17 Midface Fractures
Christopher D. Morris
| Paul S. Tiwana
OUTLINE
Le Fort Classifications Malunion of Midface Fractures
Emergency Care Treatment
Facial Examination Orbital Wall Fractures
Le Fort Type I Fractures Blowout Fractures
Anatomic Considerations of Fractures of the Maxilla Medial Wall Fractures
Treatment of Unilateral Maxillary Fractures Blow-In Fractures
Treatment of Le Fort Type I Fractures Complications After Treatment of Midface Fractures
Le Fort Type II (Pyramidal) Fractures Bleeding
Treatment Cerebrospinal Fluid Rhinorrhea and Otorrhea
Palatal Fractures Ocular Complications
Classification Neurologic Complications
Treatment Lacrimal System
Naso-Orbital-Ethmoid Injuries Anatomy
Anatomy Evaluation
Diagnosis Dacryocystorhinostomy
Physical Examination Emerging Surgical Techniques and Materials
Classification Endoscopic Management of Midface Fractures
Treatment Advances in Computer-Based Imaging Techniques
Le Fort Type III Fractures
Treatment
Complications
T
he midface is important functionally and cosmeti- complex when assaulted from a frontal direction. He
cally. It serves an important role in vocal reso- defined the three most common “linea minoros resisten-
nance within the sinuses of the facial bones as well tiae,” which are classified as the Le Fort I, Le Fort II, and
as in the function of the ocular, olfactory, respiratory, and Le Fort III fractures. These fracture patterns are charac-
digestive systems. The face is also fundamental to inter- teristic of a unidirectional, low-energy injury rather than
personal recognition and the perception of self-image. the multivector, high-energy mechanisms commonly
The midfacial complex is constructed of a series of observed today. However, this system is popular because
vertical pillars that primarily provide protection from it provides a simple, anatomically differentiated system
vertically directed forces. These include the nasomaxil- for the general classification of midfacial injuries.5
lary (nasofrontal), zygomaticomaxillary, and pterygo- The Le Fort type I fracture pattern results from a force
maxillary buttress.1 These vertical pillars are further directed above the maxillary teeth, resulting in a floating
supported by the horizontal buttresses—the supraorbital palate (Fig. 17-1). The Le Fort type II fracture pattern
or frontal bar, infraorbital rims, and zygomatic arches.2,3 results from a force delivered at the level of the nasal
Contrary to claims of a lack of sagittal buttresses, the bone, resulting in mobility of the midface through the
midface does have support, however weak, from the max- orbits and midfacial region (Fig. 17-2). The Le Fort type
illary walls, lateral nasal wall, and nasal septum. Clearly, III fracture pattern results from a force directed at the
these weaker buttresses of the midface tolerate frontal or orbital level, resulting in a craniofacial dysjunction or
laterally directed forces poorly.4 Behind this buttress separation of the entire middle third of the craniomaxil-
system sits the medial and lateral pterygoid plates inferi- lofacial skeleton from the skull base (Fig. 17-3).
orly and the skull base superiorly. This framework results
in a few anatomic sites of weakness, resulting in fairly EMERGENCY CARE
predictable patterns of fracture.
Initial evaluation of the severely injured midface can be
LE FORT CLASSIFICATIONS an intimidating experience (Fig. 17-4). Emergency care
should be immediately initiated, applying the principles
Rene Le Fort’s cadaver studies in the early twentieth of Advanced Trauma Life Support (ATLS). When dealing
century defined the three weakest levels of the midfacial with midfacial injuries in the emergency setting, certain
416
Diagnosis and Treatment of Midface Fractures CHAPTER 17 417
FIGURE 17-1 Le Fort I fracture.
FIGURE 17-4 Compound comminuted midfacial fractures.
FIGURE 17-2 Le Fort II fracture.
FIGURE 17-5 Axial CT reconstruction demonstrating panfacial

fracture.
and mild Trendelenburg position to allow optimal drain-

age. If oral or nasal bleeding is encountered, these sites
FIGURE 17-3 Le Fort III fracture. should be packed.6 If bleeding is uncontrollable, a defini-
tive airway should be established immediately.
components of the examination and treatment deserve Any patient with facial trauma is presumed to have a
special attention (Fig. 17-5). cervical spine injury and should be stabilized with a rigid
The airway is immediately evaluated for obstruction. collar until ruled out by appropriate examination. Any
The oral cavity may be full of secretions or debris, which motion of the head can be lethal because of bone frag-
may contribute to supraglottic obstruction and aspira- ment impingement or laceration of the spinal cord. The
tion. The oropharynx must be manually cleared of any presence of cervical spine injuries have been reported as
fractured teeth, dentures, and/or blood clots. If stable, 1.0% to 1.8% to as many as 9.6% of patients with facial
the patient may be placed in a lateral decubitus position fractures.7-9
The safety of orotracheal intubation by various tech-

niques in patients with cervical spine injuries has been
shown to be safe if precise in-line immobilization is
provided.10 A cricothyroidotomy is also an appropriate
option for establishing an emergency definitive airway in
this setting.11 If nonurgent airway control is needed in
the setting of cervical spine fracture, an awake fiberoptic
intubation is likely the safest option because no atlanto-
occipital extension is required with this technique.12
A lower airway obstruction, such as laryngeal or tra-
cheal fracture, requires an emergency tracheostomy.
Also, if reconstructive procedures of the midfacial inju-
ries will be limited by the presence of an endotracheal
tube, a tracheotomy is also indicated.
After definitive airway control is obtained, the ATLS
protocol may continue. In regard to midfacial fractures,
it is uncommon for hemorrhage from this region alone
to result in hemodynamic instability. However, it is impor-
tant to be cognizant of blood loss, especially if multiple
large vessels are violated, large grossly open wounds are
present, or continuous blood loss continues from this
highly vascular region. As noted, packing of the cavities
or wounds with selected clamping of blood vessels is
usually effective immediately.
FIGURE 17-6 Extensive facial edema and periorbital ecchymosis.
FACIAL EXAMINATION
After initial stabilization, a complete facial examination
is performed. This requires clinical and radiographic
components;, however, the radiographic examination
may be delayed until the patient’s condition is fully
stabilized.
The face is systematically evaluated for the presence
of any lacerations or obvious deformities of the skull
and asymmetries are noted. Otorrhea or rhinorrhea is
assumed to be cerebrospinal fluid (CSF) until proved
otherwise. No packing of the ear or nose should be per-
formed if a CSF leak is suspected. This practice is poten-
tially helpful for initially preventing a retrograde infection
that might result in meningitis.
The craniomaxillofacial skeleton is palpated bimanu-
ally in a systematic manner and any discontinuity or
irregularity is noted. The frontal area and supraorbital
rim is examined first, with a logical progression down- FIGURE 17-7 Subconjunctival ecchymosis with no lateral limit
ward, including the lateral and infraorbital rims, although should instill a high index of suspicion for osseous orbital
extensive edema in this area may make the examination fractures.
difficult.
Periorbital edema and ecchymosis are often initial
signs of orbital trauma (Fig. 17-6). The globe may pro- oculi muscle is closed with 5-0 resorbable suture; the skin
trude because of gross edema, making a complete exami- is closed with a 6-0 nonresorbable suture. Exact approxi-
nation difficult. Visual acuity is grossly examined and mation of the gray line of the lid margins is obtained with
extraocular muscle function evaluated. The presence 6-0 resorbable suture (Fig. 17-7).
and direction of diplopia or strabismus are noted. Pupil Ocular injury is present in most midfacial fractures
size, shape, and reaction to light are recorded. The loca- and is common in midfacial trauma. Al-Qurainy et al, in
tion and extent of subconjunctival hemorrhage are also a prospective study on orbital injury with midfacial frac-
recorded. A fundoscopic examination is carried out to tures of any type, have reported that 90% of patients had
evaluate for intraocular hemorrhage. If lid lacerations an ocular injury to some degree, 16% had moderate
are present, they should be closed promptly to prevent ocular injuries, and 12% had severe injuries. Almost 15%
contracture. A through and through laceration requires of patients had a decrease in vision.13 In patients with
a three-layer closure. A 6-0 plain absorbing suture may naso-orbital-ethmoid fractures, ocular injury and subse-
be used on the conjunctiva, with care to prevent protrud- quent loss of vision were reported in 30% of patients.14
ing knots that may injure the cornea. The orbicularis Isolated orbital wall fractures have also been reported to
present with an almost 30% incidence of ophthalmic substantial midface injury, earlier rather than later repair
complications.15 Current evidence supports the practice significantly enhances outcome.
that facial fractures involving the orbit should be referred The maxilla, palatine bone, and nasal bones form the
for ophthalmologic evaluation.13-18 bulk of the midface. The maxillary bones are integral in
Crepitation to palpation is indicative of orbital emphy- the formation of the three major cavities of the face—the
sema. This examination finding is most commonly upper part of the oral cavity and the nasal and orbital
observed when injuries result in communication with the fossa. The maxillary sinus, which is small at birth, expands
ethmoidal or maxillary sinuses and requires no treat- inferiorly within the maxilla with maturity until it forms
ment. The patient should, however, be instructed to not the major bulk of the midface. This factor adds to the
blow his or her nose to prevent expanding subcutaneous distinct weakness of the region. Because of the many
emphysema. The attachment of the medial canthal liga- articulations between the surrounding bones, it is diffi-
ment is evaluated by palpating the insertion of the medial cult at times to categorize fractures patterns. However,
canthal ligament for crepitus or instability and by lateral the classic Le Fort I and II classifications of midfacial
traction on the lateral canthus. Bimanual examination fractures will be discussed here and the Le Fort type III
may also be performed by application of a Kelly clamp and naso-orbital-ethmoid (NOE) fracture patterns will
intranasally and a finger on the central fragment; this is be discussed separately (Fig. 17-8).
followed by an attempt at lateral displacement of the
central fragment.19 Physical findings of medial canthal LE FORT TYPE I FRACTURES
ligament disruption include rounding of the lacrimal
lake, epiphora, and increased intercanthal distance. Le Fort type I fractures are caused by a force delivered
The zygomatic arches, nasal bones, maxilla, and man- above the apices of the teeth. The fracture occurs at the
dible are then sequentially evaluated. Mobility of the level of the piriform aperture and involves the anterior
maxilla is assessed by firmly grasping the premaxilla and and lateral walls of the maxillary sinus, lateral nasal walls
attempting to displace it in three dimensions. Ecchy- and, by definition, pterygoid plates. The nasal septum
motic areas, especially of the palate, are common find- may also be fractured and the nasal cartilage may be
ings with fractures of the maxilla. The pharynx is buckled. Sagittal fracture(s) of the palate may also be
examined for lacerations or retropharyngeal bleeding. If present. The pull of the medial and lateral pterygoid
responsive, the patient should also be questioned about muscles may contribute to displacement of the fractured
any salty, metallic-tasting discharge, which is an indica- segment in a posterior and inferior direction, resulting
tion of CSF drainage. in an open bite deformity. This fracture may present
The mandibular opening is evaluated for fracture or as an impacted, immovable, or free-floating maxillary
displacement of the zygoma, which may obstruct the segment.
forward movement of the coronoid process. The buccal Le Fort I injuries, on initial examination, may not be
vestibule is palpated with the index finger and crepita- clearly evident. Examination should include firmly grasp-
tion or displacement of the lateral antral wall; zygoma ing the maxillary arch with the finger and thumb facially
can be easily appreciated by this maneuver. The occlu- and palatally and attempting displacement of the maxilla
sion and quality of the dentition are recorded, because in three dimensions, as well as compression and expan-
these factors may significantly influence in the method sion of the maxillary arch. Malocclusion and mobility
of treatment. may be noted. Hypoesthesia of the infraorbital nerve may
Once the patient is sufficiently stabilized, radiographic be caused by the rapid development of edema. A unilat-
evaluation may proceed. The preferred radiologic modal- eral maxillary fracture may also occur, with the fracture
ity for midfacial injuries is a maxillofacial computed coursing through the palatal suture line or adjacent to
tomography scan (CT).20-22 A maxillofacial CT scan will it. Palatal ecchymosis is usually noted and may present in
provide 2- to 3-mm axial cuts with coronal reformatting. conjunction with a malocclusion or displacement of the
If desired, sagittal or three-dimensional formatting may fractured fragment.
also be provided. The CT scan allows evaluation of bone,
providing detailed information about fracture patterns. ANATOMIC CONSIDERATIONS OF FRACTURES OF
CT scans also provide characterization of soft tissues, THE MAXILLA
including the extent of edema, presence of foreign The internal and external pterygoid muscles together
bodies, formation of a retrobulbar hematoma, or entrap- have been suspected as being responsible for the poste-
ment of the extraocular musculature. Plain films, rior and inferior pull seen in fractures of the maxilla.
although necessary in the absence of CT scanning, However, unlike the mandible, the midface is more subject
provide little diagnostic information. The plain films to traumatic rather than muscular displacement.
obtained in the history include the Water’s, submento- The blood supply to the maxilla is via the internal
vertex, anteroposterior, and lateral skull views. maxillary arteries. Together with the superior and poste-
As a general principle, early management of these rior alveolar arteries, they supply the hard and soft
fractures is preferable following stabilization of the palates. Anteriorly, the nasopalatine artery reaches the
patient’s condition and diagnosis of midfacial fractures. incisive foramen and supplies the mucoperiosteum of
After 7 to 10 days, it may become more difficult to mobi- the anterior palate.
lize the maxilla and achieve an ideal reduction, particu- Neurosensory supply is via the second division of the
larly in patients in whom there is impaction of the trigeminal nerve. This nerve exits the infraorbital
fractured segment. In our opinion, in the patient with foramen and supplies the lateral nasal, superior labial,
A B
C
FIGURE 17-8 CT scans in the appropriate view can stand alone as a diagnostic radiographic tool. A, Coronal. B, Axial.
C, Three-dimensional.
and inferior palpebral regions, as well as the labial impressions are taken of the maxillary and mandibular
mucosa and anterior teeth. arches and the correct occlusal relationships are reestab-
lished on study models. An interocclusal splint is then
TREATMENT OF UNILATERAL constructed. Arch bars may be placed before or after
MAXILLARY FRACTURES placement of the interocclusal splint, depending on the
The fractured segment is reduced by digital pressure and mobility of the maxillary segments. The maxillary arch
a maxillary arch bar is applied loosely to the teeth in the bar is secured by interdental fixation and the interocclu-
mobile segment and firmly to the stable dentition in the sal splint is secured to the maxillary arch bar. The man-
unfractured maxillary segment. MMF is then applied dible is then passively guided into the interocclusal splint.
between the maxillary and mandibular arch bars and the MMF may be used to stabilize the maxillary fragments
reestablished pretraumatic occlusion is used to reduce during open reduction and internal fixation (ORIF), or
the mobile maxillary segment. Open reduction and may be used as a method of fixation if ORIF is not
internal fixation by miniplates are completed through a desired, but will require a 3- to 4-week period of MMF.
vestibular incision and MMF is removed. The patient is Impacted maxillary fractures may be impossible to
kept on a soft diet for 2 to 3 weeks while the fractures mobilize with digital manipulation alone. A disimpaction
heal. MMF may also be left in place if there is concern forceps may be used in this situation for reduction of the
for patient compliance. impacted maxillary segment. Teeth in the line of fracture
An occlusal splint is an excellent option for accurate should be left in place unless excessively mobile or hope-
reduction of the fractured maxillary segment. Alginate lessly nonrestorable.
The patient is first placed in MMF to reestablish the

TREATMENT OF LE FORT TYPE I FRACTURES pretraumatic occlusal relationship. The maxillomandib-
Early reduction of Le Fort type I injuries presents minimal ular complex can then be oriented in three dimensions
difficulty but, beyond 7 to 10 days, increasing amounts as a unit, with special attention to the position of the
of force are required because of the natural healing condyles. Ensuring that the condyles are seated properly
process. ORIF with restoration of facial contour is the in the glenoid fossa will limit subsequent development of
preferred method of treatment. MMF is also an accept- an open bite. Stabilization of a fracture must prevent
able, although less optimal, method of treatment. This translational and rotational motions in the x, y, and
requires a treatment period of approximately 6 weeks, z axes.23 Four-point fixation along the pyriform and
depending on the level of comminution. zygomaticomaxillary buttresses is routinely provided
Incisions for the open reduction are made in the for stability of this fracture pattern. Occlusion should be
buccal vestibule in a circumvestibular fashion, from the immediately rechecked following release of MMF (Fig.
first premolar to the first premolar on the opposite side. 17-11).
Wide buccal pedicles of the U-shaped incision are
retained for maintenance of the vascular supply. This
approach allows visualization of the lateral antral wall
and zygomatic buttresses. A Rowe or Hayton-Williams
forceps can then be used to complete the reduction, if
necessary (Figs. 17-9 and 17-10).
The advent of plate and screw fixation has transformed
craniomaxillofacial fracture repair from obligatory long-
term MMF and craniofacial suspension to rigid stabiliza-
tion. Rigid stabilization provides an opportunity for
primary bone healing and allows earlier function and
optimized nutrition.
FIGURE 17-10 Positioning of the Hayton-Williams forceps when

attempting to reduce a fractured maxilla.
FIGURE 17-9 A Rowe disimpaction forceps is used when FIGURE 17-11 Four-point fixation—stabilization of the midfacial
attempting to reduce a displaced maxilla. buttresses.
lymphedema. More than 90% of the lymphatic drainage

from the scalp, forehead, and upper lid passes lateral to
the orbit.
Subciliary or Lower Blepharoplasty Incision
The subciliary or lower blepharoplasty incision is made
2 to 3 mm inferior to the gray line of the lower eyelid.
The incision runs parallel to and along the length of the
lower eyelid margin. The traditional method of pre–
orbicularis oculi incision has fallen out of favor because
of high rates of ectropion development, 38% to 42%
temporary and 8% permanent.26 The post–orbicularis
oculi dissection, or skin-muscle flap, is when the incision
is made through both skin and muscle and dissection
occurs superficial to septum. This modification has
FIGURE 17-12 Le Fort II fracture. become popular because of ease of use and has been
shown to have a lower rate of early ectropion, 6% in one
study, with resolution typically within weeks.27
LE FORT TYPE II (PYRAMIDAL) FRACTURES Subtarsal or Mid–Lower Lid Incision
The Le Fort type II fracture pattern is also referred to as The incision is made 3 to 4 mm below the gray line. Dis-
a pyramidal fracture; the apex of the pyramid is the section is the same as the subciliary. Use of this incision
nasofrontal suture (Fig. 17-12). This fracture pattern has been suggested to limit lower lid distortion and
involves the nasofrontal suture, nasal and lacrimal bones, ectropion.
infraorbital rim in the region of the zygomaticomaxillary
suture, maxilla, and pterygoid plates. This fracture is Transconjunctival Incision
typically higher than the Le Fort type I fracture posteri- The transconjunctival approach was popularized by
orly. As with the Le Fort type I pattern, the nasal septum Tessier in 1973.28 This approach is made through the
may also be involved. conjunctiva parallel to the gray line and can be made
The physical examination is likely to reveal noticeable anterior or posterior to the septum.29 The incision can
signs of injury. Edema is often present overlying the frac- also be extended laterally by lateral canthotomy and infe-
ture sites. The classic raccoon sign caused by bilateral rior cantholysis and medially by a transcaruncular inci-
periorbital edema and ecchymosis may be noted. CSF sion to allow excellent access to the orbit (Fig. 17-13).
rhinorrhea may be encountered as the result of a dural Access should be carefully planned on an individual-
tear. Epistaxis is common. Hypoesthesia of the infraor- ized basis. Depending on the situation, various approaches
bital nerve is also common because of direct trauma or are available and lacerations may be used. When multiple
rapid edema formation. Malocclusion is often present in sites are affected, a coronal incision provides excellent
the form of an anterior open bite. Grasping the anterior exposure as well as access to cranial bone for bone
maxilla and attempting anteroposterior displacement grafting.
facilitates evaluation of the nasofrontal suture and infe-
rior orbital rims. PALATAL FRACTURES
TREATMENT Isolated fractures of the palate are rare, but up to 8% to
ORIF is advantageous for treatment of these fractures. If 13% of Le Fort fractures are complicated by concomitant
the nasofrontal suture area is intact and continuous with palatal fractures.30,31 Most patients will also have notable
the maxillary segment, bilateral intraoral exposure allows signs and symptoms of palatal fracture. Indications of
appropriate four-point fixation. However, the orbital palatal fracture on clinical examination include lace
floor, inferior orbital rim, or nasofrontal region often ration of the lip and concurrent gingival and palatal
requires exploration and repair. In these situations, addi- lacerations. Often, a change in occlusion is also noted
tional access is required. The basic incisions are the with the maxillary segment displaced anterolaterally.3
infraorbital, subciliary, middle to lower lid, and transcon- Diagnosis is confirmed by a maxillofacial CT with axial
junctival incisions. These methods of access will be briefly and coronal cuts.
discussed.
CLASSIFICATION
Infraorbital Incision Several classification systems have been suggested30,31 for
The infraorbital incision, first described by Converse palatal fractures. Hendrickson et al30 have described six
et al in 1944,24,25 is made transcutaneously over the infra- patterns based on the anatomic location of fracture (Fig.
orbital rim in the natural crease, 4.5 mm inferior to the 17-14; Box 17-1).
gray line. Advantages include excellent access to the
floor and surrounding areas and ease of use. Disadvan- Treatment
tages are potential poor healing, cicatricial distortion Surgical treatment planning depends on the type of
of the lower lid, and potential for development of fracture, presence or quality of the dentition, and
Subciliary incision Transconjunctival
approach
Midlid incision
Infraorbital incision
FIGURE 17-13 Various approaches to the orbit—subciliary, midlid, transconjunctival, and open sky, or use of existing laceration.
A B C
D E F
G
FIGURE 17-14 Hendrickson palatal classification system based on anatomic location of fracture.
BOX 17-1 Palatal Fracture Classifications
Type I: Alveolar fracture

Type Ia: Anterior alveolus; contains only incisor teeth and
associated alveolus
Type Ib: Posterolateral; contains premolars, molars, and asso-
ciated alveolus
Type II: Sagittal fracture, a split of the palatal midline; typically
occurs in second or third decade because of a lack of
ossification of the midline palatal suture
Type III: Parasagittal fracture; most common fracture pattern
in adults (63%) because of thin bone parasagittally; fracture
pattern differs from type Ia fracture by inclusion of maxillary
canine
Type IV: Para-alveolar fracture; occurs palatal to the maxillary
alveolus and incisors FIGURE 17-15 Traumatic telecanthus following NOE injury showing
Type V: Complex comminuted fracture; multiple fractured measurement of intercanthal and interpupillary width.
segments
Type VI: Transverse fracture, rare; involves a division in the
coronal plane
treatment of the palatal fracture to proceed with the
appropriate occlusal template.
An indication for the use of rigid fixation for sagittal
palatal fractures in the edentulous or near-edentulous
concomitant facial fractures. Treatment incorporates the patient exists if the patient does not have preexisting
possible application of rigid internal fixation, arch bars, dentures or no preoperative Gunning-type splint was fab-
and palatal acrylic splints, depending on the clinical ricated. In these rare patients, special care must be taken
situation.3,30-33 to reduce the fractures as anatomically as possible from
Although there has been much discussion on the use the facial vestibular approach. Additional stabilization of
of rigid fixation in palatal vault fractures, it is seldom the palate can then be gained from transmucosal locking
clinically indicated. The first problem with this technique plate and screw fixation, as described by Pollock, which
originates with the placement of transoral plates and attempts to preserve the critical vascular supply.35
screws to the palatal vault. This practice requires the
mouth to be open and thereby excludes the application NASO-ORBITAL-ETHMOID INJURIES
of ORIF and occlusal stabilization. This lack of occlusal
control leads almost inescapably to error in the appropri- The naso-orbital-ethmoid (NOE) injury, often referred
ate reduction of maxillary width and height. The second to as an NOE fracture, represents a significant diagnostic
consideration is vascularization of the maxilla. Although and reconstructive challenge.36,37 This region houses the
techniques for making longitudinal palatal incisions are lacrimal apparatus, medial canthal ligament, and ante-
often described, vascular studies of the Le Fort I segment rior ethmoidal artery. CSF rhinorrhea is common follow-
following osteotomy have shown that the blood flow in ing NOE fractures.38 In one series, Cruse et al have
the severely fractured or osteotomized maxilla is depen- reported that central nervous injuries are present in 51%
dent on the ascending pharyngeal and palatal mucosal of cases and 42% have CSF drainage14 (Fig. 17-15).
blood supply.34 Because management of midfacial injury Assessment of these injuries requires close attention
often require an anterior vestibular incision, if treated to the soft tissue and osseous structures and an accom-
open, any palatal flap raised under these circumstances panying CT scan, with both coronal and axial views.39
must be approached with caution. Physical examination is likely to demonstrate a severely
Treatment of the palatal fracture in dentate patients fractured nose, often with comminution and posterior
should center on occlusal reduction with MMF and a displacement. The nasal bridge is widened and the nasal
facial vestibular approach. Incorporation of occlusal complex splayed. Epistaxis is common. Traumatic tele-
splints can be extremely helpful in the comminuted canthus (see Fig. 17-15) may occur because of disruption
palatal fracture and requires preoperative dental models of the medial canthal ligament. The average intercanthal
to fabricate. The use of a palatal splint should be distance for a white adult is 28 to 35 mm, which is
approached with caution. As noted, care must be taken approximately half of the interpupillary distance. Halving
to ensure that the palatal vascular supply is not compro- the interpupillary distance is a useful tool on the prelimi-
mised. In addition, postoperative surveillance of the nary physical examination because severe periorbital
palate for healing, fistula development, or necrosis of edema is preset in most cases. Traumatic telecanthus is
segments becomes more difficult because direct inspec- suspected when the intercanthal distance is greater than
tion of the palatal vault is obscured by the splint. If a 35 mm; a measurement more that 40 mm is diagnostic
concomitant mandibular fracture exists, open reduction for this type of injury.40 Epiphora following trauma to this
and anatomic fixation of this injury first will allow the area is likely the result of damage to the
lacrimal bone and frontal process of the maxilla medi-

ally. The ethmoid sinuses, located centrally and poste-
rior to the nasal complex, are also vulnerable to injury.
Because of the proximity of the ethmoid sinuses to the
cribriform plate, the collapse and posterior displace-
ment of these structures may result in intracranial
involvement and potential for CSF rhinorrhea, pneumo-
cephalus, and olfactory dysfunction. Fractures of the
frontal sinus are also common because the floor of the
frontal sinus is a component of the medial orbital roof.
Ductal drainage leaves the frontal sinus inferoposteri-
orly, travels through the ethmoid bone, and exits at the
middle meatus of the nose. Complications because of
disruption of this system may be noted following NOE
fractures.
The medial canthal tendon is a fibrous extension of
the tarsal plates. It divides into two limbs, anterior and
posterior. The anterior limb is larger and stronger,
attaches to the frontal process of the maxilla, and func-
tionally pulls the medial commissure of the eyelid forward
FIGURE 17-16 The central nasoethmoid complex is highlighted for and down.50 The posterior or deep limb is comparatively
identification.
thinner, inserts into the posterior lacrimal crest of the
lacrimal bone, and functions to maintain the eyelid’s
position in relation to the globe. The posterior limb is
also intimately associated with Horner’s muscle, which is
lacrimal apparatus. Narrowing of the palpebral fissure, responsible for the flow of tears through the lacrimal sac.
obliteration of the caruncle, and flatting of the base of A superior limb develops from an extension of fibers
the naso-orbital valley are more likely to be noted follow- from the anterior and posterior limbs, which serves to
ing the resolution of edema. encompass the lacrimal sac and functions to add the
NOE fracture repair requires a broad knowledge of posterior and superior vector of the medial canthal
anatomy and should be based on anatomic reconstruc- tendon. The normal anatomic position of the medial
tion; the repair should be done early, when possible. canthal tendon is responsible for medial eyelid function,
Inadequate reconstruction or delay in treatment may position, appearance, and lacrimal drainage. The degree
result in a multitude of suboptimal results, generally of displacement varies significantly; the method of repair
including midface retrusion, blunted palpebral fissures, depends on whether an injury results in complete avul-
ocular complications, nasal deformities, and cerebrospi- sion or continued attachment to variously sized bony
nal fistula formation.14,41-44 fragments. In any situation, precise reconstruction of the
These injuries may occur with other midfacial frac- osseous components and medial reattachment or stabili-
tures, may be isolated or bilateral, and may have different zation of the medial canthal tendon are required to
patterns on either side of the midline, depending on the prevent telecanthus, enophthalmos, and dysfunction of
mechanism and velocity of impact.40,44-49 Repair of these the lacrimal system. When this condition is improperly
fractures requires surgical approaches that provide wide managed on initial reconstruction, the ensuing defor-
exposure and allow an anatomic repair. Attention to the mity can be debilitating and extremely difficult to manage
anatomy of this region, in particular the intercanthal secondarily.
distance, is essential to a satisfactory outcome.
DIAGNOSIS
ANATOMY Assessment of these injuries requires close attention to
The NOE region is made up of the cranium, nose, orbit, the soft tissue and osseous structures. An accompanying
and maxilla (Fig. 17-16). The frontomaxillary buttress CT scan should be obtained, with both coronal and axial
provides structural support to this region and serves as views.39
the stabilization point for reconstruction. The associated
lateral buttresses are the frontal bar superiorly and the PHYSICAL EXAMINATION
zygoma and inferior orbital rims inferiorly. The medial A thorough visual inspection is followed by manual pal-
portion of the buttress contains the perpendicular plate pation of the supraorbital rims, nasofrontal junctions,
of the ethmoid, lacrimal ones, and lamina papyracea. lateral nasal complex, inferior orbital rims, and nasal
These bones are thin, fragile, and form a so-called complex as a unit. Mobilization of the nasal complex and
crumple zone that is predisposed to medially displaced its relationship to the nasofrontal junction are examined.
comminuted fractures46 Reconstruction of the bony Mobilization of the nasal complex in three dimensions is
architecture is necessary in this area to control orbital attempted to determine mobility, possible osseous impac-
volume. tion, and the extent of the fracture.
The nasal bones are anterior to the medial orbit and The attachment of the medial canthal ligament is
connect to the frontal bone superolaterally and the evaluated by palpating the insertion of the medial canthal
ligament for crepitus or instability and by lateral traction Type II

on the lateral canthus, with evaluation of the medial Type II NOE fractures may occur in a bilateral or unilat-
canthal attachment. Bimanual examination may also be eral form and may be large segments or comminuted.
performed by application of a Kelly clamp intranasally Most commonly the canthus remains attached to a large
and a finger placed externally on the central fragment; central segment. Reduction is usually best accomplished
lateral displacement is then attempted.19 Indications of by control of the specific segment of bone that is associ-
medial canthal ligament disruption include rounding of ated with the canthal tendon (see Fig. 17-17B).
the lacrimal lake, epiphora, and increased intercanthal
distance. Type III
Measurement of the intercanthal and interpupillary This fracture includes comminution involving the central
distance is also completed at this time and compared fragment of bone where the medial canthal tendon
with normal individuals of white, black, and Asian ethnic- attaches. The canthus is rarely avulsed completely but,
ity to determine whether displacement is present and if on occasion, the fragments of bone are so small that
it is unilateral or bilateral. Another excellent method of reconstruction is not possible. In this circumstance,
determining pretraumatic intercanthal width is to obtain transnasal wiring of the canthus is required, as is osseous
preinjury photographs.51 Periorbital edema and ecchy- reconstruction (see Fig. 17-17C).
mosis will be present and must be taken into consider- Variants of type I, II, and III fractures may occur on
ation when completing this examination. one side or the other in conjunction with each other. In
Nasal tip position and telescoping of the nasal carti- any case, the type of injury and its severity will guide
lage under the osseous segments of the nasal complex treatment.
must also be determined. This is important for later
reconstruction. A complete intranasal examination may TREATMENT
be assisted by applying cocaine or oxymetazoline to Treatment of the NOE fracture begins with a specific
shrink soft tissue and performing a careful visual exami- diagnosis and careful treatment planning. The funda-
nation of the nasal septum, concha, nasal mucosa, and mentals of surgical repair are early surgical intervention,
intranasal position of osseous structures. The presence wide exposure, careful anatomic osseous reduction, and
of CSF rhinorrhea can be determined with this examina- internal rigid fixation. Special attention to the medial
tion; this is an indication of the extent of the injury into canthal tendon and its attachment is necessary to obtain
the ethmoidal sinuses and to the cranial base by way of optimal aesthetic results.
the cribriform plate.
Surgical Approaches
Imaging The coronal incision is used most frequently in the man-
Axial and coronal CT scanning are required in any agement of fractures of the NOE region. This incision
patient suspected of having NOE injuries; 1.5- to 2-mm provides wide exposure of the superior and medial
cuts are usually satisfactory for determining the extent of orbital compartments. The nasal bones are also evalu-
this injury. Correlation of the clinical and radiographic ated and fractured segments removed for later use in
examination facilitates a proper diagnosis. Attention to reconstruction. Care should be taken to limit disruption
anatomic structures in regard to location, displacement, of the nasal lacrimal duct and lacrimal sac and the infe-
size, and comminution is critical. Treatment outcome is rior extent of this incision. Determination of nasal lacri-
based largely on proper identification of the bony mal duct patency will be discussed later in this chapter.
segment and the status of the attachment of the medial A lower eyelid incision may also be necessary to gain
canthal tissue. access to the inferomedial orbital components. Further
stabilization may be necessary by an internal approach to
CLASSIFICATION gain access to the nasomaxillary buttress for stabilization
A commonly used classification system developed by Mar- of the inferior portion of the NOE complex.
kowitz et al identified NOE fractures based on their rela-
tionship to the central fragment at the site of medial Systematic Management
canthal tendon attachment.52 The fractures are typically Systematic treatment of NOE fractures is necessary for a
noted to be unilateral, bilateral, simple, or comminuted predictable outcome. A systematic approach of eight key
and are likely to have with different fracture presenta- steps in the sequencing of NOE fractures was described
tions bilaterally. They may occur as an isolated injury or by Ellis.37 These steps include surgical exposure, identi-
in conjunction with other major facial fractures. fication of the medial canthal tendon and tendon-bearing
bone fragment, reduction and reconstruction of the
Type I medial orbital rim, reconstruction of the medial orbital
The simplest form of NOE fracture involves only one wall, transnasal canthopexy, reduction of septal fractures,
portion of the medial orbital rim, with its attached medial nasal dorsum reconstruction and augmentation, and soft
canthal tendon. It may occur in a bilateral or unilateral tissue adaptation.
form. When the bilateral complete type I fracture occurs, The type I fracture is best managed by three-point
there is no medial canthal tendon displacement and rigid fixation—reestablishing the relationships of the
transnasal wiring is not required. Stabilization of the nasofrontal junction to the nasal complex, the nasal
osseous segment is all that is usually necessary (Fig. complex to the maxillary buttress, and the nasal complex
17-17A). to the infraorbital rim (Figs. 17-18 and 17-19). As noted,
Type I Fractures
Type II Fractures
Type III Fractures
C
FIGURE 17-17 A, Incomplete type I fracture. B, Complete unilateral and bilateral type II fractures. C, Type III comminuted fracture involving
attachment of the canthal tendon.
A B C
FIGURE 17-18 A, Basic fixation treatment of unilateral fracture requiring three-point fixation. B, Rigid plate fixation of unilateral fracture
requiring three-point stabilization. C, Bilateral single-segment injuries with superior and inferior rigid fixation approaches.
comminution of the nasal region may require a dorsal

nasal cantilever-type bone graft to reestablish dorsal nasal
support and nasal tip projection. This bone graft can be
placed through the coronal incision and stabilized with
intraosseous screws into the nasal process of the frontal
bone (Fig. 17-20). Cranial bone grafts can be used for
this technique and may also be needed for reconstruc-
tion of the facial buttresses. Other autogenous sites rec-
ommended for the procedure include the rib, ilium, and
mandible.53 Canthoplasty, unilateral or bilateral, may be
required. Direct transnasal wiring of the medial canthal
tendon in a position slightly posterior and superior to
the normal anatomic position will help overcome the
FIGURE 17-19 Three-point stabilization of bilateral single segment forces of migration, relapse, and telecanthus (Fig. 17-21).
injuries via coronal approach.
Transnasal Wiring Technique
Transnasal wiring or transnasal medial canthopexy is
in this type of injury, medial canthal tendon detachment performed when necessary. This step follows surgical
is rare. exposure, identification of the medial canthal tendon or
Type II fractures require a more extensive superoinfe- tendon-bearing bone fragment, reconstruction of the
rior approach because a degree of comminution is medial orbital rim, and reconstruction of the medial
present by definition. Access through the coronal flap orbital wall. This sequence of repair is important because
and infraorbital and intraoral incisions are often neces- reconstruction of the medial orbital rim is key to reestab-
sary. The small bony fragments must first be anatomically lishing the pretraumatic intercanthal distance,52 and
reduced with 28- to 30-gauge intraosseous wiring or with reconstruction of the medial orbital wall is required to
microplates. Rigid internal fixation then proceeds as for maintain an appropriate orbital volume.54-56
a type I fracture to reestablish the bony buttresses. Reat- A small incision is made approximately 3 mm medial
tachment of the medial canthal tendon is then com- to the medial canthus and blunt dissection is used to
pleted de facto by appropriate reduction of the large identify the fibers of the medial canthal tendon. Once
central fragment(s) to which the tendon is attached. the tendon is identified, a hole is made through the
The type III NOE fracture involves extensive commi- unstable central fragment and through bone on the con-
nution and displacement of the osseous structures, with tralateral side, one hole just posterior and superior to the
apparent avulsion of the medial canthal tendon unilater- lacrimal crest and the other superior to the lacrimal
ally or bilaterally from its osseous attachment. The fossa. A double 26-, 28-, or 30-gauge wire is then threaded
principles of access and repair follow the same principles through the two holes transnasally with a curved needle
as for type I and II fractures, although establishing pre- or awl. The wire is secured to a screw or small plate on
traumatic osseous and soft tissue contour is more chal- the contralateral supraorbital rim. This orientation pro-
lenging because of the level of comminution. Severe vides the posteriorly and superiorly directed pull typically
FIGURE 17-20 Comminuted NOE fracture with wire and plate fixation and dorsal basal bone graft placed with lag screw technique.
exerted by the medial canthal tendon. The same proce- leakage, edema, periorbital ecchymosis, traumatic tele-
dure may be used when the medial canthal tendon is canthus, and epiphora may be observed. The clinical
completely detached from the central fragment or, if the examination can be supplemented and diagnosis con-
traumatic disruption prevents identification of the liga- firmed by CT, with coronal, axial, and sagittal views (Fig.
ments, the tissue surrounding the tendon may be used 17-23). Plain films are suboptimal in this setting.
in a similar manner (Fig. 17-22). Transnasal wires should
be intentionally overreduced to prevent notable telecan- TREATMENT
thus and widening of the nasal dorsum.40 There is some controversy regarding the optimal timing
If a bilateral canthopexy is required, a separate mat- of the repair of midfacial injuries, particularly when sig-
tress wire is sutured through one tendon and the wire is nificant edema is present. As a general principle, treat-
passed transnasally to be secured to the contralateral ment should begin once the edema from the initial insult
supraorbital rim by a screw or small plate. Both cantho- has begun to subside but should not be delayed for more
pexies are carried out in the same manner but should than 10 to 14 days.37 In our experience, earlier repair
not be secured to each other; this is to prevent a com- generally provides a more optimal, long-term soft tissue
plete loss of anatomic position if one side becomes drape. However, concomitant neurosurgical trauma and
loose.37 other issues may delay repair beyond the surgeon’s
At the conclusion of these approaches for nasal control. The Le Fort III fracture is essentially a compli-
complex reconstruction, final repositioning of the nasal cated combination of bilateral zygoma and NOE frac-
bones is accomplished with Asch forceps and intranasal tures, and the same principles apply when treating this
splints. External splinting can be beneficial, even to the fracture pattern.
extent of providing nasal support for proper soft tissue There are two general schools of thought regarding
draping and reestablishing the correct adaptation of soft the sequence of repair. Gruss et al have proposed a
tissue into the medial canthus area. method of reconstruction whereby reconstruction begins
with the outer framework and progresses to the inward
LE FORT TYPE III FRACTURES facial structures, from stable to unstable areas.59,60 Repair
begins with rigid fixation of the mandibular fractures. In
Because of the complex nature of midfacial injures, clas- the case of a bilateral mandibular condyle fracture, at
sification is often difficult; fractures classified as Le Fort least one condyle (ideally both) must be treated by ORIF.
III may actually be combinations of Le Fort I and II and Once that is accomplished, the maxilla can assume its
zygomatic complex fractures.57 However, in one series, correct superior position and anteroposterior location.
pure Le Fort III fractures accounted for approximately A stable outer framework of the midface is established
9% of midfacial fractures.58 with reduction and fixation of the zygomaticofrontal,
The Le Fort III fracture pattern is a craniofacial dys- zygomaticotemporal, and nasofrontal sutures and the
junction. Symptoms include a classic dish face deformity appropriate reduction of the maxilla to the midface infe-
and mobility of the zygomaticomaxillary complex. CSF riorly. In turn, the proper occlusion must be established
FLT:e3
L
7
3
PI
FIGURE 17-23 Axial CT of a Le Fort III fracture.
to complete the anteroposterior and lateral positioning

of the midface. Once the outer framework has been
established, one can proceed to reconstruct, in order, the
nasal skeleton and floors of the orbits, correct any lacri-
mal system disorders, and reestablish the proper posi-
tioning of the medial canthal ligaments. Therefore, one
works from the lateral superior and inferior direction
medially to correct the Le Fort type III deformity.
A second school of thought, popularized by Markowitz
and Manson,2 focused on reestablishing facial width at
the NOE complex and proceeding in laterally. A method
described by Kelly and Manson outlines this approach.61
Marciani and Gonty have summarized the four factors
contributing to positive outcomes following reconstruc-
tion of craniomaxillofacial trauma. These are early defin-
itive treatment, anatomic and functional repair of NOE
B injuries, wide exposure of fractured segments, and ana-
FIGURE 17-21 A, Wire support stabilization of avulsed medial tomic repositioning and stable fixation in all planes.62 It
canthal tendons. B, Transnasal reduction of medial canthal must be emphasized that there are a number of effective
tendon with transnasal wire fixation to raise tendon superiorly and ways to approach these complex types of facial injuries.
posteriorly. Thoughtful review of the different viewpoints regarding
the management of these injuries has revealed that there
is no one specific method that will definitively manage
all types of injuries. Focused preoperative consideration
of the injury pattern, with special consideration to areas
of stability that will assist in establishing a stable frame-
work, are likely to yield the best results.
Surgical Approaches
The coronal approach allows excellent exposure of the
NOE complex, lateral orbital rims, and zygomatic arch.
It is aesthetically acceptable because the incision is
hidden in the preauricular areas and behind the hair-
line. In patients with a receding hairline or the probabil-
ity of baldness, this approach should be considered.
The standard high preauricular incisions are extended
superiorly and joined by a coronal incision across the
skull, behind the hairline (Fig. 17-24). The flap is dis-
FIGURE 17-22 Wiring technique for an NOE fracture. sected anteriorly in a subgaleal plane superficial to the
A B C
D E F
FIGURE 17-24 Coronal flap sequence.
pericranium. The periosteum is incised superiorly to the The scalp is closed in layers with 2-0 slowly resorbing
supraorbital ridges and the dissection is carried out sub- sutures through the galea and staples through the skin.
periosteally. The temporalis fascia is also incised superi- Non–hair-bearing incisions are closed in layers in a
orly to the supraorbital rims, extending from the routine manner with appropriate sutures. Drains are
preauricular incision medially to join the superior dissec- removed on the second or third postoperative day and
tion. This technique allows reflection of the superficial staples are removed in 10 to 14 days.
flap containing the temporalis branch of the facial nerve
and thereby prevents injury. COMPLICATIONS
The zygomaticofrontal, zygomaticotemporal, and Complications following midfacial trauma are fairly
nasofrontal sutures are well exposed. Resecting the infe- common. A retrospective study of 20 patients requiring
rior bony margin encasing the supraorbital nerve can secondary reconstruction for periorbital deformities fol-
facilitate exposure of the medial canthal tendon. This lowing initial midfacial trauma repair has concluded that
bony margin is easily removed by means of sharp chisels. the primary reason for orbital complications is a malpo-
The release of the nerve allows a continued inferior sitioned zygoma.63 Other notable complications include
extension of the flap. The infraorbital rim and floor of paresthesia of the infraorbital nerve, orbital dystopia,
the orbit must be exposed via an infraorbital approach. enophthalmos, diplopia, malunion, and lacrimal system
These incisions, in conjunction with an intraoral approach, dysfunction. These are discussed in the following
provide wide open exposure of the fracture sites. sections.
Following reconstruction, the flap is replaced. A
closed suction drain may be placed after hemostasis is MALUNION OF MIDFACE FRACTURES
achieved.
Care should be taken to provide adequate resuspen- Malunion of the midface resulting from improper reduc-
sion of the facial soft tissues of the malar, infraorbital, tion or fixation, postponement of treatment, or excessive
and temporal surface of the orbit to prevent facial comminution may result in suboptimal postrepair func-
sagging and drooping of the eyebrows. A lateral cantho- tion and aesthetics. This may require correction by
pexy is also suggested if extensive lateral dissection has appropriate osteotomies and bone grafting. Although
been used. nonunion is rarely seen with the adjunctive use of plates
and screws, it can be prevented by judicious use of bone comminuted maxilla has been used historically and may
grafts during the initial reconstruction, if warranted. be an appropriate option if the maxilla is stable against
a superior and posterior directed vector of force follow-
TREATMENT ing the application of intermaxillary fixation. The classic
Malunion can be treated by augmenting the bony depres- deformity resulting from skeletal suspension of the
sion or by performing an osteotomy. Consideration maxilla is midfacial shortening and retrusion, resulting
should be given as to whether the resulting defect is in overclosure.66 This occurs because although intermax-
primarily functional or aesthetic. illary fixation will direct closure in a horizontal direction,
If a functional deformity exists, a corrective osteotomy there is nothing to direct the vertical position of the
should be considered. If corrective osteotomies are maxilla.67
planned, they should be performed as early as possible, Rigid fixation is the most favorable method of fixation
before the fractures have healed and obscured the proper for management of facial fractures in most cases; stable
position of the fractured segments. An example is a mal- areas of solid bone should be used for anchorage. The
posed zygoma, resulting in enophthalmos, diplopia, or source of bone graft material is based on the preference
obstruction of mandibular opening caused by obstruc- of the surgeon. Cranial bone, rib, and iliac crest are the
tion of the coronoid process. most commonly used autogenous grafts. Calvarial bone
If the deformity is primarily cosmetic in nature, such has been shown to be the most resistant to resorption
as a flattened paranasal prominence or malar promi- and is also easily adapted to midfacial defects68 (Fig.
nence caused by deficient projection of the zygoma, an 17-25). The frontal bone offers straight grafts and the
onlay graft of autologous or alloplastic material may be parietal and occipital areas offer a variety of convex
acceptable. grafts. Cranial bone grafts can be harvested to provide a
large bone graft, which can be used as a full-thickness
Corrective Osteotomies graft, or the diploic bone can be split and the inner table
Diagnosis and treatment planning of secondary deformi- used for grafting purposes, with the outer table replaced
ties from midfacial trauma can be assisted greatly by the to allow reestablishment of normal contour of the cal-
use of three-dimensional CT scans. Other effective diag- varium. Alternatively, the outer table can be harvested
nostic aids include using the contralateral side of the alone, which can also provide adequate bone for midfa-
patient’s face (if uninjured) as a reference, an exophthal- cial reconstruction and is associated with low morbidity.
mometer for evaluation of exophthalmos, or a facial The diploic cavity between the inner and outer tables is
moulage for evaluation of three-dimensional deficiency. consistently 2 mm thick; however, this space diminishes
More promising is the development of computerized sur- with advancing age, which should be considered when
gical navigation techniques and preoperative planning using this type of graft.69 In our experience, the calvar-
software.64 ium is the ideal autologous choice for midfacial recon-
Possible osteotomies include the subcranial or modi- struction for many reasons and is often already exposed
fied Le Fort III osteotomy.65 Permutations include a in the field through the coronal flap, minimizing further
focused osteotomy of the Le Fort I level, nose, and morbidity for the patient.
zygoma, depending on the area and degree of secondary The rib cage is also a potential source of autogenous
deformity. The details of these procedures are beyond bone. The most common source is the fourth through
the scope of this chapter. However, judicious surgical eighth ribs. The upper ribs are larger. The most common
technique is necessary for successful mobilization of the postoperative complications have been pleural lacera-
craniomaxillofacial skeleton while preserving visceral tions. Laurie et al70 have reported such complications in
function. 9% of a series of 44 cases. Persistent intercostal pain can
The position of the soft tissues may also need to be also occur as a result of the injury. Although providing
addressed following secondary corrections. This includes some structural integrity, resorption of rib grafts, when
maneuvers such as redraping of the infraorbital tissues used to provide contour or onlay projection, remains a
or temporalis muscle with the assistance of a suspension problem over the long term. Thus, rib grafting for
sutures to minimize defects after healing. midface trauma is rarely used.
The iliac crest is also a popular source of autograft
Bone Grafting in Midfacial Reconstruction because of the amount of bone available and the percent-
If the fracture results in significant comminution or avul- age of cancellous bone present. The posterior crest offers
sion, bone grafting may be necessary. However, if tissue almost three times the amount of bone for grafting pur-
avulsion makes primary closure impossible or if the bone poses and has been associated with less morbidity. The
graft would be open to the external environment or drawback is having to turn the patient midprocedure or
mucosal secretions, a mechanically stable, plate-maintained deal with alternative positioning.71,72
reconstruction and closure should be attempted, with By approaching the anterior crest from a medial direc-
secondary reconstruction of the soft and then hard tion, one bypasses the iliotibial band, comprised of the
tissues at a later date. This will allow initial anatomic tensor fascia lata muscle and fascia lata. This is important
positioning of the maxilla and hopefully limit subsequent because failure to reattach these structures may result in
midfacial collapse and deformity. an inability to stabilize the upper thigh and lift and
Untreated maxillary fractures are likely to result in flex the leg when walking. By using the medial approach
midfacial elongation and retrusion because of the pull to the iliacus muscle, the postural muscles are preserved.
of the medial pterygoid muscles. Closed reduction of the The only gait disturbance is a result of postoperative pain
A B C
FIGURE 17-25 Cranial bone graft.
A B
FIGURE 17-26 Microvascular free tissue transfer for midface reconstruction. (Courtesy Dr. Fayette Williams)
in the area. Anesthesia and paresthesia can occur follow- injury. There are a number of flap variations and the
ing harvesting from the anterior and posterior iliac crest. decision regarding which flap to use should focus on the
Damage to the lateral cutaneous branch of the subcostal following: the adequacy and location of the proposed
nerve (T12) and lateral cutaneous branch of the iliohy- tissue bed; existing medical comorbidities; amount of
pogastric nerve (L1) causes sensory denervation of the tissue required; and whether bone (e.g., an osteocutane-
skin overlying the gluteus medius and gluteus minimus ous flap) is necessary for reconstruction73 (Fig. 17-26).
muscles. When approaching the posterior hip, damage The development of recombinant human bone mor-
to the superior and middle cluneal nerves will result in phogenetic protein (rhBMP-2)–assisted grafting has also
paresthesia over the region of the gluteus maximus been a transformative event in craniomaxillofacial recon-
muscle. struction. Limited by not having structural integrity,
The use of microvascular free tissue transfer has dra- these grafts are generally used with the assistance of
matically increased the possibilities for immediate or autogenous grafts or allografts for bulk and/or structure.
delayed reconstruction of the severely avulsive midfacial In addition, the use of a mesh or crib can be helpful in
FIGURE 17-27 Blowout fracture of the orbital floor.
providing contour and resisting soft tissue compression FIGURE 17-28 Coronal CT scan demonstrating a blow
out fracture of the orbital floor.
during consolidation.74 If delayed reconstruction is
planned, the receptor bed must be optimally vascularized
with sufficient soft tissue, skin, and mucosa for closure.
Soft tissue grafting or tissue expansion can be used to bone conduction play a role in the mechanism of orbital
develop a healthy vascular bed and then secondary blowout fractures.81
grafting can proceed. Before secondary reconstruction, Regardless of the actual mechanism of injury, blowout
the reepithelialized or grafted tissue should be allowed injuries are further described as pure, for those that
to mature to withstand manipulation during the bone occur in the presence of an intact orbital rim, and
reconstruction. impure, for those with a concomitant fracture of the
orbital rim. Blowout fractures can occur on the floor,
ORBITAL WALL FRACTURES medial wall, or lateral wall (Fig. 17-28). Medial wall frac-
tures accompany approximately 20% of orbital floor
Fracture of the orbital walls can result in ophthalmic fractures.82-84
complications such as diplopia, enophthalmos, and verti- The incidence of orbital wall fractures has been
cal diplopia. Incomplete or improper reconstruction reported to range from 4% to 70% of those who sustain
may fail to correct, or may even worsen, these conditions. orbital trauma. Isolated blowout fractures likely repre-
The same level of care should be taken to reconstruct sent between 5% and 21.4% of midfacial fractures.85-87
the orbital walls appropriately, as for the orbital rims.
Orbital wall fractures can be divided into two sections, BLOWOUT FRACTURES
anterior and posterior. The anterior section is composed Diagnosis
of the orbital rim. The posterior section is composed of It is difficult to make a clinical diagnosis of an isolated
the thinner roof, floor, and medial and lateral walls. orbital blowout fracture. Often, these fractures would not
These fractures are commonly referred to as blow-in and be clinically notable until several weeks later, when dip-
blowout, fractures depending on the direction of the lopia was noted.88 The clinical examination is also ini-
fracture.75-77 tially obscured by significant edema, which may mask
There have been two major theories proposed regard- visual observation of enophthalmos or vertical diplopia
ing the mechanism of blowout fractures. Converse and and palpation of bony step deformities.
Smith78 and Smith and Reagan,76 who are known to have Extraocular movements should be assessed by the
coined the term blowout fracture, described a hydraulic evaluation of cardinal movements. If there is any ques-
mechanism whereby hydrostatic pressure within the tion about muscle entrapment, a forced duction test of
globe or orbital contents is transmitted to the orbital all four rectus muscles is indicated. Limitations of motion
walls. An opposing theory has suggested that impact may be the result of early postinjury edema and prolapse
against the sturdy orbital rim transmits force to the more of orbital contents, but may allow normal range of motion
fragile orbital walls, resulting in a blowout fracture (Fig. prior to scarring and contracture89 (Fig. 17-29). Damage
17-27). The increased incidence of blowout fractures in to the infraorbital nerve may also be present in blowout
children is an indication that bone elasticity and orbital fractures. A blowout fracture should be suspected if par-
deformation play a role in orbital blowout fractures,79 a esthesia of the infraorbital nerve distribution is present
concept is also supported by experimental studies by following trauma, with limitation of normal ocular
Fujino and Makino.80 It is likely that hydraulic forces and motion and no notable fracture of the rim.90
Noncontrast CT scans with 1.5- or 2-mm axial, sagittal, Treatment

and coronal cuts are the most appropriate for specific Surgical approaches to the orbit have been discussed
evaluation of the orbit. The indications for surgical inter- earlier. The most commonly used are the subtarsal, sub-
vention for an isolated, radiographically evident orbital ciliary, and transconjunctival incisions, with various mod-
blowout fracture is nonresolving diplopia within 2 to 3 ifications based on the location and presence of
weeks of injury or enophthalmos greater than 2 mm. concomitant injuries.
Supporting evidence is provided by a positive forced Many materials have been suggested for orbital floor
duction test demonstrating ocular motility restriction not reconstruction. Autogenous grafts are useful for the
related to edema and CT evidence of orbital floor management of large, significant floor or wall defects,
blowout injury. Other relative indications for repair the skeletally immature orbit, and secondary orbital
include orbital floor defects larger than 1 cm2 or clini- reconstruction (Fig. 17-30). They are highly biocompat-
cally notable hypoglobus. ible but require donor site surgery. Donor sites usually
Once these criteria have been met, surgery should suggested for reconstruction of the orbit include the
proceed in a timely manner. Emery et al91 have provided anterior and posterior iliac crests and unicortical or
a natural history of diplopia in isolated orbital blowout bicortical calvarium. The anterior and posterior iliac
fractures. When diplopia was present on initial presenta- crests have the advantage of providing different shapes
tion, 55% had resolution of symptoms at 15 days, whereas and sizes, which is especially important if the posterior
others had gradual resolution of symptoms after the wall is absent or when correction of enophthalmos is
initial 15-day period, and 27% of this subgroup had some being undertaken. The wedge-shaped floor implant nec-
degree of permanent diplopia. Dulley and Fells, in a essary for forward projection of the globe requires an
review of 103 patients, have found a 72% incidence of adequate thickness of graft material. Unicortical or bicor-
enophthalmos when the repair occurred at 6 months tical calvarial bone may also be used for this purpose.
compared with a 20% incidence when surgery was per- The advantage of calvarial bone is that it is more resistant
formed at 2 weeks. Additionally, 40% of patients also to absorption and, if selected properly, may closely mimic
needed additional ocular surgery, with limited success at the shape of the orbital floor. The parietal and occipital
resolving alterations in binocular vision.92 regions of the calvarium seem uniquely suited to this
application, and the grafts may be stacked to obtain the
desired shape and thickness. Monocortical grafts provide
an adequate graft, especially in the younger age group.
The diploic space measures an average of 2 mm and
allows a safe harvest site. Jackson et al,69 Tessier,88 and
Powell and Riley,93 reporting on large series of cases,
noted few complications with this technique. Tessier
et al, in a retrospective review of several surgeons over
25 to 50 years, have reported the incidence of dural tear
as 25 in 9650 (0.26%) and never with injury to the under-
lying brain.94 For smaller defects, the lateral mandibular
FIGURE 17-29 Clinical limitation of upward gaze because of orbital cortex, lateral antral wall, and nasal septum are accept-
floor disruption. able alternative donor sites.
A B I
FIGURE 17-30 A, Orbital blowout fracture plated via the transconjunctival approach, B, Postoperative coronal CT scan.
The diagnosis of medial wall fracture is made clinically

by limitation in abduction of the globe, often in conjunc-
tion with globe retraction. This is caused by damage or
entrapment of the medial rectus muscle. A forced duction
test in this setting is mandatory. Medial wall fractures are
most easily visualized on axial scans with maxillofacial CT.
One study has shown that anteroposterior and coronal CT
slices could not detect 100% of medial wall fractures.82
Treatment
The necessity to repair a medial wall fracture depends
on the extent of the defect and degree of orbital tissue
lost. A small defect does not require repair. If the defect
is large and accompanies a floor defect, reconstruction
may be required in a similar manner as orbital floor
reconstruction.
The approach to the medial wall can be made by a
Lynch incision, lateral nasal incision, coronal flap, exist-
ing laceration, or transcaruncular approach. The Lynch
incision is a curvilinear incision made 12 mm medial
FIGURE 17-31 Axial CT scan of a blow-in fracture. to the medial palpebrae to prevent severing the inser-
tion of the medial canthal ligament. This approach, as
well as the lateral nasal approach, are prone to scarring
and unaesthetic webbing of the incision sites. Other
Many alloplastic materials are also available com approaches, such as the coronal and transcaruncular
mercially and have become popular for routine use, approaches, avoid this complication. The transcaruncu-
including titanium mesh, polymeric silicone, polytetra lar approach is made by extension of the transconjuncti-
fluoroethylene, polyethylene, and Gelfilm.95-98 These val approach through the caruncle and has been shown
materials limit the need for a donor site and most do not to provide excellent access, with few complications.112
undergo resorption. On the other hand, these materials Dissection of the medial wall should take into account
also have the potential to induce a foreign body response several anatomic landmarks. The anterior ethmoidal
that might result in infection, extrusion, and/or displace- vessels lie 24 mm posterior and superior to the anterior
ment into the maxillary sinus.99,100 Complications such as lacrimal crest, with the posterior ethmoidal vessels
these are relatively rare with these materials but, if they approximately 12 mm behind them. The optic canal is
do occur, are most likely to develop within the first few 40 mm posterior to the anterior lacrimal crest.
months postplacement. Consideration should be given
to securing these materials in the orbit with screws or BLOW-IN FRACTURES
nonabsorbable sutures to limit the chance of migration The blow-in fracture, initially described by Dingman and
until fibrous encapsulation has occurred. Natvig in 1964,113 is less common than the typical blowout
Allogenic materials have also been used with success. fracture (Fig. 17-31). In a review of clinical findings in 41
These include lyophilized dura, allogenic bone, and patients with blow-in injuries, Antonyshyn et al114 noted
cartilage.101-106 that 25% to 30% of them presented with proptosis
Tessier and others have stressed the importance of because of a decrease in orbital volume and associated
wide dissection of the periorbital tissue from the orbital restricted ocular motility and diplopia. Other unusual
walls, with particular attention to the floor defect. This findings reported include rupture of the globe, superior
is particularly important in late repair or treatment of orbital fissure syndrome, and optic nerve injury.115 There-
enophthalmos.88,107-111 Studies have suggested overcorrec- fore, the blow-in fracture should be managed acutely.
tion of the floor defect, regardless of the method of Particular attention must also be paid to orbital roof frac-
repair. Multiple procedures may be necessary to achieve tures. Separation of the orbit and dura in significant roof
adequate correction, particularly with the repair of late fractures must be preserved for several reasons. First, the
enophthalmos. orbital roof can become pulsatile with adhesion of the
Following completion of the orbital reconstruction, a orbital contents and dura; second, in the young growing
forced duction test is mandatory to ensure that the posi- child, herniation of the leptomeninges can occur.116
tioning of the reconstructive material has not trapped
inferior periorbital tissue.110
COMPLICATIONS AFTER TREATMENT OF
MEDIAL WALL FRACTURES MIDFACE FRACTURES
Diagnosis
The medial orbital wall is composed primarily of the thin BLEEDING
lamina papyracea of the ethmoid bone. This is the second In the absence of a coagulopathy, severe hemorrhage
most commonly fractured orbital wall, comprising 20% from maxillofacial injuries is rare. The primary blood
of cases of disruption in orbital floor fractures.82-84 supply to the region is from the external carotid system.
Source control is usually easily accomplished. Buchanan

and Holtmann have reported on 312 patients over 5
years and recorded epistaxis in 4% of facial fractures and Anterior and Posterior
11% of midface fractures. Only 6 patients required ethmoidal arteries
packing or transfusion and only 2 required surgery for
control of the hemorrhage.117 In the patient with the
avulsive midfacial injury, bleeding can be profuse. Direct
control is usually possible through the wound.
Nasopalatine branches
Control of Bleeding of the sphenopalatine
artery
Midfacial bleeding usually manifests as epistaxis. Control
of epistaxis requires an understanding of the vascular Greater palatine artery
supply to the region. Direct and unobscured visualization
is mandatory; phenylephrine hydrochloride (Neo-
Synephrine) or a 4% cocaine solution assist by shrinking A
and anesthetizing nasal mucosa. If the bleeding is from
the septal wall, the anterior and posterior ethmoidal
arteries that supply the anterior portion of the septum
are often the source. The nasopalatine, greater palatine, Anterior and Posterior
and superior labial arteries supply the posterior aspect of ethmoidal arteries
the septum.
Bleeding from the superolateral nasal wall emanates
from the anterior and posterior ethmoidal arteries.
Bleeding from the posterior aspect is likely from the Sphenopalatine
foramen and artery
sphenopalatine artery and the anterior aspect of the
lateral wall is usually from the nasal branch of the facial
artery (Fig. 17-32).
The patient’s head should be maintained in a forward
position to prevent pooling of blood in the pharynx and
subsequent airway embarrassment. If a vasoconstrictor-
soaked cottonoid pledget does not control the bleeding, B
cauterization may be attempted with silver nitrate. An
anterior nasal pack may also be attempted. If this fails to FIGURE 17-32 Anatomy of the medial wall (A) and lateral wall (B)
of the nasal cavity.
control the bleeding, a posterior nasal pack or pressure
balloon may be necessary.
If initial measures do not control epistaxis, angiogra-
phy should be performed to determine the source of CEREBROSPINAL FLUID RHINORRHEA
bleeding. Once the source is identified, embolization or AND OTORRHEA
ligation may be required. Following trauma of the midface, CSF may emanate from
To ligate the ethmoidal arteries, a 3-cm incision is a dural tear, resulting in rhinorrhea, otorrhea, or both.
made above the attachment of the medial canthal liga- The disruption usually occurs lateral to the cribriform
ment and below the trochlear ligament. A subperiosteal plate but may also result from disruption of the sphenoi-
dissection is carried out, exposing the confluence of the dal, ethmoidal, and frontal sinuses producing a dural
frontolacrimal and frontoethmoidal sutures. The fronto- tear and communication with the subarachnoid space.
ethmoidal sutures are followed posteriorly, taking care CSF was first described by Willis in 1676.117 CSF otor-
not to puncture the thin lamina papyracea. The anterior rhea emanating from the external auditory canal occurs
ethmoidal artery is identified and ligated with a vascular in approximately 7% of basilar skull fractures.120 Leakage
clip; the posterior ethmoidal artery can similarly be iden- is typically noted immediately following trauma but may
tified and ligated. Care must be taken during this dissec- occasionally be noted days to weeks after the traumatic
tion to stay anterior to the optic nerve, which is in close event. This situation may occur when debris such as a
proximity (Fig. 17-33). blood clot or avulsed tissue obstructs free passage of the
Ligation of the external carotid artery plays a limited CSF, resulting in late leakage following clot lysis or an
role in the management of facial bleeding, generally increase in intracranial pressure.
because of collateral circulation from the contralateral Diagnosis of CSF leakage is often complicated by
external carotid arterial system, and this technique pre- mixture with nasal secretions, lacrimal secretions, and
vents subsequent attempts at arteriography and emboli- blood. Clear CSF should be collected in a vial, an absence
zation.118,119 Arteriography with selective embolization is of sediment and a glucose level of approximately 45 mg/
a rapid and effective method to gain control of midfacial dL is usually confirmatory. A more specific, albeit slower,
bleeding. In most cases, beyond those for which direct laboratory examination is the CSF-specific beta-2 trans-
packing is useful, this technique has garnered universal ferrin test.116 CSF will also form concentric rings when
acceptance because of the associated minimal morbidity poured on linen or soft filter paper. When bleeding is
and efficacy. present, one should suspect the presence of a CSF leak
1 2
3 4
A
FIGURE 17-33 Correct technique for anterior packing of the nose. A, 1. The gauze is gripped 4 to 6 cm from the end. 2. The first layer is
placed along the floor of the nose. 3, 4. Subsequent layering of the gauze packing.
Anterior ethmoidal
artery is ligated and divided
Posterior ethmoidal
artery
C
FIGURE 17-33, cont’d B, Posterior nasal packing. C, Ligation of the anterior and posterior ethmoidal arteries. (A from Roberts J, Hedges
J: Clinical procedures in emergency medicine, ed 5, Philadelphia, 2010, Saunders.)
until proven otherwise. Once a provisional diagnosis is Pneumocephalus may be noted on CT scans in any
made, the patient should be placed in a semirecumbent extradural, subdural, intracerebral, subarachnoid, or
position and instructed on how to minimize increases in ventricular site. Pneumocephalus may be the result of
intracranial pressure, including straining, sneezing and fractures of the cribriform region, where the bone is very
blowing of the nose. thin and the dura is bound tightly to the skull, or from
Meningitis is a potential complication of skull base any basilar skull or sphenoid fracture in which air in the
fracture with a concomitant dural tear. The absence of ventricular and subarachnoid regions is common. Pneu-
leakage does not imply the absence of a tear. The use of mocephalus is not immediately a cause for alarm but may
prophylactic antibiotics for potential meningitis is con- indicate an accompanying CSF leak. It requires observa-
troversial and varies among institutions. Meningitis may tion for subsequent infection and development of a
develop in spite of antibiotic therapy because of oppor- cerebral abscess. The risk of meningitis secondary to
tunistic or resistant organisms, or the presence of a large a conservatively managed dural tear is significant and
bacterial load of nasopharyngeal and respiratory flora. adequate follow-up is of paramount importance.
Some studies have shown a decreased incidence of men-
ingitis with prophylactic antibiotic therapy.121-123 OCULAR COMPLICATIONS
The presence of a dural tear is not a contraindication Traumatic Diplopia
to surgical repair of midfacial fractures. Early reduction Among the most significant complications encountered
and fixation will likely reduce the changes in intracranial in midfacial trauma and reconstruction are diplopia,
pressure associated with mobile fractures that results enophthalmos and, on rare occasions, blindness. The
in intermittent pumping of CSF through a dural disrup- most commonly noted ocular complication is traumati-
tion. Finally, if CSF leakage has not subsided in 3 to 4 cally induced diplopia.
weeks postreduction, surgical correction of the leak is Diagnosis. Traumatic diplopia occurs from 3.4% to
indicated.124 20% of the time in the presence of midfacial trauma
and may be temporary or permanent if not managed

appropriately.125-129 The condition is caused by the inter-
ference of extraocular muscles. This may be secondary
to edema or hemorrhage with increased intraocular pres-
sure, displacement of globe position, entrapment of
muscle or fat in the line of fracture, bony displacement,
and resultant alterations in extraocular muscle attach-
ments. Also, adhesions between orbital contents such as
the periosteum, muscle, or fat may form at the bony
fracture sites, resulting in limitation of ocular motion.
Damage or impingement of cranial nerves III, IV, and VI,
may also result in diplopia.
Note that entrapment of the inferior rectus is not the
major cause of diplopia. Tessier has maintained that dip-
lopia is the result of an oculomotor imbalance and
reported true entrapment in only 3 of 600 post-traumatic FIGURE 17-34 Performance of a forced duction test.
orbital repairs.88
An ophthalmologist should make the diagnosis of dip-
lopia; the presence or development of symptoms of dip-
lopia should initiate a prompt ophthalmologic referral.
Putterman et al130 have introduced a simplified method
for evaluation and documentation of the degree of dip-
lopia. The patient is initially positioned in primary gaze
and the examiner shines a light into the eye. Then the
patient is asked to move into each of the gaze positions
and the patient states whether one or two lights is seen.
This test is repeated several times in the first week and
then weekly, preferably by the same examiner. Persistent
diplopia greater than 30 degrees of primary gaze is an
indication to proceed with surgical repair.
Binocular diplopia can become permanent unless
treated. Binocular diplopia is most likely to be observed
when midfacial trauma results in inferior displacement
of the zygoma at the level of the zygomaticofrontal
suture (i.e., above Witnall’s tubercle) and results in
displacement of Lockwood’s suspensory ligament. Dis-
placement or disruption of Lockwood’s ligament is nec-
essary for diplopia to occur. A disruption of the floor FIGURE 17-35 Clinical demonstraction of a forced duction test of
below Witnall’s tubercle alone will not produce diplopia the inferior rectus muscle.
predictably without disruption of the suspensory
ligament.
As noted, herniation of the orbital contents into the result is usually the result of a trapdoor type of injury
maxillary antrum may result in restriction in the primary (Fig. 17-35).
upward and lateral gaze. Lateral gaze restriction may also Timing of repair should take into account enough
occur with rupture of the medial wall by the same mecha- time to allow a workup, treatment planning, and resolu-
nism. Assessment is limited initially by edema, bleeding, tion of initial edema. Waiting a period of at least 1 week
or both. This usually takes 7 to 10 days to resolve suffi- allows this process to proceed smoothly and also provides
ciently to determine whether the diplopia is transitory. an opportunity to observe spontaneous resolution of dip-
The differential diagnosis includes edema, neurologic lopia, as well as development of enophthalmos. Reduced
damage to the affected extraocular muscles, and entrap- vision and retrobulbar hemorrhage are also complica-
ment. A forced duction test can assist in ruling out tions that have been described following injury and
entrapment. before surgical management.131,132
A forced duction test is performed by initially placing Treatment. The timing for treatment of diplopia has
a drop of local anesthetic in the cul-de-sac of the lower been controversial. It is clear that an inferiorly displaced
lid and, using a pair of small toothed forceps, grasping zygoma, a large orbital floor defect with disruption of
the tendon of the rectus muscle in question and rotating Lockwood’s ligament and subsequent inferior reposition-
the globe passively away from the restriction (Fig. 17-34). ing of the globe, or a trapdoor injury with restriction of
Limitation of motion can be caused by orbital edema, movement should be expediently repaired. The contro-
hemorrhage, or both and is not invariably an indication versy is when to operate in the case of slow resolution of
of muscular entrapment. Conversely, absence of resis- diplopia and a concomitant cosmetic deformity. Steroids
tance may indicate a neurologic deficit or possibly the should be administered for 5 to 7 days to help determine
presence of a large nonrestrictive floor defect. A positive whether diplopia is caused by edema or hemorrhage of
FIGURE 17-36 Bird’s eye view of patient with enophthalmos. FIGURE 17-37 Axial CT scan displaying post-traumatic
enophthalmos.
the orbital muscle or fat.133 A maxillofacial CT scan of However, because most of the lateral orbital wall is pos-
the orbit can help determine entrapment versus contu- terior to this axis, displacement of this osseous segment
sion of the extraocular muscles. A contused muscle will will result in an increase in orbital volume and resultant
appear round as opposed to its normal flat appearance. enophthalmos. Comminuted fractures to the lamina
In case of entrapment, a forced duction test is mandatory papyracea also lie behind the global axis, with the same
as the final indicator for immediate repair. effect. Intraconal fat is present behind the global axis,
Objectives for reconstruction of the orbital floor and loss of this structure will likely result in the develop-
include preventing the loss of orbital contents, providing ment of enophthalmos.
a smooth floor, and reconstructing the floor or wall to Enophthalmos is more likely the result of an increase
mirror the contralateral side anatomically. With a trap- in bony orbital volume by displacement of the medial
door injury, the tissue is carefully dissected from the line orbital wall, posterior floor, or lateral orbital wall than
of fracture without any other reconstruction of the the anterior orbital floor. Treatment should therefore
orbital floor. If the defect is large enough to allow extru- focus on repair of these areas and secondarily on the
sion of the orbital contents, these should be elevated and anterior orbital floor. Anterior orbital floor reconstruc-
the defect sealed, as discussed earlier. tion should focus on changes in the vertical relationship
of the globe and not on the correction of anteroposterior
Enophthalmos problems.
Enophthalmos secondary to orbital trauma was described Physical Examination and Imaging. Physical examina-
over 100 years ago.134 The incidence of post-traumatic tion proceeds in the usual fashion, with particular atten-
enophthalmos secondary midfacial trauma is unclear; a tion to the frontozygomatic suture and infraorbital rim
retrospective study by Gilbard et al135 have reported an region. A step deformity of the infraorbital rim may be
incidence of 22% but a more recent prospective study evidence of an inferior and lateral displacement of the
by al-Qurainy et al have reported an incidence of 8%13 zygomatic complex. Frontozygomatic, zygomaticomaxil-
(Fig. 17-36). lary, and zygomaticotemporal sutures are commonly dis-
Post-traumatic enophthalmos has been attributed to placed in low-velocity injuries and should be evaluated
atrophy of the orbital fat, enlargement of the bony orbit, for position and displacement. The zygomatic arch may
dislocation of the trochlea, cicatricial contraction of the be inferiorly displaced because of the dual effect of mas-
retrobulbar tissue, unrepaired fracture of the orbital seter pull and gravity on the fractured segment. A com-
wall, and displacement of the orbital tissue. Tessier has plete examination of the globe for gross injuries, changes
pointed out that loss of orbital fat rather than postin visual acuity, and changes in extraocular muscle func-
traumatic fat atrophy plays the predominate role in trau- tion by forced duction test are mandatory. A Hertel
matic enophthalmos.107 As noted earlier, disruption of exophthalmometer may be used to determine the degree
the orbital floor alone, with an intact suspensory system, of enophthalmos; more than 3 mm of deficit is consid-
does not result in globe displacement.55 However, dis ered aesthetically unacceptable.
ruption of the orbital walls resulting in significant dis- Pathologic Features. The most common cause of enoph-
placement of ligamentous attachments for suspensory thalmos is the lateral and inferior repositioning of the
ligaments of the globe causes a decrease in anterior body of the zygoma, resulting in increased intraorbital
support and subsequent enophthalmos (Fig. 17-37). volume posterior to the axis of the globe. Reconstructive
The axis described extends from the lateral orbital rim efforts must pay close attention to the position of the
to the anterior portion of the lacrimal bone. Most fat zygoma in three dimensions. Osseous reconstruction and
along the orbital floor is extraconal, meaning that it is rigid fixation for the zygomatic fracture and those areas
anterior to this axis. Displacement of this fat through an posterior to the global axis will ensure a stable orbital
orbital floor fracture will seldom result in enophthalmos. volume and a satisfactory postoperative appearance.
Blowout fractures, isolated or in conjunction with mechanism of injury was described by Hayreh et al142 and
zygoma or rim fractures, must extend behind the axis of Ghufoor et al,143 who suggested that retrobulbar pressure
the globe to create the volumetric expansion necessary results in occlusion of the ciliary arteries that are respon-
for a resultant enophthalmos. Usually, this is the result sible for blood supply to the optic nerve head. The sub-
of a concomitant medial wall component. Repair of these sequent optic neuropathy is caused by ischemia.
fractures should include elevation and securing of all Signs and symptoms of retrobulbar hemorrhage are
herniated tissue back into the orbital cavity. It is essential pain, proptosis, and decreasing visual acuity. Other
to complete the dissection far enough posteriorly to indications include ophthalmoplegia, increased intraoc-
ensure that any orbital floor disruption posterior to the ular pressure, and papilledema. Ophthalmologic find-
axis of the globe has been addressed to prevent late ings in retrobulbar hemorrhage are inconclusive. The
enophthalmos. cherry-red macular spot of central retinal artery occlu-
Secondary Repair. Dulley and Fells have emphasized sion has been reported by Ord136 and Nicholson and
the importance of prevention in regard to enophthal- Guzak.144
mos, reporting a 72% incidence of postoperative enoph- Timely evaluation, diagnosis, and treatment must be
thalmos when treatment was delayed longer than 6 carried out to increase the chance of preserving sight in
months following orbital trauma compared with 20% this patient subgroup. Even though the incidence of ret-
when repair was performed within 14 days. Also, in the robulbar hemorrhage is low, it is good clinical practice
late repair group, 40% required additional surgeries.92 In for all orbital trauma patients to undergo a thorough
the secondary repair of enophthalmos, a similar physical ophthalmologic examination. Treatment must be insti-
and radiographic examination is indicated to determine tuted as soon as the diagnosis is suspected. Hayreh et al140
the component of the orbital cavity that is primarily have recommended that treatment be instituted within
responsible for the increase in orbital volume. Access to 90 minutes following the presentation of symptoms.
the orbital cavity proceeds in the usual manner, with wide If the physical signs are unaccompanied by decreased
undermining of the periorbital soft tissues. The globe is visual acuity, it is mandatory to admit the patient at fre-
freed, as determined by a forced duction test. When the quent intervals for observation of visual acuity. There
culprit is a lateral and inferior displacement of the body have been reported cases of delayed loss of visual acuity.141
of the zygoma, osteotomies are performed at the junc- All patients with an ocular component of midfacial
tion of the zygoma and maxilla. Bone grafts can then be trauma should have regular follow-up and be instructed
used to elevate the body of the zygoma into the appropri- to return immediately if visual changes occur.
ate position. Rigid fixation is used to stabilize the segment. Following diagnosis, medical treatment should be
Wedge-shaped grafts may be positioned with the thicker instituted immediately. Intraocular pressure can be
edge to the posterior globe and may also be used to reduced rapidly by the administration of supplemental
project the globe into a more anterior and superior posi- oxygen, 20% mannitol (2 g/kg IV over 30 minutes, with
tion. Cranial bone grafts or preformed alloplastic wedges no more than 12.5 g in 3 to 4 minutes); 500 mg of acet-
may be used for this purpose, providing a sufficient bulk azolamide sodium (Diamox) IV, and 1g methylpredniso-
of material to be held in position by fixation to the infra- lone sodium succinate (Solu-Medrol) IV.141,145,146 Medical
orbital rim. As noted, secondary correction of this issue treatment is aimed primarily at limiting the ischemic
is difficult and planning a certain amount of overcorrec- insult by dilating the intraocular vessels, reducing intra-
tion is often necessary, with multiple procedures, to ocular pressure, limiting inflammation and edema, and
achieve an acceptable result. stabilizing cell membranes. If this does not improve
symptoms, surgical decompression should be under-
Blindness taken. Ord136 has suggested a waiting period of 30 to 45
The most devastating ophthalmic complication of midfa- minutes. The sooner decompression is performed, the
cial trauma is blindness. The rate of occurrence has been better the prognosis.
reported to range from 0.03% to 3%.136,137 It may be the The aim of surgical evacuation is to gain access to the
result of ischemia secondary to retrobulbar hemorrhage bleeding site rapidly and evacuate the developing hema-
or direct trauma to the optic nerve. toma. This can be performed by a lateral canthotomy;
Prompt radiologic assessment by CT should be used inferior cantholysis can be performed simply and safely
in the setting of decreased visual acuity following trauma. in the emergency room setting. Local anesthetic is
Manfredi et al138 have found a larger number of optic injected. The lateral canthotomy is then carried out by
canal fractures in patients sustaining blindness from placing the medial blade of tissue scissors on the lateral
facial trauma. Kellela et al have found swelling of the orbital rim and cutting at a 45-degree angle posteroinfe-
optic nerve to be the most common CT finding in riorly. Inferior cantholysis ensures that the inferior crus
patients with post-traumatic blindness, followed by frac- of the lateral canthal tendon is completely incised, result-
ture of the optic canal.139 ing in complete release of the lateral lower eyelid attach-
Retrobulbar Hematoma. The most common cause of ment (Fig. 17-38).
blindness in the setting of midfacial trauma is retrobul- An adjunct to this procedure is the placement of an
bar hemorrhage. This condition occurs in less than 1% artery clip at the lateral canthus between the upper and
of midfacial trauma injuries.140 Retrobulbar hemorrhage lower lids, with advancement toward the lateral orbital
typically occurs within the first few hours post-trauma or rim. This serves to crush the tissue and thereby limit
after surgical repair141; however, it has been reported to bleeding, and to guide the placement of the lateral
occur hours to days following the initial injury.132 The canthotomy.146
Alternatively, to allow decompression of the expanded Traumatic Optic Neuropathy

hematoma, a lateral brow incision can be followed by Treatment of traumatic optic neuropathy is controver-
subperiosteal dissection; if bleeding is extraperiosteal or sial. If a patient loses sight at the time of trauma, it is
intraconal, the periosteum should be incised. The inter- unlikely to return. Penetrating trauma and subsequent
canthal space may be entered with fine hemostats after loss of vision have a poorer prognosis than loss of vision
separation of the septum between the inferior and lateral secondary to blunt trauma. For the patient with trau-
rectus muscles. matic optic neuropathy, three commonly used treatment
Following open evacuation, drains may be placed for modalities have been described—surgical decompres-
24 hours. Proposed medical follow-up regimens include sion, high-dose steroids, and observation. Wang et al148
the following: 20% mannitol, 2 g/kg IV every 8 hours for have evaluated 61 patients by an algorithm based on the
24 hours; acetazolamide sodium, 250 mg IV every 6 degree of reduced visual acuity; they used megadose ste-
hours; and steroids, every 6 hours for 2 to 3 days. A roids in all patients and optic nerve decompression for
topical beta blocker such as timolol maleate eye drops, patients with no light perception or useless vision at 48
0.25% topical solution, 1 or 2 drops daily, has also been hours. In their series, in those with no light perception,
suggested to decrease production of aqueous humor.147 27% improved after treatment compared with 100%
Oral medication is then instituted. Surgical repair of the improvement in the light perception or better category.
facial fractures should be delayed until the resolution of Mine et al have suggested that surgical decompression
visual acuity, positively or negatively. may benefit the patient whose vision initially could per-
ceive hand motion or more.149
Superior Orbital Fissure Syndrome and
Orbital Apex Syndrome
Hirschfeld first described the superior orbital fissure and
orbital syndrome in 1858.150 The contents of the superior
orbital fissure include, from the apex downward, the
lacrimal nerve, frontal nerve, superior ophthalmic vein,
cranial nerve (CN) IV, superior division of CN III, naso-
maxillary nerve, CN VI, inferior division of CN III, and
ophthalmic vein (Fig. 17-39).
Symptoms of the superior orbital fissure syndrome are
the result of depletion of its contents. Depending on the
location and degree of involvement, they may include
A B loss of sensation over the forehead because of involve-
FIGURE 17-38 Lateral canthotomy and inferior cantholysis. ment of the frontal branch of CN V, loss of the corneal
reflex resulting from the involvement of the nasociliary
Superior orbital Levator palpebrae

fissure superioris muscle Superior oblique
muscle
Superior rectus
muscle
Trochlear nerve (IV)
Optic nerve
Lacrimal nerve
Nasociliary nerve
Frontal nerve
Inferior rectus
Ophthalmic vein
muscle
Superior division
Abducens nere (VI)
of oculomotor nerve
Inferior division Infraorbital nerve

of oculomotor nerve
Lateral rectus muscle
FIGURE 17-39 Anatomy of the orbital apex.

branch of the first division of CN V, a fixed dilated pupil

resulting from blockage of the parasympathetic supply Lacrimal gland Superior lacrimal
carried via CN III, and resultant unopposed sympathetic punctum
control of the pupil. Various presentations of external Lacrimal sac
ophthalmoplegia may also be present secondary to
involvement of CN III, IV, and VI.
Reflex and accommodation to direct light may be
affected because of blockage of the efferent arc by paraly-
sis of CN III and loss of the parasympathetic (motor) root
of the ciliary ganglion via CN III. Persistent edema is
noted because of venous obstruction of the ophthalmic
vein. Proptosis may also occur as a direct result of pres- Inferior lacrimal
punctum
sure, antral and extraconal hemorrhage, or secondary to
decreased muscle tone caused by compromised motor Nasolacrimal
innervation of the extraocular muscles. duct
Clinical signs and symptoms guide treatment. If orbital
compartment syndrome is suspected, surgical decom-
pression is immediately indicated. This is most easily
accomplished by lateral canthotomy and inferior can- Inferior meatus
and turbinate
tholysis, as discussed earlier.
The orbital apex syndrome is a superior orbital apex
syndrome with concomitant injury of the optic nerve.
This is often the result of a fracture that propagates
through the optic canal; it is managed similarly to trau-
matic optic neuropathy. Decompression of the optic FIGURE 17-40 Anatomy of the lacrimal system.
nerve, as proposed by Murakami,151 is controversial.
NEUROLOGIC COMPLICATIONS
The most frequently reported neurologic complication in the medial aspect of each eyelid (Fig. 17-40). From the
of midfacial trauma is damage to the infraorbital nerve. puncta, the ducts (usually measuring 1 cm in length)
Lund has reported a 37% incidence of infraorbital nerve travel vertically and then medially to join the lacrimal sac.
disturbance in those who underwent open reduction of The sac measures approximately 12 mm and sits within
the lower orbital rim who experienced higher rates of the lacrimal fossa. It is protected laterally and inferiorly
nerve dysfunction.152 Schmoker et al have found a 76% by the lateral limb of the medial canthal ligament and
incidence of infraorbital nerve dysfunction in the imme- medially by the weaker medial limb of the ligament. The
diate postinjury period, with a 43% incidence of long- lacrimal sac empties into the inferior meatus via the naso-
term anesthesia.153 This correlates with Waldhart’s report lacrimal duct. The duct is approximately 20 mm in
of 70% of patients with orbitozygomatic fractures who length, about 50% of which is incased in bone. The
experienced early paresthesia; 25% of cases were long portion of the nasolacrimal system that is most prone to
term.154 Haug et al have found infraorbital nerve pares- damage is the bony nasolacrimal duct,156 and 80% of
thesia to be the most common complication in 50 patients lacrimal secretions are handled by the inferior canalicu-
with maxillary fractures, with an incidence of approxi- lus. Therefore, a nonfunctional superior canaliculus will
mately 24%.155 not usually result in epiphora.
Persistent paresthesia involving the inferior palpebral, The incidence of lacrimal system injury appears to be
lateral nasal, and superior labial regions demonstrates less than originally hypothesized. Gruss et al157 have
complete nerve involvement. The infraorbital nerve may reported on 46 patients with NOE injuries and found
be damaged at any point but usually as it exits the infra- that postoperative epiphora is primarily the result of lid
orbital foramen. Care must be taken following reduction malposition and not nasolacrimal obstruction. Of this
of facial fractures or placement of orbital floor grafts to group, 17.4% required dacryocystorhinostomy. Harris
prevent compression on the nerve. If paresthesia does and Fuerste158 have recommended primary silicone intu-
not resolve within 6 months, exploration of the nerve at bation of the disrupted distal lacrimal pathway to prevent
the infraorbital foramen is indicated, particularly in case future cicatricial obstruction. The tube is left in place for
of closed reduction. 4 to 6 months. A detailed history and workup are manda-
tory before one can undertake the reconstruction of the
LACRIMAL SYSTEM nasolacrimal system effectively.
It should be noted that disruption of the nasolacrimal
ANATOMY system is not the sole cause of epiphora. Aging, with
The lacrimal system can potentially be disrupted by mid- resultant pulling away from the puncta, paralysis of CN
facial trauma, especially comminuted NOE fractures. VII, disruption of the medial canthal ligament, and
The lacrimal system consists of a lacrimal gland situated obstruction of Hasner’s valve are all potential causes of
in the anterior superolateral portion of the orbit and two epiphora. Epiphora may be secondary to trauma to the
lacrimal canaliculi that drain the eye via puncta situated region or may be a coincidental finding. A history of
iritis, dacryocystitis, allergies, previous nasal surgery, or probe demarcates the position of the sac and the location
tumor resection can indicate a cause that is unrelated to for the formation of the nasal opening. The incision is
the trauma sustained. carried medially and the orbicularis oculi muscle and
fascia are incised to reveal the medial canthal ligament.
EVALUATION The ligament is exposed and resected, the lacrimal fascia
The physical examination should include an assessment is opened, and the incision is continued inferiorly to
of the puncta for discharge and evaluation of the sac for expose the lateral and medial aspects of the sac. The sac
enlargement, redness, or fistula. One should also look is dissected free from its bony moorings and the bony
for lagophthalmos, ectropion, and patency of the puncta. ostium is made medial to the lower part of the sac with
The patency of the nasolacrimal system is determined by a 10-mm trephine bur. The lacrimal bone and part of the
the Jones I and II tests.159 The Jones I test is carried out anterior lacrimal crest are removed. The opening is
by injecting 2% fluorescein dye into the conjunctival sac enlarged with Kerrison’s forceps to measure at least
and, after 5 minutes, noting whether the dye emerges in 15 mm in length and 10 mm in width. The sac and nasal
the nose. A cotton applicator with 5% cocaine is placed mucosa are incised longitudinally opposite the ostium.
under the inferior turbinate following shrinkage of this Releasing transverse incisions are carried out superiorly
region. If no dye is noted on the applicator, the patient and inferiorly. The posterior nasal and sac flaps are
should be instructed to blow his or her nose. Alterna- sutured, as are the corresponding anterior flaps. Sutures
tively, the head should be placed in a forward position to (4-0 polyglactin 910) are used for the closure. The overly-
allow drainage to occur more freely, and not into the ing tissue is closed in layers (Fig. 17-41).
pharynx. A contraindication to the performance of a dye Hollwich161 has modified the classic technique by
test is the presence of dacryocystitis. suturing the posterior flaps of the nasal mucosa and sac.
If no dye is retrieved from the nose, the Jones II test The anterior mucosal flap of the sac is sutured to the
should be carried out to determine the location of the overlying subcuticular skin. Busse has reported a success
obstruction in the system. The dye is flushed out of the rate of 84.9% using this technique.162
sac and a cannula is inserted into the inferior canaliculus There are a few important factors to keep in mind
via an anesthetized punctum. The patient’s head is bowed when performing this procedure. The nasal bone
forward and saline is injected into the system. The opening must be large enough, its borders must be
appearance of fluid in the nose containing the dye indi- smooth so that granulomas do not form, and daily lavage
cates a partial blockage that was overcome by the injec- with Ringer’s solution should be started on the postop-
tion. This problem is amenable to surgical correction via erative day 2 and continued for approximately 4 weeks.
dacryocystorhinostomy. Similarly, dacryocystorhinostomy In the case of an obstruction of the nasolacrimal system
should be performed if there is reflux of fluid from the that was not diagnosed during the initial facial recon-
opposite punctum, indicating that the obstruction exists struction, DCR usually can be performed safely 3 to 4
at or below the level of the nasolacrimal sac. months after the initial reconstruction.
Intubation dacryocystography is a useful means of
determining the exact location of an obstructed system EMERGING SURGICAL TECHNIQUES
and is an alternative to the Jones I and II diagnostic tests.
It demonstrates the location of the disruption and loca- AND MATERIALS
tion and size of the sac.
Ashenhurst et al160 have introduced the technique of ENDOSCOPIC MANAGEMENT OF
combined CT and dacryocystography for lacrimal prob- MIDFACE FRACTURES
lems following, for example, midfacial trauma. In this Endoscopic surgical techniques have been suggested for
technique, the lacrimal system is injected with contrast smaller incisions, limited dissections, and subsequent
and the midface is scanned by CT. decreased recovery times and postoperative pain.163,164
Endoscopic surgery has also been suggested to limit
DACRYOCYSTORHINOSTOMY potential complications of various traditional incisions.
History and physical examination proceed as described In the zygomatic complex region, these include alopecia,
earlier. When the obstruction to flow is distal to the sac, blood loss, injury to the facial nerve, and sensory loss to
a dacryocystorhinostomy (DCR) should be performed. the scalp. In the inferior orbital floor and orbital rim,
This technique has undergone a number of variations. these include scarring, ectropion, vertical lid shortening,
Functionally, the procedure bypasses the nasolacrimal and eyelid edema.165 Disadvantages include limited expo-
duct by anastomosing the lacrimal sac with the nasal sure, a steep learning curve with potentially longer oper-
mucosa. ating times.166,167
This procedure is typically performed under general These techniques have been suggested for fractures of
anesthesia. The nose is packed with gauze impregnated the zygomatic arch, orbit, frontal sinus, mandibular
with a vasoconstrictor. An incision is made in the skin angle, and subcondyle, among others.168-171 Equipment
overlying the medial canthal ligament, approximately used with endoscopic surgery necessitates the use of an
1cm medial to the inner canthus, extending inferiorly endoscope with an overlying sheath to create an optical
approximately 2 cm and commencing approximately cavity for adequate visualization. Additionally, a video
0.5 cm above the level of the attachment of the medial system composed of a camera, light source, camera con-
canthal ligament. A Bowman probe is passed through the verter, and monitor is necessary. Approach, technique,
lower punctum and canaliculus to enter the sac. This and applications for endoscopic surgery are similar to
Lacrimal sac
Anterior
A Lacrimal crest B
Nasal mucosa
C D
FIGURE 17-41 Technique for DCR.
those used in routine endoscopic craniomaxillofacial orthognathic surgery, have found no statistical difference
surgery. between computer-generated predictions and postsurgi-
cal results174 (Fig. 17-42).
ADVANCES IN COMPUTER-BASED Intraoperative navigation has recently become avail-
IMAGING TECHNIQUES able commercially for midfacial surgery and is a useful
Computer-aided craniomaxillofacial surgery can be adjunct to certain common maxillofacial procedures.
divided into three interrelated categories—computer- This technique requires the establishment of fiducial
aided presurgical planning, intraoperative navigation, markers or laser surface scanning to align the three-
and intraoperative CT–magnetic resonance imaging dimensional scan with the navigational system for accu-
(MRI).172 Advances in presurgical planning include the rate intraoperative manipulation.175 These systems have
use of stereolithographic models, which can help guide been shown to allow precise positioning of fractured seg-
preoperative plate contouring and precise positioning of ments secondary to facial trauma.176
plates and fractured segments. Computer-assisted surgi- Intraoperative cone beam CT has shown to be an
cal simulation without physical models can also be used effective way to allow immediate confirmation of appro-
to plan and evaluate surgical moves virtually. Three- priate reduction of fractured segments, particularly in
dimensional CT scans can be used to mirror a contralat- complex facial fracture patterns.177 This technology also
eral unaffected side and to superimpose the image limits the need for revisional surgery with a second
precisely over the fracture site to provide an accurate general anesthetic in case of an initial suboptimal reduc-
template reconstruction.173 Tucker et al, in a recent study tion. Tsiklakis et al have mentioned an 8- to 10-fold
comparing postsurgical outcomes with three-dimensional reduction in dosage when using cone beam CT in place
surgical simulations on 14 patients undergoing of conventional CT.178 This is particularly important
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FIGURE 17-42 Stereolithographic model.
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CHAPTER
Ophthalmic Consequences of
18 Maxillofacial Injuries
Clifford R. Weir
| Gordon N. Dutton
| Isam Al-Qurainy
OUTLINE
Ophthalmic Assessment Ocular Motility Disorders Caused by Orbital Injury
History Blowout Fracture
Clinical Examination Fractures of the Orbital Roof
Examination for Structural Disorders Trauma to the Trochlea
Minor Eye Injuries Displacement of the Globe
Subconjunctival Hemorrhage and Bruised Eyelids Proptosis
Corneal Abrasion or Corneal Foreign Body Enophthalmos
Nonperforating Eye Injuries Vertical Displacement
Conjunctiva and Cornea Horizontal Displacement
Anterior Chamber Traumatic Herniation of the Globe into the Maxillary Sinus
Abnormal Depth of the Anterior Chamber Injuries to the Eyelids
Iris And Pupil Eyelid Swelling and Hematoma
Angle Recession Eyelid Lacerations
Lens Eyelid Avulsion
Ciliary Body Progressive Shortening of the Lower Eyelid
Retinal Injury and Choroidal Injury Nasolacrimal Injuries
Perforating Eye Injuries Canalicular Lacerations
Perforating Injuries of the Orbit Indirect Ophthalmic Consequences of Injury
Retrobulbar Hemorrhage Traumatic Retinal Angiopathy (Purtscher’s Retinopathy)
Clinical Features Caroticocavernous Sinus Fistula and Arteriovenous
Management Anastomosis
Traumatic Optic Neuropathy Facial Palsy
Disorders of Ocular Motility Papilledema
Disorders of Central Control of Eye Movement Relationship Between Maxillofacial and Eye Injuries
Cranial Nerve Injury
T
he globe is protected from injury by a number of eyes is mandatory for every patient who has sustained
structures and mechanisms, including the promi- midfacial trauma severe enough to cause a fracture. This
nence of the bones of the orbit and the natural chapter reviews methods of ophthalmic examination and
reflexes of self-protection—namely, blinking, averting the ophthalmic consequences of injury and provides
the head, and protecting the eye with the hand or guidelines for ophthalmologic referral.
forearm. Despite these factors, the eye may sustain injury,
but the resilient structure of the globe allows it to with- OPHTHALMIC ASSESSMENT
stand blows of considerable force without rupture.
Both prospective and retrospective studies of patients The assessment comprises the history, evaluation of visual
who have sustained midfacial fractures indicate that as function, and examination for structural disorders.
many as 40% may sustain serious ocular injury that war-
rants ophthalmologic referral.1-8 A recent study9 has dem- HISTORY
onstrated that up to 91% of patients with orbital fractures The following data are recorded:
who had an ophthalmic evaluation within 1 week of their 1. The time, place, and circumstances of the injury
injury sustained some form of ocular injury. Many of 2. The exact nature of the injury
these were classified as mild but 45% were deemed to be 3. The nature of the object that caused the injury (e.g., a
moderate or severe injuries. kick is more likely to damage the eye than a head butt)
Some ophthalmic injuries may be clearly apparent. 4. The velocity and vector of the traumatic force
However, other potentially blinding complications can 5. Whether glasses were worn (the glasses may have pro-
easily be missed unless they are actively sought. Inade- tected the eye or may have given rise to a glass foreign
quate care can result in blindness, with its attendant body entering the eye)
social and medicolegal implications. Examination of the 6. The antecedent visual status
451
How good was the vision before the injury? This infor-
mation may be important, especially if legal claims are
involved. If patients were in the armed forces, they would
have had good vision in each eye. If they had visited an
optometrist or ophthalmologist in the past, a record of
visual acuity may exist.
CLINICAL EXAMINATION
Assessment of Visual Function
At the time of initial assessment, visual acuity, which is a
measure of the resolving power of the eye, is determined
in every case of fracture of the midface if possible. Dis-
tance acuity is assessed with the patient at 6 m (20 feet)
from a Snellen chart. The test letters are constructed so
that the edges of the lines composing the letter subtend
a visual angle of 1 minute of arc when they are a certain FIGURE 18-1 Pinhole occluder and portable visual acuity device for
specified distance away. The complete test letter sub- practical assessment of visual acuity in the injured patient. When
tends a total angle of 5 minutes of arc at the eye, for an presented at 0.33 m, each line of letters approximates to the near
equivalent of 6/60 (20/200), 6/36, 6/24, 6/18, 6/12, 6/9, and 6/6,
eye with 6/6 (20/20) vision.
respectively. (Courtesy Clement Clarke International, London.)
Visual acuity is recorded as a fraction. The numerator
denotes the distance of the patient from the chart and
the denominator the line that he or she sees at this dis-
tance. For example, the top letter of the Snellen chart child points to the identical letter on a chart held by a
subtends 5 minutes of arc at the eye when read from second examiner or a parent who is sitting with the child.
60 m (200 feet). If the patient can read only the top letter
of the chart, the visual acuity is 6/60 (20/200). Visual Fields
One eye must be fully covered while acuity is deter- Visual fields are assessed in patients who have sustained
mined. If the patient cannot read at 6/6 (20/20) and yet severe head trauma, in those who are aware of a defect
does not have glasses for distance, acuity is measured in their vision, and in those whose behavior indicates that
with the patient looking through a pinhole; a device for a visual field defect may be present. Confrontation
this purpose can be easily improvised with a card and a methods of visual assessment are most commonly used
pin. If acuity improves, the most likely cause of the poor to screen for a visual field defect. However, more sensitive
acuity is a refractive error. Occasionally, acuity improves methods must be used if a minor defect is to be detected.
in patients with cataracts or opacities in the vitreous. We recommend the following strategy.
When visual acuity is less than 6/60 (20/200), the Testing Central Visual Function. The patient is instructed
distance at which the top letter can be read is recorded to look at a red object with each eye in turn, and he or
(e.g., 3/60 or 10/200). When the chart cannot be read, she is asked to compare the color for each eye. A patient
the patient is asked to count fingers (CF), and the dis- with traumatic optic neuropathy will be aware of color
tance at which this task is achieved is documented (e.g., desaturation (i.e., the red will look duller with the
CF, 0.5 m). If acuity is less than this, the perception of affected eye). Unequal pupils preclude such light bright-
hand movements is recorded as HM or the perception ness assessment because an enlarged pupil increases
of light only as PL. apparent brightness. Next, the patient is told to look at
In some patients with multiple injuries, it may be pos- the examiner’s nose with each eye in turn and is asked
sible to assess only the visual acuity for near vision. The whether any part of the examiner’s face appears to be
reduced Snellen letters subtend the same angle at the missing or blurred. This method is accurate for detecting
eye at 0.33 m as the full Snellen letters at 6 m. a paracentral scotoma, which, for example, may be
For convenience, the clinician can carry a means of caused by a choroidal tear.
assessing visual acuity for near vision in her or his pocket. Binocular Visual Field Testing by Quadrants. This method
For older patients, near acuity must be determined with is used to test for homonymous visual field defects. The
the use of reading glasses or a pinhole (Fig. 18-1) because examiner sits opposite the patient at a distance of 1 m (3
the eye’s ability to accommodate declines with age. If a feet). The patient is asked to look at the examiner’s eyes.
formal means of visual acuity assessment is not available, Both hands are placed in the lower outer quadrants and
the clinician can estimate visual acuity using a newspaper then in the upper outer quadrants. The patient is asked
or paper currency. to identify a small movement of the extended forefinger
of each hand. The examiner moves each finger in turn
Visual Acuity in Children and then moves both fingers together. The patient is
It is equally important to assess visual acuity in a child asked to point at the moving finger (or fingers). A patient
who has sustained a facial injury. The most practical with a left homonymous hemianopia, in which the left
method for a child who is unable to read letters is the field of vision in each eye is deficient, will not point to
Sheridan-Gardiner test. Single Snellen letters are shown the moving fingers on the left. A patient with a visual
to the child from a distance of 6 m (20 feet), and the inattention defect in that area will not perceive
Ophthalmic Consequences of Maxillofacial Injuries CHAPTER 18 453
movement when the finger is moved in the outer half of This occurs in defects in the visual pathway anterior to
the visual field at the same time. Inattention hemianopia the chiasm, gross retinal detachment, and traumatic
is indicative of unilateral diffuse occipital pathologic optic neuropathy.
conditions. Direct and Consensual Pupillary Reflexes. The back-
Assessment of the Central Visual Field to Confronta- ground illumination is diminished by switching off the
tion. Traumatic damage to the visual pathways is more lights or drawing the curtains. The patient is asked to
likely to cause impairment of the central 30 degrees of fixate into the distance to relax his or her accommoda-
the visual field than of the periphery. Therefore, a small tion. A penlight source is used to illuminate the eyes
target, such as a small red pin, should be used to screen from below, but not from the front, because such lighting
for such defects. The examiner sits opposite the patient could cause an accommodative reflex. The light is shined
and closes one eye. The examiner asks the patient to twice into one eye, and first the direct and then the con-
cover her or his corresponding eye with the palm of the sensual reflexes are observed. The procedure is repeated
hand and to fixate on the examiner’s open eye. The red for the other eye. An obvious afferent pupillary defect,
target is introduced from the periphery to the center in which the pupil reacts poorly to direct stimulation but
along a coronal plane halfway between the examiner and briskly to consensual stimulation, can be detected by this
the patient. The patient is instructed to say “now” as soon method.
as he or she becomes aware of the head of the pin. The Swinging Flashlight Test. This test is used to detect a
examiner is specifically looking for a quadrantic field subtle defect caused, for example, by incomplete optic
loss; therefore, the pin is introduced into the fields along nerve damage. The pupils are illuminated in the same
the oblique meridians (if the examiner tests only in the manner, but on this occasion the light is shined into each
horizontal and vertical meridians, she or he may miss the eye for about 2 seconds and then swung rapidly to illu-
field defect). minate the other eye. For an incomplete right afferent
To determine the sensitivity of the technique, the pupillary defect, when the light is shined into the right
examiner checks the position and dimensions of the eye, both pupils constrict. When the light is swung to the
blind spot by placing the target in his or her own blind left eye, both pupils constrict further. When the light
spot. The examiner’s blind spot should correspond reilluminates the right eye, the pupils return to their
approximately to that of the patient. previous resting position and dilate slightly. This
Testing Peripheral Visual Field. The examiner tests technique can be used even in the presence of a unilat-
peripheral vision using a large white pin. The patient is eral third nerve palsy, in which one pupil is poorly reac-
asked to cover one eye. Sitting opposite the patient, the tive or nonreactive. The swinging flashlight test is
examiner introduces the target from behind the patient performed and the size of the contralateral pupil is deter-
and moves it in an arc of an approximate radius of 0.33 m mined for both its direct and its consensual reflexes. Any
(1 foot), centered on the patient’s eye. The target should difference in size indicates a relative afferent pupillary
be identified as soon as it comes into the extreme periph- defect.
eral field of vision. This technique can be modified for For example, a fracture at the right orbital apex may
use in children. One eye of the child is patched. The damage the right oculomotor and optic nerves. The right
child is given a toy to play with. The examiner stands pupil would, therefore, not react directly or consensually
behind the child and introduces the target into the because of the oculomotor nerve damage. However, the
periphery. As soon as it is seen, the child turns his or her diameter of the left pupil will be smaller for its direct
head to look at the target. response than for the consensual response from illumi-
Subjective Visual Field Assessment. Occasionally, all nating the right eye.
these tests may be normal, but the patient still complains
of impaired vision. The examiner sits opposite the
patient. The examiner closes one eye and covers the cor- EXAMINATION FOR STRUCTURAL DISORDERS
responding eye of the patient. The patient is asked to Examination of the Anterior Segment
fixate on the examiner’s pupil, and the examiner places Careful examination of the anterior segment of the eye
the red pin close to the patient’s face in each quadrant is essential if clinical signs of ocular trauma are to be
of the patient’s visual field adjacent to the examiner’s detected. Ideally, a slit lamp microscope should be used.
eye. The patient is asked to compare the colors in each Operating loupes with focal illumination provide a useful
position. In particular, in cases of traumatic chiasmatic alternative. The anterior segment of the eye is examined
damage, the patient is aware of color desaturation in the carefully for any of the pathologic conditions described
upper temporal fields, but no other detectable visual in the next section.
field defect may be noted with any of the other methods
used. Ophthalmoscopy Through Dilated Pupils
When a visual field defect is detected, more accurate This test is indicated for all patients with reduced visual
charting of the defect by perimetry may be necessary to acuity. Tropicamide 1% produces rapid pupillary dilation
determine the pattern and extent of the defect. with little effect on accommodation and with a return to
normal within 3 hours. The addition of phenylephrine
Pupils 10% may be necessary for those patients with pigmented
If the patient’s visual acuity is reduced and shows no irides the examiner must check first for any history of
improvement with use of the pinhole, the pupils are cardiac dysrhythmia or systemically administered mono-
tested to seek evidence of an afferent pupillary defect. amine oxidase inhibitors.
The contraindications to pupillary dilation are as 4. To observe a scene through a keyhole, the eye
follows: needs to be placed close to the keyhole. The same
1. An iris-supported intraocular lens, which could be principle applies to ophthalmoscopy—the closer to
dislodged if the pupil were dilated the patient’s eye is the examiner, the wider the
2. A history of intermittent blurring of vision and pain angle of view.
in the eye, suggestive of angle-closure glaucoma 5. To examine the fovea, the patient is asked to look
3. A shallow anterior chamber at the light.
Although the optic disc can be assessed without dilat- 6. To examine the peripheral retina, the patient is
ing the pupil, the central and surrounding retina cannot asked to move her or his eyes in sequence in differ-
be adequately examined. ent directions. When the patient looks up, the
The reader will no doubt be conversant with the examiner is looking at the upper retina as it is
normal appearance of the retina (Fig. 18-2) and the use brought down into view; the same principle applies
of the direct ophthalmoscope. The following hints may, to the other positions of gaze.
however, be of value:
1. The examiner looks through the ophthalmoscope Examination of Eye Movements
from a 0.33-m (1-foot) distance, examining the red Eye movements are commonly impaired following facial
reflex initially. By this means, the examiner can and head injury. It must be remembered, however, that
identify any opacities in the media—for example, an antecedent squint is not uncommon. Moreover, ptosis,
vitreous hemorrhage or traumatic cataract. blurred vision as a result of the eye injury, amblyopia, and
2. The patient is asked to fixate into the distance with a history of patching of the eye in childhood all may
the other eye. If the patient focuses for near vision, prevent the patient from experiencing double vision. Eye
the examiner will have difficulty in focusing the movements are therefore objectively assessed in all
ophthalmoscope. patients who have sustained an injury likely to be com-
3. If a bright light reflex gets in the way, the light is plicated by a motility disorder (e.g., a blowout fracture).
reflecting from the cornea. If the ophthalmoscope Figure 18-3 indicates the primary directions of action of
is rotated very slightly, the light reflex will diminish each of the extraocular muscles. The eye movements into
or disappear, because it will no longer be reflected each of these positions of gaze are examined.
back along the examiner’s visual pathway. The assessment of eye movements is a skilled proce-
dure. The following strategy is suggested as a means of
identifying patients who warrant referral.
The examiner sits directly opposite the patient and
uses a penlight to examine the eye movements. The pen-
light is moved in a manner similar to that for peripheral
visual field testing. The light is held at approximately
0.33 m (1-foot) from the patient. The examiner observes
the exact position of the light reflexes on the cornea with
respect to the pupil. The patient is asked to follow the
light. The light is moved in an arc into each position of
gaze, with the light constantly directed at the eyes. The
symmetry of the light reflexes and symmetry of the
positions of gaze are closely examined (see Fig. 18-3).
The skilled observer is able to detect most motility
disorders.
The cover-uncover test is performed while the patient
fixates on the light in the primary position of gaze and
in the positions of gaze in which double vision is experi-
enced and a motility disorder has been detected. An eye
occluder or a piece of a card is used. The examiner
watches one eye and covers the other one. The eye that
the examiner is watching should not move. If the eye
FIGURE 18-2 The normal optic disc and retina. does move to look at the light, it is a squinting or deviated
SR IO IO SR
LR MR MR LR
FIGURE 18-3 Actions of the extraocular
muscles. IO, Inferior oblique; IR, inferior rectus;
LR, lateral rectus; MR, medial rectus; SO,
IR SO SO IR
superior oblique; SR, superior rectus.
eye. The procedure is repeated for the other eye. This

method provides an objective means of validating and
quantifying the patient’s subjective double vision.
Forced Duction Test. This test can be performed on a
patient with a motility disorder in whom the differential
diagnosis between entrapment and muscle weakness is in
doubt. Topical local anesthetic (e.g., benoxinate) is
instilled into both eyes. The conjunctiva in line with the
muscle in question is grasped just adjacent to the corneo-
scleral junction (the limbus) with a pair of fine-toothed
forceps and the globe is gently rotated. The procedure
is repeated for the other eye to allow a comparison
between both eyes to be made. The force required for
rotating the globe is estimated in relation to the normal
contralateral eye. Tethering of the globe is indicative of
entrapment.
An alternative means of rotating the globe is to use a FIGURE 18-4 Subconjuctival hemorrhage.
cotton swab (cotton-tipped applicator) soaked in local
anesthetic and to rotate the globe by pressing the swab bruising of the eyelid suggests orbital hemorrhage. Such
onto the eye and applying a tangential force. With prac- bruising is usually benign, but it may be related to severe
tice, this method can be equally sensitive and is less likely ocular injury. Careful examination of the eye is required
to cause subconjunctival hemorrhage. However, it should in every case.
be noted that in our experience, not all patients will
tolerate the forced duction test. CORNEAL ABRASION OR CORNEAL FOREIGN BODY
This injury causes severe pain, blurring of vision, photo-
Position of the Globe phobia, and lacrimation, except in the presence of
In every case of facial fracture, the position of the eye corneal anesthesia. Loss of the corneal epithelium may
should be carefully examined. The eyes may be displaced be caused by direct injury to the eye or inadequate eyelid
in any one of three dimensions. closure as a result of facial palsy, eyelid laceration, or
Horizontal Displacement. This displacement is mea- injury during surgery. Alcohol-based skin preparations,
sured by comparing the distance from the center of the incomplete eyelid closure, and accidental injury to the
bridge of the nose to the center of the pupil on each cornea during surgery all must be carefully avoided.
side. When such a lesion is suspected, fluorescein stain allows
Vertical Displacement. Vertical displacement is most a diagnosis to be made.
easily assessed with the use of a short, clear plastic ruler,
which is held horizontally with reference to symmetrical Treatment
landmarks, such as the eyebrows. Any vertical displace- After the administration of one drop of topical local
ment of one eye with respect to the other is then mea- anesthetic, which allows clinical examination and gives
sured with a second ruler. A vertical displacement of the temporary pain relief, a medium-acting cycloplegic agent
globe may be misinterpreted as a squint; however, the such as cyclopentolate (24 hours), which alleviates pain
light reflexes are symmetrical and there is no diplopia. caused by ciliary spasm, and a topical antibiotic such as
Anteroposterior Displacement: Enophthalmos or Exoph- chloramphenicol are instilled. If a foreign body is present,
thalmos. This displacement is most accurately measured it is removed. A corneal foreign body is removed with
with an exophthalmometer. These instruments, however, great care, preferably using binocular magnification.
use the lateral orbital margin as the reference point, The physician can usually lift off a foreign body on the
which precludes their use in patients in whom there is surface of the cornea by using a hypodermic needle held
bone displacement or asymmetrical swelling of the soft tangentially to the corneal surface, ensuring throughout
tissue of the orbital margin. An alternative means of the procedure that the patient is unable to move forward
assessment in these cases is to examine the patient from toward the needle. One drop of a topical nonsteroidal
above, comparing the positions of the corneas with anti-inflammatory preparation is then instilled to allevi-
respect to the supraorbital margins. With experience, a ate pain.10
fairly accurate assessment can be made with this method.
NONPERFORATING EYE INJURIES
MINOR EYE INJURIES A blunt injury severe enough to cause an orbital fracture
may also damage the eye. Depending on the nature,
SUBCONJUNCTIVAL HEMORRHAGE AND direction, and force of the injury, any anatomic compo-
BRUISED EYELIDS nent of the globe may be disrupted. The effects of blunt
Subconjunctival hemorrhage (Fig. 18-4) with bruised injury can be divided into those resulting from distortion
eyelids commonly follows midfacial injury. Blood may and those resulting from concussion. Both types of injury
track forward from an orbital injury, or bleeding may are commonly seen in the same eye.
take place locally. A clear demarcation line to the
A high-speed anteroposterior force results in marked Loss of the corneal epithelium (Fig. 18-7) is fairly
distortion of the globe (Fig. 18-5). The eye is transiently common and causes the same signs and symptoms as a
deformed, with notable distention in the coronal plane corneal erosion. The corneal endothelium is comprised
and shortening of the anteroposterior dimension. The of a monolayer of cells that probably do not replicate
sclera is inelastic and the aqueous and vitreous cannot following injury. Their function is to maintain the clarity
be compressed. The iris, ciliary body, zonule of the lens, of the cornea by pumping water out of the cornea and
and peripheral retina may be torn from their insertions into the anterior chamber. Damage to the corneal endo-
and, in severe cases, the sclera may rupture. Distortion thelium results from a combination of contusion, reac-
of the posterior segment of the eye can result in a tear tive inflammation, and raised intraocular pressure.11 This
of the choroid associated with subretinal hemorrhage condition may culminate in permanent edema if the
and, in the most severe case, avulsion of the optic nerve endothelial cell population is reduced below a critical
from the globe. level. Recovery of corneal clarity can take place in some
The concussional component of the injury results patients after a number of months. However, if corneal
from a coup-contrecoup effect. The cells of the cornea, edema is persistent, a penetrating corneal graft may be
lens, retina, and choroid all are susceptible to such injury required to restore visual function.
and may transiently or permanently cease to function.
In this section, the results of injury to each component ANTERIOR CHAMBER
of the eye are discussed separately. However, almost any The anterior chamber comprises the space between the
combination of injuries can occur, which can occasion- cornea and iris and is occupied by aqueous fluid secreted
ally result in disorganization of the structures of the from the ciliary processes. Blunt trauma can result
globe (Fig. 18-6). in bleeding in the anterior chamber, or hyphema (Fig.
18-8), and inflammation.
CONJUNCTIVA AND CORNEA
Swelling of the conjunctiva (chemosis) is common in Hyphema
association with subconjunctival hemorrhage and resolves Hyphema, or bleeding in the anterior chamber, probably
spontaneously. A tear of the conjunctiva is suggestive of results in most cases from tearing of blood vessels at the
a more severe blunt injury. In every case, internal injury root of the iris.12 When the patient is upright, the blood
to the globe must be sought. settles at a fluid level, the height of which should be
FIGURE 18-5 A, B, Distortion of the eye produced by

anteroposterior injury to the globe. During the brief
period of distortion, the coronal diameter is elongated
and the zonule, iris, ciliary body, and vitreous adhesions
to the peripheral retina are stretched (arrows 1 and 2),
resulting in lens subluxation, angle recession or
iridodialysis, cyclodialysis (rare), and retinal dialysis,
respectively.
FIGURE 18-6 Disorganized anterior segment. The normal FIGURE 18-7 Corneal erosion stained with fluorescein dye. There
structures within the anterior chamber are not recognizable. is also a diffuse subconjunctival hematoma caused by the injury.
FIGURE 18-9 Iridodialysis. The superior iris has been ripped from
its insertion by a blunt compressive eye injury.
FIGURE 18-8 Horizontal fluid level of blood in the anterior chamber

(hyphema) secondary to blunt eye injury. An iridodialysis is also
present superiorly.
measured daily. The amount of bleeding is related to the

long-term prognosis.13 A history of blurring of vision after
the patient lies down, which gradually clears spontane-
ously when the patient is erect, indicates that a small
hyphema may have been missed. Most patients with
hyphema are admitted to the hospital and observed. In
most cases, spontaneous resorption of hemorrhage takes
place but, in a small proportion, rebleeding can occur.
Severe hemorrhage may be associated with impairment FIGURE 18-10 Traumatic mydriasis. Arrows indicate the points at
in the drainage of aqueous, which leads to a raised intra- which the pupil sphincter has been torn.
ocular pressure. Under these circumstances, bloodstain-
ing of the cornea may take place and surgical intervention
may be necessary.
IRIS AND PUPIL
Traumatic Iritis An iridodialysis (Fig. 18-9) results when the iris is ripped
Traumatic iritis is common. Injury to the iris results in from its root. This condition is clearly apparent on direct
the release of protein and inflammatory cells into the ophthalmoscopy because a red reflex is seen through the
anterior chamber, which can be observed by means of a tear and through the pupil.
slit lamp microscope. Traumatic iritis is treated by using Traumatic mydriasis (Fig. 18-10) is common following
topical steroids (e.g., dexamethasone, betamethasone) blunt eye injury. In this case, the pupil fails to react
and a pupillary dilator (e.g., atropine). This treatment directly and consensually. Pupil sphincter rupture can be
prevents the iris from sticking to the lens behind (poste- seen with the slit lamp. This injury produces a widely
rior synechia). dilated pupil and is permanent. On the other hand, a
mid-dilated pupil without a pupil sphincter rupture ordi-
ABNORMAL DEPTH OF THE ANTERIOR CHAMBER narily recovers its function during the ensuing weeks.
On macroscopic examination, the anterior chambers are A spastic miosis (small pupil) is common after less
compared by viewing each eye obliquely from the side to severe blunt injury to the globe. In such cases, the miosis
provide an approximate estimate of depth. The slit lamp may be accompanied by a transient spasm of accommo-
is used to obtain a more accurate assessment. Shallow- dation brought about by axonal reflexes. This spasm
ness of the anterior chamber may suggest hemorrhage may be followed within minutes or hours by a paralytic
into the choroid, a choroidal detachment, swelling of the mydriasis.
lens, or leakage of aqueous through a penetrating wound. Care should be taken to exclude other causes of pupil-
Deepening of the anterior chamber suggests that the lens lary dilation, such as an antecedent Adie’s pupil and, in
may have subluxated or dislocated posteriorly. the unconscious patient, a palsy of cranial nerve III
FIGURE 18-12 Traumatic posterior subcapsular cataract. This red

reflex photograph illustrates the sunflower appearance that
characterizes this type of cataract.
FIGURE 18-11 Subluxation of the lens. The edge of the lens is

seen to be distinct from the dilated pupil margin. dislocation is an ophthalmic emergency because it may
interfere with the flow of aqueous and cause an unusual
form of acute glaucoma.
resulting from intracranial injury, with tentorial hernia- Both subluxation and dislocation of the lens result in
tion of the cerebrum. a change in the patient’s refraction. However, in such
cases, the injury is likely to have been severe enough to
ANGLE RECESSION give rise to other causes of visual impairment. In addi-
In some cases, the iris may be partially stripped from its tion, the lens is likely to develop opacities (cataract) with
root without being torn completely. In severe injury, this time.
tearing may take place for the 360-degree circumference Small, discrete subepithelial and subcapsular lens
of the eye. Lesser degrees of angle recession are more opacities or a rosette-shaped posterior subcapsular cata-
common. ract (Fig. 18-12) may develop shortly after severe concus-
This injury results in damage to the cells that line the sive injury. In serious cases, the pupillary margin is
surface of the trabecular meshwork. As the name implies, impacted on the anterior surface of the lens and leaves
this structure is like a fine three-dimensional web or a pigmented ring (Vossius’ ring) deposited on the ante-
sponge through which the aqueous passes into the canal rior lens capsule. The presence of such a ring indicates
of Schlemm and then returns to the bloodstream. Sub- that the injury has been very severe and that the eye
sequent fibrosis and scarring in the region of the angle should be thoroughly examined for other pathologic
can diminish the outflow of aqueous, thereby resulting conditions.
in increased intraocular pressure and the development Rupture of the lens capsule may also take place. This
of secondary glaucoma.14,15 Angle recession occurs at the rupture allows aqueous humor into the lens, which then
time of injury and may be seen by gonioscopic examina- becomes opalescent. Release of soft lens matter into the
tion (slit lamp examination with the use of a prism system eye can result in severe inflammation. Lens protein is
to see into the angle) permanently thereafter. It can, sequestered from the immune system during embryonic
however, be easily missed if this examination is not development and is thus perceived by the immune system
carried out. The medicolegal implications are obvious. as foreign. This situation can result in a severe inflamma-
tory reaction in the eye, with raised intraocular pressure.
LENS Surgical removal of the lens is indicated in these cases.16
Subluxation of the lens (Fig. 18-11) is most easily diag-
nosed following full dilation of the pupil. The margin of CILIARY BODY
the subluxated lens can then be seen. Additional clinical The functions of the ciliary body are to produce aqueous
signs include a reduction in visual acuity, deepening of humor, which provides nutriment for the eye and main-
the anterior chamber, and wobbling of the iris, which is tains the intraocular pressure, and brings about accom-
seen as a fine shimmer as the patient moves the eye modations of the lens. When the ciliary muscle contracts,
(iridodonesis). the zonule relaxes and the lens adopts a more biconvex
In severe cases, the lens may be dislocated. In this situ- shape, which causes the eye to focus for near vision.
ation, it lies freely in the vitreous and an aphakic correc- Damage to the ciliary body can therefore result in
tion is required to allow the patient to see. Rarely, the impairment in the formation of aqueous and a conse-
lens may dislocate into the anterior chamber. This quent reduction in intraocular pressure. Moreover, injury
to the ciliary muscle gives rise to impairment in accom-

modation, which is a fairly common short-term sequela
of eye injury.17 The patient complains that he or she has
difficulty in focusing, and clinical examination reveals
that the near point of accommodation (the nearest point
at which he or she can focus clearly) is farther away than
before the injury. No specific treatment exists for either
of these conditions. The intraocular pressure is normally
restored during the few days following injury, and accom-
modation similarly recovers spontaneously in most cases.
Traumatic cyclodialysis refers to the tearing of the
ciliary body from its root. This condition is unusual and
results from severe blunt eye injury. A persistent, very low
intraocular pressure may indicate that a cyclodialysis has
taken place.
Changes in Intraocular Pressure
Reduced Intraocular Pressure. The intraocular pressure
is commonly reduced after blunt trauma to the eye. The
normal range of intraocular pressure is 12 to 20 mm Hg.
A pressure between 5 and 10 mm Hg may follow blunt FIGURE 18-13 Pathologically cupped optic disc.
injury, presumably because of damage to the ciliary body.
However, the intraocular pressure may be reduced to 0
to 2 mm Hg when the differential diagnosis includes
cyclodialysis, scleral rupture, and severe diffuse injury to
the ciliary body. A persistently low intraocular pressure
may be associated with choroidal effusions.
Raised Intraocular Pressure. Glaucoma can be defined
as a condition in which the intraocular pressure is suffi-
ciently increased to cause damage to ocular structures,
whether it be transient or permanent. Ocular hyperten-
sion, on the other hand, is a condition in which the
intraocular pressure is increased without detectable
damage to the eye.
The causes of increased intraocular pressure include
angle recession, traumatic iritis, hyphema, blockage of
the trabecular meshwork by lens debris, and ghost cell
glaucoma, which is a condition that occasionally follows
hemorrhage into the vitreous. Multiple ghost cells, which
are erythrocytes without hemoglobin, are seen by histo-
FIGURE 18-14 Retinal detachment. A severe blunt injury has
logic examination to occlude the trabecular meshwork.
resulted in intraretinal hematoma and retinal detachment.
Rarely, a marked acute increase in intraocular pres-
sure may occur following eye injury. It causes severe pain,
photophobia, and a sensation of seeing halos around
lights. Clinical examination reveals a mid-dilated nonre- blunt eye injury can result in the retina being torn.
acting pupil, circumlimbal injection (i.e., a red eye, par- This condition causes a retinal dialysis (Fig. 18-15) or
ticularly the area of the sclera close to the cornea), and the formation of a retinal hole, because the distor-
hardness of the eye on palpation. Corneal edema pre- tional forces produce vitreous traction at the retinal
vents examination of the posterior segment by direct periphery.
ophthalmoscopy. On the other hand, a gradual increase It has been suggested that almost all cases of retinal
in intraocular pressure may cause no symptoms or a mild dialysis are secondary to trauma.20 Approximately 10% of
aching pain around the eye. In the chronic case, gradual traumatic retinal detachments occur immediately, 70%
cupping of the optic nerve head ensues, with progressive within 2 years, and 20% more than 2 years after injury.21
loss of the visual field (Fig. 18-13). Injuries to the globe may also cause changes in the
vitreous (syneresis) in which the vitreous gel collapses
and tearing of the peripheral retina results. The patient
RETINAL INJURY AND CHOROIDAL INJURY may complain of the sudden development of floaters—
Retinal Detachment because of the condensation of the vitreous and vitreous
The distortional effects of concussive injury may cause hemorrhage—accompanied by a sensation of flashing
retinal detachment (Fig. 18-14)18,19 The vitreous gel is lights in the periphery of the vision. Any patient having
firmly adherent to the peripheral retina, and the acute these symptoms should be carefully examined by a
coronal distention that accompanies anteroposterior surgeon who specializes in retinal detachment.
FIGURE 18-16 Traumatic retinal edema.
FIGURE 18-15 Retinal dialysis. This peripheral retinal photograph

shows the torn edge of the retina, which is curled over.
The embryonic derivation of the eye is such that the

retina is not firmly adherent to the underlying pigment
epithelium. If a hole or tear develops, fluid derived from
the vitreous may pass through the hole and gradually lift
the retina off. As soon as the retina is detached, the part
that is detached does not function.
Treatment of a retinal detachment is complex and not
always successful in restoring normal vision. Therefore,
it is important to prevent retinal detachment by sealing
retinal holes by means of photocoagulation or cryother- FIGURE 18-17 Macular hole. A central retinal hole has resulted
apy. All patients who have sustained significant blunt following a blunt ocular injury.
ocular injury sufficient to cause any of the internal ana-
tomic disturbances described earlier should be seen by a
surgeon specializing in retinal detachment to screen for Traumatic Pigmentary Retinopathy
and treat peripheral retinal breaks and tears. Following a very severe blunt injury to the retina, photo-
Exudative retinal detachment is a rare sequela to receptor disruption and damage to the pigment epithe-
blunt eye injury. Extensive blunt injury to the retina can lial cells occur to such an extent that post-traumatic
result in the accumulation of subretinal fluid, presum- replication and migration of pigment epithelial cells give
ably because the pigment epithelium is damaged to such rise to a clinical pattern indistinguishable from that of
an extent that it is unable to pump the water through retinitis pigmentosa. This condition is accompanied by
into the choroid. In these cases, the retina may flatten little recovery of function.23,24
spontaneously, but the prognosis for the recovery of
vision is poor. Retinal and Vitreous Hemorrhage
Rupture of the blood vessels may be accompanied by
Traumatic Retinal Edema hemorrhage into the retina and into the vitreous, with
Traumatic retinal edema is also known as commotio loss of vision. Spontaneous recovery of vision accompa-
retinae, or Berlin’s edema (Fig. 18-16). If the injury nies resolution of the vitreous hemorrhage. Occasionally,
involves the retina of the posterior pole, the patient com- fibrosis in the vitreous can result in a tractional retinal
plains of rapid loss of vision following the injury. However, detachment.
if the injury is more peripheral, the patient may be
asymptomatic because only the peripheral visual field is Macular Hole
affected. Most patients report a gradual improvement in Macular holes (Fig. 18-17) are also observed following
vision although in some cases, however, severe injury may blunt trauma from detachment of the vitreous or as a
result in a more prolonged recovery.22 sequela of retinal edema.25
FIGURE 18-18 A traumatic choroidal tear has resulted in a

subretinal hematoma, which is clearing to reveal the tear passing
through the macula. FIGURE 18-19 Optic nerve avulsion. Severe trauma has resulted in
the optic nerve’s being avulsed from the eye.
Choroidal Tear
Tears of the choroid (Fig. 18-18) characteristically occur accompanied by restoration of intraocular pressure and
circumferential to the optic disc and follow concussional prevents the complication of fibrous ingrowth.
injury in which the eye is severely compressed and dis-
torted. The patient is aware of loss of central vision. This Avulsion of the Optic Nerve
loss of vision is attributable initially to extensive subreti- In very severe injuries, the optic nerve may be avulsed
nal hemorrhage. At this stage, the tear of the choroid from the eye, with accompanying permanent loss of
cannot be seen. Over the ensuing weeks, as the hemor- vision (Fig. 18-19).
rhage resolves, the choroidal tear becomes apparent. A
line of underlying white sclera, usually concentric with PERFORATING EYE INJURIES
the optic disc, can be seen on ophthalmoscopy. If the
tear does not pass through the fovea, the prognosis for It is important to recognize that perforation of the globe
spontaneous recovery of vision is good. However, a lesion may accompany orbital fractures, particularly in patients
beneath the fovea results in loss of central vision. A cho- who have been involved in motor vehicle accidents. Any
roidal tear can be complicated by the development of patient who has sustained multiple facial lacerations
abnormal new blood vessels beneath the retina, which must be suspected of having a corneoscleral laceration
may themselves bleed. In some cases, such a lesion may until proven otherwise.
warrant laser photocoagulation. Therefore, all patients A detailed history of the nature of the circumstances
with a choroidal tear should be evaluated and followed surrounding the injury is necessary. Penetrating injuries
up by an ophthalmologist. still continue to be missed and are a major source of liti-
gation. Perforation may be caused by a small, fast-flying
Choroidal Effusion missile—resulting in a retained intraocular foreign
In cases of ocular hypotonia (see earlier), the choroid body—or by a sharp implement (Fig. 18-20).
may detach from the underlying sclera because of the With perforating eye injuries, the examiner ascertains
accumulation of underlying plasma-like fluid. Treatment the patient’s visual acuity, when possible. The eye is
of the hypotonia (e.g., by closing a scleral rupture surgi- inspected with great care, with the examiner taking every
cally) usually results in spontaneous reapposition of the precaution to preclude pressure on the globe, which
choroid. could result in the herniation of ocular contents. There-
fore, the eyelids are retracted without direct pressure on
Scleral Rupture the eyeball. The eye and adnexa are examined for the
It is important to recognize that a rupture of sclera may following:
be silent and the only clinical sign is ocular hypotonia. If 1. Laceration or perforation of the eyelids
a scleral rupture is not repaired, persistent hypotonia or 2. Evidence of a foreign body
the ingrowth of fibrous tissue into the eye may develop. 3. Perforation of the globe
In addition, sympathetic ophthalmia, in which inflamma- 4. Asymmetry of the pupil, which could be a result of
tion of the other eye occurs, may rarely complicate scleral prolapse of the iris
rupture. 5. Opacification of the ocular media caused by intra-
Surgical exploration is indicated for most cases of per- ocular hemorrhage
sistent hypotonia for which there is no alternative expla- 6. A shallow anterior chamber
nation, because repair of the scleral rupture is usually 7. Prolapse of the iris, ciliary body, or vitreous
FIGURE 18-21 Chorioretinal necrosis and hematoma from an

FIGURE 18-20 Impact site of an intraocular foreign body, which airgun pellet injury to the sclera.
struck the retina just below the optic disc.
Radiologic examination is also mandatory for all cases

of suspected retained intraocular foreign bodies. All
patients with confirmed or suspected perforating eye
injuries should be transferred immediately to the care of
an ophthalmologist for further evaluation.
A prognostic model, the ocular trauma score, has
been developed to predict the visual outcome of patients
following ocular trauma.26 Poor initial visual acuity, globe
rupture, endophthalmitis, retinal detachment, and the
presence of a relative afferent papillary defect are all
predictors of a poor outcome.
PERFORATING INJURIES OF THE ORBIT

Nonorganic intraorbital foreign bodies, such as airgun
pellets, are usually inert, and it may be deemed safer to
leave such a foreign body in the orbit than to remove it.27 FIGURE 18-22 Splinter of wood within the nasal aspect of the right
However, if an airgun pellet is immediately accessible, orbit.
surgical removal is indicated. An airgun pellet may rico-
chet off the sclera as it enters the orbit. Therefore, full
clinical examination of the peripheral retina is indicated
in every case because necrosis of the choroid and retina probably causes no problem, but arterial hemorrhage
occurs at the impact site (Fig. 18-21) and subsequent can lead to compromise of optic nerve function and
retinal detachment may ensue. This detachment can be central retinal artery obstruction. This complication is
prevented by appropriate and timely surgery. most likely in young individuals, in whom the orbital
A high index of clinical suspicion is necessary if there septum is inelastic and impermeable, thus preventing
is a small perforating wound of the eyelid. A detailed spontaneous decompression by anterior displacement of
history may provide useful information. A foreign body the globe and leakage of blood into subcutaneous tissue.
retained in the orbit may be radiopaque, but organic Arterial bleeding may occur as a direct result of the
material, such as a thorn or piece of wood (Fig. 18-22), injury, perhaps from rupture of the infraorbital artery or
may be radiolucent and may require computed tomog- of the anterior or posterior ethmoidal arteries, or it may
raphy (CT) for optimal imaging. Detailed scrutiny is occur as a postoperative complication of surgical explo-
required to exclude orbitocranial injury or globe ration of the orbit.
perforation.28
CLINICAL FEATURES
RETROBULBAR HEMORRHAGE The patient complains of a severe aching pain accompa-
nied by progressive loss of vision. Proptosis occurs and is
Intraorbital hemorrhage is a common sequela to midfa- accompanied by increased intraocular pressure, marked
cial fracture. In most cases, this problem resolves spon- subconjunctival hemorrhage, and gross eyelid swelling.
taneously, with no adverse sequelae. Venous hemorrhage As vision is lost, the pupil becomes fixed and dilated.
MANAGEMENT DISORDERS OF OCULAR MOTILITY

Arterial bleeding within the orbit is an ophthalmic emer-
gency. The visual acuity, pupillary reaction, and intraocu- Disturbances in ocular motility following trauma may
lar pressure are recorded initially at 5-minute intervals. arise from the following: (1) disorders of the central
In the unconscious patient, reliance is placed on the control of eye movement; (2) injury to cranial nerves III,
pupillary reaction and intraocular pressure alone. In IV, or VI; or (3) orbital injury with associated muscle
some cases, spontaneous decompression takes place and injury or entrapment.
surgical intervention is not required. In this situation,
progressive loss of vision, proptosis, and elevation of
intraocular pressure are documented for the first 10 to
20 minutes, but the vision spontaneously recovers there- DISORDERS OF CENTRAL CONTROL OF
after. No treatment may be required. EYE MOVEMENT
If, after 20 minutes, spontaneous recovery does not These disorders include horizontal and vertical gaze
occur, the loss of vision is progressive, the intraocular palsies, impairment or failure of convergence, and loss
pressure becomes notably increased (e.g., 30 to 40 mm of fusion. They are more likely to occur following closed
Hg; normal range is 12 to 20 mm Hg), and the pupil head injury.
reaction becomes sluggish, immediate therapeutic
intervention is required. In the postsurgical case, the Impairment or Failure of Convergence
surgical wound is opened and blood may escape under This impairment may follow a closed head injury. The
pressure. The patient may be aware of an immediate exact pathogenesis is uncertain but may be related to
spontaneous improvement in vision and the normal upper midbrain injury. When convergence is impaired,
pupillary reaction returns. The source of bleeding is the patient complains of difficulty in reading and looking
arrested. at near objects. Complete paralysis of convergence causes
In other cases, the source of bleeding may not be symptoms of double vision whenever the patient attempts
known. The patient may be treated medically with a slow to focus for near vision. In most cases, spontaneous
IV injection of acetazolamide (adult dose up to 500 mg), recovery takes place.17
which reduces intraocular pressure. When the site of the
hemorrhage is not known, surgical treatment includes Loss of Fusion
lateral canthotomy, in which the palpebral aperture is Loss of fusion of the images from both eyes may result
widened, and lateral cantholysis, in which a pair of in double vision. It is an unusual but well recognized
sharp-pointed scissors is used to divide the lateral consequence of a closed head injury.35 In this condition,
canthal ligament. This procedure allows the globe to the patient is unable to maintain single fused images
move forward and facilitates the escape of blood from when synoptophore, prism, or stereoscopic tests are
the orbit. It is usually accompanied by a temporary and used. Trauma is also a well-recognized cause of the break-
sometimes permanent improvement in vision.29 If down of a preexisting latent squint that has received
imaging facilities are available, an immediate orbital CT orthoptic treatment by patching in the past. The patient
scan is performed and any locule of blood is drained. complains of constant diplopia. Both cerebral contusion,
When a CT scan is not available and visual function with or without skull fracture, and whiplash injury may
deteriorates further, division of the orbital septum supe- cause this problem. Spontaneous recovery may or may
riorly and inferiorly, with insertion of drains, is carried not occur.36 Because all tests of fusion require a subjective
out. Only rarely is this procedure accompanied by the assessment by the patient, the results may on occasion be
release of hemorrhage; however, it does allow for pro- difficult to interpret, especially when compensation is
lapse of orbital fat and thereby gives rise to orbital involved.
decompression, which may be accompanied by an
improvement in visual function. Orbital decompression Lateral Gaze Palsy
via a transcranial approach has also been reported, Lateral gaze palsy is a condition in which there is
although this is controversial.30 impairment of the deviation of both eyes in a horizon-
tal direction. Lesions of the frontal cortex or the pons
may cause this condition, with or without persistent
TRAUMATIC OPTIC NEUROPATHY conjugate deviation of the eyes. In cerebral contusion,
the eyes are deviated toward the damaged side and
Traumatic optic neuropathy can occur following direct spontaneous recovery of function usually occurs within
or indirect optic nerve injury and is a rare but potentially 1 to 4 weeks.37 Pontine lesions, on the other hand,
blinding complication of orbital trauma.31 Optic nerve manifest a range of other clinical signs, such as distur-
swelling within the optic canal following the injury can bance of horizontal conjugate gaze and horizontal jerk
result in retinal ganglion cell loss. Both optic nerve nystagmus combined with vertical nystagmus, and tend
decompression and high-dose steroid treatment have not to improve. Caloric tests and the doll’s eye phe-
been advocated as a means of improving visual outcomes. nomenon provide methods of distinguishing between
However, because there is a significant spontaneous rate the two pathologic conditions. With cerebral lesions,
of visual recovery in this condition, the role of surgery these tests are normal, whereas with pontine dysfunc-
and steroids remains unclear.32-34 tion they are abnormal.
Referral to an ophthalmologist is indicated for all

Skew Deviation cases of this type of cranial nerve injury. Sequential
Skew deviation is a condition in which there is a vertical assessment is carried out to determine whether recovery
disparity in the positions of the eyes on eccentric gaze. is taking place before considering whether extraocular
This condition may result from a closed head injury. muscle surgery is indicated.
However, the sign is not of localizing value.37
Parinaud’s Syndrome OCULAR MOTILITY DISORDERS CAUSED BY
Parinaud’s syndrome results from midbrain trauma. The ORBITAL INJURY
pupils are mid-dilated and fixed, convergence is not Diplopia is a common sequela to orbital injury. Causes
impaired, and there is paresis of upward gaze.37 include entrapment of an extraocular muscle or its adja-
cent fascia, intramuscular hemorrhage and edema,
Post-Traumatic Nystagmus orbital hematoma, disinsertion of an extraocular muscle,
Post-traumatic nystagmus may occur as a result of trauma and injury to the trochlea, through which the superior
to the petrous part of the temporal bone, with associated oblique tendon passes.
damage to the labyrinthine system, or may be caused by
brainstem trauma.37 Anatomy of the Orbit
The anatomy of the orbit is described in Chapter 13. The
CRANIAL NERVE INJURY orbital walls are thin and are protected anteriorly by the
Traumatic damage to cranial nerves III, IV, and VI is a thick orbital rim. The weak areas constitute the floor
common sequela of a closed head injury.38 anterior to the inferior orbital fissure, which continues
medially as the lamina papyracea of the ethmoid. The
Cranial Nerve III Palsy medial half of the orbital floor is weakened further by
Cranial nerve III palsy typically occurs following a frontal the infraorbital canal or groove. Fine connective tissue
blow to the head, such as in a motorcycle accident. The septa surround the globe and invest the muscles and
condition is usually unilateral. The signs include ptosis, other intraorbital contents. They connect with the peri-
fixed dilation of the pupil (caused by the unopposed orbita of the orbit. In the case of an orbital fracture,
action of the sympathetic supply), and abduction with entrapment of the septa may result in mobility distur-
slight depression of the globe (caused by the unopposed bance. The extensive interconnections of these septa
actions of the lateral rectus and superior oblique probably contribute to the wide range of motility disor-
muscles). Three outcomes are possible: (1) no recovery; ders that may follow an orbital wall fracture, with little
(2) recovery caused by regeneration; and (3) aberrant radiologic evidence of entrapment of soft tissue.
regeneration. Recovery may take up to 12 months. When
aberrant regeneration occurs, paradoxical eye move-
ments are observed. Typically, eyelid elevation occurs on BLOWOUT FRACTURE
attempted adduction or downward gaze. Pupil constric- In 1943, Pfeiffer39 was the first to review a series of cases
tion and accommodation may accompany downward with traumatic enophthalmos and proposed a possible
gaze, with pupil dilation on abduction. Cocontraction of mechanism of orbital floor fracture. In 1957, Smith and
the vertical rectus muscles may result in restriction of Regan40 reproduced blowout fractures experimentally in
upward gaze. cadavers. They demonstrated that posterior impaction of
the globe may cause a blowout of the thin orbital floor
Cranial Nerve IV Palsy by transmission of sudden pressure.
Cranial nerve IV palsy may be unilateral or bilateral. The Similar fractures can, however, also be produced by
superior oblique muscle is responsible for depression of blunt injury to the inferior orbital rim of a skull without
the globe in adduction and also produces intorsion. Ver- orbital contents.41 When a small missile (e.g., squash
tical diplopia, which may be accompanied by torsional ball) strikes the eye, a blowout fracture is unlikely to
double vision (in which the two images appear to be occur, whereas a large compressive object is more likely
rotated with respect to each other), occurs. Torsion is to cause such an injury. Evidence suggests that a com-
especially problematic with bilateral cases. The presumed pressive bone injury contributes significantly to the devel-
site of injury is the origin of the trochlear nerve from the opment of a pure blowout fracture. Thus, both hydraulic
posterior brainstem, perhaps following contrecoup injury forces and buckling of the inferior orbital floor probably
on the tentorium cerebelli. Spontaneous recovery may contribute to the orbital floor blowout fracture. Converse
occur up to 12 months after injury. Surgery for the squint and Smith42 introduced the concepts of the pure blowout
is deferred to allow recovery to take place. fracture, in which only the orbital floor is involved, and
the impure lesion, in which the compression produced
Cranial Nerve VI Palsy in an orbital rim fracture causes a similar pathologic
Cranial nerve VI palsy results in failure of abduction. The condition.
nerve may be damaged at its exit from the brainstem or
within the cavernous sinus. Abducens palsy may also Clinical Signs
result from a traumatic caroticocavernous sinus fistula. The clinical signs of blowout fracture are as follows:
Surgery for the squint is again deferred to allow sponta- 1. Enophthalmos may initially be masked by tissue swell-
neous recovery to take place. ing (Fig. 18-23).
FIGURE 18-23 Enophthalmos. The patient also has significant FIGURE 18-24 Limitation of elevation of the right eye.
limitation of elevation of the left eye.
It may result from the combined effects of prolapse of 5. Infraorbital nerve anesthesia may occur.
orbital fat, enlargement of the size of the orbital cavity, 6. Serious injury to the eye can occur in a significant
fat necrosis from trauma or infection, and fibrotic short- proportion of patients, as described earlier.
ening of extraocular muscles. Visual function is therefore assessed in all cases, and
2. Impairment of eye movement, which may cause dip- a detailed slit lamp and ophthalmoscopic examination of
lopia, may be caused by muscle entrapment, fascial the globe should be carried out in every case to check
entrapment, injury to extraocular muscles, intraor- for treatable abnormalities that might otherwise be
bital or intramuscular hemorrhage, nerve damage, or missed.
the breakdown of a previously latent squint that has
become manifest. Diagnosis of Blowout Fracture
Double vision may not occur for a number of reasons. CT is the investigative modality of choice and is described
For example, one eye may have poor vision because of in more detail in Chapter 17.43
amblyopia. We have seen a number of patients who had
a previous eye injury or an intrinsic eye pathologic condi- Medial Wall Blowout Fracture
tion (e.g., retinal detachment) that might have contrib- Medial wall fractures rarely occur in isolation and are
uted to the failure of the patient to take evasive action. usually associated with orbital floor fractures.44-46 It is
Some patients who have received successful patching for important to recognize this condition because of the
amblyopia when they were children are unaware of potential sequelae of enophthalmos and, more rarely,
double vision, despite normal acuity in each eye. This entrapment, resulting in restriction of lateral gaze, for
situation results from alternating fixation, in which the which the results of late surgery are poor. The clinical
patient chooses to use one eye or the other, but never signs of restriction of abduction and retraction of the
both simultaneously. In such cases, the motility disorder globe on horizontal gaze should be sought in all cases.
does not in itself provide an indication for surgery. Subcutaneous emphysema and epistaxis should
Typically, there is restriction of up and down gaze (Fig. increase the index of suspicion for this diagnosis. Plain
18-24). Elevation of intraocular pressure on attempted radiography and CT may reveal an opaque ethmoid
upward gaze is suggestive of entrapment. Occasionally, sinus. Early surgical intervention for such fractures
retraction of the globe on upward gaze may be seen, (within 2 weeks) has been advocated to avoid more
caused by entrapment of the inferior rectus muscle. This complex repair, which may result from post-traumatic
is a subtle clinical sign in which the eye retracts back from wound healing.47
the lower eyelid by approximately 0.5 to 1.0 mm. The eye
movements are examined as described earlier. It is impor- Treatment Goals
tant to differentiate between entrapment and muscle The goals of treatment are to preserve normal binocular
bruising. Retraction of the globe, elevation of intraocular vision by restoring normal ocular motility and to prevent
pressure on upward gaze, and a positive forced duction cosmetically unacceptable enophthalmos. The field of
test can be helpful in this regard. binocular single vision (BSV) is the area in which the
3. Pseudoptosis and deepening of the supratarsal fold patient has single vision. The aim with regard to ocular
accompany the enophthalmos. motility is to obtain as large a field of BSV as possible,
If the eyelid covers the pupil, the patient will centered on the primary positions of gaze and downward
attempt to elevate both eyelids, and lid retraction will gaze. It may not be possible to abolish double vision
be seen on the opposite side. entirely.
4. Orbital emphysema may be seen shortly after injury, Whether surgical repair of the orbital floor should be
but it absorbs spontaneously. carried out—and, if so, when—is a subject of controversy.
Surgery within 2 weeks is generally recommended for

most patients with significant diplopia or at risk of enoph-
thalmos, and observation for those with a good range of
extraocular movements and at low risk of enophthal-
mos.48,49 However, it has also been suggested recently that
surgery can be delayed for up to 4 weeks, with satisfactory
outcomes.50 These guidelines do not apply to pediatric
white-eyed blow-out fractures, which usually require early
surgical intervention.51
Notable enophthalmos with an extensive orbital floor
defect at the time of the initial examination will not
resolve spontaneously, and surgical repair of the orbital
floor can be carried out soon after injury. A motility dis-
order is common following surgery. Gradual recovery of
eye movement subsequently takes place in most cases.
Patients who remain symptomatic may require glass
prisms or surgery for the squint. FIGURE 18-25 Hypoglobus.
Anecdotal evidence has suggested that orthoptic exer-
cises may expand the field of BSV. There have been no hematoma, notably of the orbital roof,55 may give rise to
clinical trials of this treatment, but it is logical to teach persistent proptosis associated with downward displace-
the patient to develop as wide a range of eye movement ment of the globe. Persistent proptosis may also result
as possible. In theory, this therapy may have the com- from inward displacement of orbital bone fragments.
bined benefits of diminishing the scarring (fibroblasts
cannot grow across moving tissue planes), increasing the ENOPHTHALMOS
range over which the patient can fuse images, and sus- Enophthalmos is a common late sequela that may ini-
taining the power of the extraocular muscles after injury. tially be masked by intraorbital tissue swelling and hema-
toma. Expansion of the orbit, prolapse of soft tissue
FRACTURES OF THE ORBITAL ROOF through a blowout fracture, necrosis of soft tissue, and
Up to 9% of all facial fractures involve the orbital roof.52 fibrosis all contribute to the clinical picture. A sunken
In addition, penetrating injuries may perforate the upper eyelid may be a factor in the poor cosmetic appear-
orbital roof and enter brain tissue. Careful neurologic ance. Impaired ocular motility may or may not be present.
assessment and comprehensive radiologic evaluation are
required if such an injury is suspected. Ophthalmic VERTICAL DISPLACEMENT
assessment is also essential; one study has reported the Vertical displacement commonly accompanies an orbital
incidence of ocular injuries following orbital roof frac- fracture. In the acute phase, the eye may be displaced
ture to be 38%.53 A range of clinical sequelae has been upward by hematoma. In the late phase, downward dis-
described, including the presence of bone fragments, placement of the globe (hypoglobus) is more common
which can interfere with superior rectus muscle function (Fig. 18-25).
and cause impairment of elevation and also ptosis of the
upper eyelid. HORIZONTAL DISPLACEMENT
Horizontal displacement occurs laterally when the medial
TRAUMA TO THE TROCHLEA ligament has been severed or the orbital bones have been
The superior oblique muscle passes through the trochlea laterally displaced. A displaced globe may simulate a
close to the medial superior orbital margin. If the muscle squint. However, the corneal light reflexes are symmetri-
is injured, subsequent fibrosis can result in tethering, cal, and neither vertical nor horizontal displacement
which in turn leads to restriction of elevation of the eye causes double vision.
in adduction. Entrapment of the superior oblique tendon
in an orbital roof fracture has also been described.54
Many patients recover spontaneously, but injection of TRAUMATIC HERNIATION OF THE GLOBE INTO
steroids or ophthalmic surgical intervention may be THE MAXILLARY SINUS
required. Patients with this disorder have been reported56,57 to have
good recovery of visual function following surgical resto-
DISPLACEMENT OF THE GLOBE ration of the normal anatomy. Clinical evaluation is
described in the ophthalmic assessment section of this
The eye may be displaced in any dimension following chapter. Surgical treatment is indicated for patients with
orbital injuries—namely, anteroposteriorly, horizontally, an unsatisfactory cosmetic appearance. Deep recession
or vertically. of the upper eyelid may accompany enophthalmos.
In these cases, packing of the orbital floor beneath the
PROPTOSIS periosteum may give good cosmetic results. In a patient
Proptosis (exophthalmos) is common initially because of in whom enophthalmos is accompanied by a blind eye,
hematoma and swelling of orbital tissue. In most cases, a good cosmetic result may be obtained with the use of
this condition resolves spontaneously. Subperiosteal a positive (magnifying) lens in the patient’s glasses, or a
and any lacerations are sutured. The integrity of the

orbital septum is restored. The eyelid is then repaired.
Failure to recognize damage to the levator may result in
unsightly ptosis, which is difficult to repair by secondary
surgery.58
EYELID AVULSION
Avulsion of the eyelids requires immediate treatment to
protect the cornea. An antibiotic eye ointment or 1.5%
methylcellulose is instilled regularly to prevent corneal
ulceration. Prompt surgical management is required for
these challenging cases and, ideally, this should be per-
formed by an oculoplastic surgeon using lamellar repair
principles.59
PROGRESSIVE SHORTENING OF THE LOWER EYELID

FIGURE 18-26 Laceration of upper eyelid following orbital trauma. This condition, caused by fibrosis, may occasionally com-
plicate any approach to the inferior orbital floor.
vertical prism can be used to improve cosmesis when a
blind eye is vertically displaced. NASOLACRIMAL INJURIES
Damage to the lacrimal drainage system following trauma
INJURIES TO THE EYELIDS often results in epiphora. Although spontaneous recov-
ery can occur, surgical management such as dacryocysto-
EYELID SWELLING AND HEMATOMA rhinostomy may be indicated after several months
Eyelid swelling and hematoma are common following
orbital injury. These injuries are usually innocuous but CANALICULAR LACERATIONS
may indicate a major underlying ocular injury, particu- Lacerations of the canaliculi are repaired at the time of
larly when the bruising is clearly demarcated, resembling primary surgery, ideally with the use of an operating
the eye of a panda. Spontaneous resolution takes place microscope. Detailed descriptions of this surgery are
during the ensuing weeks. available in standard ophthalmic surgical texts. However,
the results of surgery are often disappointing, and sec-
EYELID LACERATIONS ondary intervention may be necessary.
Eyelid lacerations (Fig. 18-26) should be repaired within
72 hours. It is better to wait for good operating room INDIRECT OPHTHALMIC CONSEQUENCES
facilities and to carry out formal surgery than to perform
an unsatisfactory repair in the middle of the night. The OF INJURY
eye and orbit are examined for evidence of injury and a
high index of clinical suspicion is maintained for retained TRAUMATIC RETINAL ANGIOPATHY
foreign bodies. Radiologic examination, including CT, is (PURTSCHER’S RETINOPATHY)
performed if retained organic material is suspected. Multiple discrete, superficial infarcts of the retina mani-
Appropriate antitetanus treatment is provided and the festing as loss of central vision, accompanied by the
wound is immediately débrided. Corneal exposure is an development of multiple cotton wool spots adjacent to
indication for immediate treatment. the optic nerve head, may appear as a result of severe
skull fracture, chest compression, and long bone frac-
Surgical Repair tures.60 The patient complains of loss of vision in one or
Surgical repair requires accurate repositioning in layers, both eyes 24 to 48 hours after injury. No specific treat-
not just superficial skin closure. When the eyelid margin ment exists, but the prognosis is good, with spontaneous
has been severed, the integrity of the margin is restored gradual recovery of vision taking place during the ensuing
with a nonabsorbable suture passing through the gray 2 to 3 months in most cases.
line. This step is carried out first and allows subsequent
accurate suture placement. The tarsal plate is repaired
with an absorbable suture, with care being taken that this CAROTICOCAVERNOUS SINUS FISTULA AND
suture passes through only a partial thickness of the plate ARTERIOVENOUS ANASTOMOSIS
to prevent corneal damage. Tissue should not be dis- Fistula formation between the arterial and venous systems
carded because even unattached tissue may heal. Local may occur following craniomaxillofacial trauma.61,62 The
skin grafts and flaps may be required if there has been condition is usually painful. Clinical signs include gradu-
gross loss of tissue. ally increasing ophthalmoplegia, chemosis, proptosis,
Repair of the upper eyelid requires great care to and dilated blood vessels (of both the conjunctiva and
prevent ptosis. The wound is explored to ensure the the eyelids), which may be accompanied by pulsating
integrity of the levator and superior rectus muscles and exophthalmos (Fig. 18-27). In some cases, an intracranial
of the globe. The levator complex is carefully isolated, bruit may be heard. The intraocular pressure is usually
4. He D, Blomquist PH, Ellis E, 3rd: Association between ocular inju-

ries and internal orbital fractures. J Oral Maxillofac Surg 65:713,
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5. Jamal BT, Pfahler SM, Lane KA, et al: Ophthalmic injuries in
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with periorbital fractures. J Trauma 19:730, 1979.
7. al-Qurainy IA, Stassen LF, Dutton GN, et al: The characteristics of
midface fractures and the association with ocular injury: A prospec-
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8. Larian B, Wong B, Crumley RL, et al: Facial trauma and ocular/
orbital injury. J Craniomaxillofac Trauma 5:15, 1999.
9. Mellema PA, Dewan MA, Lee MS, et al: Incidence of ocular injury
in visually asymptomatic orbital fractures. Ophthal Plast Reconstr Surg
25:306, 2009.
10. Weaver CS, Terrell KM: Evidence-based emergency medicine.
Update: Do ophthalmic nonsteroidal anti-inflammatory drugs
reduce pain associated with simple corneal abrasion without delay-
FIGURE 18-27 Caroticocavernous sinus fistula showing marked ing healing? Ann Emerg Med 41:134, 2003.
chemosis and dilated blood vessels. 11. Slingsby JG, Forstot SL: Effect of blunt trauma on the corneal
endothelium. Arch Ophthalmol 99:1041, 1981.
12. Ashaye AO: Traumatic hyphaema: A report of 472 consecutive
increased and loss of vision may ensue if the condition cases. BMC Ophthalmol 8:24, 2008.
13. Walton W, Von Hagen S, Grigorian R, Zarbin M: Management of
becomes more severe. Neurosurgical referral is traumatic hyphema. Surv Ophthalmol 47:297, 2002.
indicated. 14. Sihota R, Kumar S, Gupta V, et al: Early predictors of traumatic
glaucoma after closed globe injury. Arch Ophthalmol 126:921, 2008.
FACIAL PALSY 15. Tumbocon JA, Latina MA: Angle recession glaucoma. Int Ophthal-
mol Clin 42:69, 2002.
All patients who have facial palsy as a result of injury 16. Venkatesh R, Tan CS, Kumar TT, Ravindran RD: Safety and efficacy
should be assessed for the presence of Bell’s palsy. The of manual small incision cataract surgery for phacolytic glaucoma.
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of the cornea is determined. The cornea is examined in 17. al-Qurainy IA: Convergence insufficiency and failure of accommo-
detail for the development of ulceration. Tarsorrhaphy dation following midfacial trauma. Br J Maxillofac Surg 32:71, 1995.
18. Dolan BJ: Traumatic retinal detachment. Optom Clin 3:67, 1993.
is indicated for patients who have corneal ulceration; 19. Olsen TW, Chang TS, Sternberg P, Jr: Retinal detachments associ-
ointment is instilled at night into the eyes of patients in ated with blunt trauma. Semin Ophthalmol 10:17, 1995.
which corneal coverage is incomplete. Alternatively, bot- 20. Ross WH: Traumatic retinal dialyses. Arch Ophthalmol 99:1371, 1981.
ulinum toxin can be injected into the levator palpebrae 21. Cox MS, Mackenzie-Freeman H: Traumatic retinal detachment. In
Mackenzie-Freeman H, editor: Ocular trauma, New York, 1979,
superioris.63 This results in complete ptosis and protects Appleton-Century-Crofts, pp 285–295.
the cornea for 4 to 6 weeks. Such treatment is indicated 22. Friberg TR: Traumatic retinal pigment epithelial edema. Am J Oph-
when recovery of facial nerve function is anticipated. thalmol 88:18, 1979.
23. Cogan DG: Pseudoretinitis pigmentosa: Report of two traumatic
PAPILLEDEMA cases of recent origin. Arch Ophthalmol 81:45, 1969.
24. Crouch ER, Jr, Apple DJ: Post-traumatic migration of retinal
Examination of the optic nerve heads for the develop- pigment epithelial melanin. Am J Ophthalmol 78:251, 1974.
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of having raised intracranial pressure resulting, for combat ocular trauma. Retina 29:349, 2009.
example, from a chronic subdural hematoma. 26. Kuhn F, Maisiak R, Mann L, et al: The Ocular Trauma Score (OTS).
Ophthalmol Clin North Am 15:163, 2002.
27. Fulcher TP, McNab AA, Sullivan TJ: Clinical features and manage-
ment of intraorbital foreign bodies. Ophthalmology 109:494, 2002.
RELATIONSHIP BETWEEN MAXILLOFACIAL 28. Chibbaro S, Tacconi L: Orboto-cranial injuries caused by penetray-
AND EYE INJURIES ing non-missile foreign bodies. Experience with 18 patients. Acta
Neurochir 148:937, 2006.
29. Vassallo S, Hartstein M, Howard D, Stetz J: Traumatic retrobulbar
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ated with ocular injuries of varying severity. All patients cantholysis. J Emerg Med 22:251, 2002.
who have sustained such trauma should have their visual 30. Amagasaki K, Tsuji R, Nagaseki Y: Visual recovery following imme-
acuities checked at the time of examination. If an eye diate decompression of traumatic retrobulbar hemorrhage via tran-
scranial approach. Neurol Med Chir (Tokyo) 38:221, 1998.
injury is suspected, the patient should be managed 31. Steinsapir KD, Goldberg RA: Traumatic optic neuropathy. Surv
appropriately and referred promptly for a thorough oph- Ophthalmol 38:487, 1994.
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decompression surgery. Eye 18:1169, 2004.
33. Levin LA, Beck RW, Joseph MP, et al: The treatment of traumatic
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2. Cook T: Ocular and periocular injuries from orbital fractures. J Am 35. Pratt-Johnson JA: Acquired central disruption of fusional ampli-
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3. Kreidl KO, Kim DY, Mansour SE: Prevalence of significant intraocu- 36. McLean CJ, Lee JP: Acquired central fusional disruption with spon-
lar sequelae in blunt orbital trauma. Am J Emerg Med 21:525, 2003. taneous recovery. Strabismus 6:175, 1998.
37. Lee J: Ocular motility consequences of trauma and their manage- 52. Haug RH, Van Sickels JE, Jenkins WS: Demographics and treat-
ment. Br Orthop J 40:26, 1983. ment options for orbital roof fractures. Oral Surg Oral Med Oral
38. Dhaliwal A, West AL, Trobe JD, Musch DC: Third, fourth and sixth Pathol Oral Radiol Endod 93:238, 2002.
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26:4, 2006. ophthalmic complications. Ophthal Plast Reconstr Surg 19:359, 2003.
39. Pfeiffer RL: Traumatic enophthalmos. Arch Ophthalmol 30:718, 54. al-Qurainy IA, Dutton GN, Moos KF, et al: Orbital injury compli-
1943. cated by entrapment of the superior oblique tendon: A case report.
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thalmol Otolaryngol 67:622, 1963. 91:253, 1981.
43. Go JL, Vu VN, Lee KJ, Becker TS: Orbital trauma. Neuroimaging Clin 57. Beirne OR, Schwartz HC, Leake DL: Unusual ocular complications
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44. Brannan PA, Kersten RC, Kulwin DR: Isolated medial orbital wall 58. Collin JRO: A manual of systematic eyelid surgery, ed 3, London, 2006,
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45. Rauch SD: Medial wall blow-out fracture with entrapment. Arch comes of total upper and lower eyelid reconstruction. Arch Oph-
Otolaryngol 111:53, 1985. thamol 125:1601, 2007.
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some orbital floor fractures: The white-eyed blowout. Ophthal Plast
Reconstr Surg 14:379, 1998.
CHAPTER
Evaluation and Management of Frontal
19 Sinus Injuries
Brent A. Golden
| Michael S. Jaskolka
| Allan Vescan
|

Kristian I. MacDonald
OUTLINE
Development, Anatomy and Function Imaging Studies
Pathophysiology Management of Frontal Sinus Injuries
History of Treatment Antibiotic Therapy
Overview of Clinical Decision Making Operative Treatment
Goals of Treatment Postoperative Management
Epidemiology Complications in Frontal Sinus Injuries
Fracture Classification Perioperative Complications
Diagnosis of Frontal Sinus Injuries Early Complications
History and Physical Examination Late Complications
T
he frontal sinus is an important component of the understanding of the anatomy and subsequent patterns
complex skeletal junction between the cranium of injury in the frontal region. This must be combined
and face. Injury to this area can occur in isolation with an appreciation of normal physiologic function to
or, more commonly, may be associated with other injuries help direct treatment.
to the brain, skull, orbits, globes, midface, and overlying The craniofacial skeleton shows evidence of intra-
soft tissues. As such, treatment of traumatic injuries membranous ossification of the nasal and frontal bones
to this region may require transcranial, subcranial or at 50 to 60 days’ gestation.1,2 By 4 months in utero, the
conventional maxillofacial surgical techniques and earliest signs of frontal sinus development are present as
commonly requires multidisciplinary evaluation and the middle meatus begins to expand superiorly, creating
treatment. The goal of contemporary management is the an early frontal recess.3 At this intranasal location, it is
restoration of form and function, with minimization of common for numerous furrows to form that will eventu-
morbidity and mortality. ally evaginate into the frontal and ethmoid bones.4 One
The last several decades have been witness to consider- or more of these frontal recess furrows most often pneu-
able changes in the diagnosis and management of facial matize the frontal bone to become the developing frontal
trauma in general, and frontal sinus injuries in particular. sinus. Alternatively, ethmoid infundibular cells may
The greatest impact has been made by the ready avail- provide the source of pneumatization that leads to sinus
ability of computed tomography (CT) imaging, which formation; more rarely, the frontal recess may propagate
now allows for accurate visualization and diagnosis of directly into the frontal bone.5 Additional accessory
injuries. The development and popularization of cranio- furrows of the frontal recess are important for the devel-
facial techniques by Paul Tessier and others have com- opment of agger nasi cells and anterior ethmoid air cells.
bined with the refinement of surgical equipment and Some of these remain modest in size and contained
microplate fixation to allow for the predictable execu- within the ethmoid while others expand considerably
tion of complex surgical reconstruction. More recent without this confinement.
advances in endoscopic instrumentation and skull base The developmental complexity and heterogeneity of
techniques are continuing to transform management of the frontal sinus and anterior ethmoid air cells has the
frontal sinus injury by increasing emphasis on the resto- secondary effect of creating a highly variable nasofrontal
ration of a functional sinus in addition to a safe sinus. drainage system. In as many as 80% to 85% of the popula-
The purpose of this chapter is to provide an overview tion, no discernible duct is present and an ostium-type
of the contemporary diagnosis and management of inju- outflow tract serves to drain the sinus.6,7 Alternatively,
ries of the skull involving the frontal sinus. relative compression of the proximal part of the frontal
sinus by developing ethmoid cells may create a true
DEVELOPMENT, ANATOMY, AND FUNCTION ductal drainage system. When a duct is present, it may
vary from 1 to 20 mm in length and 1 to 6 mm in width.8
The embryology and development of the frontonasal Drainage into the nose will typically occur below the
region provide an important context for a thorough middle turbinate near the middle meatus, bearing a
470
Evaluation and Management of Frontal Sinus Injuries CHAPTER 19 471
16 years
12 years
8 years
4 years
FIGURE 19-1 A midsagittal view characterizes the normal skeletal

anatomy of the intranasal region. The blue marker demonstrates
the frontonasal outflow tract draining medial to the uncinate
process below the middle turbinate (removed).
FIGURE 19-2 Frontal sinus development correlated with age—

green, 4 years; blue, 8 years; purple, 12 years; pink, 16 years.
variable relationship to the ethmoid infundibulum based
on the sinus origin (Fig. 19-1). Usually, drainage is
directly into the frontal recess and medial to the uncinate
process, but less commonly this may occur above or into
the ethmoid infundibulum lateral to the uncinate, with
rare occurrences above the ethmoid bulla.9,10
Over time, the frontal sinus pneumatizes to a highly
variable degree. Underdevelopment of the frontal sinus D
is relatively common, with an estimated 4% of the popu-
lation showing no development and another 5% demon-
C
strating minimal pneumatization.11 Approximately 10%
of the population has only unilateral development of the A B
frontal sinus.3 When present, the sinus is not typically
identifiable radiographically before the age of 6 years
and does not show appreciable development until
puberty.12 Size consistent with that of the adult is nor-
mally attained by the mid to late teen years (Fig. 19-2).
The fully developed frontal sinus is expected to be
highly variable in size and shape. When present, asym- FIGURE 19-3 Inferior view of the frontal bone demonstrates A,
metry between right and left is the norm and bony septa- Orbital roof. B, Cribriform plate (removed). C, Fovea ethmoidalis.
tions may be present. The sinuses may be present in D, Frontonasal ostium.
duplicate or triplicate bilaterally. In general, the sinus is
rather diminutive, with a capacity of between 5 and
16 mL.4,12 The average height of a developed frontal rises superiorly from the cribriform plate; laterally, the
sinus is 32 mm and the average width is 26 mm.13,14 cribriform plate transitions to the fovea ethmoidalis of
The proximity of the frontal sinus to important ana- the anterior skull base (Fig. 19-3). On the deep surface,
tomic structures accentuates the importance of thought- the dura is dense and tightly adherent and thins
ful management of these injuries. The anterior portion along the midline of the anterior skull base due to mul-
of the sinus borders the dense frontal bone superiorly tiple neurovascular foramina.15 Notably, after complete
and supraorbital rim inferiorly; these are the thickest and pneumatization of the sinuses, the final position of the
strongest boundaries. In between these buttresses, the cribriform plate is variable and often becomes situated
anterior wall becomes more attenuated and somewhat in a position well inferior to the neighboring ethmoid air
weaker across the face of the sinus. The thinner cortical cells.
posterior wall of the sinus is adjacent to the intracranial The posteromedial portion of the sinus floor contains
cavity and skull base. In the midline, the posterior wall an ostium that is the beginning of the nasofrontal outflow
of the frontal bone is adjacent to the crista galli, which tract (Fig. 19-4). The lateral aspect of the floor is
A B
FIGURE 19-4 The nasofrontal outflow tract drains in the posteromedial floor of the frontal sinus. A, This is demonstrated on a skull model
sectioned in the midsagittal plane and in a clinical example viewed from above (B). B, Prerepair.
confluent with the medial portion of the orbital roof. Interestingly, the frontal sinus is the only sinus in which
Anteriorly and inferiorly is the nasoethmoidal complex, there is some retrograde flow of mucus, with movement
which has a significant likelihood of concurrent injury. superiorly along the medial wall, laterally along the supe-
This may manifest with telecanthus, loss of nasal bridge rior aspect, and then back to the ostium along the infe-
support, and medial orbital wall fractures. The relevance rior aspects of the sinus. The rate is slowest at the roof
of these injuries in the context of frontal sinus trauma is of the sinus and the fastest around the nasofrontal
their relationship to nasofrontal outflow tract obstruc- duct.13,21
tion as well as the position of the cribriform plate and
potential for intracranial violation. PATHOPHYSIOLOGY
The arterial supply to the frontal sinus region is from
the anterior ethmoid artery and the branches of the The location of the frontal sinus allows it to serve a pro-
sphenopalatine artery via the middle meatus.2 The supra- tective role to the brain, in addition to providing normal
orbital, anterior superficial temporal, anterior cerebral, sinus function. Although the presence of a frontal sinus
and middle meningeal arteries all supply the frontal has been confirmed to increase the likelihood of frontal
bone.16 Venous drainage is transosseous into the subcu- bone fracture, it acts as a shock-absorbing barrier to the
taneous, orbital, and intracranial veins. The diploic veins intracranial contents.22 The frontal bone at the anterior
of Breschet are associated with foramina in the frontal sinus wall is able to withstand direct trauma up to 990 kg
bone significant for deeply invaginating sinus mucosa, of force.23,24 Conceptually, this force can be attained by
which can be a source of mucocele formation if incom- an unrestrained passenger suffering a motor vehicle col-
pletely removed during obliteration or cranialization lision at 30 mph.25 As the frontal bone’s protective capac-
procedures. Also, they allow for direct vascular connec- ity is exceeded, concomitant intra- and extracranial
tions between the mucosal and dural venous systems.3,12,17,18 injuries should be anticipated. The surrounding bones
This pattern of venous drainage has clinical implications of the anterior skull base, orbits, and nasoethmoid
for the development and management of intracranial complex are significantly weaker, leading to their poten-
abscess associated with frontal sinusitis and infection. tial for associated fracture. The posterior wall and ante-
The frontal sinus is innervated by nerves that follow arte- rior cranial base are particularly concerning because of
rioles including the lateral posterior superior nasal the potential for dural tears, leading to communication
branches of V2, as well as the anterior ethmoid nerve between the intracranial compartment and sinus envi-
branching from V1.19 ronment, with the possibility of meningitis or brain
Normal sinus function is maintained by pseudostrati- abscess.
fied, columnar, ciliated respiratory epithelium covered Normal frontal sinus function relies on adequate
by a layer of mucin. The cilia beat at the rate of about 10 drainage, which may become impaired with nasofrontal
to 15/second, with mucociliary clearance from the outflow tract damage or obstruction. In simplistic terms,
frontal sinus into the middle meatus of the nose.10,20 obstruction can lead to mucus buildup and development
of an expanding mucocele within the frontal sinus. This Fractures of the frontal sinus in the first half of
can be compounded by bacterial infection and, together, the twentieth century were generally approached nonop-
lead to erosion of surrounding bone and development eratively and most healed uneventfully.34 Even so, com-
of osteomyelitis or sequestration. Drainage will follow the pound fractures were expected to have high mortality,
path of least resistance and may present externally as a approaching 50% if untreated when associated
draining sinus tract. A more subtle presentation may be with pneumocephalus.35 Treatment was still required
seen with intracranial or orbital extension. As such, in select circumstances and Jacobs has stated thatt
assessment of the patency and subsequent management because of “continued reports of at least a 30% failure
of the nasofrontal outflow tract are critical decision rate with the Lynch frontoethmoidectomy, as well as the
making elements in the treatment of frontal sinus inju- associated difficulty in visualizing the distal portions of
ries. Chronic inflammation in the adjacent thin-walled the frontal sinus, the osteoplastic school began to gain
spaces of the ethmoid and frontal recess air cells can lead acceptance.”5
to edematous changes in the nasofrontal outflow tract, Beginning in 1934, Bergara and Itoiz developed the
contributing to frontal sinus drainage problems. Patients osteoplastic flap approach, in which the anterior frontal
with a history of recurrent anterior ethmoid sinusitis are sinus wall was removed but maintained on an inferior
at a higher risk of developing recurrent frontal sinus pedicle of pericranium to allow replacement of the bone
infections after trauma to the frontal sinus. flap.36,37 This procedure allowed improved access to the
damaged sinus so that removal of the mucosal lining
HISTORY OF TREATMENT could be accomplished more thoroughly, all while pre-
serving the anterior table for a more natural-appearing
Complications from frontal sinus trauma and sinusitis in reconstruction. The use of adipose tissue for obliteration
the age before antibiotics could be devastatingly morbid of the frontal sinus can be traced back to Marx in 1910,26
and frequently lethal. The history of surgical interven- but Bergara and Itoiz36,37 and later Montgomery scientifi-
tions was largely based on the treatment of chronic sup- cally examined and popularized the technique, publish-
puration and sinusitis. The earliest reported operation ing a series of papers emphasizing the importance of
on the frontal sinus was by Viega in 1586 for treatment of nasofrontal drainage function and frontal sinus oblitera-
a frontal osteoma.26 As early as 1870, an attempt at surgi- tion with autologous fat to prevent inflammatory
cally treating a frontal pyocele by external and intranasal complications.38,39
approaches was published by Wells.5,27 Soon after, reports Once considered the gold standard for chronic frontal
of treatment for infection of the frontal sinus by punctur- sinusitis, the osteoplastic flap has since fallen out of favor
ing the frontal recess to improve drainage or pack the because of its associated complications—cerebrospinal
sinus followed, but were not embraced secondary to the fluid (CSF) leak, frontal bossing, supraorbital neuralgia,
risk of inadvertent entry into the intracranial space. chronic sepsis, mucocele formation, and osteitis.40-42 With
Jacobs credits Ogston in 1884 with the first substantial the development of modern craniofacial techniques, it
description of an external approach to the frontal sinus became clear that wide subperiosteal undermining, most
to establish drainage, outflow tract dilation, and intrana- often through a coronal scalp incision along with primary
sal drain placement.5,28 Reidel, in 1898, reported on a bone graft reconstruction, were viable strategies in the
radical exenteration of the sinus walls and supraorbital craniomaxillofacial region. Subsequently, this led to
bar, followed by removal of all sinus mucosa and leaving further improvements in surgical access and more aggres-
the overlying soft tissues to retract into the defect against sive attempts at primary reconstruction using these prin-
the posterior wall.26 The hope was to reduce the potential ciples. Impressive results, with low morbidity after
for mucocele, mucopyocele, meningitis, or brain abscess, mucosal exenteration and fat graft obliteration of sinuses
but at the cost of profound disfigurement. with injured nasofrontal ducts according to these
In 1903, Killian presented a more conservative varia- methods, have since been reported.6,43
tion of Reidel’s procedure that maintained the supraor- Removal of the posterior wall of the frontal sinus in
bital bar limiting the ablation to the anterior table and cases of severe comminution or pneumocephalus had
frontal sinus mucosa while using postoperative stents in been described earlier,34,35 but cranialization of the
the outflow tract.5,29 Despite the limited improvement in frontal sinus in its contemporary form can be attributed
cosmesis, morbidity and mortality remained high second- to Donald and Bernstein.44 Encouraged by the work of
ary to persistent disease, most likely from postoperative Nadell and Kline performing primary reconstruction of
closure of the outflow tract.30 This too was quickly dis- depressed skull fractures in penetrating cranial injury
carded as a viable treatment option.31 with low rates of infection,45 they described a procedure
By 1921, Lynch had introduced a promising proce- in which the posterior frontal sinus wall was removed, all
dure whereby a medial periorbital incision was used for sinus mucosa was eliminated, and the intracranial con-
access to the floor of the frontal sinus and anterior tents were isolated from the nose by obstructing the naso-
ethmoid air cells, with the aim of extirpating the mucosal frontal outflow tract. Importantly, they advanced the idea
lining and opening the nasofrontal drainage system, that one could reconstruct the anterior table, even in the
again using stents to maintain the sinus drainage.32 setting of contaminated injury after disinfection. This
Despite the appeal of a more limited operation, results provided improved cosmetic and functional results in the
with this technique were also disappointing because com- group of patients with complex frontobasilar injury.
plete removal of the mucosal lining was difficult and Since that time, treatment has largely focused on varia-
restenosis of the nasofrontal outflow tract was common.33 tions of the techniques of cranialization, obliteration,
commonly made between lateral and central injuries.52,64

anterior table reconstruction, and management of the Injuries of the lateral fronto-orbital skeleton frequently
nasofrontal outflow tract. involve the supraorbital margin and lateral orbital wall,
as well as occasionally involving the temporal or parietal
OVERVIEW OF CLINICAL DECISION MAKING skull. Care is focused on assuring dural and cranial vault
integrity and the reconstruction of orbital volume, with
GOALS OF TREATMENT limited regard for sinus involvement.
Central injuries are directly related to the frontal sinus
The goals of management of frontal sinus injuries are and further distinction should be made based on the
structural protection of the intracranial contents, isola- integrity of the naso-orbital-ethmoid (NOE) complex12
tion of the intracranial compartment from the aerodiges- and skull base.65 Classification here is divided into spe-
tive tract, provision of a functional sinus, cosmetic cific functional and anatomic units, including the ante-
restoration of natural frontal contour with the use of rior table, posterior table and skull base, dural competency
minimally visible incisions, minimization of perioperative (cerebrospinal fluid leakage), NOE complex and naso-
morbidity, and prevention of postoperative infectious frontal outflow tract integrity. With the ready availability
and inflammatory complications. of high-resolution CT imaging, diagnosis and distinction
A review of the literature provides little definite direc- of these injuries are realistic.
tion regarding the management of patients with frontal Numerous treatment algorithms can be found
sinus injuries. Most studies are retrospective reports and throughout the literature.15,58,61,66 Similar to classic facial
series, with biased samples and limited follow-up. Treat- trauma treatment principles, an inside-out approach is
ment outcomes are poorly documented, as are the effects advocated that emphasizes the importance of frontobasi-
of operative versus nonoperative management. Impor- lar integrity and seeks functional sinus preservation,
tantly, Chuang and Dodson have suggested that we do when possible.
not know how often bad outcomes occur in the untreated
injury and we have no information to support that
treatment decreases the risk for an adverse outcome.46 DIAGNOSIS OF FRONTAL SINUS INJURIES
Treatment recommendations are therefore based on
theoretical outcome predictions according to knowledge HISTORY AND PHYSICAL EXAMINATION
of frontal sinus pathophysiology and local intracranial Frontal sinus fractures are commonly caused by high-
vulnerability, which likely encourages overtreatment with velocity events and are frequently associated with other
the hope of minimizing complications. Further work will systemic or craniomaxillofacial injuries.51 Over 50% of
hopefully bring additional clarity to the proper use of patients diagnosed with frontal sinus fractures will suffer
current techniques. neurologic injury, with as many as 25% demonstrating
associated ophthalmologic injury.12 Subdural or epidural
EPIDEMIOLOGY hematomas requiring acute neurosurgical intervention
Since frontal sinus development is not appreciable in may be found in as many as 8% to 10%.67 Rodriguez et al
early childhood and gradually enlarges throughout the have found cervical spine injuries in 7% to 14% of his
teen years, fractures are rare in children and uncommon series, depending on the severity of the injury.58 Prior to
in adolescents.47,48 For those treating adults, frontal sinus arrival at the hospital, patients are regularly intubated,
trauma remains infrequent being reported in 5% to 15% sedated, and medically paralyzed. Initial evaluation often
of all facial fractures from major trauma centers and occurs in the emergency department or intensive care
presumably represents a much smaller proportion at unit and the most of the history is often taken from first
community centers.13,34,49-57 In the contemporary civilian responder records and other medical staff, depending
literature, frontal sinus injuries are frequently associated on the condition of the patient and availability of family
with blunt trauma secondary to motor vehicle accidents members or historians. Even in the setting of an appar-
(MVAs), causing demographics to skew toward major ently isolated frontal sinus injury, one needs to maintain
trauma statistics.53,55,58 Although young and old are a high degree of suspicion for other craniomaxillofacial
reported, the average age is consistently in the fourth and anatomically remote injuries. A comprehensive and
decade and the overwhelming majority of injured are systematic trauma examination is always indicated and
male (Fig. 19-5).50,51,59,60 Associated maxillofacial frac- reviewed elsewhere in this text.
tures may be present in over 70% of patients.58,61 Regard- The comprehensive craniomaxillofacial examination
ing the sinus itself, most fractures involve the anterior should begin with a focused neurologic evaluation, with
table alone (43% to 61%) or the anterior and posterior particular attention to the Glasgow Coma Scale (GCS)
tables (19% to 51%). Frontal recess or frontonasal floor score and cranial nerve function. This is closely tied to a
involvement with possible disruption of the drainage thorough ophthalmologic examination, looking spec
system occurs less commonly (2.5% to 21%). Isolated ifically for visual acuity, pupillary reactivity and symme-
injuries of the posterior table are rare (0.6% to 6%).57,62,63 try, signs of foreign bodies and globe injury, and/or
increased intraocular pressure. Careful inspection and
FRACTURE CLASSIFICATION palpation of all the hard and soft tissues with specific
There is no universally accepted classification of frontal detailed attention to several key areas also follows. All
sinus injuries and specific numbering systems are largely the bony buttresses must be firmly palpated through the
academic. From a clinical perspective, distinction is often edematous overlying soft tissues to identify any
A B
C D
FIGURE 19-5 A, Frontal sinus trauma is most commonly seen in men. B, Anterior table involvement demonstrated on CT scan. C, Use of
existing laceration for surgical access. D, CT scan demonstrating postoperative result.
irregularities, mobility, and crepitus. If aware, patients cally alters patient and injury management. In a series
may complain of pain or paresthesia in the forehead by Bell and Chen, rhinorrhea was present in 26% of
and scalp. Identification of medial canthal displacement frontobasilar fractures, but CSF leakage in only 4.6%.51
is critical and is indicative of concomitant NOE injury. If If cooperative, patients may be asked to lean forward
present, dressings should be temporarily removed to and perform the Valsalva maneuver to increase CSF
allow for visualization of the soft tissues. Significant peri- flow or may be asked about posterior nasal drainage.
orbital edema and ecchymosis are common, making the Use of the ring or halo test can be suggestive of the pres-
examination challenging. When identified, lacerations ence of CSF. Suspected fluid is placed on gauze or filter
should be carefully explored to identify any underlying paper and an inner ring of blood may be seen, sur-
open bony injuries. Specific attention should be given rounded by an outer ring of clear CSF. Assessing the
to periorbital lacerations and the status of the lacrimal chemical composition of the fluid may also provide addi-
system. Further review of specific soft tissue injuries tional diagnostic support because CSF has a higher
and their management is also presented elsewhere in glucose concentration and lower chloride concentration
this text. compared with serum. Importantly, the presence of the
The nasal cavity should be gently cleaned and beta-2 transferrin isoenzyme is most diagnostic.68
inspected for septal or mucosal injuries. The presence of However, collected fluid requires electrophoresis for
rhinorrhea or otorrhea is not uncommon in the setting separation of the proteins and the Western blot tech-
of complex midfacial trauma and may be related to CSF nique to detect the beta-2 transferrin isoenzyme, which
leakage. Identification of a CSF leak is important, may take up to 4 days to process in the laboratory, result-
although at times difficult, because this finding specifi- ing in a delay in diagnosis.69
bilaterally. The use of a postauricular coronal incision

IMAGING STUDIES eliminates visible scars and decreases risk to the frontal
Although the clinical examination must never be deval- branch of the facial nerve in reoperated patients. If sig-
ued, few areas of craniofacial trauma are aided by modern nificant exposure of the root of the zygoma is antici-
CT technology as much as frontobasilar injury. Multislice pated, the inferior extension is moved to the preauricular
helical CT scanners allow for rapid, high-resolution data position. The inferior extent of the incision dictates the
acquisition; 1- to 1.5-mm axial slices provide detailed degree of inferior and caudal exposure of the facial skel-
images, which are extremely useful for assessing injuries eton, not the anteroposterior position. Use of a sinusoi-
to the frontal sinus and midface.13,70-72 Axial, coronal, and dal incision avoids a straight line scar and is thought to
sagittal images are requisite for comprehensive data col- be useful in camouflaging the scar after healing, espe-
lection (Fig. 19-6). Axial images clearly reveal the loca- cially when the hair becomes wet. Occasionally, second-
tion, severity, and degree of comminution of anterior ary operations are performed in cases where a previous
and posterior table fractures, as well as demonstrate the coronal scalp flap has been used. Although it may be
presence or degree of nasoethmoid impaction and status tempting to place the incision in a different location, it
of the lacrimal system. Coronal images best demonstrate is preferable to incise through the original scar due to
fractures of the frontal sinus floor, orbital roof, and walls. the potential effect of the previous scar on flap perfusion
Sagittal views are important for assessing the nasofrontal and wound healing.
outflow tract. Three-dimensional image reconstructions There are a number of other approaches to the frontal
provide excellent pictorial representations of fracture and nasoethmoid areas (Fig. 19-8). Not infrequently,
patterns and the position of major segments. However, existing lacerations can be used and extended if neces-
they are generated by volume-rendering algorithms that sary to provide limited access to the anterior table of the
average and eliminate surface detail and should not be frontal sinus (Fig. 19-9) The gull wing or eyeglass incision
used exclusively for fracture diagnosis. can result in rather unattractive scars, which tend to be
highly visible because of their presence in the promi-
nence on the brow and the resultant reflection of the
MANAGEMENT OF FRONTAL light. The open sky approach is equally problematic,
SINUS INJURIES leaving an H-shaped scar over the brows and nasion
region. The use of these direct approaches should be
ANTIBIOTIC THERAPY limited to patients who are balding and have heavy
Antibiotic use in the setting of facial trauma continues rhytids or scars (Fig. 19-10).
to be controversial because the literature is devoid of
well-planned and executed randomized prospective Management of Posterior Table Fractures
trials. A practical approach to antibiotic therapy is to Management of posterior table fractures is determined
treat fractures prophylactically with external contamina- by the degree of frontobasilar involvement, condition of
tion or gross disruption until the bones have been recon- the nasofrontal outflow tracts, and amount of concomi-
structed and stabilized and the soft tissues cleansed and tant brain injury. There is little debate that grossly dis-
repaired.73 For open frontal sinus injuries, extended- rupted anterior and posterior table injuries with violation
spectrum penicillins, cephalosporins, or clindamycin are of the dura and frontal lobe contamination require oper-
appropriate. Otherwise, perioperative antibiotic therapy ative treatment. Displaced basilar skull fractures with CSF
should follow the surgical recommendations and guide- leakage also belong in the operative category. More
lines for clean contaminated surgery in the head and nuanced views lead to controversy as posterior table inju-
neck, including incisions through oral and pharyngeal ries become more moderate. Using an animal model to
mucosa, as indicated.74 quantify risk stratification, Donald has recommended
surgical treatment for patients with posterior table defects
of greater than 25%.18 Other clinicians have advocated
OPERATIVE TREATMENT that with a patent nasofrontal outflow tract and no con-
Access to the Fronto-Orbital Region current dural tears or brain injury, any amount of poste-
Surgical access that minimizes facial scarring is a basic rior table displacement is inconsequential and may be
tenet of craniomaxillofacial surgery. When considering managed with observation.58 Determination of what con-
elective approaches to the frontal sinus region, the pre- stitutes a complex posterior table fracture necessitating
ferred approach to meet this objective is the coronal flap. surgical intervention for treatment and protection of the
If performed correctly, it rapidly and bloodlessly provides intracranial contents requires clinical judgment and col-
complete access to the frontal bone and upper face and laboration with a neurosurgical colleague in equivocal
also provides the most desirable aesthetic results, except situations.
in bald or balding patients (Fig. 19-7). An added benefit Cranialization is the preferred technique to ablate the
of coronal access is the ready availability of autogenous sinus while maintaining forehead contour in the setting
bone and soft tissue that may be needed during repair of complex frontobasilar injury.15,44,76,77 Neurosurgical
and reconstruction of frontal injuries, with minimal addi- involvement is often necessary for craniotomy access,
tional dissection. management of intracranial injury, and dural repair (Fig.
The coronal approach has been meticulously described 19-11).
by Ruiz et al75; it consists of an incision behind the top Access to the entire frontal sinus is generally limited
of the vertex of the head with postauricular extensions through the anterior table fracture. Complete exposure
A B
C D
H
5mm/div
R L
E F 5mm/div
FIGURE 19-6 Multiple plane, fine cut CT scans are required for diagnosis and management of frontal sinus injuries. A, B, Preoperative
axial and sagittal CT scans demonstrating anterior table fracture with a patient NFOT. C-E, Postoperative axial, sagittal and three-
dimensional reconstructions of repair.
A B
FIGURE 19-7 A, Immediate postoperative result after coronal incision for frontal sinus fracture repair. Note the posterior position of the
incision. B, Result after regrowth of hair. Note the well-hidden scar.
A B C
D E F
FIGURE 19-8 Surgical access and incisions to the frontal sinus region. A, Coronal, coronally from the temporal region to the temporal
region. B, Open sky, two incisions in the medial orbital region connecting over the nasal bridge. C, Two gull wing curved incisions at or
inferior to the brow, ending at the nasion. D, Butterfly, a combination of gull wing and open sky incisions. E, Sewall, a single-side medial
orbital incision. F, Incisions through the existing lacerations.
A B
C D
FIGURE 19-9 A-D, Lacerations associated with a frontal sinus injury that has allowed for direct reconstruction.
of the posterior table is achieved by means of a bifrontal sinus is recommended; studies have reported that local
craniotomy. The entire posterior table is then removed, soft tissue flaps decrease the risk of infection.15,77-79 The
including loose or necrotic fragments. Meticulous elimi- pericranial flap is readily available for additional rein-
nation of the frontal sinus mucosa is carried out and forcement and demonstrates continued vascularity fol-
often requires the use of a rotary drill and hand curettes. lowing harvest.80 It can be harvested centrally or laterally
Necrotic brain tissue is excised and dual repair is com- when concurrent forehead lacerations are present (Fig.
pleted, commonly with pericranial patches or allogenic 19-13). Finally, the anterior table fragments are cleaned
dural replacement materials and tissue glue. Any bony and, if necessary, disinfected before being replaced and
irregularities of the inner frontal bone are smoothed stabilized with biodegradable or titanium microplate
with hand or rotary instruments (Fig. 19-12). fixation.
Any remaining sinus mucosa can then be everted into
the nose and the nasofrontal outflow tract is sealed. Management of Cerebrospinal Fluid Leaks
Various materials can be used for obstruction, including Traumatic CSF rhinorrhea can be classified as accidental
abdominal fat, autogenous bone, temporalis muscle, and or surgical. Management has consisted of conservative
fascia. A layered approach from the nose to the frontal therapeutic measures, lumbar diversion, intracranial or
A B
C
FIGURE 19-10 Preexisting scars and skin creases may be used for access to treat frontal sinus injuries in carefully selected patients.
extracranial operative repair, and transnasal endoscopic A meta-analysis of CSF rhinorrhea treated surgically
repairs. Again, we find little guidance from the literature has reported greater than 90% and 97% success rates
about the appropriateness of prophylactic antimicrobial with the first and second attempts, respectively.84 Factors
therapy, the usefulness of lumbar drainage, or the risks to consider in the approach to closure include the cause
and benefits of early or late surgical intervention. of the leak, associated elevated intracranial pressure,
The most common surgical causes of ACSF leak are encephalocele formation, and site and type of defect.82
from rhinologic and neurosurgical procedures,81 and Endoscopic repair of CSF rhinorrhea has become the
any CSF leak identified intraoperatively should be gold standard, particularly for the ethmoid roof and
repaired. Accidental CSF rhinorrhea can present imme- sphenoid sinuses.85,86 Schlosser and Bolger have pub-
diately or delayed, with 95% manifesting within 3 months lished extensively on CSF rhinorrhea and described sur-
of injury.82 gical considerations in detail.82 Proper exposure is first
With a clinical suspicion of CSF rhinorrhea, the most obtained and several millimeters of mucosa around the
important next diagnostic steps are confirmation of a bony defect are removed. Any encephalocele should not
leak and localization of the defect. Beta-2 transferrin is be pushed intracranially, but should instead be reduced
the gold standard for leak confirmation.68 Fine-cut with bipolar cautery followed by meticulous hemostasis.
coronal and axial CT scans should be the primary imaging Frontal sinus skull base defects may also be treated
modality; magnetic resonance imaging (MRI) may be a with an external approach. This includes a frontal osseous
useful complement. Adjunctive localizing tests include flap and frontal sinus obliteration. The mucosa in the
radionuclide cisternography with the use of intrathecal frontal sinus is removed and the bone is drilled with a
tracers and intranasal pledgets, CT cisternography with diamond burr to prevent mucocele formation in the
IV contrast, and MRI cisternography.81 postoperative period, as described earlier.82
Intrathecal fluorescein is the most commonly used Leaks can be repaired with an overlay, underlay, or
CSF tracer, usually in the preoperative period. A retro- combined approach (Fig. 19-14). Defects larger than
spective review of 420 applications of intrathecal fluores- 5 mm may be better managed with a combined approach.
cein has described two grand mal seizures, which were Materials and sealants used include temporalis
attributable to simultaneous intrathecal application of fascia, fascia lata, muscle, turbinate mucosa, fat, cartilage,
contrast.83 bone, human acellular dermis, xenogenic collagen dural
5mm/div
R L
F 5mm/div
A B
C
FIGURE 19-11 Complex frontobasilar injury requires combined neurosurgical and craniofacial treatment, often with bifrontal craniotomy for
increased exposure. A, Preoperative CT scan showing complex injury. B, Intraoperative access with bifrontal craniotomy.
C, Postoperative CT scan demonstrating reconstruction.
substitutes, and fibrin glue.81 There is no apparent differ- stool softeners, and avoidance of coughing, sneezing, or
ence with graft choice and much of it depends on surgeon straining for 1 to 2 weeks. The use of prophylactic anti-
preference.84 Fibrin glue has been shown to increase biotics is controversial, because these have not been
graft adherence and strength of repair in animal models.87 shown to decrease the incidence of meningitis. A lumbar
Degradable packing such as Gelfoam and Surgicel are drain may be inserted, depending on the extent of the
commonly used. Foley catheters can act as a bolster to leak, likelihood of spontaneous closure, and coexistence
help promote graft adherence. Postoperatively, patients of elevated intracranial pressure.81 Over two thirds of
are restricted to bed rest and the lumbar drain is these leaks have been shown to close with conservative
managed, if present. Antibiotics are not routinely admin- management.88,89
istered, but acetazolamide may have a role to decrease
CSF production. Continuous positive airway pressure is Management of Frontal Recess Fractures Involving
usually restricted.82 the Nasofrontal Outflow Tract
There is support for the idea that post-traumatic CSF Fractures of the nasoethmoid complex, supraorbital rim,
leakage in minimally displaced fractures is largely self- and frontal sinus floor may obstruct the nasofrontal
limiting and can be initially treated with conservative outflow tract. This is used as a surrogate for frontal sinus
measures such as bed rest, head elevation, function because it is hypothesized that damage to the
Posterior wall
removed, dura
repaired as
indicated
Plug inserted
to obstruct the
nasofrontal A
duct
Frontal sinus
Frontal sinus
ostia
B
FIGURE 19-12 After careful débridement of the frontal sinus region,
with meticulous removal of all remaining sinus mucosa, the FIGURE 19-14 A, Intraoperative endoscopic view of an iatrogenic
nasofrontal ducts are obliterated. CSF leak during a skull base resection of a pituitary adenoma.
This was repaired with a combined approach. B, A dural
substitute (Durasis) was used for the underlay. This was then
covered with a pedicled nasoseptal flap.
functional significance of each radiographic finding is

difficult to determine; intraoperative exploration and
evaluation are at times necessary.
From a superior approach, saline, various dyes, or
contrast may be used intraoperatively to assess patency of
the drainage system. One approach is to place a wide-
bore angiocatheter into the opening of the nasofrontal
outflow tract and introduce propofol into the duct. The
fluid should be visualized from beneath the middle tur-
binate or as a collection in the posterior pharynx to
confirm nasofrontal outflow tract patency. A nasal specu-
lum or endoscope can assist in the identification and
diagnosis.
If the nasofrontal outflow tract is not patent, conven-
tional management recommendations support open sur-
FIGURE 19-13 Anteriorly based pericranial flap that can be used gical treatment with obliteration.58 The goals of
for repair and obliteration. obliteration are the elimination of all sinus mucosa,
obstruction of the drainage system, and obliteration of
the remaining dead space. Access to the frontal sinus
nasofrontal drainage system and associated obstruction should be performed with the aim of complete exposure
of frontal sinus drainage increases the risk of developing and access while facilitating natural-appearing postop-
mucoceles and postoperative inflammatory complica- erative reconstruction (Fig. 19-15).
tions. As such, assessing the status of the nasofrontal Just as with cranialization techniques, complete
outflow tract is a key issue in managing frontal sinus removal of the sinus mucosa is carried out by curettage
injuries. and the use of a surgical burr with irrigation. Unilateral
The status of the frontal sinus floor and nasofrontal injury of a nasofrontal drainage tract is not predictably
outflow tract is first assessed by CT. Specific indicators of treated by removing the intersinus septum, which relies
injury include gross outflow tract comminution, frontal on the contralateral drainage system; therefore, treat-
sinus floor fracture, and anterior table medial wall frac- ment of the sinus as a single entity is recommended.15
ture. However, evaluating the patency of the drainage Any remaining nasofrontal duct mucosa can then be
system by imaging can be challenging because the inverted into the nose; obstruction of the nasofrontal
outflow tract should be carried out in a layered approach The anterior table is then reconstructed with the pre-
with autogenous tissue. viously removed frontal bone, titanium mesh, or free
Sinus obliteration has been performed with a host of cranial bone grafts, all secured with biodegradable or
materials reported in the literature, including hydroxy- titanium microplate fixation (Fig. 19-16).
apatite, bone cements, bone, cartilage, muscle, absorb-
able gelatin sponges, spontaneous osteoneogenesis, Endoscopic Approach
temporalis fascia, acrylic or methyl methacrylate, and More contemporary views allow for the growing suitabil-
fat.15,26,90-99 Fat is the most common choice, can be easily ity of endoscopic approaches for injuries in which there
harvested from the abdomen, and has been shown to is evidence of nasofrontal outflow tract obstruction
persist in a cat model,100 although this method is not and/or anterior table fractures.102,103 This allows the
without its detractors. Rodriguez et al have demonstrated surgeon to avoid obliteration of the sinus and is estab-
a higher rate of complications when obliterating with fat lished as an appropriate option in the nontraumatic
(22%) compared with obliteration without fat (5%).58 setting.104Although gaining interest, it is yet to be com-
Others have suggested that no one technique has been monly used in frontal sinus trauma. A review of 158
demonstrated to be superior to another.101 frontal sinus fractures has described just one patient who
was treated endoscopically.57 However, with the increase
in skills, techniques, and technology, endoscopic man-
agement of frontal sinus disease, including traumatic, is
gaining relevance.103
The endoscope can be inserted through a small treph-
ination to diagnose frontonasal duct damage and can aid
in placing a stent. Stenting of the frontal recess in the
acute setting, however, has been associated with a high
incidence of restenosis.6,17,55
The modified Lothrop technique, or Draf III proce-
dure, involves removal of the floor of the frontal sinuses,
including the anterosuperior septum and intersinus
Obliteration of septum.105 This approach also avoids injury to the supra-
sinus trochlear and supraorbital nerves. Endoscopic clinical
(example: fat
or other follow-up may be easier than interpreting MRI images in
materials) patients who have undergone frontal sinus obliteration.
This approach has been successful in the primary man-
agement of selected frontal sinus fractures.103
Postoperatively, patients who have had Draf III proce-
dures are followed closely for frequent débridement.
Saline irrigation is usually recommended. With these
measures, up to 90% of patients will have a patent frontal
recess, with normal mucociliary drainage104 (Fig. 19-17).
Management of Anterior Table Fractures
Simple greenstick or minimally displaced anterior table
fractures do not require surgical management. Histori-
FIGURE 19-15 The appropriate harvested or grafted material is cally, displacement of less than the thickness of the ante-
packed into the prepared sinus cavity. rior table has been considered inconsequential.
A B
FIGURE 19-16 A, Comminuted frontal sinus and NOE fracture. B, Bone reconstruction completed with titanium fixation in place.
years, and then once every subsequent 5 years.13 For all

frontal sinus injuries, immediate postoperative radio-
graphic evaluation and serial postoperative CT may be
indicated for an extended period of time because muco-
celes have been diagnosed decades after surgery by
various investigators.7
COMPLICATIONS IN FRONTAL
SINUS INJURIES
Advancement of the quality of care requires a review and
discussion of complications. Furthermore, identification
of injuries and procedures that are at a higher risk of
complications should direct surgical techniques as well
as follow-up. However, the frequency of complications
FIGURE 19-17 Endoscopic view taken in clinic of a right frontal associated with the observation or surgical management
sinus 3 months after a Draf procedure. of frontal sinus injuries is challenging to ascertain. The
literature on this topic is limited for several reasons and
Frequently, clinical reevaluation after 7 to 10 days may is therefore devoid of clear-cut answers. Sample sizes are
be required to determine the amount of visible deformity small due to the rarity of frontal sinus injuries. Care is
after soft tissue swelling has resolved. Displaced and mul- further diluted across many hospitals and treatment insti-
tifragmented fractures may require operative interven- tutions, and therefore limits research initiatives. Diagnos-
tion to address contour deformities and perhaps decrease tic methods continue to improve and treatment methods
the risk of mucocele formation. Case reports have indi- continue to evolve across multiple specialties that overlap
cated that minimally displaced and noncomminuted to treat craniomaxillofacial injuries. Local, consistent
fractures may be addressed via an endoscopic or insuffla- long-term follow-up of patients treated for facial injuries
tion approach.101,103,105,106 These injuries are largely cos- is unlikely ever to be a reality.
metic in nature and may be amenable to delayed Chuang and Dodson have meticulously reviewed the
recontouring or camouflage with autogenous grafting or literature with the use of a Medline search from 1980 to
alloplastic implants. Antibiotics are not indicated unless 2003, looking for significant inflammatory complica-
the fractures are open or contaminated. Sinus deconges- tions, including persistent frontal sinus pain or head-
tants are a useful adjunct during the observational ache, meningitis, brain abscess, mucopyocele,
period. osteomyelitis, and persistent CSF leak or fistulae after
treatment. In their study, 25 articles were included but
POSTOPERATIVE MANAGEMENT were largely noted to be of poor quality (level 4 case
Initial postoperative management efforts include serial series).46 They concluded that despite significant limita-
clinical examinations with an emphasis on wounds and tions in the articles reviewed, in the setting of operative
neurologic and ophthalmologic findings. An initial post- management of frontal sinus injuries, the mean inci-
operative CT scan is indicated for evaluation of the post- dence of serious inflammatory complications is approxi-
operative bony reconstruction and then as a baseline for mately 9% (range, 0% to 50%; 95% confidence interval
future examinations. Other postoperative medical man- [CI], 0% to 21%). An additional review of elective cra-
agement considerations include addressing pain, inflam- niofacial procedures that induced iatrogenic injury to
matory concerns, and sinus patency issues. Postoperative the frontal sinus was also included to estimate complica-
pain management should address the patient’s chief tion rates associated with observation of injuries for
complaints. The use of perioperative prophylactic antibi- comparison.
otics in the head and neck for 24 hours or less is currently Two significant retrospective reviews have been pub-
recommended. In case of foreign body or gross contami- lished more recently, both of which have included treat-
nation, antibiotic treatment may be continued for a ment algorithms. In the first, Bell and Chen reviewed
period of 7 to 14 days.107 their contemporary treatment of 144 patients over the
Decongestants should also be considered following past 10 years.51 In their study, 28 patients were excluded
frontal sinus surgery. Common decongestants include due to insufficient records. The focus of the treatment
the systemic α-adrenergic agonists (e.g., pseudoephed- algorithm was the maintenance of a functional sinus
rine) as well as topical (e.g., oxymetazoline spray); these when possible. Of the 116 patients that were included,
medications can effectively decrease the volume of nasal 66 were observed due to minimally displaced fractures,
mucosa by acting on receptors in venous vessels. while 50 underwent surgical treatment. There were no
Complications can occur years after injury, making complications recorded in the observational group, while
follow-up a critical component of the successful manage- 16% of the surgical group sustained a complication
ment of frontal sinus injuries; however, this may be dif- within the 90-week follow-up period.
ficult to achieve in practice. One current recommended In the second report, Rodriguez et al included a more
strategy is weekly follow-up for the first month, then every extended 26-year review of the treatment of 857 patients
3 months for the first year, then annually for the first 5 with frontal sinus fractures.58 Using the status of
the nasofrontal outflow tract as the main diagnostic trauma, this tends to resolve and is usually of little
parameter, 353 patients were observed (no clear naso- consequence.108
frontal outflow tract obstruction), with a 3.1% complica- Tension pneumocephalus results from a combination
tion rate, and 504 patients underwent surgical treatment of air pressure from the aerodigestive tract and a ball
(suggested nasofrontal outflow tract obstruction), with a valve phenomenon (Fig. 19-18). CT imaging is the best
10.4% complication rate. By their protocol, patients who initial investigation. If mild in severity and without symp-
demonstrated nasofrontal outflow tract obstruction toms, it may initially be managed conservatively. Surgical
required cranialization or obliteration with autogenous treatment to close the communication usually involves
tissue other than fat. Both procedures carried an approx- the same approach as the initial surgery. This can include
imate 10% complication rate. endoscopic, external, or combined approaches.108,109
A prospective trial to define treatment approaches
and complication rates further is neither feasible nor Sinusitis
ethical. With this understanding in mind, the above- Frontal sinusitis may occur early in the postoperative
noted studies can be used to provide a framework for the period. Patients may present with increased edema, ery-
discussion of complications associated with the treatment thema, and generalized tenderness in the forehead and
of frontal sinus injuries. periorbital regions. As noted, decongestants are prophy-
Additional delineation of specific types of complica- lactically recommended for all patients undergoing sinus
tions and their chronologic occurrence is also clinically surgery to prevent nose blowing. They also help mini-
relevant. Characterization may be made based on the mize mucosal inflammation and facilitate normal drain-
severity and subsequent requirement for reoperation or age and function, with the goal of preventing postoperative
hospitalization, as well as the timing of appearance. sinusitis. Radiographic imaging is a necessity and may
demonstrate mucosal thickening. Initial medical man-
PERIOPERATIVE COMPLICATIONS agement of the delayed presentation of sinusitis consists
Perioperative complications may be related to the repair of decongestants, with consideration given to the use of
of the maxillofacial injury or other systemic traumatic antibiotics, depending on the severity of associated clini-
injuries, if present. Specific injuries may include intracra- cal and radiographic findings such as fevers and sinus
nial bleeding, seizures, neurologic damage, cerebrospi- opacification.
nal fluid leakage, ophthalmologic injury, and hematoma.
In general, with meticulous surgical technique, these are Meningitis
rare. Postoperative infection, meningitis, and brain Invasive infection may progress from bacterial sinusitis.
abscess may occur more frequently, depending on the Intracranial abscess and meningitis may be the most
level of comminution, extent of exploration and surgical serious early infectious complication associated with
repair, and presence of wound or sinus contamination. frontal sinus trauma. The reported incidence of
meningitis appears to be between 0.9% and 6%.17,51,61,67
EARLY COMPLICATIONS The cause may be associated with incomplete obstruction
Early complications are defined as those occurring within of the nasofrontal outflow tract, allowing aerodigestive
the first 6 months after injury.15 They are categorized as communication with the intracranial space or obliterated
inflammatory, infectious, or aesthetic. frontal sinus cavity. Also, inadequate frontonasal sinus
drainage, remnants of sinus mucosa, dural tears, and
Sinonasal and Intracranial Communication cranial defects may all create conditions favorable to
Pneumocephalus can result from craniofacial trauma the development of an infectious complication. Direct
or as a postoperative complication. With frontal sinus extension of contaminated materials or tissues through
A B
FIGURE 19-18 This patient previously had a craniotomy and frontal sinus cranialization. Postoperatively, he developed tension
pneumocephalus with sneezing. A, Before bag-mask ventilation. B, Subcutaneous emphysema with bag-mask ventilation.
small fractures of the diploe can also result in menin-

gitis, empyema, cavernous sinus thrombosis, and intra- LATE COMPLICATIONS
cranial abscess. Patients may present with sinusitis Late complications of frontal sinus fractures occur 6
symptoms as well as severe headaches, seizures, focal months or more after the initial injury15 and have a repu-
neurologic findings, change in vision, and fevers. Again, tation for being indolent and insidious in nature. These
follow-up imaging is a necessity and management may are generally infectious or inflammatory and include
require medical therapy (e.g., antibiotics, deconges- mucocele or mucopyocele formation, late frontal sinus-
tants), with or without surgical exploration and treat- itis, and brain abscess secondary to a frontal sinus infec-
ment (e.g., abscess drainage, repair of dural or cranial tion. Some of these complications appear many years
defects, separation of the aerodigestive tract and after the original injury. The delay between injury and
central nervous system, obliteration of dead space, appearance of a complication may draw into question
cranialization). the true relationship between the injury and subsequent
complications.
Cosmetic Irregularities
Contour irregularities and cosmetic deformity may be Mucocele and Mucopyocele Formation
noticeable as the edema from the initial injury subsides. Respiratory mucosa trapped between fracture segments
This can be seen in observed and reconstructed patients. or remaining after sinus obliteration may continue to
In addition, loss of frontal bone through infection or grow, resulting in mucoceles or mucopyocele, some-
resorption may compromise the original repair. This can times decades after the injury. A mucocele is an expan-
usually be managed after a period of soft tissue matura- sive cyst filled with mucus secreted by goblet cells in
tion by the addition of free bone grafts, alloplastic the ciliated mucosa.110 In the post-traumatic setting,
implants (e.g., porous high-density polyethylene this is usually a late manifestation of frontal recess
[Medpor], polyetheretherketone [PEEK]), or onlay obstruction. Mucoceles can range from small to large,
bone cement. Palpable or visible hardware can be with bony expansion and erosion (Fig. 19-19). CT and
removed, if necessary, at times through small stab inci- MRI imaging can help determine the extent and
sions. The availability of low-profile rigid fixation and the whether there is intracranial communication.111 The
use of primary bone grafts have decreased the likelihood expansile nature of this benign lesion accounts for its
of frontal bone contour deformities in the contemporary potential morbidity, which can include brain mass effect
management of these injuries. and blindness.112
A B
C
FIGURE 19-19 Saggital (A) and coronal (B) CT images of two left ethmoidal mucoceles, stacked on each other, with orbit expansion and
frontal recess outflow obstruction. This patient was treated endoscopically, with removal of the mucoceles. C, Endoscopic view of left
frontal sinus.
Surgical treatment of a mucocele includes endoscopic, complexity, and absence of good data supporting clinical
external, and combined approaches. A simple marsupi- decision making. The goals of management are struc-
alization with restoration of the frontal outflow tract is tural protection for the intracranial structures, isolation
an effective option, with low morbidity. This may be the of the intracranial and extracranial compartments, resto-
best option in a mucocele that erodes the posterior wall ration of natural frontal contour, and prevention of
of the sphenoid or frontal sinus. Removal of the poste- infectious and inflammatory complications. Fronto-
rior aspect of the mucocele would potentially result in a orbital fractures involving the central face are most influ-
CSF leak. Leaving it maintains sinonasal and intracranial enced by the frontal sinus and require complex decision
separation. Frontal sinus obliteration and cranialization making regarding treatment. Operative treatment should
are other options.110 proceed based on the complexity of frontobasilar involve-
Mucopyoceles are infected mucoceles and are more ment, presence of persistent CSF leakage, degree of
likely to be acutely symptomatic (Fig. 19-20). Manage- nasofrontal drainage disruption, and degree of anterior
ment is more urgent and intracranial and/or intraorbital table displacement. Complications may occur many years
extensions are more common.113 IV antibiotics are after treatment, requiring long-term radiographic and
included in their treatment. Surgical management clinical follow-up.
includes the same options as listed above.114
SUMMARY ACKNOWLEDGMENTS
The management of frontal sinus injuries continues to We wish to thank Drs. Sung-Kiang Chuang and
challenge craniomaxillofacial trauma surgeons because Thomas B. Dodson for their previous contributions to
of the low incidence of injury, regional anatomic this chapter.
A B
C D
FIGURE 19-20 Mucopyocele complicating frontal sinus repair. A, Cutaneous fistula and purulent drainage. B, CT demonstrates frontal
epidural abscess, mucocele, and osteomyelitis. C, Aerodigestive communication with the intracranial cavity. D, Mucocele and
osteomyelitis. Continued
E F
H
FIGURE 19-20, cont’d E, CT scan showing débridement. F, Pedicled soft tissue coverage of the NFOT. G, Autogenous fat–layered
closure. H, Reconstructed bone coverage using titanium miniplates.
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CHAPTER
Nasal Fractures:
20 Evaluation and Management
Sharon Aronovich
| Bernard J. Costello
OUTLINE
Function of the Nose Treatment of Nasal Injuries
Epidemiology Closed Reduction of Nasal Fractures
Anatomy Open Treatment of Severe Nasal Injury
Evaluation of Injury to the Nose Post-Traumatic Deformity
History and Physical Examination Special Considerations for Pediatric Patients
Nasal Patency and Airflow Dynamics Complications
Radiographic Examination Prevention of Nasal Injuries
N
asal trauma is a common occurrence in pediatric rate of fractures with the highest rate in football, basket-
and adult patients because of the exposed and ball, and soccer.4 The investigators found that when facial
central position of the nose on the face.1-4 There fractures occurred, nasal fractures were the most common
is a broad spectrum of primary and secondary nasal injury and resulted in more than 3 weeks of time lost or
trauma deformities that the craniomaxillofacial surgeon medical disqualification from participation in sports, in
must be able to address. This chapter reviews the evalu- addition to incurring substantial costs to the patient’s
ation and treatment of nasal trauma and secondary nasal family and health care system.
deformities. Regional differences in the presentation of nasal frac-
tures can be observed. In a retrospective study of Brazil-
FUNCTION OF THE NOSE ian children aged 5 to 17 years, Cavalcanti and Melo have
found that facial injuries were 3-fold more frequent in
The nose and perinasal tissues have functional and aes- males aged 13 to 17 years; the most common causes of
thetic roles. The aesthetic value of the nose is a key aspect these injuries were falls and MVAs.3 Among facial injuries
of facial appearance and a very recognizable feature of in that study, nasal fractures were also most common,
the face. It is also the most exposed and prominent area 51.3%, followed by the zygomatic-orbital complex, 25.4%.
of the face. The nasal form is directly related to its func- In another retrospective study, Hwang et al have reviewed
tion. When treating nasal trauma, clinicians should aim and analyzed the medical records of 236 patients with
at optimizing function as a primary objective in conjunc- facial bone fractures caused by athletic activity who were
tion with the aesthetic goals. Nasal function is important treated at one institution between 1996 and 2007.9 The
for normal respiration, humidification, speech produc- investigators noted that the age group with the highest
tion, and sensations associated with smell and as an aes- frequency of these injuries was 11 to 20 years (40.3%),
thetic facial feature. with a significant male predominance across all age
groups (13.75 : 1). There were 128 isolated nasal frac-
EPIDEMIOLOGY tures, with soccer accounting for 39%, followed by other
sports, including martial arts.
Nasal fractures are the most common facial fractures Nasal injuries have been shown to be common in
seen and occur at least twice as often in males as in adults and children and may be associated with signifi-
females.1-6 The high frequency of nasal fractures can be cant morbidity. Associated injuries of adjacent structures
attributed to its prominent location in the facial skeleton should be suspected based on common injury patterns.
and the comparatively smaller amount of force needed The age and the environment play a key role in deter-
to produce a fracture when compared with other facial mining the injury incidence and pattern.
bones. Athletic injuries, interpersonal altercations, falls,
and motor vehicle accidents (MVAs) account for the ANATOMY
greatest proportion of causes. In the children and ado-
lescents, sports and falls are the major causes of isolated The nasal bones are paired and joined at the midline;
nasal bone fractures.2-4,7,8 For example, a study of sports- they articulate with the frontal bone superiorly and the
related fractures in U.S. high schools has found a 10.1% frontal process of the maxillary bones laterally. Caudally,
491
Nose
Anterolateral view Inferior view
Major alar cartilage
Frontal bone
Nasal bones Lateral Medial
Frontal process of maxilla crus crus
Lateral process of
septal nasal cartilages
Septal cartilage
Minor alar cartilage
Accessory nasal cartilage
Lateral crus
Major alar cartilage
Medial crus
Alar Anterior
Septal nasal cartilage fibrofatty nasal spine
Anterior nasal spine of maxilla tissue of maxilla
Alar fibrofatty tissue Septal nasal
cartilage Intermaxillary
Infraorbital foramen suture
FIGURE 20-1 Bone and cartilage structures of the nose. (Netter illustration from www.netterimages.com, © Elsevier Inc., All rights reserved.)
they interact with the upper quadrilateral cartilages. lymphatic vessels course at or superficial to the musculo-
Basally, they articulate with the nasal septum, which is aponeurotic layer of the nose. Therefore, open
formed by the perpendicular process of the ethmoid and approaches must limit dissection deep to this musculo-
the vomer inferiorly (Fig. 20-1). aponeurotic layer to maintain nasal tip blood supply and
Nasal air passage may be affected by a variety of condi- drainage conduits.10
tions. Anatomically the internal and external nasal valves
must be patent, with the former having an angle of at
least 10 to 15 degrees. A deviated nasal septum, nasal EVALUATION OF INJURY TO THE NOSE
spurs, concha bullosa, nasal polyps, and inflammatory
sinonasal disease represent examples of altered anatomy HISTORY AND PHYSICAL EXAMINATION
that potentially become sources of nasal obstruction and A detailed history exploring the mechanism and timing
may contribute to nasal airflow obstruction (Fig. 20-2). of injury, and loss of consciousness, will help distinguish
The neurosensory innervations of the nose are rich isolated nasal and septal fractures from those likely to be
and complex (Fig. 20-3). The overlying nasal skin receives associated with other injuries. Any history of prior nasal
its innervation from the dorsal nasal and external nasal and/or septal trauma or surgery should also be docu-
nerves, branches of the anterior ethmoidal and ophthal- mented. Recent pretraumatic photographs may be
mic (to infratrocheal) nerves, respectively. Intranasally, helpful to appreciate the extent of nasal and septal defor-
the septum and lateral walls are innervated by branches mities. The possibility of nonaccidental trauma must be
of the sphenopalatine and anterior and posterior eth- considered. Concussion and brain injury symptoms such
moidal nerves. The nasal floor receives some fibers from as headache, nausea or emesis, dizziness, disorientation,
the nasopalatine nerve and from the greater palatine or lethargy must be elicited and managed appropriately
nerve. The parasympathetic supply originates from the by the trauma and neurology teams.
superior salivatory nucleus in the medulla, travels with Observing the nasal dorsum from the frontal,
the nervus intermedius and cranial nerve VII to the worm’s eye, and bird’s eye views will help the clinician
geniculate ganglion, and continues along the greater appreciate any external nasal deformities. Overlying
petrosal nerve and through the vidian canal to reach the edema is frequently present with decreased definition
pterygopalatine ganglion. The postganglionic fibers of the melonasal angle and may mask the severity of
travel to the sinonasal mucosal, including the septum the underlying skeletal deformity. The clinician should
and turbinates. examine for the presence of nasal and septal deviation,
Although concerns exist among clinicians about nasal step deformities, and crepitus on palpation. The intra-
tip edema or vascular insufficiency resulting from opera- nasal examination with a nasal speculum, appropriate
tive management of nasal injuries and the use of vaso- lighting, suction, and vasoconstrictor is important to
constrictors, this has not been substantiated by research assess the status of the cartilaginous and bony nasal
studies. Lymphoscintigraphy, along with cadaver dissec- septum, rule out septal hematoma, and determine the
tions and histologic studies, have revealed that the origin and extent of epistaxis and/or cerebrospinal
primary blood supply for the nasal tip arises from the fluid (CSF) rhinorrhea. In some cases, it may be
lateral nasal branches of the facial artery (Fig. 20-4). helpful to use nasoendoscopy with a fiberoptic scope to
Other arteries supplying the nasal tip include the colu- evaluate the posterior nasal complex and nasopharynx
mellar branch of the superior labial artery and the exter- further. Those skilled in the use of this type of instru-
nal nasal branch of the anterior ethmoid artery. Moreover, mentation may also find it helpful to evaluate the pos-
it was found that the major arterial, venous, and terior airway and the presence of bleeding.
Nasal Fractures: Evaluation and Management CHAPTER 20 493
Coronal section
Olfactory bulbs
Falx cerebri
Brain Frontal sinus
Nasal cavities
Orbital fat
Nasal septum
Ethmoidal cells
Middle
nasal concha Opening of
maxillary sinus
Middle
nasal meatus Infraorbital Recesses of
Zygomatic maxillary
Maxillary sinus Alveolar sinus
Inferior
nasal meatus Buccinator muscle
Alveolar process of maxilla

Inferior nasal concha
Body of tongue
Hard palate
Sublingual gland
Oral cavity
Mandible (body)
A
Nasal cavities
Eyeball
Nasal septum
Ethmoidal cells
Medial wall
Orbital fat and muscles of orbit
Optic nerve (II)
Sphenoidal sinuses
Brain
Optic chiasm
Horizontal section
B
S-shaped septal deformity occluding Anteroposterior S-shaped septal

C airway bilaterally D bulge (horizontal section)
FIGURE 20-2 Internal structures of the nose. A, B, coronal and axial sections of the nasal region. C, D, Coronal and axial sections of the
deviated septum that is S-shaped and obstructing both nasal cavities. (Netter illustrations from www.netterimages.com, © Elsevier Inc.,
All rights reserved.)
Anterior ethmoidal nerve
Lacrimal gland
(from nasociliary nerve)
External
Ophthalmic nerve (V1) nasal
branch of
Trigeminal anterior
(semilunar) ganglion ethmoidal
nerve
Trigeminal
nerve (V)
Nasal branch
of infraorbital
nerve
Infraorbital
nerve
Mandibular nerve (V3)
Maxillary nerve (V2)
Efferent fibers Trigeminal nerve (V)

Afferent fibers ganglion and nuclei
Proprioceptive fibers Ophthalmic nerve (V1)
Parasympathetic fibers
Sympathetic fibers
Anterior ethmoidal nerve

Internal nasal
branches
and
External nasal
branches
of anterior
ethmoidal nerve
Maxillary
nerve (V2)
FIGURE 20-3 Neuroanatomy of the nasal complex. (Netter Mandibular nerve (V3)
illustrations from www.netterimages.com, © Elsevier Inc., All
rights reserved.)
A detailed facial examination is also important and sees and treats concussions on a regular basis. This is
should include visual acuity, extraocular muscle move- particularly important for patients who plan on return-
ment, pupil size and reactivity, intercanthal distance, ing to physical activity or sports that might involve blows
medial canthal tendon position, mandibular range of to the head.
motion, and occlusion. In many cases, forces great
enough to fracture the nasal and septal bones are sub- NASAL PATENCY AND AIRFLOW DYNAMICS
stantial enough to injure adjacent structures, such as the The internal nasal valve primarily determines nasal resis-
globe and orbit floor. tance to airflow because this is typically the narrowest
During the examination, the astute clinician will rec- zone.11-14 This valve is triangular in shape and is formed
ognize that some patients may exhibit signs and symp- by the junction of the caudal upper lateral cartilages and
toms of a concussion. As such, a symptom-driven nasal septum.15-23 Inferiorly, it is bound by the nasal floor
neurologic examination is important in a subset of and posteriorly by the inferior turbinates. It has a cross-
patients with facial injuries. Sports-related concussions sectional area of approximately 55 mm2, with an angle of
associated with facial fractures are often undertreated 10 to 15 degrees in whites. Fixed and dynamic causes of
and those with other causes may be missed entirely. valve obstruction may be responsible. For instance,
Patients who have complaints of headaches, irritability, dynamic obstruction on inspiration may be seen with
confusion, visual changes related to traumatic eye injury, post-traumatic weakness of the upper or lower lateral
poor sleep patterns, or other related symptoms should cartilage. The Cottle test, in which the cheek is pulled
have an evaluation by a properly trained specialist who laterally, may improve nasal airflow by pulling the upper
Frontalis muscle
Supraorbital artery and nerve
Supratrochlear artery and nerve
Procerus muscle
Corrugator supercilii muscle
Dorsal nasal artery
Angular artery
External nasal artery and nerve
Nasalis muscle (transverse part)
Infraorbital artery and nerve
Lateral nasal artery
Transverse facial artery
Nasalis muscle (alar part)
Depressor septi nasi muscle
Orbicularis oris muscle
Facial artery
Posterior
lateral nasal
Anterior lateral nasal branch branches of
sphenopalatine
External nasal branch artery
of anterior ethmoidal Anterior septal branch
Sphenopalatine
artery
artery
Posterior septal branch of

sphenopalatine artery
Alar branches of
lateral nasal
branch
(of facial artery)
Maxillary
artery Nasal septal branch
of superior labial
External carotid branch (of facial
artery artery)
Lesser palatine foramen and artery
Greater palatine foramen and artery

B Lateral wall of nasal cavity
FIGURE 20-4 A, B, Vascular supply of the nasal complex. (Netter illustrations from www.netterimages.com, © Elsevier Inc., All rights reserved.)
lateral cartilage laterally and opening the internal valve and a clear history of the mechanism can be diagnosed
area.24 Imaging modalities such as computer tomography and treated without the need for exposing the patient to
(CT) may demonstrate the presence of contributing radiation. Plain radiographic films may be adequate to
factors such as sinonasal disease, concha bullosa, and a assess the extent and displacement of nasal bone frac-
posterior septal spur or septal deviation. tures when no other injuries are suspected, but they are
used less often with the advent of CT.
RADIOGRAPHIC EXAMINATION Additionally, because of extensive overlap of other
A variety of options are available for imaging and catego- anatomic structures, some nasal fractures cannot be com-
rizing nasal fractures and the surrounding region.25-30 pletely visualized with plain films alone. CT, although not
Many isolated nasal injuries with no loss of consciousness required in every patient, provides excellent detail. In
addition, concomitant fractures such as orbital, naso- Cook et al compared the manipulation and reduction
orbital ethmoid, zygomatic, maxillary, and frontal sinus of nasal fractures under local anesthesia (LA) and general
or cribriform plate fractures may be identified more anesthesia (GA). In this study, LA was administered with
easily and treated more precisely. On occasion, identifi- 0.5% bupivacaine blocking the infraorbital, infratroch-
cation of these additional fractures may alert the clini- lear, and external nasal nerves.35 Patients in the LA group
cian to possible complications, such as obstruction of the rated how painful the combined anesthesia administra-
nasolacrimal duct with its associated epiphora or suspi- tion and fracture manipulation had been on a scale from
cion of a dural tear with CSF rhinorrhea. On occasion, 1 to 5 at the 4-hour and 8-week time point after reduc-
pneumocephalus may be identified if the injuries extend tion. They also rated nasal airway patency and the surgeon
into the anterior cranial base. Recently, cone beam CT rated the cosmetic result. After manipulation, the patency
has been used in dental offices and other settings to of nasal airways was comparable between the LA and GA
visualize bony lesions, dysmorphology, and fractures. If groups. The local anesthesia group rated their median
one suspects injury extensive enough to cause multiple pain score as 3 out of 5. Pain was attributable to the
fractures at multiple sites, cone beam CT may not be infiltration of LA solution. When asked about their
recommended because imaging of the brain tissues may choice of anesthesia in case they would require nasal
be needed to evaluate the possibility of epidural or sub- manipulation in the future, 24 of 25 patient in the LA
dural bleeding, parenchymal brain injury, or bleeding in group and 16 of 25 in the GA group indicated that they
the cisterns. would opt for LA. There were no reported cases of peri-
operative airway compromise documented in these
patients.
TREATMENT OF NASAL INJURIES The same investigators also randomized two LA tech-
niques among 50 consecutive adult patients with clini-
For most routine nasal fractures, operative management cally displaced nasal fractures.36 One group received
of nasal fractures requires consideration for the timing, blocks of the infraorbital, infratrochlear, and external
anesthetic, setting in which treatment is rendered, and nasal nerves by intranasal infiltration and the other
details of the operative approach.31-33 The recommended group was given generalized infiltration of the nasal
time frame to repair nasal fractures is within the first dorsum by an external route. All patients received intra-
week after injury. It is acceptable to perform immediate nasal cocaine. Postoperatively, patients recorded their
treatment, but at times it may be helpful to allow swelling overall discomfort level and subjective nasal airway
to decrease prior to definitive treatment. Some recom- patency. The surgeon also recorded the cosmetic result.
mend delaying surgery because it is may sometimes be They found the internal route to be significantly more
difficult to judge the adequacy of reduction in the pres- painful (p < .001) and with no advantage to the patient
ence of significant edema. However, surgeons must with respect to postoperative airway patency or cosmesis.
remember that the elastic cartilaginous framework may Their study suggested that the external method is prefer-
be difficult to reduce as fibrin organization and fibrosis able. Epistaxis was never severe enough in any of the
ensues; thus, delayed repairs beyond 1 week may become patients to warrant nasal packing or hospital admission.
increasingly more difficult to treat with closed reduction In addition, the group undergoing intranasal infiltration
alone. Children have a tendency to heal the bony tissue expressed a greater willingness to have GA in case they
more quickly, which may make it more difficult to achieve were to have the procedure again as compared with the
a detailed repositioning. Treatment within the first external infiltration group, but the difference did not
several days facilitates the healing process, limits patient reach statistical significance. The authors noted that
disability, and decreases the patient’s time spent away local anesthesia is an effective, economical, and well-
from school, work, or other activities.34 tolerated treatment option for closed reduction of nasal
Local anesthesia or the use of sedation can be used, fractures in adults. However, they cautioned against using
but it may put the patient at increased risk for bleeding LA in pediatric patients because of behavioral and com-
in and around the airway. This can lead to laryngospasm pliance issues, anxiety, and airway concerns.
in patients who are obtunded, particularly children. Although the operative approach for isolated nasal
When the nasal complex is bleeding, it may complicate bone fractures typically consists of closed reduction,
airway management and reduce the surgeon’s ability to nasal fractures associated with significant obstruction,
reduce the fracture adequately under good conditions in septal deviation that is not reducible with closed maneu-
a safe manner. We prefer to treat nasal and septal frac- vers, or loss of nasal septal support may require open
tures with a brief general anesthetic in the operating repair and reconstruction. The open techniques
room using an endotracheal tube or laryngeal mask ven- are sometimes accomplished with osseous and/or carti-
tilation device. Either airway option can be used for laginous grafts, primarily or in a secondary staged
adults or children. procedure.
While the authors prefer general anesthesia for chil-
dren during operative manipulation of nasal fractures.
However, there are advocates for the choice of either CLOSED REDUCTION OF NASAL FRACTURES
local or general anesthesia, and some data to support Most nasal fractures are treated with closed reduction
that decision. Contributing factors may include patient and various forms of external stabilization, with or
cooperation, financial constraints, operator experience without packing materials for the internal nose
or comfort, and others. (Fig. 20-5). This approach efficiently repositions the
A B C
D E
FIGURE 20-5 A, Axial CT scan shows

displacement of a nasal fracture in a
teenager after an assault.
B, Displacement is evident clinically.
C, After reduction of the nasal and
septal bones, the nasal complex is
more symmetric. D-G, Diagrammatic
representation of the procedure
typically performed for reduction of the
nasal and septal bones, with external
F G and internal splinting of the reductions.
comminuted segments and is successful for achieving stabilize comminuted nasal bones and prevent inward
appropriate form and function for most injuries. collapse of bony fragments. Packing may allow control of
After induction of general anesthesia, the airway is bleeding and prevent septal hematoma formation. Over
secured with an oral endotracheal tube (ETT) or laryn- the long term, they can prevent synechiae in patients
geal mask airway (LMA). A throat pack may be placed, with extensive mucosal laceration and abrasion because
if desired. Although corneal protection is encouraged, the swollen and displaced mucosa can become inappro-
adequate clearance must be present for nasal manipula- priately healed to an adjacent site, causing significant
tion and application of a nasal splint. The extent of the obstruction.
nasal deformity and deviation is noted from the frontal, On occasion, formal posterior nasal packing may be
worm’s eye, and bird’s eye views. An appropriately sized needed to control bleeding temporarily. A posterior
nasal speculum and good suction help provide good visu- nasal pack may consist of three cottonoids tied together
alization of the nasal cavity. It is important to reexamine and introduced orally to the nasopharynx via a red
the nose under these more ideal conditions, including rubber catheter that is passed nasally and retrieved in the
the nasal septal form, integrity of the nasal floor, nasal oropharynx. Alternatively, a posterior nasal pack may be
turbinates size, patency of external and internal valves, quickly established with the following: a Foley catheter
presence of bleeding sites, and integrity of the cartilagi- introduced nasally and inflated for proper seal after
nous structures. passing the velopharyngeal valve; or one of several com-
A local anesthetic is injected for postoperative patient mercially available devices that have balloons available to
comfort, blocking the infraorbital nerves bilaterally. inflate for various areas of the nose. Bleeding can then
Local anesthetic may also be used intranasally to block be addressed in the operating room with electrocautery
the anterior ethmoidal, sphenopalatine, nasopalatine, or other local measures. Rarely, extended surgical maneu-
and superior labial nerves; however, care must be taken vers for control of bleeding or interventional radiology
not to distort the overlying dorsal nasal soft tissues. A techniques may be necessary for recalcitrant bleeding.
vasoconstrictor such as oxymetolazone nasal spray is Appropriate evaluation for the potential for blood dys-
applied bilaterally. In addition, cotton pledgets or neuro- crasias should be carried out in those who have unusual
sponge patties soaked in oxymetolazone are inserted for bleeding.
optimal mucosal vasoconstriction prior to manipulation. Finally, an external nasal splint may be applied. Splints
Care should be taken to avoid drops of oxymetazoline are custom-made from plaster, cut and shaped to fit and
from contacting the cornea or sclera, because this leads made out of metallic and cloth material, or customized
to decreased tear volume and tear flow. In addition, an from a thermoplastic material that is softened in hot
associated anesthetic sensation may promote a postoper- water. The overlying skin is cleaned and dried. A mild
ative corneal abrasion; patients will often scratch their skin adhesive is applied onto the nasal skin, and 1 4 -inch
eyes after extubation prior to arriving at the postopera- strips are placed from the radix to the tip to protect the
tive care unit and create a significant corneal abrasion. skin from thermal injury and provide a sticky surface for
Nasal bones can be repositioned with digital manipu- the splint. One strip may be applied as a sling, suspend-
lation using the maxillary and frontal bones for anchoring the nasal tip to the nasal dorsum superiorly and
age and guidance for reduction. Adequacy of the providing upward support to the tip during healing.
reduction is determined by palpation and visual inspec- Another thin coat of adhesive is then applied over the
tion from multiple views, as noted. The Goldman eleva- wound strips, being careful not to allow the adhesive to
tor may be used to restore nasal septal projection, lifting drip in the eye, because this can cause significant damage
the overlying nasal bones superiorly and anteriorly while to the cornea. The thermoplastic splint material is
palpating with an overlying finger. The instrument is also trimmed and dipped into the hot water bath to make it
run along the superior-lateral portion of the pyriform pliable and moldable. Care is taken to avoid thermal
rim to appreciate any step deformities. A common error injury to the patient’s skin. The splint should be molded
made by inexperienced surgeons is to overproject the with active digital pressure along the entire length as it
fractured nasal bones more laterally and anteriorly than cools and sets. The splint helps maintain the symmetrical
their original positions, thereby giving the patient a position of the nasal bones and protects the injured area
much broader appearance to the lower portion of the from displacement by external forces. It also helps reduce
nasal bones as they integrate with the maxillary bones the overlying soft tissue edema. It is usually triangular in
laterally and inferiorly. shape and should not extend too closely to the medial
The Asch forceps may be used to assess and treat nasal canthi, nasal tip, or lateral ala region.
septal deviations. Care must be taken because these Nasal packs are usually removed 1 to 3 days after
maneuvers may damage or lacerate the nasal mucosa. surgery. The septal splint may be maintained for 1 week
Some prefer using the Walsham forceps and Boies eleva- or longer, as needed. Patients are instructed to avoid
tor. Throughout the operative manipulation, the nasal strenuous physical activity for a period of 4 to 6 weeks
cavity should be suctioned aggressively to minimize blood while the disrupted nasal bones, cartilage, and mucosa
pooling in the nasopharynx and hypopharynx. heal. Exertion may bring about epistaxis in some patients;
Significant septum manipulation or mucosal disrup- it is important to warn patients who may attempt return
tion may warrant placing a septal splint secured with to sports or other activities about this risk.
mattress sutures bilaterally. Gauze packing, 1 4 inch, or Patients are followed postoperatively and are evalu-
commercially produced packs coated with antibacterial ated for a patent nasal passage and unhindered nasal
ointment may be used. Nasal packs and the splint help airflow, as well as nasal septal symmetry and aesthetics.
Massage of the nasal bones is encouraged, starting including a columellar strut, peck, umbrella, and/or
between 2 and 4 weeks postoperatively, to mold commi- shield grafts.
nuted fragments and encourage remodeling until a more For most of these injuries, patients will require an
smooth nasal contour is achieved. open approach with some form of a columellar-splitting
incision to gain proper access to each anatomic compo-
OPEN TREATMENT OF SEVERE NASAL INJURY nent (Fig. 20-8). Post-traumatic asymmetrical deformities
Most open approaches to complex nasal fractures are can be particularly challenging. Surgeons must be com-
accomplished from a bicoronal incision in coordination fortable with a wide variety of rhinoplasty techniques to
with other related fractures such as the frontal sinus and address the post-traumatic nasal deformity successfully
naso-orbital-ethmoid (NOE) complex (Fig. 20-6). NOE and achieve a successful reconstruction.
fractures are discussed elsewhere in this text. Fixation Septoplasty is commonly required when revision nasal
from above, with small, low-profile fixation devices, is surgery is being considered. A deviated nasal septum can
helpful when significant comminution is present. It is be repositioned using an intranasal approach with uni-
important to establish appropriate projection of the lateral access to the nasal septum via a Killian hemitrans-
nasal bones in conjunction with these other fractured fixation incision and subperichondrial plane of dissection.
structures. Rarely, primary bone grafting may be helpful The obstructing midline maxillary crest of bone and infe-
at the initial reconstruction. These grafts are usually rior septum may need to be removed to allow the remain-
taken from the readily accessible parietal bone as a ing septum to hinge back into position. The septum
partial-thickness graft cantilevered from the nasofrontal position can be altered by cross-hatching or making
junction. Primary bone grafting techniques are helpful radial cuts in the cartilage, allowing the deviated portion
for patients who have had an unusual degree of com- to bow in a more appropriate direction. Resection of a
minution or those who have had the bones avulsed from deviated component may be a good alternative as long
a unique traumatic injury, such as a dog bite or ballistic as appropriate structure remains for nasal support. A
injury.37-40 However, in most cases, the components portion of the resection may be helpful for columellar
required for the reduction of even severe fractures are strut grafting. Alignment of the septum is maintained
present and can be repositioned without resorting to with trans-septal mattress sutures; stability is provided
primary grafting techniques. with an internal nasal splint for approximately 1 week.
Rarely, direct open approaches via more local rather In addition to septal deviation, separation of the upper
than a coronal incision may be used for isolated severe lateral cartilage from the nasal bones may collapse the
nasal fracture repairs, such as those from dog bites or internal nasal valve. Not all intranasal obstruction after
ballistic injury (Fig. 20-7). These are generally used trauma should be attributed to a deviated septum. A
because the existing laceration allows for access. Flaps detailed assessment of the turbinates, nasal valve, nares,
are raised to access the lower or upper lateral cartilages and sinus health should be performed. A positive Cottle
and septum for manipulation, reduction, and fixation. test may necessitate treatment by placement of spreader
Trans-septal sutures, external splinting, and repairs of grafts.48 These cartilaginous grafts are placed between
the cartilaginous structures may be helpful. Fixation the septum and upper lateral cartilages to increase the
placed through local incisions must have adequate soft internal nasal valve angle and improve efficiency of
tissue coverage to prevent wound healing problems and breathing. They may also help the aesthetics of the
the devices must be placed accurately with a very low dorsum in some cases.
profile.41 A saddle nose deformity often requires an osseous or
cartilage dorsal strut graft, which may be harvested from
the calvarium (parietal bone), iliac crest, or rib. Inferior
POST-TRAUMATIC DEFORMITY subperiosteal and subcutaneous planes of dissection to
the nasal tip via a coronal flap or intranasal incision
A significant number of patients who endure nasal frac- create a pocket of the thin and custom-shaped graft. The
tures may benefit from secondary rhinoplasty and/or graft is shaped, contoured, and cantilevered off the
septoplasty to address residual deformities after closed frontal bone with a miniplate or, if placed from below,
reduction techniques are performed.42-47 Typically, 6 placed within a self-retaining pocket of dissection. Tem-
months or more of healing and remodeling is recom- porary fixation sutures and an external nasal splint may
mended prior to performing a secondary septorhino- be used to stabilize a cartilage graft if placed from an
plasty. A discussion of the specific techniques is beyond intranasal incision (Fig. 20-9).
the scope of this chapter, but the reader is encouraged
to review the concepts of rhinoplasty, which include treat-
ment of the deviated nose, asymmetric nasal tip, poorly SPECIAL CONSIDERATIONS FOR
projected nasal tip, lack of a supra–tip break, nostril PEDIATRIC PATIENTS
deformities, and deviated septum. Nasal bone osteoto-
mies, dorsal reduction, trimming and repositioning of Nasal fractures are uncommon in infants and very young
the upper and lower lateral cartilages, alteration of the children because of the lack of projection and relative
nasal valve, and use of the columellar strut graft are all elasticity of the underdeveloped nasal bones and associ-
helpful techniques commonly used in a secondary rhino- ated cartilage. They also lead relatively protected lives
plasty. Alterations of the nasal tip projection, contour, during young childhood. Nonetheless, nasal fractures
and position can be made using a variety of techniques, still represent one of the most common types of facial
A B
C D
E F
FIGURE 20-6 This teenager was involved in an MVA and sustained complex and cranial injuries, which included a complex nasal fracture.
Detailed imaging is required to plan the reconstruction in this type of injury. A-C, Axial, coronal, and saggital views of the craniofacial
skeleton detail the fractures and their degree of comminution, displacement, and involvement with the cranial base. D, The axial view
of the skull and brain shows a subdural in the frontal region, with some brain injury. E, A zigzag coronal incision is shown prior to
dissection. This approach provides full access to the nasal fractures. F, The comminuted cranial vault and nasal bones are shown prior
to reduction and plating. The open approach provides the appropriate visualization for this level of injury.
A B
C D
FIGURE 20-7 A-C, An open approach is required for this young boy who suffered a dog bite to the nasal complex, with loss of some
lower lateral cartilage and overlying soft tissue. D, E, Primary repair is achieved with a detailed closure. F-H, Initial healing is good, but a
revision will likely be helpful once additional growth is complete.
E F
G H
FIGURE 20-8 An open rhinoplasty approach to reposition

traumatically disarticulated lower lateral cartilages and a loss of
dorsal support after severe nasal trauma sustained from a
snowmobile accident.
ages, when necessary. In the young child, the use of

internal nasal splints and packing may require additional
anesthetics to manage their removal. Parents should be
cautioned that secondary rhinoplasty may be helpful to
address post-traumatic deformities that may be more
obvious or significant later in life. Most of these can be
addressed in the teenage years, but more significant
deformities can be addressed after the age of 5 years if a
substantial psychosocial or functional benefit can be
gained with operative intervention. Thus, in those for
whom nasal airflow and psychosocial issues are not pri-
orities, treatment of secondary traumatic nasal deformi-
ties should be delayed beyond the majority of growth in
the area of concern. This approach favors more stable
and predictable long-term results. Long-term follow-up
is important in children because nasal obstruction,
growth disturbances, or cosmetic outcome throughout
the different phases of maturation may change.
A fractured and displaced nasal septum may cause
airway obstruction and growth disturbances that require
timely management. Although standard techniques of
closed reduction are appropriate in most cases, open
FIGURE 20-9 A lack of dorsal support is seen 1 year after severe techniques may be necessary in unusual or severe cases.
craniofacial, nasal, and septal fractures from a fall from two Many believe that acute open repairs are best avoided
stories. A dorsal graft is helpful to mask the deformity. until maturation of the nasal complex, whenever possi-
ble. Some surgeons also emphasize the importance of
avoiding the nasal spine of the maxilla during open
fractures in this group. As a child nears adolescence, the reduction septoplasty because this is thought to be an
pattern and prevalence of nasal fractures follow more important area of growth. There is little evidence to
closely that of adults. As with any injury, the clinician support this concern, but a conservative approach is used
should be aware of possible nonaccidental trauma and, by most, given the potential growth consequences.
when it is suspected, take appropriate steps in the setting
of a comprehensive trauma team that has appropriate COMPLICATIONS
resources to investigate and deal with any related issues
appropriately. In the United States, clinicians are A septal hematoma is a rare complication of nasal trauma
required by law to use the appropriate mechanisms for and may present with a complaint of nasal obstruction,
reporting these injuries if any suspicion exists that the pain, or fever when infected.55-60 The intranasal examina-
cause is nonaccidental trauma. tion typically reveals a distinct bulge of a cherry to purple
There is considerable postnatal growth of the naso- hue arising from the septum, with palpable fluctuance.
maxillary complex downward and forward because of It may be unilateral or bilateral, with its epicenter typi-
continued expansion of the brain and cranial base. The cally over Kiesselbach’s plexus. This collection of blood
nasofrontal suture plays a mediating role. The nasal separates the septal cartilage from its perichondrium and
septum also grows vertically because of its intrinsic and should be treated promptly to prevent necrosis of the
extrinsic growth potential. In addition, as with other septal cartilage. Treatment consists of incision and drain-
bones of the membranous viscerocranium, areas of surface age, nasal packing to prevent reaccumulation of the
apposition and resorption affect its final shape and size. hematoma and promote intimate contact between the
Injury early in this process may impede growth.49-52 perichondrium and nasal septum, and antibiotic
Skeletal nasal width has been measured anthropo- coverage.61-65 Occasionally, a drain may be indicated and
metrically. The nose finishes most of its growth by age 5, intranasal splints sutured to the septum to compress the
but still has significant growth throughout the adolescent perichondrium onto the septum. Complications of a
years. At 8 years of age, the widest distance between the septal hematoma include local infection, meningitis
lateral nasal walls reach roughly 90% of their final size. and/or brain abscess, nasal airway obstruction, and
The adolescent years are marked by significant vertical septal perforation. Rarely, the latter can lead to a loss of
nasal growth and are primarily limited to cartilage and dorsal nasal support and a saddle nose deformity.
soft tissue, because the nasal bones usually have com- Epistaxis is a potential complication associated with
pleted growth earlier. By the age of 14, most patients will nasal fractures and may be anterior or posterior. Signifi-
have anatomic components that are more completely cant bleeding may compromise the airway. Anterior
grown and there is little difference in fracture patterns epistaxis typically arises from Kiesselbach’s plexus,
or treatment protocols when compared with adults.52 supplied by the sphenopalatine, anterior ethmoidal,
In children, nasal fractures are treated in a similar greater palatine, and superior labial arteries. Posterior
fashion.53,54 Growth will not typically correct nasal fractures. nasal epistaxis may arise from the proximal aspect
Closed reduction techniques may be performed at all of the anterior ethmoidal, posterior ethmoidal, or
sphenopalatine arteries. These are located posterior to Procacci et al have reported on the fabrication of indi-
the middle turbinate or at the posterior superior aspect vidual protective facial masks. Impressions of the patients’
of the nasal cavity. The surgeon should position the faces were taken 1 day after surgery with a mixture of
patient upright, with his or her head slightly flexed impression plaster, with the eyes covered by cotton gauze
down to help prevent blood from entering the naso- and the surrounding hair protected with petroleum
pharynx. Monitoring is helpful because some patients jelly.67 Based on this, polymethyl methacrylate and
will experience vasovagal syncope. The surgeon can poly(trimethyl hexamethylene terephthalamide) were
then localize the source of bleeding with proper light- used to fabricate the customized facial protection shields.
ing, a nasal speculum, topical vasoconstriction, and Their design allows for the diversion of forces from the
suction. Consideration should be given to topical or nasal region onto the zygomatic and frontal bones while
local anesthesia with epinephrine. Options for achieving allowing for unimpeded peripheral vision.
hemostasis include manual pressure, chemical cautery
with silver nitrate, local hemostatic agents, and anterior SUMMARY
or posterior nasal packing, such as 1 4 -inch gauze,
sponge, or commercially produced packing material. Skilled management of nasal and septal fractures requires
Posterior nasal packing may be accomplished with a thorough understanding of facial anatomy, causes of
cotton balls tied together and introduced transorally injuries, function and aesthetics of the nose, modern
into the nasopharynx. Balloons and inflatable catheters operative techniques, timing for reconstruction, setting
can also be rapidly applied in case of airway compro- and anesthesia choices, and possible complications.
mise, but are often temporary measures to control Some special considerations warrant attention and occa-
bleeding. After passing a Foley catheter transnasally and sionally a specialist with particular experience in areas
visualizing it in the oropharynx, the bladder may be such as complicated post-traumatic rhinoplasty or pedi-
inflated with saline and pulled back out to occlude the atric fractures. Although most operative repairs have
nasopharynx and the associated choanal arch, which is good results, secondary reconstructions are surprisingly
often the source of posterior nasal bleeding. With a pos- common. Accordingly, long-term follow-up may be
terior nasal bleed, an additional anterior nasal pack is helpful in select patients, but most patients should be
often necessary for adequate occlusion. Finally, the informed of the possible long-term aesthetic and func-
surgeon must remain cognizant that nasal packing may tional consequences of their injuries.
be uncomfortable and may require procedural sedation
or a formal anesthetic. REFERENCES
Many nondisplaced nasal fractures heal without cos-
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78:9, 1986. versus open reduction. Facial Plast. Surg 8:220, 1992.
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A review and critical evaluation of the different techniques. Rhinol- 71. Cole P, Fenton RS: Contemporary rhinomanometry. J Otolaryngol
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gol Head Neck Surg 133:972, 2005.
CHAPTER
Management of Soft Tissue Injuries
21 Raymond J. Fonseca
| James A. Bertz
| Michael P. Powers
|
Barry W. Beck
| James B. Holton
OUTLINE
Initial Examination Delayed Primary Wound Closure
Wound Contamination Skin Grafts
Wound Débridement Flaps
Anatomy of the Skin Apposition of the Skin Margin to Mucosal Membranes
Local Anesthesia Animal Bites
Articaine Hydrochloride (Septocaine) Injuries to Structures Requiring Special Treatment
Topical Agents Lip
Suture Material Ear
Absorbable Sutures Nose
Nonabsorbable Sutures Eyebrow
Surgical Tape Eyelid
Surgical Needles Oral Mucosa and Tongue
Wound Closure Salivary Glands and Ducts
Classification and Management of Soft Tissue Wounds Lacrimal Apparatus
Contusions Scalp
Abrasions Scar Formation
Lacerations Burns
Avulsion Injuries
S
oft tissue injuries to the facial structures are com- with local measures of pressure and clamping, ligation,
monly encountered in the treatment of the trauma- or electrocautery of visibly bleeding vessels. Scalp wounds
tized patient. Soft tissue wounds may be limited to or disruption of major vessels may result in blood loss to
superficial structures, but more serious injuries may the point of hypovolemic shock. According to Lynch,1 if
extend to involve anatomic structures, such as the facial a patient exhibits shock with facial trauma, one of three
bones, the sensory and motor nerves of the face, the conditions is usually present: (1) the trauma is very
parotid, submandibular, or nasolacrimal glands or ducts, extensive and complex, with underlying facial fractures,
and dentoalveolar structures. Soft tissue injuries include oropharyngeal wounds, or both and possible intracranial
abrasions, contusions, clean-cut lacerations, contused injury; (2) treatment has been inordinately delayed and
lacerations, bites, burns of various degrees, and avulsive an extended period of controlled hemorrhage or
wounds. repeated episodes of bleeding have occurred; or (3) the
head and neck wounds are associated with other unrec-
INITIAL EXAMINATION ognized injuries, such as long bone fractures or chest or
abdominal trauma. The face is well supplied with blood
The initial management of the injured individual must vessels, which are generally small in diameter and gener-
include establishment of the airway, control of hemor- ously supplied with elastic fibers. When the blood vessels
rhage, and stabilization of injuries to other major systems of the face are completely transected, they tend to con-
before evaluation of facial soft tissue wounds. Fractures tract and collapse; bleeding stops spontaneously because
of supporting facial bones then must be excluded by the vessels become occluded with thrombi and com-
careful clinical and radiographic examination. Fractures pressed by the enveloping hematoma. However, partially
should be reduced and stabilized before final soft tissue transected vessels have a propensity for continued hem-
repair. Facial lacerations do not require immediate treat- orrhage. With an incomplete laceration of an artery, such
ment because of the excellent blood supply to the facial as the facial or lingual artery, massive bleeding may occur,
region. During the assessment period or during treat- possibly producing compression of vital structures and
ment of other injuries, the wounds should be kept moist potential airway compromise. Along with concomitant
with gauze soaked in an antibiotic solution until final injury to the accompanying vein, an arteriovenous fistula
management. may develop.
Hemorrhage associated with most head and neck Persistent bleeding should be evaluated by direct
wounds may be substantial but can usually be controlled inspection to prevent damage to other vital structures.
506
Management of Soft Tissue Injuries CHAPTER 21 507
The wound may bleed after cleansing and débridement. identified and marked with colored tags so that they can
Copious irrigation with saline or balanced salt solutions be easily located for future reconstruction procedures.
assists with removal of blood clots and granulation tissue
that may slowly ooze. Direct pressure helps control bleed- WOUND CONTAMINATION
ing from the wound surface and limits hematoma forma- Wounds can be divided into two groups, clean and con-
tion. Hematoma formation is a major cause of infection taminated. Prophylactic antibiotics are usually not indi-
and wound breakdown. If hemostasis cannot be achieved, cated in clean fresh lacerations of the skin. The probability
drains should be considered.2 of contamination increases rapidly and is directly related
It is recommended before final treatment of the to the length of time that has elapsed since the initial
wounds and after cleansing of the skin that photographic injury. The contamination of the clean wound is usually
records be obtained for insurance and legal purposes. via Streptococcus and Staphylococcus spp. on the skin of the
Lawsuits are initiated more and more on the basis of face and multiple types of bacteria if the mucosal layers
results—not negligence—and the lay public often expects are violated. Wounds that involve the mucosal linings of
almost perfect results, whether these are realistic or not.3 the oral cavity and pharynx, especially through and
Follow-up photographs will aid in the assessment of through lacerations from the skin through the mucosal
healing and scar maturation and the necessity for future layers, should be considered contaminated. Saliva may
scar revision.3 After the patient’s condition has been sta- carry normal oral flora to deeper structures and wound
bilized, or if there are minimal associated injuries, defini- infections may develop.3
tive treatment of the soft tissue wounds should be carried The species of bacteria present are of less concern in
out (Fig. 21-1). Clean wounds may be closed primarily the development of an infection than the total number
up to 48 hours following injury. Healing of head wounds of bacteria present within the wound. The infectious
(nonoral) has been found to be independent of time inoculum must exceed 105 organisms/g of tissue for
from the injury to repair.4 Head wounds may be physio- gram-positive and gram-negative aerobic bacteria.6-8 The
logically distinct from other types of injuries. The rela- critical number for anaerobes has not yet been deter-
tively greater vascularity of the scalp and face decreases mined. Wounds such as simple lacerations and abrasions
the susceptibility of open wounds to infection. Head have low bacterial content. Crushing of tissue, the embed-
wounds are especially amenable to very late primary ding of foreign bodies or soil, and perforation into the
closure, days compared with the 18 to 19 hours recom- oral cavity with contamination of saliva markedly increase
mended for nonhead wounds.4 This delay in the primary the bacterial count and set the stage for infection.
closure of soft tissue wounds may be indicated if the sup- Wounds caused by impact injuries are 100 times more
porting facial bones have been fractured. Treatment of susceptible to infection than wounds caused by shear
the fracture should be completed before final soft tissue forces.9,10
closure because the wound may provide access to the The location of the injury may be predictive of the
fracture site and the closure may be damaged during number of pathogens in the wound. In general, the com-
fracture reduction. position of the skin microflora allows for subdivision of
Repair of soft tissue wounds may be done with the the body into three major areas.9
patient under local or general anesthesia, depending on High numbers of potentially infective organisms exist
circumstances. If injuries are extensive, general anesthe- in the maxillofacial region and in extremely high
sia is indicated. If no jaw fractures exist, it is best to numbers—almost double the reported infective dose—
intubate the patient orally for injuries above the occlusal in the oral cavity.11,12 This source of heavy contamination
plane and nasally for those below. It may be necessary to accounts for the high infection rates from skin wounds
change the route of intubation during the procedures. exposed to saliva and human and animal bites.
With fractures of the maxilla, mandible, and/or dento- Tetanus prophylaxis should be instituted with con-
alveolar structures, and with soft tissue injuries, nasoen- taminated wounds (Table 21-1). Two thirds of reported
dotracheal intubation is necessary to allow for placement tetanus cases in the United States in recent years have
of intermaxillary fixation, if only temporarily, when rigid followed lacerations, puncture wounds, or crush type of
fixation is used. A tracheotomy may be necessary if airway injuries.10 With a previously immunized patient, if a
management dictates it for presurgical, surgical, or post- course of active immunization has not been given within
surgical care. 10 years of the injury, a booster dose of 0.5 mL of tetanus
During the final examination, it is extremely impor- toxoid is recommended. In nonimmunized patients,
tant to evaluate whether vital tissue has been damaged. passive immunization with hyperimmune (human)
Deep lacerations across the course of the branches of the tetanus globulin, followed by a course of active tetanus
facial nerve, hypoglossal nerve, and sensory branch of immunization, should be instituted.1,5,13 Any particularly
the trigeminal nerve should be evaluated for possible contaminated wound should be considered for adminis-
transection. A nerve stimulator may be helpful to stimu- tration of tetanus prophylaxis, even though the patient
late the appropriate muscle groups in the nonparalyzed may have had a booster shot in the past 5 years9,14 (Table
patient under general anesthesia. If a nerve has been 21-2). Antibiotics such as penicillin, cephalosporin, and
damaged, appropriate microsurgical techniques should other drugs active against gram-positive organisms are
be used to attempt to restore function of the nerve. In the drugs of choice for soft tissue injuries.
some avulsive injuries, secondary nerve graft procedures Factors that impair host resistance to infection may be
may be indicated. During the examination phase and classified into those that are localized to the wound and
initial treatment, the severed nerve trunks should be those that are systemic in the host (Box 21-1). In heavily
A B
C
FIGURE 21-1 A, The patient initially came to the emergency room with significant intracranial injuries, which had to be stabilized before her
facial wounds could be definitively repaired. Before transfer, the emergency room physicians used large silk sutures and surgical staples
to close the multiple facial wounds temporarily. B, Soft tissue wounds in the facial region are especially amenable to very late primary
closure caused by the relatively greater vascularity of the scalp and soft tissue. The wounds may be primarily closed several days
following the injury once the life-threatening injuries have been stabilized, fractures of the underlying bones have been identified, and initial
soft tissue swelling and edema have subsided. Waiting for the initial soft tissue swelling associated with the accident to subside provides
for careful reapproximation of the wound margins and alignment of the facial structures. C, 1 month following repair of the facial
lacerations. D-F, 4 months following the accident.
contaminated wounds, local anesthetics with vasocon- but soap may enter the wound and cause cellular damage
strictor should be avoided.15 and necrosis. Toxic materials, such as alcohol, hydrogen
peroxide, and benzalkonium chloride, and strong soaps,
WOUND DÉBRIDEMENT such as those containing hexachlorophene or povidone-
Cleansing of the clean wound involves washing the skin iodine, should not have direct contact with the open
and removing foreign bodies from the wound. Soap does wound because these materials kill cells on contact.16 If
not harm the skin surface, because the thick cornified these are used around the wound, the wound should be
layer of epidermis protects the underlying tissue surface, thoroughly irrigated with a balanced salt solution (e.g.,
F
or the hairline should never be shaved but rather clipped

TABLE 21-1 Characteristics of Tetanus-Prone Wounds closely with scissors to provide a landmark for accurate
positioning of the soft tissue during the closure.20 It is
Tetanus-Prone Nontetanus-Prone important that the alignment of the eyebrow or hairline
Clinical Features Wounds Wounds not be altered because improper orientation is aestheti-
Age of wound >6 hr ≤6 hr cally displeasing, and the hair can be used as a guide for
reconstruction.
Configuration Stellate wound Linear wound
The wound must again be inspected for the presence
Depth >1 cm ≤1cm of foreign materials. A pulsatile type of irrigating device
Mechanism of Missile, crush, Sharp surface is useful for removing debris, necrotic tissue, and loose
injury burn, or frostbite (e.g., knife) material. An abrasive wound that contains ground dirt,
Signs of infection Present Absent glass, or other debris should be scrubbed with a scrub
Devitalized tissue Present Absent brush or toothbrush and detergent soap to remove the
Contaminants (dirt, Present Absent foreign material. A no. 15 blade may be used to scrape
feces, soil, saliva) material that cannot be brushed clean or to remove
Denervated or Present Absent deeply embedded particles, frequently seen with blast
ischemic tissue, or injuries. All material should be removed and time should
both be taken to clean the wound as completely as possible. If
a contaminant is allowed to remain within the tissue, it
may become a source of infection or may heal as a per-
lactated Ringer’s solution, normal saline). A rule regard- manent type of tattoo that is difficult to treat with future
ing the application of antiseptic is never to put anything procedures. Polymyxin B sulfate ointment may be used
in a wound that could not be comfortably tolerated in on the wound to remove residual grease or tar that
the conjunctival sac.17,18 cannot be removed with routine scrubbing techniques.
If the laceration extends into the scalp, mustache, or The wound should then be copiously irrigated with a
beard, the area should be shaved to provide good access balanced salt solution. Time spent meticulously débrid-
for débridement and repair.19 Areas such as the eyebrows ing traumatic wounds during the primary repair period
BOX 21-2 Indications for Removal of Foreign Bodies from

TABLE 21-2 Recommendations for Tetanus Prophylaxis
Soft Tissue*
DTP* TIG Td¶ TIG
(0.5 mL IM) (250 U IM) (0.5 mL IM) (250 U IM) • Reactivity (thorns, spines, wood, and other vegetative
material)
History of • Heavy contamination (soil, teeth)
adsorbed • Toxicity (heavy metals, spines with venom)
tetanus toxoid • Impingement of vital structures (vessels, nerves, and
(for children tendons)
< 7 yr) • Impairment of mechanical function (restricted joint
Unknown or Yes† Yes‡ Yes† Yes mobility)
less than three • Intra-articular location
doses • Intravascular location
Three or more No¶ No No¶ No • Persistent pain
doses • Established infection
• Allergic reaction
Note: All dog and cat wounds should be considered tetanus-prone
wounds. • Cosmesis
*Use diphtheria, tetanus (DT) if pertussis vaccine is contraindicated. • Psychological distress
†
The primary immunization series should be completed.
‡
Administer in contralateral extremity. *Adequate débridement includes removal of foreign materials from the
§
Yes, if the routine immunization schedule has lapsed or if more than 5 wound. Accurate localization before removal is essential. Blind searching
years since last dose of tetanus toxoid. is time-consuming and may produce further trauma.
¶
Use DTP for children <7 years old (DT if pertussis vaccine is contraindi-
cated); Td is preferred to T if patient is ≥7 years old.
¶
Yes, if >5 years since last dose. (More frequent boosters are unnecessary the material must be removed to prevent wound infec-
and may accentuate side effects.) tions (Box 21-2). The wounds should be cleansed with
DTP, Diphtheria, tetanus, pertussis; IM, intramuscular; TD, tetanus, diph-
theria; TIG, tetanus immune globulin.
detergent soaps and thoroughly irrigated with lactated
Adapted from American College of Emergency Physicians: Tetanus immu- Ringer’s solution or normal saline. Animal bites should
nization recommendations for persons seven years of age or older. Ann be cleansed with detergents and water to remove the
Emerg Med 15:1111, 1986; and American College of Emergency Physi- animal’s saliva and other contaminants from the wound
cians: Tetanus immunization recommendation for persons less than seven
before closure.
years of age. Ann Emerg Med 16:1181, 1987.
A conservative approach should be the rule in débride-
ment of facial wounds. Débridement should be limited
to devitalized tissue and tissue that is stained by road tar
or contains dirt or other particles that cannot be removed
BOX 21-1 Factors That Impair Host Resistance
with meticulous scrubbing.
There are at least three mechanisms whereby devital-
LOCAL ized soft tissues potentiate infection: (1) as a culture
Foreign bodies medium promoting bacterial growth; (2) by inhibition
Necrotic tissue of phagocytosis and subsequent bacterial control by leu-
Contused tissue kocytes; and (3) by the anaerobic environment limiting
Vasoconstrictors (local)
leukocyte function.22
Closure under tension
Hydrogen peroxide should not be used routinely to
Hematoma
cleanse a wound.23,24 Studies have shown that hydrogen
Dead space
Sutures
peroxide actually impedes wound healing and has poor
bactericidal activity. Hydrogen peroxide 3% diluted 1 : 1
SYSTEMIC does not appear to harm wounds protected by mature
Hypovolemic shock (hypoperfusion) granulation tissue but is toxic to fibroblasts unless diluted
Malnutrition more than 1 : 100, at which point it has minimal, if any,
Diabetes bactericidal activity.25 Povidone-iodine (Betadine Surgi-
Atherosclerosis cal Scrub) is also toxic to fibroblasts and bacteria. The
Corticosteroid therapy
stock solution (10% povidone-iodine, 1% available
Distant infections
iodine) must be diluted 1 : 1000 (1 mL/liter) to prevent
Chemotherapy
fibroblast toxicity. At this concentration, the bactericidal
effectiveness has been compromised.
These agents should be kept out of the fresh wound
will prevent unfavorable or aesthetically displeasing and used only to scrub skin surfaces. A gauze sponge can
results from infection, hypertrophic scars, and foreign be folded into the wound to prevent the inadvertent
body granulomas.19,21 entry of detergents during wound healing. Mechanical
Wounds that have been contaminated with foreign scrubbing should be avoided unless there is an over-
materials, such as dirty gravel, metal, tooth fragments, whelming amount of foreign debris in the wound.
grass, wood, glass, and organic materials, must be thor- Although scrubbing can remove particulate matter from
oughly examined during the initial treatment phase, and the wound, scrubbing of the wound has been shown to
increase wound inflammation.24 If scrubbing of a wound blood supply to the region, excessive débridement is
is necessary, a fine pore sponge and nonionic surfactant, unnecessary and tissue will survive with a very small
such as Shur-Clens, should be used to minimize the pedicle. It is better to err on the side of retaining tissue
inflammatory response. When the effect of scrubbing that may not eventually survive than to remove tissue that
wounds with povidone-iodine or hexachlorophene (pHi- is necessary for satisfactory repair of the injury. If the
soHex) surgical scrub solutions on the infection rate was wound margin is extremely irregular and reapproxima-
evaluated, researchers found an increased susceptibility tion is difficult, the irregular edges should be excised to
to infection because of the greatly increased inflamma- produce clean wound margins and minimize scar forma-
tory response produced by these solutions coming into tion. Occasionally, additional small incisions are helpful
contact with the injured tissue. in reapproximating tissue and breaking up straight line
In otherwise healthy patients, Dire and Welsh26 found scars.
no statistical difference in infection rates when wounds During the final examination, it is extremely impor-
were irrigated with normal saline, 1% povidone-iodine tant to evaluate whether vital tissue has been damaged.
solution, or a nonionic detergent (Shur-Clens). They Deep lacerations across the course of the branches of the
noted that the mechanical action of high-pressure irriga- facial nerve and hypoglossal nerve and the sensory
tion, not the solution used, is more important in the branch of the trigeminal nerve should be evaluated for
prevention of wound infection. Shur-Clens is a nonionic possible transection. A nerve stimulator may be helpful
detergent that can be safely used to cleanse periorbital in stimulating the appropriate muscle groups in the non-
lacerations. Topical application of this agent to experi- paralyzed patient under general anesthesia. If a nerve
mental animals and humans did not elicit ocular lesions. has been damaged, appropriate microsurgical tech-
In contrast, Betadine, Hibiclens (an antimicrobial soap), niques should be used to attempt to restore function of
and pHisoHex surgical scrub solutions caused notable the nerve. In some avulsive injuries, secondary nerve
irritation to the eyes and thus should not be used in the graft procedures may be indicated. During the examina-
periorbital area. tion phase and initial treatment, the severed nerve trunks
Two groups of antiseptic agents, containing an iodo- should be identified and marked with colored tags so
phor or chlorhexidine, have shown promise for prepara- that they can be easily located for future reconstruction
tion of the intact skin around the wound. Both types procedures (Fig. 21-2).
exhibit activity against a broad spectrum of organisms.
They also have a long shelf life, with no significant inac- ANATOMY OF THE SKIN
tivation. They display a substantive effect on the skin
membrane, suppressing the proliferation of bacteria. The skin covers the body in varying degrees of thickness,
However, the superiority of one antiseptic over another elasticity, texture, and mobility and makes transitions
is difficult to ascertain because most of the comparative into mucosal membranes about the oral cavity, nostrils,
studies involve hand washing rather than washing of the and eyelids. The thickness of the skin on the facial region
operative site. Although these agents can reduce the bac- ranges from 0.013 inch over the upper eyelid, 0.030 to
terial concentration of the skin, they appear to damage 0.040 inch over most of the face, approximately 0.065
wound defenses and invite the development of infection. inch over the eyebrows, and 0.080 to 0.090 inch over
Consequently, inadvertent spillage of these agents into the neck.31
the wound should be avoided.9,23 The skin is an extensive sensory organ with numerous
Spillage of an antiseptic solution into a patient’s eye nerve endings that provide feedback to touch, pressure,
can be disastrous. It has been reported in two patients temperature, and painful stimuli (Fig. 21-3). It protects
that accidental exposure to Hibiclens resulted in severe against loss of body fluids caused by dehydration, inva-
and permanent corneal opacification. In experimental sion of pathogenic organisms, and excessive exposure to
studies, rabbit eyes exposed to Hibiclens developed ultraviolet radiation. The skin is also involved in tempera-
severe irreversible and progressive corneal damage.9,27 ture regulation via heat loss through evaporation.32 Sub-
Irrigation can remove enough wound bacteria to cross cutaneous voluntary muscles in the face and neck allow
the threshold to noninfected wounds, but only if the for movement of the skin and for facial expression.
irrigant is delivered with sufficiently high pressure to The skin is composed of the surface layer epidermis
disrupt bacterial adherence to the wound surface and the underlying dermal layer. The epidermis is strati-
mechanically. To be clinically effective, irrigants should fied squamous epithelium with five layers (in order from
be delivered with a fluid jet impacting on the wound with the surface to the dermal layer): the stratum corneum,
psi of 7 lb. This level of pressure can be generated by stratum lucidum, stratum granulosum, stratum spino-
forcefully expressing saline from a 35-mL syringe through sum, and stratum germinativum. The epidermis sends
an 18-gauge needle, but cannot be generated by a bulb projections into the dermis and irregularities of the
syringe or by gravity flow irrigation.28-30 dermis interlock with the epidermis; these are termed
Rapid and complete invasion of the wound space by epidermal pegs and dermal papillae, respectively.32
fibroblasts is a critical step in normal healing. Dead tissue The stratum germinativum, or basal layer, is usually
fragments, hematomas, and foreign bodies act as physical one or two cells thick and has much mitotic activity.31 The
barriers to fibroblast penetration.17 Débridement of basal layer is responsible for regeneration of the cells in
facial wounds should be limited to obviously devitalized the epidermis in the repair process and for normal turn-
and necrotic tissue. Radical excision of soft tissue in the over of cells in the epidermis. On the face, regeneration
facial region should be avoided. Because of the rich results from the germinal layer and epidermal pegs.
FIGURE 21-2 A large wound created by a crush type

of injury resulting in a large stellate laceration with
surrounding abrasions. Initially, the wound should be
thoroughly irrigated with a balanced saline solution
and inspected for foreign bodies. Débridement
should be limited to obviously devitalized and
necrotic tissue. Excessive débridement is limited by
the rich vascular supply. Scrubbing the wound
should be avoided, unless an overwhelming amount
of foreign material is present in the wound, because
the scrubbing causes more inflammation and further
injury. Next, the wound is cleansed with a nonionic
detergent, and gross spillage into open areas is
avoided. The wound is then ready for closure.
Capillaries Hair shaft to the dermal papillae with fine fibrils of collagen and
Free nerve endings Receptor provides a blood supply to the avascular epidermal layer.32
Epidermis
The papillary dermis and epidermis together form a
Arrector pilli functional unit that provides an important metabolic
muscle area for retaining the normal integrity of the skin.33,34
Oil gland Dermis The reticular layer of the dermis is a thick dense mass
of collagenous and elastic connective tissue fibers. Retic-
ular fibers, which give the layer its name, are young,
Sweat gland
finely formed collagen fibers with a narrower diameter
than that of mature collagen.34 Elastic and other collagen
Subcutaneous
layer fibers in the papillary dermal layer tend to be perpen-
dicularly oriented to the overlying epidermal layer, and
Vein
the fibers in the reticular layer are mainly oriented tan-
Hair follicle
Nerve Artery gentially to the epidermal layer.32 Collagen fibers provide
Adipose tissue
the skin with tensile strength, whereas elastic fibers give
FIGURE 21-3 Cross section of the skin, which contains three the skin its elastic properties.
layers—the epidermis, dermis, and subcutaneous connective The orientation of the fibers in the reticular layer and
tissue. (From VanMeter K, Hubert R: Microbiology for the their relationship to the epidermal layer create lines of
healthcare professional, St. Louis, 2010, Mosby.) tension in the skin that are greater in a plane perpen-
dicular to the fibers of the reticular layer than in a plane
parallel to these fibers. The predominant orientation of
the fiber bundles in relation to the surface differs in dif-
ferent regions of the body. These patterns were described
Because of the large number of epidermal pegs on the by Langer in 1861.35 He punched holes in the skin of
face, a notable portion of the epidermal layer can be cadavers and noted the direction of the gape of the
removed without significant scarring.33 The stratum spi- wound, indicating the line of tension. Langer’s lines run
nosum, or prickle cell layer, consists of polyhedral cells parallel to the principal fiber bundles of the reticular
with ovoid nuclei. The granular layer is named for its layer and thus produce less tension on the wound margins
histidine-rich cytoplasmic granules of keratohyalin, (Fig. 21-4).
thought to be important in keratin formation.34 Changes Langer’s lines usually indicate the most favorable
in the formation of the granular cell layer are seen in the direction for surgical incisions on the skin, except in
development of the healing wound. The stratum lucidum some areas of the facial region because of the close rela-
is found only on the palms of the hands and soles of the tionship between the muscles of facial expression and
feet. The stratum corneum, the outermost layer of the the skin. The most inconspicuous scars are those that fall
epidermis, is formed of keratinized flattened cells that within natural creases or wrinkle lines in the skin.3 When
are usually without nuclei. The corneum layer is respon- the facial muscles contract, they produce tension on the
sible for the variable thicknesses of skin found on skin in a direction perpendicular to that of the muscle
the body. group. Thus, favorable crease lines for surgical incisions
The dermis is divided into two layers, a superficial on the face run parallel to the muscles of facial expres-
papillary layer and a deeper reticular layer. The papillary sion; they may not coincide with Langer’s lines and, in
zone is a thin, finely textured zone immediately beneath some areas, such as the upper lip, may run perpendicular
the epidermal rete ridges. The papillary layer gives rise to them.20
prevented when a thorough patient history has been

taken; these reactions are usually caused by the para-
aminobenzoic acid (PABA) found in ester local anes-
thetic solutions or by the preservative methylparaben
found in the amide local anesthetic solutions.36,37
However, the vast majority of patients who claim to be
allergic to local anesthetics are not truly allergic to these
agents.38,39 Many patients have been incorrectly labeled
as having an allergy to local anesthetics after previously
experiencing dizziness, syncope, dyspnea, localized ery-
thema, or pruritus around the time of anesthetic admin-
istration.40,41 Nonetheless, it is difficult to determine
those who may truly be sensitive to a particular agent
accurately. An alternative local anesthetic for patients
who report local allergies is diphenhydramine (Benad-
ryl). At a concentration of 1%, diphenhydramine has a
slower onset but a comparable duration and produces
anesthesia equivalent to 1% lidocaine, although it is
somewhat more painful on injection.42,43 Diphenhydr-
amine local anesthetic solution is effective for small
wounds and can be infiltrated or used for regional blocks.
A quantity of 1 mL or 50-mg/mL diphenhydramine solu-
tion is diluted in 5 to 10 mL of normal saline to produce
a 1.0% to 0.5% solution. When the facial area is involved,
a 1% solution is recommended.44 The risk of complica-
FIGURE 21-4 Langer lines. (From Kaminer M, Arndt K, Dover J, tions with the use of diphenhydramine is low, but ery-
et al: Atlas of cosmetic surgery, ed 2, St. Louis, 2009, Saunders.) thema, regional edema, vesiculation, and sloughing of
tissue have been reported. Although in most cases a
higher concentration was used (5%), it is recommended
to avoid using this agent in areas of poor collateral perfu-
The dermis also contains a small amount of fat, numer- sion such as the digits, pinnae of the ears, and nose.
ous blood vessels, lymphatics, nerves and sensory nerve Common adverse reactions to diphenhydramine used as
endings, hair follicles, sweat and sebaceous glands, and a local anesthetic also include sedation, dizziness, dis-
smooth muscle. The dermis is supported by subcutane- turbed coordination, epigastric distress, and thickened
ous connective tissue that is thinner in the facial region bronchial secretions. Patients should be warned against
than in most of the body and is nonexistent in the eyelids. driving or other dangerous activities because of the asso-
The muscles of facial expression are in the subcutaneous ciated sedation.
layer and insert into the reticular layer of the dermis.32 Toxic reactions to local anesthetics are more common
than allergic reactions and are usually caused by acciden-
LOCAL ANESTHESIA tal intravascular injection or administration of large
quantities of the drug. Patients at the extremes of age are
Local anesthesia, with or without premedication, may be particularly at risk. Older adults can have elevated blood
used in cases of less severe wounds such as small lacera- levels of the drug because of a decline in liver function
tions, contusions, and abrasions. A 1% lidocaine solution and an increased incidence of cardiovascular disease.
with 1 : 100,000 epinephrine or 0.5% bupivacaine (Mar- Overdosage is the common cause of toxicity in pediatric
caine) solution with 1 : 200,000 epinephrine may be patients.45 Maximum dosages of all drugs administered
injected into the wound margin. If possible, nerve blocks by injection should be calculated and should not be
are helpful for minimizing the amount of solution neces- exceeded46 (Tables 21-3 and 21-4).
sary for this field block in large wounds and preventing The initial signs and symptoms of toxicity caused by
distortion of the tissue by the anesthetic solution. For local anesthetics are mediated primarily by the central
delivery of a local anesthetic, the following guidelines are nervous system. Initially, the patient may experience
recommended: slurred speech, shivering, muscular twitching in the face
• Use a needle that is small (25 gauge or smaller). and distal extremities, flushing of the skin, dizziness, tin-
• Insert the needle into the wound margin, as opposed nitus, and disorientation. Numbness of the tongue and
to piercing the intact skin. perioral tissue is not mediated by the central nervous
• Pass the needle through subcutaneous tissue. system. Rather, the paresthesia is caused by the direct
• Inject slowly. anesthetic effect on the free nerve endings in this tissue.
• Insert the needle no more than two thirds of its length Further elevations of local anesthetic blood levels
to prevent complications associated with needle produce seizure activity and later cardiac and respiratory
breakage. depression, which can lead to death.46 The lack of under-
Adverse reactions to local anesthetics do occur, but standing about maximum dosages has led to fatalities in
fortunately are rare. Allergic reactions can usually be children.45
TABLE 21-3 Dosages and Properties of Injectable Local ARTICAINE HYDROCHLORIDE (SEPTOCAINE)
Anesthetics* Articaine is an amide local anesthetic introduced in
Characteristic Procaine Lidocaine Mepivacaine Bupivacaine Germany in 1976 and subsequently throughout Europe
Potency 1 2 2 8 and Canada (Ultracaine D-S). Articaine (Septocaine) was
Onset Slow Fast Fast Moderate
introduced into the United States in 2000. Articaine is
supplied for dental use in 1.8-mL cartridges as a 4%
pKa 8.9 7.9 7.6 8.1
(40 mg/mL) solution combined with 1 : 100,000 epi-
Duration (min) Short Moderate Moderate Long nephrine. The onset of action is 1 to 6 minutes, provides
(60-90) (90-200) (120-240) (180-600) an average pulpal anesthesia for 45 to 60 minutes, and
Protein 6 64 78 96 is active in soft tissue for approximately 2 to 5 hours.
binding (%) The administered dose is excreted in the urine within
MAXIMUM DOSE (MG/KG) 24 hours. The maximum dose is 7 mg/kg or 3.2 mg/lb.
Plain 7 4.5 7 2 One advantage of the use of articaine anesthesia in
the oral cavity is that the articaine formulation may pos-
With 9 7 8 3
sibly spread through hard tissue more effectively than
epinephrine
other local anesthetics and provide infiltration anesthe-
*Toxic reactions to local anesthetics are more common than allergic reac- sia as effective as nerve block techniques. Some have
tions; many are caused by accidental intravascular injection or administra- claimed that buccal infiltration of articaine adjacent to a
tion of large quantities. The young and the very old are particularly at risk,
so it is prudent to avoid excessive dosages and always aspirate prior to maxillary or mandibular premolar provides adequate
delivery. anesthesia to remove the tooth without a palatal injec-
From Webster RG, McCullough EG, Giandello PR, et al: Skin wound tion. Further investigations were carried out to evaluate
approximation with new absorbable suture material. Arch Otolaryngol the use of buccal infiltration of articaine and the elimina-
111:517, 1985.
tion of palatal anesthesia injections for the routine
forceps removal of teeth.48
The pharmacologic and toxic effects associated with
articaine are qualitatively similar to those of other amide
local anesthetics. Articaine has been associated with met-
TABLE 21-4 Maximum Dosages of Local Anesthetics hemoglobinemia after IV regional anesthesia, but no
reports have been published about methemoglobinemia
DOSAGE after injection for dental anesthesia.49 In a study by
Drug mg/lb mg/kg Maximum (mg) Malamed et al,50 4% articaine with 1 : 100,000 epineph-
Lidocaine 2 4.4 300 rine was compared with 2% lidocaine with 1 : 100,000
Mepivacaine 2 4.4 300 epinephrine. Similar effectiveness and similar rates of
Bupivacaine* 0.6 1.3 275 adverse events were noted between the two local anes-
thetics, but a 0.9% incidence of paresthesia in a total of
Prilocaine 2.7 6 400
882 patients was found. Long-term paresthesia, especially
Procaine 3 6.6 400 of the lingual nerve during inferior alveolar nerve blocks,
*Bupivacaine is not recommended for patients < 12 yr. is a growing concern with the use of this anesthetic for
routine dental procedures.51,52 One may choose to use
articaine primarily for infiltration techniques and with
caution for nerve blocks.
Vasoconstrictors can limit plasma levels of local anes-
thetics by decreasing the rate of absorption, which
reduces the risk of toxic reactions. Additional benefits of TOPICAL AGENTS
vasoconstrictors include increased duration of action of A combination of tetracaine (0.5%), epinephrine
local anesthesia and assisting with hemostasis at the surgi- (1 : 2000), and cocaine (11.8%; TAC), is available for use
cal field. However, the use of vasoconstrictive drugs as a topical anesthetic agent.53-55 In wounds of the scalp
should be avoided or kept to a minimum in patients and face, the degree of anesthesia is comparable with
receiving certain medications such as beta blockers, that of local infiltration with lidocaine. TAC (0.09 mL/
monoamine oxidase (MAO) inhibitors, and tricyclic anti- kg) is applied to gauze or cotton balls and held in contact
depressants, or in patients with conditions such as hyper- with the wound margin for 5 to 10 minutes or until visible
thyroidism, elevated blood pressure (systolic blood blanching occurs, signaling the onset of adequate anes-
pressure greater than 200 mm Hg, diastolic blood pres- thesia. TAC is rapidly absorbed through the mucous
sure greater than 115 mm Hg), and recent cerebrovas- membranes, eyes, and burned or denuded skin and
cular accident or myocardial infarction.46 should not come into contact with these surfaces or the
For the patient’s comfort, it has been found that lido- patient may be at risk for severe systemic toxicity or even
caine buffered with sodium bicarbonate can decrease death. It should also be avoided in areas of end-arterial
pain on injection. It is recommended that 9 mL of 1% flow (e.g., the digits, tip of the nose, and pinna) because
lidocaine be mixed with 1 mL of sodium bicarbonate of its intense vasoconstriction. TAC is used primarily for
(44 mEq/50 mL) to provide a buffered solution for small wounds, such as simple lacerations, and is most
injection.47 popular in the treatment of pediatric patients.
For example, if the diameter of the suture is doubled,

the tensile strength quadruples. In addition, a knotted
suture has only about one third the tensile strength of
an unknotted suture, although this relationship varies
with the type of knot and the suture material used.62
Suture materials should be at least as strong as the
tissue in which they are used. A wide variety of materials—
silk, linen, cotton, horsehair, animal tendons and intes-
tines, and wire made of precious metals—have been used
for wound closure. The evolution of suture materials has
provided a number of options when selecting the correct
suture for a particular procedure. The selection of suture
material is based on the condition of the wound, tissue
to be repaired, strength and knot-holding characteristics
of the suture material, and reaction of the surrounding
tissue to the suture material.3,17 Suture material can be
classified as absorbable or nonabsorbable, coated or
uncoated, natural or synthetic, and multifilament
(braided) or monofilament. Synthetic, nonabsorbable
sutures include Dacron (Mersilene, Polydek, Tevdek,
FIGURE 21-5 The chronology of early wound healing. (Adapted Ethibond, and Tycron), nylon (Ethilon and Dermalon),
from Trott A: Surface injury and wound healing. In Wounds and and polypropylene (Prolene and Surgilene). Natural,
lacerations: Emergency care and closure, ed 2, St. Louis, 1990, nonabsorbable sutures include silk, cotton, and metals
Mosby.) such as stainless steel, tantalum, and titanium. Natural
absorbable sutures are made of catgut and plain and
chromic collagen. Synthetic absorbable sutures include
polyglycolic acid (Dexon), polyglactic acid (Vicryl), and
When treatment is provided in the outpatient clinic polydioxanone (PDS).63
with the patient under local anesthesia, the same care Monofilament sutures are made of a single strand of
and diligence should be applied in treating soft tissue material. They encounter less resistance when passing
wounds as is practiced in the operating room when the through tissue than multifilament sutures and resist har-
patient is under general anesthesia. boring microbial organisms. The handling properties of
monofilament sutures are good, but care must be taken
SUTURE MATERIAL not to crimp or nick the material because breakage is
likely. Multifilament sutures consist of several strands of
The primary purpose for using sutures is to approximate material braided or wound together, which increases
wound margins and enhance tissue healing. To under- flexibility and tensile strength.61,64 Multifilament suture
stand the interaction of suture materials with biologic materials have been reported to cause more reactions in
tissue, an appreciation of the wound-healing process is oral tissue compared with monofilament sutures. This
important (Fig. 21-5). Wound healing can be divided increased the incidence of reactions that may be caused
into three phases. During the initial lag phase (up to day by permeation of the multifilament suture materials by
5), there is no gain in wound strength and the wound is oral bacteria. Silicone and Teflon coating of multifila-
dependent on sutures and epidermal cellular adhesion ment sutures does not seem to reduce bacterial invasion
to maintain closure. During the fibroblastic phase (days of tissue.65-69
5 to 15), a rapid increase in wound strength occurs. The Measurement of the in vivo degradation of sutures
maturation phase (day 14 and beyond) is characterized provides a general classification of surgical sutures.
by further connective tissue remodeling. By the end of Sutures that undergo degradation rapidly and lose their
the second week, when most skin sutures are removed, tensile strength within 60 days are termed absorbable.
only 3% to 7% of the final tensile strength has been Those that maintain their tensile strength for longer
achieved. By the end of the third week, 20% of the tensile than 60 days are termed nonabsorbable.64,70
strength is attained and, at the end of the first month, Absorbable sutures are used to hold wound edges
50% is present. Wounds never regain more than 80% of together temporarily. The suture material is degraded by
the strength of intact skin.56-60 Because the tissue reduces enzymatic processes, as in gut sutures, or by hydrolysis,
suture strength over time, the relative rates at which the as in many of the synthetic materials. Although absorb-
suture material loses strength and the wound gains able sutures have advantages, they respond to the envi-
strength are important. Wounds do not gain strength ronment into which they are placed. In infected tissue or
until 4 to 6 days after injury, so the entire burden of in a patient who is febrile or protein-deficient, suture
approximating the tissue during this period rests on the breakdown may be accelerated. If the loss of tensile
sutures.61 Thus, tensile strength, the amount of tension strength outpaces the healing phase of the wound, failure
or pull the suture can withstand before breaking, is may result. It is important to note that when using absorb-
an indispensable property of suture material. Tensile able sutures, one must place them well into the dermis
strength is proportional to the diameter of the suture. to facilitate their hydrolysis and subsequent absorption.
If they are placed in the papillary dermis, they will not and should not be placed at an infected site. It is also not
hydrolyze as rapidly and may persist for weeks or months recommended to use polyglycolic acid suture percutane-
longer than anticipated. ously, but this suture is effective in deeper tissue layers.
Glycolic Acid (Maxon)
ABSORBABLE SUTURES Maxon is a monofilament strand composed of polygly-
Surgical Gut Sutures colic acid and trimethylene carbonate. Polyglycolic acid
A surgical gut suture is a twisted suture of proteinaceous suture, along with PDS suture, offers the greatest tensile
sheep or beef intestinal wall that is approximately 98% strength of any type of resorbable suture. The suture
highly purified collagen strands. The tensile strength of retains 70% of its tensile strength at 14 days and 55% at
gut material is good, but absorption is by phagocytosis, 21 days.62 This period of tensile strength is much longer
which is unpredictable and results in gradual loss of than that of the chain polymer form of glycolic acid
strength. The suture will become wiry if allowed to (Dexon). Complete absorption is accomplished by
dry out. hydrolysis in 180 days. In vitro studies have suggested that
Plain gut suture is rapidly absorbed, maintaining the suspected degradation products of polyglycolic acid
tensile strength for only 7 to 10 days, and is completely and nylon sutures are potent antibacterial agents. These
absorbed within 70 days. Plain gut suture can also be heat byproducts—glycolic acid, 1,6-hexane diamine, and
treated to form fast-absorbing gut suture, which is used adipic acid—have shown a marked reduction in bacterial
in epidermal suturing when support is necessary for only counts when incubated with Staphylococcus aureus.64
5 to 7 days.70,71 Lister was the first to sterilize sutures and
also introduced the treatment of catgut suture with Polyglactin 910 (Vicryl)
chromic acid to slow its rate of absorption.72 To minimize This commonly used synthetic suture is composed of a
tissue reaction, increase tensile strength, and slow the mixture of lactide and glycolide acids and calcium stea-
absorption rate of macrophage activity, catgut can be rate produced in a braided configuration that improves
coated with a thin layer of chromium salt solution, which handling properties. The lactide component has hydro-
resists enzymatic degradation by the tissue and thus phobic qualities. This water-repelling property slows the
increases tensile strength and prolongs absorption time penetration of water into the suture filaments, thus delay-
to longer than 80 days.73 In noncontaminated wounds, ing the loss of tensile strength. Approximately 65% of its
chromic gut sutures minimize tissue reaction, causing tensile strength is retained at 14 days and 40% at 21
less irritation than plain gut in the early stages of wound days.77 The suture is degraded by hydrolysis and absorp-
healing. Tensile strength is retained for 10 to 14 days. It tion is complete after 56 to 70 days, with byproducts
should also be noted that when placed into contami- excreted primarily in the urine. Vicryl is coated with a
nated tissue, plain gut sutures elicit less infective response second type of polyglactin (polyglactin 370) and calcium
than chromic gut sutures.58 A mild chromic gut suture is stearate, which allows for easy passage through tissue and
also manufactured that is absorbed rapidly (50% in 3 to easier knot placement. This suture should be buried in
5 days) and is used primarily in ophthalmologic surgery.62 the subcutaneous tissue or in deeper layers. When used
The advantages of chromic catgut materials include in these locations, Vicryl has minimal tissue reactivity and
absorbability, tensile strength, and knotting qualities. is appropriate if the tissue is infected. However, percuta-
The disadvantages include the wide range of biologic neous placement is not recommended. When used to
variability in loss of tensile strength over time and a close skin wounds, Vicryl is associated with delayed
broad range of reactions to these materials in individual absorption and increased inflammation. Occasionally,
patients.63 the suture is extruded without inflammation, resulting in
A thin chromic catgut suture has been used for closure a small nodule in the suture line. Although this type of
of the epidermal layer in facial wounds. The 6-0 catgut suture is available purple and undyed, only the colorless
material (Davis-Geck 6-0 mild chromic, or Ethicon 6-0 type should be used on the face to prevent showing
rapidly absorbing gut) is absorbed within 3 to 5 days and through thin skin.78
does not have to be removed. The material may be used
with sterile strips to relieve surface wound tension.3,74 Irradiated Polyglactin 910 (Vicryl Rapide)
Vicryl Rapide is irradiated polyglactin 910. It is a braided
Glycolic Acid Homopolymer (Dexon) copolymer that is surface-treated with polyglactin 370
This suture, composed of a polymer of glycolic acid, is and calcium stearate and has been gamma irradiated.
characterized by a greater knot pull and tensile strength This radiation alters the suture material’s molecular
than those of gut. It was introduced in 1970 as the first structure and enhances its absorption rate. The suture is
synthetic absorbable suture.75 Like Vicryl (polyglactin indicated for short-term wound support for superficial
910), polyglycolic acid is absorbed primarily by hydroly- closure, providing stability of the wound for 7 to 10 days.
sis, which results in minimal tissue reactivity. However, The suture is absorbed over 12 to 14 days and does not
because polyglycolic acid has been shown to persist require removal. Microscopically, the suture is absorbed
longer in the wound, it generates more tissue reaction primarily by phagocytosis by day 35.79,80 The degree of
than Vicryl, but less than plain gut or chromic gut.76 inflammation is less than that observed with plain or
Polyglycolic acid suture is braided and often catches on chromic catgut suture. However, Vicryl Rapide is not
itself, making knot tying and passage through tissue dif- recommended for use on facial skin.81 The suture is
ficult. The suture does not tolerate wound infections well slightly brittle but requires little adjustment to normal
suturing techniques. From an economic standpoint, associated with silk sutures. Multifilament nylon is weaker
Vicryl Rapide is at most 10% more expensive than simi- and less secure when knotted, offering little advantage
larly packaged gut or chromic gut sutures. Polytetrafluo- over monofilament nylon.87
roethylene (PTFE) sutures are at least four times more Monofilament (Dermalon, Ethilon). The monofilament
expensive. nylon suture has characteristics similar to those of the
braided form of nylon suture, although it is uncoated.
Vicryl Plus (Polyglactin 910 Coated with Triclosan) Monofilament nylon suture is relatively inert and
In December 2002, the U.S. Food and Drug Administra- nonirritating to tissue, with smooth passage through the
tion (FDA) approved Vicryl Plus antibacterial suture. tissue. Nylon sutures are well suited for retention
Designed to reduce bacterial colonization on the suture, and skin closure because of their elastic nature. Nylon
this was the first and only suture designed with an anti- is widely used because of its favorable qualities, such
bacterial agent. The agent, triclosan, has been shown to as high tensile strength and low tissue reactivity. The
be effective against S. aureus, Staphylococcus epidermidis, sutures degrade at a rate of 15% to 20% per year by
and methicillin-resistant strains of Staphylococcus (MRSA hydrolysis. They have some memory and will tend to
and MRSE), which are the leading surgical site bacteria.82 return to their original linear shape over time. Because
There appears to be no adverse effect on wound healing.83 of this tendency, more throws in the knot are indicated
The addition of triclosan also appears to have no effect to securely approximate the tissue during healing, even
on the strength, healing of wounds, handling character- compared with braided nylon sutures.62 Moistened
istics, or performance when compared with commonly nylon-monofilament sutures are more easily handled,
used polyglactin (Vicryl) sutures.84 and some types are packaged wet for use in plastic
surgery procedures. A careful four-throw knot usually is
Polydioxanone (PDS II) sufficient.
This synthetic monofilament suture is made from the
polyester derivative poly-p-dioxanone. PDS suture has Polyester: Braided (Tycron, Mersilene, Uncoated,
excellent tensile strength qualities and retains 70% of its Dacron, Ethibond, Coated)
original tensile strength at 14 days, 50% at 28 days, and Polyester sutures are constructed from multifilament
25% at 42 days.85 The suture passes through tissue easily, fibers of polyester or polyethylene terephthalate. The
but has significant memory, which compromises the ease polyester suture has excellent tensile strength, which is
of knot tying and knot security. Tissue reaction to the maintained indefinitely.62 Mersilene is uncoated, is some-
material is minimal, but there is a tendency for the PDS what rougher and stiffer than the coated form, and has
suture to extrude through the wound over time. Because a significant amount of drag when passed through the
of this tendency, it is recommended that this suture mate- tissue. Ethibond is a braided polyester suture that is
rial be used only in tissue layers deeper than the subcu- coated with polybutilate, which provides a low infection
ticular layer3 or be used, in a 6-0 size, for the closure of rate, secure knot tying, smooth removal, low reactivity,
the epidermal layer in the face.13 PDS is commonly used and easy passage through the tissue. Ethibond is an excel-
in wounds under tension and is appropriate in contami- lent suture for skin surgery; however, it is more expensive
nated tissue.86 Like Vicryl, PDS II is also degraded by than other sutures with similar indications for use.
hydrolysis. Absorption is minimum until day 90 and is Polyester-braided sutures are stronger than nylon or
complete after approximately 6 months, with minimal polypropylene sutures but have an increased risk of con-
tissue reaction. tamination and therefore are not generally used for skin
closure. When used in deeper layers, the polyester suture
NONABSORBABLE SUTURES has been shown to last indefinitely.88
Nonabsorbable sutures are categorized by the U.S. Phar-
macopeia (USP)61 as follows: Surgical Cotton
• Class I: Silk or synthetic fibers of monofilaments with Surgical cotton is the weakest nonabsorbable suture and,
twisted or braided construction as the name implies, is composed of long stable cotton
• Class II: Cotton or linen fibers, coated natural or syn- fibers. Cotton suture has good knot security but is associ-
thetic fibers in which the coating does not contribute ated with high tissue drag and reactivity and has been
to tensile strength shown to produce a marked tissue reaction.89 Surgical
• Class III: Metal wire of monofilament or multifilament cotton sutures are unsuitable for use in contaminated
construction wounds or in the presence of infection. These undesir-
able qualities and the fact that newer synthetic sutures
Nylon provide superior performance have resulted in cotton
Braided (Surgilon, Nurilon). This suture is a synthetic sutures being rarely used in surgical procedures today.
nonabsorbable material composed of an inert polyamide
polymer. The nylon fibers are braided and then sealed Stainless Steel
with a silicone coating. Nylon has excellent knot security, Stainless steel sutures are monofilament strands of
tensile strength, and knot pull strength, and little tissue ferrous alloy that have desirable characteristics of strength
reactivity. The buried suture loses approximately 20% and low tissue reactivity. However, this suture has the
of its tensile strength yearly through hydrolysis.62 Nylon- potential to corrode or break at points of twisting,
braided sutures look, feel, and handle like silk but are bending, or knotting.90 Stainless steel suture is hard to
stronger and do not have the increased tissue response tie and the knot ends require special handling. Both
monofilament and twisted or braided multifilament It is important to note that even the least reactive
stainless steel sutures are available. Stainless steel sutures nonabsorbable suture, nylon, tends to elicit some degree
offer the greatest amount of tensile strength, even in the of infection in tissue contaminated with Escherichia coli or
presence of infected tissue, and are the most inert of all S. aureus bacteria. The incidence of gross infection in
suture material. The difficulty in handling of stainless contaminated tissue containing nylon sutures has been
steel suture and its tendency to cut through tissue make shown to be significantly greater than the infection rate
it unpopular for cutaneous surgery, but it may be used in contaminated needle puncture tracks not containing
successfully for closure of deeper layers that are infected.62 suture.64 These results suggest that sutures should be
avoided or the number of sutures minimized in infected
Silk tissue, whenever possible.
Silk sutures are braided, siliconized, proteinaceous thread
spun of silkworm larval cocoons. Each silk filament is pro- SURGICAL TAPE
cessed to remove the natural waxes and sericin gum. After Microporous tape for wound closure is useful alone or
braiding, the strands are dyed, stretched, and impreg- in conjunction with subcutaneous or skin sutures to
nated with a mixture of waxes and silicone. Silk sutures decrease tension at the wound margin. Skin tape comes
provide good knot security. Dry suture is stronger than in 1 8 -, 1 4 -, and 1 2-inch wide strips that may be reinforced
wet silk suture but is not as strong as comparable sizes of with rayon filaments to increase the tensile strength of
synthetic materials. Silk sutures should not be used in the the strips. The skin margin is prepared with tincture of
presence of infection.62,87 Silk sutures represent the his- benzoin to provide better adhesiveness for the tape. The
torical and material standard of performance against tape should be placed perpendicular to the wound on
which newer types of suture materials are judged, one skin side first; the wound margins are then pulled
although silk sutures offer little advantage over modern together with the fingers or by an assistant, and the tape
synthetic materials. Silk sutures may be braided or twisted; is secured to the skin on the other side of the wound.
the braided form has better handling characteristics. Silk Thus, tension over the wound is diminished. Before
suture is useful in the periocular area, intraorally, and on placement of the tape, a thin coat of antibiotic ointment
other mucosal surfaces because it remains soft and may be placed along the wound margin to protect the
pliable and does not easily cut through tissue.3,63 Although wound from skin oils and bacteria. To remove the adhe-
characterized as a nonabsorbable material, studies have sive tape and prevent separation of the epithelial margins,
shown that silk sutures lose most of their tensile strength the ends should be lifted equally toward the wound
after 1 year and cannot be detected in tissue after 2 margin and then lifted evenly from the wound.3
years.91
Polypropylene (Prolene) SURGICAL NEEDLES
Polypropylene suture is an isostatic crystalline stereoiso- One of the earliest descriptions of needles used for surgi-
mer of a linear hydrocarbon polymer permitting little or cal purposes appears in the Edwin Smith Surgical Papyrus,
no saturation. The material is extremely inert and will written approximately 3000 to 2500 bc. The twisted, or
retain its tensile strength for at least 2 years.92 Polypro- “harelip,” suture in which a needle was inserted on either
pylene suture holds knots better than most other syn- side of the defect and the suture material was intertwined
thetic monofilament sutures and is indicated for use about the needle in a figure-eight fashion (Fig. 21-6) has
when minimal suture reaction is necessary, such as been described in surgical texts published in the late
infected tissue and contaminated wounds. This suture 1800s, although it has commonly been assumed to be a
does not adhere to tissue and is flexible, and thus is surgical technique used in ancient times.94
useful for pull-out types of sutures. Simple knots are inef- Needles today are manufactured from stainless steel
fective, but carefully tied four-throw knots will provide wire, which initially is soft and then submitted to varying
adequate security.87 heat-treating techniques to provide strength and other
desirable characteristics, such as temper, hardness, mal-
Polybutester (Novofil) leability, and sharpness. The needles can be shaped or
Polybutester is a monofilament, nonabsorbable suture milled into the various types commonly used today
made of polyglycol terephthalate and polybutylene tere- (Fig. 21-7). Needles may be eyed or swaged. Eyed needles
phthalate and is considered to be a modified polyester require threading of the suture material before use,
suture.62 In contrast to polypropylene and nylon, this which results in pulling a double strand of suture mate-
suture does not have significant memory, is easier to rial through the wound and an increased risk of losing
manipulate, and has greater knot security. A unique the needle in the tissue. Tying the suture to the eye is not
feature of polybutester sutures is their capacity to elon- recommended because it increases the bulk of suture
gate or stretch with increasing wound edema. After tissue material drawn through the tissue. Swaged needles do
edema has subsided, the suture resumes its original not require threading and permit a single strand of
shape, which theoretically makes polybutester an ideal suture material to be drawn through tissue. A new and
suture material for lacerations secondary to blunt undamaged needle is provided with each strand of
trauma.93 The tensile strength of Novofil is high and lasts suture, allowing for less trauma when passed through the
for an extended period of time. Novofil has minimal tissue.94,95
tissue reactivity as well. The popularity of this suture in One common type of suture needle used in closing
cutaneous surgery has been gradually increasing. facial wounds is the reverse cutting needle (Table 21-5).
Chord length
Needle
point Swage
Needle
radius
Needle
diameter
Needle
body Needle length
FIGURE 21-7 Anatomy of a surgical needle.
labeled as P (for premium or plastic) or PS (plastic

surgery), and PC needles are coded for precision cos-
metic use. Needles in the PC series are made of a stron-
ger stainless steel alloy and have modified, flattened, and
conventional cutting profiles. A number is used to indi-
cate the size of the needle in the various manufacturers’
series. The larger the number, the smaller the needle size
FIGURE 21-6 The twisted, or harelip, suture, in which suture in that specific series.25
material was used in a figure-eight fashion around a needle
passed through a lip defect. WOUND CLOSURE
With repair of facial wounds, the following guidelines
The reverse curved cutting needle has a cutting edge should be followed:
along the convex surface, rather than along the concave 1. The injured tissue should be handled gently and mini-
surface, as in the conventional cutting needle. There is mally débrided to ensure an adequately clean bed.
less likelihood that the needle will cut considerable tissue 2. Complete hemostasis must be obtained.
in its path through the tissue, and thus its use will prevent 3. Incisions should be placed to follow tension lines and
needless tissue damage and wound enlargement. It has the natural folds of the skin.
been calculated that the strength of the needle in the 4. The skin margins must be relaxed without tension.
reverse cutting shape is increased 32%. The increased 5. Fine sutures should be used and removed as early as
strength of the needle makes possible the use of a smaller possible.
diameter wire, resulting in a smaller wound produced by 6. The wound edges should be everted.
the needle.62,94 7. Dead space must be obliterated.
The most commonly used curved needles are three- 8. The tissue should be closed in layers.
eighths circle needles. These needles are easily manipu- 9. The scar tissue must be allowed to mature before revi-
lated in relatively large and superficial wounds, because sion procedures.96,97
their introduction, passage, and withdrawal require more Tissue is composed of multiple elements that are com-
space than the one-half curved needles and less wrist bined to produce properties related to its functions.
movement. Half-circular needles are recommended for Parameters used to characterize tissue properties are
suturing tissue in small wounds, deep wounds, and body tensile strength, breaking strength, and burst strength.
cavities and orifices. They require less space relative to Tensile strength is measured as the load per unit cross-
needle size because of their greater length, even though sectional area at the point of rupture. The tensile strength
more pronation and supination of the wrist are necessary of the tissue is related to the nature of the tissue, rather
for passage of the needle. The most extreme are the five- than to tissue thickness. Although the skin and fascia are
eighths circle needles, which may be selected for use in the strongest tissues in the body, they regain their tensile
confined areas, such as the oral cavity. strength during slow healing compared with other tissue.
The two basic varieties of needles are cuticular and Breaking strength is the load necessary to break a wound
plastic. Cuticular needles are sharpened 12 times, whereas regardless of its thickness. The size, age, and weight of
plastic needles are sharpened an additional 24 times and the patient, the thickness of tissue, and presence of infec-
designed to produce less trauma during penetration of tion or edema all affect strength characteristics.
tissue for cosmetic closures. Needle terminology, created With the closure of facial wounds, minimal tissue
by manufacturers, has developed in a haphazard manner; trauma during repair is important to prevent excessive
Ethicon currently supplies approximately 80% of the scarring of the wound margins. Meticulous attention to
suture market. Cuticular needles may be designated as C detail is necessary to minimize tissue injury and prevent
(cuticular) or FS (for skin). Plastic-type needles may be further scarring from poor suturing techniques. Skin
TABLE 21-5 Characteristics of Surgical Needles Commonly Used in Skin Closure
Needle Series Type of Cutting Edge Alloy Point Body

FS Reverse 420   Triangular to swage
P Prime Reverse Ethalloy   Square-bodied
PS Prime Reverse Ethalloy   Square-bodied
PC Prime Conventional Ethalloy   Square-bodied
FS, For skin; P, plastic; PC, precision cosmetic; PS, plastic surgery.
Adapted from from Ethicon: Wound closure manual, Somerville, NJ, 1994, Ethicon, pp. 74-75.
hooks should be used for retraction and stabilization of of the remaining wound margins will assist in proper
tissue during débridement and repair and, when tissue orientation (Fig. 21-9). Irregularities in the wound should
forceps must be used, only those with multiple fine teeth, be noted and approximated. Straight line portions of the
such as Adson-Brown forceps, should be used. Wound laceration may then be closed, with the first suture placed
edges should be grasped only at the level of the subcuta- to bisect the wound into equal sections and subsequent
neous tissue to prevent puncture marks on the skin sutures placed in a similar fashion to provide even closure
surface.31 The wound margins should be undermined and prevent creation of so-called dog ears at the end of
slightly to prevent undue tension on the wound margins the wound. If dog ears develop, the sutures should be
and permit closure of the wound in layers with subcutane- removed and closure should be attempted again; a skin
ous tissue and eversion of the wound margin.21 Unless hook can be inserted in the end of the wound, the tissue
necessary to elevate rotational flaps, excessive undermin- can be elevated, and redundant tissue can be incised
ing of the facial tissue should be avoided to prevent around the base on one side of the wound margin.98
unnecessary scarring and distortion of adjacent features, Every attempt should be made to accomplish closure
such as the ala of the nose, commissure of the mouth, and without the necessity for removing tissue because of
eyelid. Only sharp blades and scissors should be used for dog ears.
débridement and preparation of wound margins. Appro- Wounds in the facial region should be repaired in
priate suture material on an atraumatic cutting needle is layers to provide anatomic alignment and prevent dead
desirable for repairing facial wounds. The sutures should space (Fig. 21-10). All deep lacerations must be inspected
be placed to allow slight elevation of the wound margin, carefully. Divided muscles should be reapproximated.
and with the tying of surgical knots it is important to When muscle is severed, layered closure is essential; oth-
remember to “approximate, not strangulate.”19 erwise, the muscle will retract, with a hematoma filling
The principles of knot tying include the following: the gap and eventually organizing to form a depressed
1. Using the simplest knot that will prevent slippage scar. Deep layers should be approximated with 3-0 or 4-0
2. Tying the knot as small as possible and cutting the absorbable sutures and the skin should be repaired with
ends of the suture as short as reasonable to mini- 5-0 or 6-0 suture.
mize foreign body reaction If the muscular layer is involved, the tissue should be
3. Avoiding friction as the suture passes through the approximated with absorbable sutures tied lightly to
tissue (“sawing” of the tissue inevitably results in prevent crushing of the muscle.5 Subcutaneous sutures
further trauma to the wound) placed in the subcutaneous layer and reticular dermal
4. Preventing damage to the suture material that may layer are useful for closing dead space, minimizing
compromise the integrity of the tied suture wound tension at the skin level, and assisting with ever-
5. Avoiding excessive tension that may break sutures sion of the wound margins. Slight eversion of the wound
or cut tissue margin is desirable to produce a scar that will be level
6. Approximation of the tissue-tying sutures too tightly with the adjacent skin after scar contraction is com-
strangulates the tissue plete.21,31 It is important that the knot on the subcutane-
7. Maintaining traction at one end of the suture after ous suture be inverted, or buried, so that the knot does
the first loop is thrown to prevent loosening of not lie between the skin margin and cause inflammation
the knot or infection. To bury the knot, the first pass of the needle
8. Placing the final throw as horizontally as possible should be from within the wound and through the lower
to keep the knot flat portion of the dermal layer. The needle should then be
9. Limiting extra throws to the knot, because they do passed through the dermal layer at approximately the
not add strength to a properly tied knot same level in the opposite wound margin and should
Wound closure should follow examination, débride- emerge through the subcutaneous tissue again at a level
ment, and preparation of the wound margins (Fig. 21-8), similar to that of the subcutaneous suture of the oppos-
if indicated, to allow meticulous alignment of the tissue. ing wound margin. If the sutures are placed at different
Key landmarks, such as the eyebrows, mucosal margins levels, the wound margins may not be level at the skin
of the lip and nose, eyelids, and other anatomic struc- and may produce an unacceptable scar. Suturing that is
tures, must be aligned and repaired properly. Key sutures not level in the subcutaneous layers may be indicated to
placed to approximate these landmarks before closure level off an oblique wound through the tissue. The suture
Non-hair-bearing skin Hair-bearing skin
90° 120° 45° 120°
Correct Incorrect Correct Incorrect
A B C D
FIGURE 21-8 The angle of the blade with reference to the non–hair-bearing skin should be 90 degrees. If this angle is exceeded, the
wound edge becomes beveled and interferes with wound closure. In hair-bearing skin, the blade is angled approximately 45 degrees
parallel to the path of the hair follicle.
should be tied and the skin wound margins approxi- Skin wounds regain tensile strength slowly. However,
mated under minimum tension. it is recommended that skin sutures be removed between
Skin sutures are placed in an interrupted fashion or 3 and 10 days, when the wound has gained only 5% to
as a continuous subcuticular pull-out suture. Interrupted 10% of its final tensile strength, with most of the tension
sutures should be of 5-0 or 6-0 strength, and nylon, poly- forces absorbed by the fascia, which holds the wound
propylene (Prolene), and polydioxanone (PDS) suture closed. Skin sutures in the face should be removed 4 to
materials are indicated, but occasionally 6-0 chromic gut 6 days after placement. Sutures in thin-skinned areas,
suture may be used. Sutures should be placed close to such as the eyelid, should be removed 3 to 5 days follow-
the wound margin and close enough to each other to ing placement.13 Alternate sutures can be removed begin-
relieve all wound margin tension.21 Excessive numbers of ning at day 4 and the wound should be supported by
sutures are unnecessary. The needle should enter the adhesive strips. The remaining sutures may be removed
tissue at a 90-degree angle to the skin surface, approxi- 2 days later. Suture marks are usually caused by three
mately 2 mm from the wound margin. The needle should factors: (1) skin sutures left in place longer than 7 days,
then be passed into the wound by rotation of the wrist resulting in the epithelialization of the suture track;
along the arc of the needle and pass through the dermal (2) tissue necrosis from sutures that were tied too tightly
layer to assist in eversion of the wound margin. The or became tight from tissue edema; and (3) the use of
needle should then be passed through the tissue of the reactive sutures in the skin.5 Interrupted skin sutures
opposite wound margin at the same level in the dermal should not be used in patients who are subject to hyper-
layer and should exit the skin at the same distance from trophic scars.101
the wound margin as that of the insertion.19,31 The suture The continuous subcuticular suture is good for
should be tied without undue tension to prevent suture approximation of the skin margins and can be left in
marks. The two most common reasons for suture scars place for 3 to 4 weeks, without the formation of suture
are closure under tension and delayed removal. tracks.21 Polypropylene or nylon synthetic monofilament
In lacerations without extensive tissue loss, meticulous materials of 4-0 strength are used for the subcutaneous
attention should be paid to hair and eyebrow alignment, suture. After absorbable sutures are placed to close deep
wrinkle continuity, and orientation of muscle movements tissue, the needle is passed through the skin 5 to 10 mm
to produce unobtrusive scars and restore normal ana- from the wound edge into the wound at the dermal
tomic function99 (Fig. 21-11). Blanching of the skin indi- layer. A small hemostat should be placed on the free
cates that the knot is too tight. Uneven wound margins end of the suture. The needle is passed back and forth
with closure indicate that too deep a bite of subcutane- through the dermal layer at the same level in the dermis
ous tissue was enclosed in the suture. Scalloped edges on opposite margins of the wound and parallel to the
with open wound margins between sutures are the result epithelial layer. Skin hooks are useful for manipulating
of bites of tissue that are too small.31 A thin line of anti- the wound margin during placement of the needle and
biotic ointment may be placed over the wound and adhe- for orienting the tissue for proper placement of the
sive strips placed over the sutures to minimize tension suture, which is critical for level approximation of the
around the wound margins. One technique involves the wound margins. It is also helpful to have an assistant
placement of adhesive strips between sutures to allow for follow, or keep a slight amount of tension on, the suture
taking out the sutures without the necessity for removing material already placed in the wound to facilitate proper
the plastic strips.100 The eventual width of the scar is orientation of the suture in the dermal layers. Removal
proportional to the amount of tension necessary for of the suture in long wounds will be made easier if the
closure. suture is brought out through the epithelium near the
A B
C
FIGURE 21-9 A, B, Wound closure should follow examination, débridement, and preparation of the wound margins to allow meticulous
alignment of the tissue. Relevant landmarks, such as the eyebrows, mucosal margins of the lip and nose, eyelids, and other anatomic
structures, must be aligned and repaired properly. Key sutures placed to approximate these landmarks before closure of the remaining
wound margins will assist in proper orientation. Irregularities in the wound should be noted and approximated. Wounds in the facial
region should be repaired in layers to provide anatomic alignment and prevent dead space. When muscle is severed, layered closure is
essential; otherwise, the muscle will retract, with a hematoma filling the gap and eventually organizing to form a depressed scar. Deep
layers should be approximated with 3-0 or 4-0 absorbable sutures and the skin should be repaired with 5-0 or 6-0 sutures. C, 6 months
following repair of the facial injuries. Slight eversion of the wound margin is desirable to produce a scar that will be level with the adjacent
skin after scar contraction is complete.
wound margin and is reinserted at the same level adhesive strips should be used to relieve tension at the
through the epithelium. The suture is continued margin. If areas in proximity to the wound margin are
through the dermal layer to the end of the wound. At not level on closure of the wound with continuous sub-
the end of the wound, the needle is passed out through cuticular sutures, interrupted sutures or adhesive strips
the skin 5 to 10 mm from the margin. The ends of the can be placed to level the margin. The suture is removed
suture can be tied in a knot above the skin or secured to by cutting one free end of the suture at the skin level or
the skin with adhesive strips. A thin line of antibiotic by cutting the epithelial loop and pulling the suture out
ointment should be placed at the wound margin and the free end. As the suture is removed, support should
B
C
FIGURE 21-10 A, Careful examination of the facial injuries should include clinical and radiographic evaluation of the underlying facial bones
for possible fracture. Repair of the soft tissue injury should be delayed until the facial fractures have been repaired. This patient has a
nasal bone fracture associated with a complicated soft tissue injury that involves the nose, eyebrow, and scalp. B, C, The soft tissue
would provide access to the fracture site; the fractured bones are stabilized with plate fixation. D, The soft tissue injury is repaired in
layers with interrupted sutures to reapproximate the eyebrow and facial structures.
C
FIGURE 21-11 A, A scalp injury associated with a motor vehicle accident should first be débrided of all foreign material, without removal
of tissue. Small pieces of tissue should be saved, as the blood supplied tends to be maintained and will heal. B, 5-0 or 6-0 skin sutures
should be placed in an interrupted fashion. Nylon, polypropylene (Prolene), and polydioxanone (PDS) suture materials are indicated, but
occasionally 6-0 chromic gut sutures may be used. Sutures should be placed close to the wound margin and close enough to each
other to relieve all wound margin tension. C, 4 months following repair.
be given to the wound margin to prevent pulling the subcutaneous level to allow for closure of the mucosal or
wound open. The wound should then be supported with skin layer without tension. If the contused laceration
adhesive strips. involves vital structures that would not tolerate tissue
Cyanoacrylate (Histoacryl) is a polymeric glue mate- removal, such as the eyelid or nose, débridement and
rial that has been used successfully for closure of small primary closure should be delayed until the contusion
linear lacerations, especially in children. Lacerations in resolves. During the resolution of contusion type of inju-
one study were limited to those that were smaller than ries, hypopigmentation or hyperpigmentation of the
3 cm in length, those with nonragged edges, and super- area is not unusual but is rarely permanent.
ficial nonhemorrhagic wounds away from the eyelids and
the vermilion border of the lip.102-105 The glue is applied ABRASIONS
by means of a glass capillary tubing with the skin edges Abrasions result from deflecting type of trauma, such as
held together. A thin film of glue is applied while the sliding along pavement, dirt, or glass, that removes the
skin edges are held in approximation for 30 seconds, or epithelial layer and papillary layer of the dermis and
until the glue becomes opaque. Histoacryl appears to be leaves the raw, bleeding reticular layer of the dermis
safe when used for skin closure, although the polymer exposed. This type of wound may be painful because of
should not be allowed to come into contact with tissue exposed nerve endings in the reticular dermal layer. Care
below the level of the skin, where it can cause inflamma- should be taken to clean small particles, dirt, grease,
tion and even tissue necrosis because of toxic byprod- carbon, and other pigments from the dermal layer as
ucts.106 Dressings are not applied unless the child is very soon as possible to prevent fixation within the tissue and
young. Gluing is quick, atraumatic, and cost-effective, formation of a traumatic tattoo. Local anesthesia should
with good cosmetic results. This technique obviates injec- be used and the wound should be scrubbed clean with a
tions, suturing, and postoperative suture removal for mild soapy solution, followed by copious irrigation with
small lacerations. In one study, 98.6% of patients and saline. To prevent drying and desiccation of the exposed
patients’ parents were satisfied and would prefer this wound surfaces, the abrasion should be covered with a
technique over conventional wound closure. Because thin layer of antibiotic ointment, such as bacitracin, and
complications, infections, and unusual scarring have dressed with cotton gauze or covered with an antibiotic-
been reported in as many as 10% of patients, careful coated cellulose acetate gauze.5,13,21,108
selection of simple wounds with a low risk of contamina- Epithelialization is complete 7 to 10 days after injury,
tion is essential. without notable scarring if the epidermal pegs have not
Fibrin tissue adhesives are made up of two compo- been completely removed.5,20 After 3 days, the epidermal
nents; component I contains fibrinogen, factor XIII, and cells begin to migrate onto the abraded dermis. At 14
calcium chloride, and component II is composed of days, fibroblast and capillary formation in the dermis
bovine thrombin and an antifibrinolytic agent.106,107 Dif- increases and new elastic fibers develop by 3 months.
ferent fibrin tissue adhesives have different characteris- Regeneration is not complete for 6 to 12 months.
tics. Raising the fibrinogen concentration increases the If the wound extends deeply into the dermal layer,
binding strength. Thrombin catalyzes the conversion of notable scarring from granulation tissue formation will
fibrinogen to fibrin and initiates the activation of factor result. Excision of the remaining dermal tissue or exci-
XIII. Therefore, the speed of fibrin polymerization is sion of secondary scar tissue, with primary closure of the
directly related to the concentration of thrombin. Factor skin wound with 4-0 chromic sutures in the dermal layer
XIII is necessary to initiate the cross linking of the fibrin and 6-0 nylon sutures at the surface, is indicated.2,16,20
clot. Fibrin tissue adhesives can be prepared from autolo- Exposure of abraded skin wounds to excessive sunlight
gous, single-donor, or multiple-donor sources. This during the first 6 months after injury may cause perma-
feature may limit their use in emergency room settings nent hyperpigmentation. These healing wounds may
but may be of value in delayed wound closure in certain benefit from protection with a sun-blocking agent with a
patients. These adhesives are used commonly to fixate sun protection factor of 15 or higher.
split-thickness skin grafts and skin flaps. They also have
been used as a hemostatic and sealing agent in many LACERATIONS
patients with certain blood dyscrasias. Lacerations may be sharp, with little jaggedness or contu-
sion of the wound margins; they may have contused,
ragged, or stellate margins, as seen in a crushing type of
CLASSIFICATION AND MANAGEMENT OF injury; or they may involve partial avulsion of tissues that
SOFT TISSUE WOUNDS remain pedicled to surrounding structures. After exami-
nation, débridement, and irrigation, the wound should
CONTUSIONS be repaired in layers.
Contusions are usually produced by blunt trauma that
results in edema and hematoma formation in the subcu- Simple Lacerations
taneous tissue. The hematoma will usually resolve without Simple lacerations may be clean, contaminated, or con-
incident or necessity of treatment unless it is large or tused. Clean lacerations may be repaired with little
becomes infected. Usually, the overlying skin and mucosa débridement or preparation necessary. Contaminated
are intact, but if the contusion is associated with a lacera- wounds should be cleansed and closed primarily, even if
tion, the contused margins should be excised before a delay of up to 5 to 7 days after trauma is necessary.
closure.1,13,21 The margins should be undermined at the Contused wounds should be evaluated and tissue
removed about the margins of the wound if enough Half-buried horizontal mattress tip stitch
tissue is available, or treatment should be delayed until
the contused tissue stabilizes enough to allow for primary
closure of the wound. If the laceration is beveled and
ragged, the beveled portion of the wound should be
excised with supporting dermal tissue to provide perpen-
dicular skin edges and to permit closure with some 2 1
wound margin eversion to prevent excessive scar forma-
tion.1,21 Undermining of soft tissue wound margins is
3 4
helpful for suturing tissue without extensive tension at
the wound margin. Excessive undermining should be
avoided because natural wound contraction may lead to
tissue elevation at the margins of the wound and to exces-
A
sive scarring. Displaced tissue should be returned to the
original anatomic position and orientation. Only occa-
sionally is there an indication for changing the direction
of the wound margins by Z-plasty or for making tissue
allowance for scar contracture at the time of primary
wound repair.13 These procedures should be done as
secondary revision procedures, if indicated.
Stellate Lacerations
Ragged lacerations usually have a contused portion
because of the blunt crushing trauma that is commonly
responsible for this type of injury. To facilitate closure, B
ragged edges should be trimmed with a scalpel blade
to make beveled wound margins perpendicular.21 Inter- FIGURE 21-12 Half-buried horizontal mattress suture. Half of the
rupted sutures should be used to close the wound as far suture lies beneath the skin in the subcuticular plane and the knot
as the stellate portion of the wound margin, when mul- lies above the skin for easy removal. This suture is useful for
tiple lacerations meet. Strangulation of the flap tip is approximating corners of irregular wounds. (From Robinson JK,
commonly encountered with placement of interrupted Hanke CW, Siegel DM,, et al: Procedural dermatology, ed 2,
skin sutures through such small portions of tissue. A St. Louis, 2010, Mosby.)
partially intradermal horizontal mattress suture placed
through the dermal layer of the tissue flap and exiting AVULSION INJURIES
the skin on the larger portion of the wound is useful for The actual loss of tissue in facial wounds is fairly rare. Even
closing the triangular wound without impairing the if the initial evaluation suggests a loss of tissue, meticulous
blood supply in the tip of the flap109 (Fig. 21-12). Adhe- examination usually reveals that the tissue margins have
sive strips will assist in relieving tension on the wound been retracted or rolled under the wound margin. If small
margin. areas of tissue are missing, simple local undermining of
the skin may provide for primary closure without tension
Flaplike Lacerations on the wound margins. If there has been a notable loss of
Flaplike lacerations involve significant undermining of tissue and the wound cannot be closed free from tension
the soft tissue, usually at the subcutaneous tissue or with local undermining, the raw surface should be covered
supraperiosteal level, without loss of tissue. The tech- with a skin graft, local flaps, or apposition of the skin
niques of wound débridement and preparation already margin to the mucous membrane.19,21,31 Under no circum-
discussed must be meticulously followed. It is not uncom- stances should a wound on the face be allowed to heal by
mon to find debris in deep tissue under the flapped secondary granulation tissue because of excessive scar
tissue. Preparation should include minimal débridement formation (Fig. 21-13).
of involved tissue and removal of beveled wound margins
for perpendicular closure. The excellent blood supply to DELAYED PRIMARY WOUND CLOSURE
facial structures will support tissue on very small Delayed primary wound closure is also indicated in
pedicles.13,21,32 patients with extensive facial edema or subcutaneous
In flap wounds, pressure dressings play an important hematoma and when the wound margins are badly con-
role in minimizing dead space and limiting hematoma tused and tissues are devitalized. Primary repair in such
and fluid formation within the deep tissue. Hematoma damaged tissue is difficult and the possibility of bacterial
and lymph pooling may become infected or may promote infection with wound breakdown is increased. Limited
fibrin deposition and excess scar formation beneath the débridement to remove devitalized tissue, moist dress-
flap.13 Semicircular flaplike wounds of the head and neck ings, and antibiotic therapy until resolution of the edema
may have a Z-plasty or W-plasty incorporated to align the and control of infection are indicated until definitive
skin edges more along resting skin tension lines and treatment of the wound can be accomplished.
prevent possible trap door deformities and scar forma- Open wound treatment, formerly universally accepted
tion (see Chapter 22). for contaminated wounds and bite injuries, is no longer
A B
C D
E
FIGURE 21-13 A, An avulsive scalp wound. B, The avulsed tissue should have as much of the subcutaneous layer and fat removed as
possible to allow for adequate perfusion of the skin. C, The flap is then sutured into place and a compression dressing placed to prevent
hematoma formation below the flap. D, The flap becomes revascularized. E, It eventually heals with hair-bearing tissue except for a small
defect that will heal by secondary epithelialization.
practiced for facial wounds, except abrasive wounds.100 edema or has a large subcutaneous hematoma, a crush-
Immediate definitive treatment of maxillofacial injuries ing type of injury, wound edges that are badly contused
was used in the Vietnam conflict. Wounds of the face and or devitalized, or both, or an increased risk of infection.
anterior cervical region were repaired with primary Delayed primary closure is accomplished by limited
closure, when possible. Minimal, careful débridement débridement removing only gross foreign substances
was performed and the anatomy was restored to as and overtly devitalized tissue. If the wound is to be treated
normal a position as possible. Most of these patients with delayed primary closure because of contamination,
could expect no major impairment of function110 except edema, fractures, or other clinical findings, the patient
when very destructive wounds with loss of important ana- should be treated with systemic antibiotics, the wound
tomic parts were present. should be cleansed and débrided, and a sterile
Open wounds allowed to heal with granulation tissue dressing should be placed until final treatment can be
leave large unsightly scars on the face. These wounds instituted.19
should be mechanically débrided and closed primarily
or, in the case of defects, closed primarily by local flaps SKIN GRAFTS
or skin grafts. Delayed primary wound closure may be Primary closure of defects with adjacent tissue and local
indicated if a patient is seen late with extensive soft tissue flaps provides the most predictably successful results.
A B
C D
FIGURE 21-14 A, An avulsive injury was repaired primarily, but

eventually the blood supply to the avulsed tissue was lost
and the avulsed flap became necrotic and was lost. B,
Because of the location of the lost tissue, the decision was
made 10 days following the injury to allow the wound to heal
by secondary epithelialization. C, 1 month after repair. D, 10
E
weeks after repair. E, 4 months after repair.
Loss of tissue may be so notable that primary closure is Free grafting of tissue involves tissue transfer without
not possible. Closure of wounds following large tissue preservation of blood supply. Therefore, vascularization
loss is usually secondary to epithelialization with epithe- and perfusion of the graft must occur rapidly to ensure
lial migration and wound contraction (Fig. 21-14). Place- graft survival. Cortical bone denuded of its periosteum
ment of skin grafts limits the amount of contraction and cannot accept a skin graft. Tendons, nerves, or cartilage
usually limits tissue deformity. Other indications for skin are unable to support skin grafts without their corre-
grafting include lining cavities, resurfacing mucosal defi- sponding connective tissue sheaths. Other tissues, includ-
ciencies, and providing temporary coverage before defining muscle, fat, fascia, dura, and periosteum, are
itive treatment. amenable to skin grafting if the wound surface is viable
FIGURE 21-15 Free skin grafts are classified according to their thickness. Split-thickness grafts are divided into thin, medium, and thick.
(From Rothrock J: Alexander’s care of the patient in surgery, ed 13, St. Louis, 2007, Mosby.)
with good hemostasis, there is no infection, and the host survive if no part of the graft is more than 1.0 to 1.5 cm
is systemically healthy. away from the nutrient bed.21
Free skin grafts are classified according to the thick- With free skin grafts, pressure dressings should be left
ness of the graft. Split-thickness skin grafts consist of the in place for 7 to 10 days to prevent hematoma or fluid
epidermis and a portion of the dermis and can be further accumulation and to facilitate perfusion of the graft. The
classified as thin (0.008 to 0.012 inch), medium (0.012 grafted skin should be kept well lubricated with oil-based
to 0.018 inch), and thick (0.018 to 0.030 inch). Full- lotion to prevent excessive drying and prolonged expo-
thickness skin grafts include both the epidermis and sure to the sun should be avoided.111
dermis (Fig. 21-15).111 Thinner grafts rapidly vascularize In preparation, the wound should be débrided thor-
and survive under less than optimal conditions. Split- oughly and irrigated with a physiologic saline solution or
thickness grafts can be expanded if necessary and have Dakin’s solution (10% sodium hypochlorite in saline).
multiple donor sites that heal with minimal scarring at Many standard scrub solutions provoke an inflammatory
the donor site. Thin split-thickness grafts should be used response and may compromise the recipient bed. Moist
on the face as a tissue dressing to prevent infection until dressings may be applied until the graft is placed. Full-
repair with flap procedures can be used to reconstruct thickness grafts may be harvested by dissection, with the
the defect.31 physician carefully separating the skin from the underly-
The thicker a split-thickness graft, the more closely it ing fat, which may act as a barrier between the blood
will resemble the qualities of color, texture, and limited supply and graft tissue. Donor sites should be closed
contraction of a full-thickness skin graft. Thick split- primarily. Split-thickness grafts may be harvested with a
thickness grafts are ideal and often provide definitive dermatome, with the physician carefully maintaining the
repair for large clean defects. The anterolateral area of correct angle with a pulling motion.
the neck can serve as a donor site for skin grafts to the Graft immobilization is key to the success of skin graft-
face, because the skin is similar in color and texture.13 ing. Grafts are held in place with sutures, staples, or tape
Full-thickness skin grafts provide tissue of good and should be tension-free, because even minimum
color and texture match but are limited by their shearing forces result in tearing. Tie-over dressings may
devascularization at the defect site. Optimal wound con- be best for ensuring graft immobilization. Initially, the
ditions are necessary and the donor site must be able to graft survives by the plasma exchange of nutrients, called
be closed primarily. Full-thickness skin grafts are usually plasmodic imbibition; this process is responsible for graft
used to repair small defects in the lip, nose, eyelid, or nutrition for the first 48 hours. Fluid is passively absorbed
eyebrow (Fig. 21-16). In general, donor sites that are as by the graft, which leads to edema within 2 to 3 days.
close as possible to the defect should be selected to Inosculation is the vascular supply of the graft spreading
achieve the best possible color match and a texture to the host bed. Vascular ingrowth by vascular beds
approximating that of the surrounding skin. Such donor from the recipient site also occurs. Revascularization
sites include the postauricular area, upper eyelid, supra- is complete within 4 to 7 days, and lymphatics are estab-
auricular area, and antecubital fossa.13 Free composite lished after 4 to 5 days. A wound will contract after graft-
grafts can be obtained from the ear primarily to recon- ing. Full-thickness grafts show minimum contracture,
struct avulsions of the nasal alar base. These grafts will whereas a split-thickness graft may contract by up to 30%
A B
C D
FIGURE 21-16 A, An avulsive injury involving the upper eyelid, eyebrow, and scalp with loss of soft tissue so that primary closure was not
possible. B, A split-thickness graft was obtained from the lateral portion of the neck to cover the defect. The anterolateral area of the
neck provides a donor site for skin grafts to the face because the skin is similar in color and texture. C, The thinner the graft used,
the quicker the graft will vascularize and survive. The graft is secured with interrupted 6-0 sutures and a pressure dressing is applied.
D, The pressure dressing is secured to the area to prevent hematoma or fluid accumulation and to facilitate perfusion of the grafted skin.
The grafted skin should be kept well lubricated to prevent excess drying and avoid prolonged exposure to the sun. E, F, 6 months
following reconstruction, with good function of the upper eyelid maintained. Hair grafts may be considered in the future to restore the lost
portion of eyebrow.
E F
to 35%.112,113 Most grafts will also undergo pigmentation Transpositional flaps involve swinging flaps into areas
changes as a result of damage to pigmented cells. Usually, of defect over healthy tissue, with a secondary defect at
the wound goes through a period of hypopigmentation the donor site that is closed primarily by undermining
early and then a period of hyperpigmentation before it adjacent tissue or by coverage with a free skin graft. The
returns to normal color. Reinnervation is complete in donor site is usually in the neck or scalp region and
most grafts but appears to be superior in split-thickness closure is within the natural creases or in the hair. With
grafts compared with full-thickness grafts.114,115 large defects, a flap may have to be swung up from the
The most common causes of graft failure are hema- chest region.31
toma formation and failure of immobilization. Careful Microvascular anastomotic flaps are usually not indi-
hemostasis and periods of proper immobilization prevent cated in defects of the face, although some favorable
failure and the necessity for revision procedures. Careful results have been reported with the reconstruction of
treatment planning, taking of the patient’s history, and scalp wounds.116 With facial avulsive defects, adequate
examination of the recipient bed increase the chances of arteries or veins may not be close enough to the defect
graft success. Improper orientation of the grafted tissue, for successful anastomosis. When successful, these flaps
such as securing a graft upside down or wrong side down, provide excellent coverage but are often bulky on the
may lead to graft failure. face and may require multiple revisions to thin. Conven-
tional coverage with a free skin graft or local skin flaps
FLAPS may provide a superior result, with a much simpler oper-
Local or regional flaps provide one-stage repair of avul- ative procedure.13
sion defects with similar tissue that has its own vascular Local flaps can be divided into two groups, those that
supply and is not dependent on the perfusion of damaged rotate about a fixed point to reach the defect (rotational,
tissue, as with free skin grafts. The disadvantages include transpositional, and interpolated) and those that advance
additional incisions, elevation of tissue on the face, and into the defect (single pedicle, bipedicle, and V-Y advance-
increased scarring. In the design of all flaps, the blood ment). The fundamental motion of the tissue should be
supply and venous drainage are of prime concern. The a straight line from donor site to recipient site, with
method of closing the secondary defect must be planned minimal rotational or lateral movement.
before the procedure. Facial flaps do best when based
laterally or inferiorly, with the incisions following normal Rotational Flap
skin folds and lines of expression.13 The basic skin flaps The movement of the rotational flap is in an arc around
used on the face are advancement, rotational, transposi- a fixed point, primarily within one plane. The act of rota-
tional, and microvascular anastomotic flaps. tion results in less reliance on tissue elasticity for flap
Advancement flaps involve making two parallel inci- movement, allowing these flaps to be useful in areas of
sions from the defect and undermining the tissue inelastic skin, such as the scalp and nasal dorsum.117,118
until the flap can be advanced into the defect under An example is the semicircular flap (Figs. 21-17 and
minimal tension. Dog ears created at the base of the flap 21-18). When possible, the flap should be designed so
should be carefully excised. Rotational or rotational- that it is inferiorly based, which promotes lymphatic
advancement flaps use a semicircular flap to rotate tissue drainage and reduces flap edema. The disadvantages of
into a defect, with primary closure of the secondary rotational flaps are relatively few. The defect itself must
defect. This flap requires careful planning to keep the be somewhat triangular or modified by removing normal
incision from crossing too many natural skin folds. The tissue to create a triangular defect. As with all pivotal
circumference of the circle should be eight times the size types of flaps, rotational flaps develop cutaneous defor-
of the defect and at least twice the diameter.19,31 mities at their bases that may not be easily removed
the head and neck region. The length of the flap should
not exceed three times the width, although the abundant
vascularity of the head and neck often enables the devel-
opment of flaps that exceed this 3 : 1 ratio. The more it
is rotated, the shorter the flap becomes. Like rotational
flaps, these flaps tend to be pushed rather than pulled
over the defect by forces created by closure of the second-
ary defect. They also tend to drape into place with very
little tension. Careful planning is necessary because once
flaps have been incised, they cannot be enlarged. Fre-
A B quently, dog ears are created; these are best removed
after the flap is fixed into place so that a precise amount
of tissue can be removed.117-119
Interpolated Flap
With the interpolated flap, the donor site is separated
from the recipient site and the pedicle of the flap must
pass over or under the tissue to reach the recipient area.
A second surgical procedure is usually necessary to
release and modify the flap (Fig. 21-20). An advantage of
the interpolated flap is the use of distant tissue with aes-
thetically pleasing characteristics, such as skin texture,
C D thickness, and color match. An example is the nasolabial
flap for reconstruction of the nose.
FIGURE 21-17 The rotational flap is useful in soft tissue surgery of
the face. A, The flap is planned with judicious removal of tissue Single-Pedicle Advancement Flap
about the defect, allowing for rotation into this space. B, The flap With the single-pedicle advancement flap, a rectangle of
and adjacent tissue are undermined, allowing for movement. skin is pulled forward on the basis of the elastic proper-
C, To gain further rotation into the primary defect, it is sometimes
ties of the skin. The design of the flap should take advan-
useful to make a small incision to release the posterior portion of
tage of local skin tension lines, cosmetic borders, and
the base. D, The flap is then secured over the defect and the
regional blood flow patterns. Generally, inferiorly or lat-
secondary defect is then occasionally able to be closed primarily.
erally based flaps are best. Excision of deformities caused
by flap design, such as Burrow’s triangles, may facilitate
movement of the flap and help prevent of tissue bunch-
ing and dog ears. It is unwise to move advancement
flaps toward free margins, such as the lip and eyelid,
because of the increased risk of ectropion and eclabium.
Movement across or parallel to free margins is recom-
mended.118,120 Single-pedicle advancement flaps work
well in certain areas, such as the forehead, helical rim,
upper and lower lips, and medial cheek. Mucosal advance-
ment flaps are also useful for vermilion reconstruction.119
Bipedicle Advancement Flap
With the bipedicle advancement flap, or H-plasty, the
same principles apply as for the single-pedicle advance-
ment flap. An incision is made parallel to the defect and
the flap is undermined and advanced. The length of
A B each flap is 1.5 to 2.0 times the width of the defect. The
FIGURE 21-18 Double-rotation (O-Z) flaps. A, A circular defect may equal and opposite motion of the two flaps minimizes
be closed with the double-rotation flap, with the primary tension the impact on the surrounding tissue. Because each flap
shown at the junction of the two flaps. B, A square defect may be
covers only half of the defect, they are smaller and move
divided into two triangular defects. Each triangular defect is closed
less, which results in better relative blood flow and less
with its own advancement flap.
tension on the closure.119,120 Often, this type of advance-
ment requires skin grafting to close the donor site.
without compromising the vascularity of the flap. Thus, a
second-stage removal of the deformity may be necessary. V-Y Advancement Flap
With the V-Y advancement flap, an elliptical incision is
Transpositional Flap planned over the defect using a 3 : 1 ratio, in which the
The transpositional flap is a rectangular flap that rotates length of the ellipse is three times the length of the
about a pivot point (Fig. 21-19). Transposition is the most defect. The advancing edges of the two flaps are trimmed
common method of moving tissue into local defects of and subcutaneous dissection is started. Each V-shaped
Flap
Defect
60˚
30˚ 30˚ 30˚
E C B Defect
A C E
A Flap
D
F F
B
FIGURE 21-19 Transpositional flaps. The base of the flap is parallel to the lines of maximal extensibility. The secondary defect is closed
primarily. A, A bilobed transpositional flap is used to close a scalp defect. B, The classic rhomboid transpositional flap (Limberg flap) and
a modified 30-degree rhombic flap (inset).
flap is undermined until a small central vertical base of undermined and closed primarily. With primary
tissue is formed. The two island flaps are advanced and closure of the wounds, infection, delayed healing, and
approximated over the primary defect. The secondary scar contracture will be prevented.119,121 There will be no
defects are then closed primarily (Fig. 21-21). When flaps distortion of local tissue around the defect, which will
are constructed on the lip or cheek, more advancement allow for secondary reconstruction of the defect, with
is possible compared with flaps on the forehead because stable anatomic landmarks.
of the thicker layer of subcutaneous fat.119,121
ANIMAL BITES
APPOSITION OF THE SKIN MARGIN TO Approximately 1 to 2 million animal bites are treated
MUCOSAL MEMBRANES annually; dog and cat bites alone account for approxi-
Full-thickness defects in the cheek, nose, or lip— mately 1% of all emergency room visits in the United
commonly seen with gunshot wounds—usually cannot be States annually.122 Usually, 10 to 20 dog bite–related fatal-
repaired primarily by skin grafting or flap procedures. ities occur annually. Dog bites are most common,
The mucous membrane and skin margin should be accounting for 63% to 93% of reported animal bites to
1 3
Part
trimmed
A B
FIGURE 21-21 The V-Y plasty, or island advancement flap. 1, The

four rounded tips of the advancing flaps are trimmed and the 3 : 1
dimension of the total length of the ellipse is planned. 2, The
C D
V-shaped island of tissue is raised and dissected from its base
FIGURE 21-20 Interpolated flap. A, The flap is planned. B, The until a small central line of tissue is formed in the center of the
flap is elevated and closed over the defect, and the donor site is island. 3, The first suture is placed to align the advancing edges
closed. C, Once the flap is revascularized, its pedicle is divided. of the two flaps. The tip sutures are placed to align the tails. Next,
D, The base is closed primarily. the subcutaneous sutures are placed to approximate the corners
and closure is completed.
humans, primarily children. Head and neck bites are

more common in younger age groups, in children penicillin or amoxicillin is recommended. If the infec-
younger than 10 years.123-125 Although infections resulting tion develops beyond 24 hours after injury (implicating
from animal bites are polymicrobial, Pasteurella spp. (P. Staphylococcus or Streptococcus), an antistaphylococcal pen-
multocida) are most frequently cultured from dog bite icillin, such as dicloxacillin or cephalexin, is suggested
wounds, followed by S. aureus. The feline oral flora is for antibiotic coverage.132 Animal bites should be consid-
more likely to harbor P. multocida.126,127 Infections that ered prone to tetanus and treated accordingly.
occur with Pasteurella species are most likely to be seen Rabies is a serious consideration with any animal bite.
within 24 hours after the incident whereas, after 24 Immediate and thorough washing of the wound with a
hours, wounds are more likely to contain Staphylococcus soap or scrub solution is probably the best prevention
or Streptococcus species.128 against rabies. Postexposure rabies prophylaxis is recom-
With animal bites, the wounds should be evaluated, mended for patients attacked by suspected animals or in
with the patient receiving local anesthetic. Radiographs geographic locations in which the incidence of rabies is
should be obtained if there is considerable edema about particularly high. It consists of human diploid cell vaccine
the wound or if bony penetration or foreign bodies are (HDCV) or rabies immune globin (RIG). If necessary,
suspected. Canine jaws are capable of compressive forces captured animals may be tested to determine the neces-
of 200 to 450 psi and skull fractures with cranial penetra- sity of treatment.132 For more detailed information, see
tion have been reported122,129,130 (Fig. 21-22). Chapter 23.
Wounds should be thoroughly débrided and irrigated.
Historically, animal bite wounds were not closed primar-
ily, although some investigators supported closure.124,131 INJURIES TO STRUCTURES REQUIRING
In most laceration types of injuries, it is safe to close the SPECIAL TREATMENT
wounds primarily after proper wound preparation
without increased risk of the development of infection. LIP
Puncture types of wounds should not be closed primarily The lip provides special challenges to repair following
because it is difficult to clean and prepare the wound trauma because of the anatomy of the region of the ver-
adequately. Bite wounds with extensive crush injury and milion border, which involves the transition of mucosal
wounds requiring a considerable amount of débride- tissue to skin, associated edema of the tissue after trauma
ment are best treated with delayed primary closure.122,132 to the area, and aesthetically displeasing and difficult to
Proper antibiotic therapy is important for the pre correct puckering defect that results from an irregular
vention and treatment of infections caused by animal vermilion margin (Fig. 21-23). A mismatch of even 1 mm
bite wounds. For prophylaxis of uninfected wounds, at the vermilion may be readily noted by an observer
dicloxacillin or Keflex (cephalexin monohydrate) is rec- (Fig. 21-24). Scars or defects that affect the sphincter
ommended.122 For infections presenting within the first activity of the orbicularis oris muscle produce drooling,
24 hours of the incident (implicating P. multocida), functional difficulties in eating, and alterations in speech.
A B C
FIGURE 21-22 A large avulsive forehead wound with loss of the pericranial tissue and exposed bone. The wound is closed primarily with
rotational advancement flaps.
A B
C
FIGURE 21-23 A, The lip provides special challenges to repair following trauma because of the anatomy of the region of the vermilion
border. A mismatch of even 1 mm may be readily noted at the vermilion by an observer. B, After examination, a single 5-0 suture should
be placed at the mucocutaneous line, or gray or white line, to reorient this important junction. The muscular layer is reapproximated
with 3-0 or 4-0 chromic sutures; the dermis and subcutaneous tissues are closed with 4-0 or 5-0 chromic sutures. The skin should be
carefully approximated with 6-0 sutures placed evenly and the mucosal layer is loosely reapproximated with 4-0 sutures. C, 3 months
after repair.
After examination, a single 5-0 nylon suture should be

placed at the mucocutaneous line (gray or white line) to
reorient this important junction (Fig. 21-25). The wound
should be débrided, hemostasis achieved, and local anes-
thesia achieved in the surrounding tissue or via mandibu-
lar or mental nerve blocks. Blocks are preferred to
prevent unnecessary edema in tissue to be approximated.
The wound should then be closed in layers. Proper reap-
proximation of the orbicularis oris muscle is important
if the muscle has been disrupted (Fig. 21-26). Severed
muscle fibers tend to retract, which may lead to later
depression of the scar with maturation of the wound. The
muscular layer is reapproximated with 3-0 or 4-0 chromic
sutures, the dermis and subcutaneous tissue are closed
with 4-0 or 5-0 chromic sutures, the skin should be care-
fully approximated with 6-0 nylon sutures placed evenly,
and the mucosal layer is loosely reapproximated with 4-0
chromic suture (Fig. 21-27).
Incorrect
Correct
FIGURE 21-26 Large lip laceration with concomitant maxillary
fracture and tooth avulsion. Proper reapproximation of the
orbicularis oris is essential for preventing later depression of
the scar.
FIGURE 21-24 The vermilion skin junction should be crossed at 90
degrees so that correct alignment may be achieved.
A B
FIGURE 21-25 Closure of the commissure of the mouth presents an unique challenge with this child, who suffered a dog bite. The wound
should be débrided, hemostasis achieved, and a local anesthetic administered in the surrounding tissue. The wound should then be
closed in layers. Proper reapproximation of the orbicularis oris muscle is important with any lip repair if the muscle has been disrupted.
In avulsive injuries to the lips, 25% of the upper lip to rotate tissue into the avulsed area. Another type of
and up to 25% of the lower lip can be lost without resul- rotational flap is the Karapandzic flap, which uses full-
tant functional or aesthetic defects.133 The tissue margins thickness perioral tissue about the oral stoma. The lips
should be straightened, with removal of a full-thickness are advanced along with the orbicularis oris, neurovas-
wedge of lip tissue to facilitate closure. If there has been cular bundle, and underlying mucosa to close the defect.
an extensive avulsive injury, an Abbe-Estlander flap The major complication is the reduced size of the oral
between the affected lip and the opposite lip can be used stoma3 (Fig. 21-28). Distinct cutaneous creases outline
A B
C
FIGURE 21-27 Flaps of tissue, no matter how small, should be maintained if still attached. The island of vermilion border is secured with
multiple interrupted 5-0 nylon sutures, with care taken to maintain the alignment of the gray line of the vermilion border junction with
the skin.
A B
C
FIGURE 21-28 Reconstructive flaps used in avulsive lip injuries. A, The Abbe flap. B, The Abbe-Estlander flap. C, The Karapandzic
flap.
A B C
FIGURE 21-29 The excellent blood supply to the ear can support large portions of tissue on very small pedicles. The first sutures should
reapproximate known landmarks and secondary sutures should reapproximate adjoining tissue. Conservative débridement should be
used to maintain as much tissue as possible.
FIGURE 21-30 A-C, The pinna consists of a thin central area of relatively avascular cartilage that depends on the thin overlying layer of
skin for its blood supply. The ear has a good blood supply and can maintain large portions of tissue on very small pedicles. Conservative
débridement and manipulation should be used to maintain as much tissue as possible. Sutures should first be used to reapproximate
known landmarks and then should be placed to reapproximate adjoining tissue. The skin should be approximated with 6-0 or 7-0 nylon
sutures or other fine suture material. Suturing of the cartilage is usually unnecessary and may lead to devitalization of the region of
cartilage, or may provide a pathway for infection. D, 3 months after repair.
the anatomic lip unit. The mental crease divides the lip sutures are recommended.135 Torn cartilage should be
and chin, the nasolabial crease defines the lateral borders, repaired with a minimum number of sutures (Fig. 21-30).
and the base of the nose serves as the superior limit. In avulsive injuries involving segmented portions of
These dominant features of the lower face are important the external ear that are missing or attached only with a
in facial aesthetics because they are excellent locations small pedicle flap, the tissue should be returned to
for camouflage of scar lines in lip repair. Distortion of proper anatomic position and secured with sutures to the
these lines may be significantly deforming.134 skin. The skin from the dorsum of the ear should be
dermabraded and attached to a skin flap elevated from
EAR the mastoid region for a vascular bed.136 Postoperative
In the assessment of injuries to the ear, a complete exami- treatment should include bed rest, use of a supportive
nation of the external ear, pinna, tympanic membrane, bandage, application of ice to cool the replanted part
and hearing should be performed and documented and decrease the metabolic rate within the segment,
before treatment (Fig. 21-29). The external ear consists heparin anticoagulant treatment, and antibiotics to cover
of the pinna, external auditory meatus, and tympanic gram-positive bacteria.
membrane. The pinna consists of a thin central area of Total amputation of the external ear is a difficult
relatively avascular cartilage that depends on the thin repair and reconstruction problem. Plastic surgery graft-
overlying layer of skin for its blood supply.32 The ear has ing procedures to reconstruct the external ear with rib
a good blood supply and can maintain large portions of cartilage, skin flaps, or Silastic or silicone implants have
tissue on very small pedicles. Conservative débridement had variable results137,138 and are rarely satisfactory. Some
and manipulation should be used to maintain as much success has been reported with microvascular techniques.
tissue as possible. Sutures should first be used to reap- The superficial temporal artery or posterior auricular
proximate known landmarks and then should be placed arteries are used, but there are problems with artery size
to reapproximate adjoining tissue. The skin should be and poor venous drainage that make salvage difficult.136
approximated with 6-0 or 7-0 nylon sutures or other fine Prosthetic rehabilitation of the external ear and other
suture material. Suturing of the cartilage is usually unnec- specialized facial structures has been greatly improved
essary and may lead to devitalization of the region of with the development of silicone and plastic materials
cartilage or may provide a pathway for infection. If for more reliable and stable color match, comfort,
sutures in the cartilage are necessary, fine chromic and durability.35,139 Attachment of the prosthesis to eye-
A B
C D
FIGURE 21-31 After aspiration or incision and drainage of an

otohematoma, the ear may be dressed by using dental cotton
rolls bolstered with sutures through the pinna, as shown above. FIGURE 21-32 A significant deformity may develop if hematoma
This technique provides compression to prevent recurrence. formation is not well controlled over the cartilage of the ear. The
hematoma may become fibrosed and result in a thickened ear,
known as a cauliflower ear. Placement of compression sutures
eliminates dead space and prevents recurrence.
glasses is the most common method used, although

some prostheses are held with glue to the skin margins.101
The disadvantages with gluing are that the glue may not results by eliminating dead space and preventing recur-
tolerate sweat or oils, and allergic skin reactions are pos- rence. This technique uses a small incision over the
sible. Retention and good fit with an eyeglass-supported hematoma, with decompression and primary skin closure.
prosthesis are also difficult to achieve. With the develop- Horizontal mattress sutures are then passed through the
ment of osteointegrated implants and techniques for entire thickness of the ear overlying the area of hema-
placement of the implants in the mastoid region, zygo- toma formation. These sutures should incorporate a
matic buttress, and other supporting bone, prosthetic small bolster dressing on either side of the ear (see Fig.
devices can be anchored to replace missing external ears, 21-31). Usually, two to three sutures of this type are neces-
orbits, and noses.137 sary. A precise head dressing with moist gauze or heavy-
Sometimes, the skin of the external ear is lost but the bodied impression material is molded into the ear
cartilage is preserved. If only a small defect exists or if interstices. Dry cotton gauze or fluffs are placed over the
the perichondrium still covers the cartilage, a skin graft pinna and between the external ear and mastoid region.
should be used to cover the defect.140 A good donor site Finally, a soft gauze bandage is firmly wrapped around
is the retroauricular skin of the contralateral ear. When the patient’s head. The head dressing is removed in 2 to
the perichondrium is missing, the best treatment is cov- 3 days and the tie-through dressing and sutures are
erage with a retroauricular skin flap.136 removed in 7 to 10 days.141-143
Hematomas of the ear should be aspirated with a fine Anesthesia of the auricle is achieved with a solution of
needle or small incisions in dependent drainage areas. 1% lidocaine or 2% bupivacaine , without vasoconstric-
A hematoma that is not removed may become fibrosed tor, injected subcutaneously at the base of the auricle to
and cause a thickened ear, known as a cauliflower ear. block the nerves providing sensation to the external ear.
Dressings are extremely important and should be These nerves consist of the auriculotemporal branch of
molded to the shape of the ear to support the ear and the mandibular nerve, lesser occipital nerve, great auric-
provide gentle pressure to prevent recurrence of the ular nerve, and auricular branch of the vagus nerve
hematoma140 (Fig. 21-31). One technique is to place (Arnold’s nerve; Fig. 21-33).
cotton balls soaked in antibiotic solution along the area Exposed cartilage presents a special problem. Peri-
involved. A mixture of rubber base or silicone impres- chondritis may develop and, if left untreated, necrosis of
sion material is pressed into the ear, with a cotton ball in the cartilage may occur. For this reason, conservative
place to protect the external auditory meatus. The mate- débridement of devitalized tissue and complete coverage
rial is allowed to set and acts as an excellent compressive of all cartilage with skin are indicated, if possible.
bandage. The dressing should be left in place for 5 to
7 days. NOSE
Otohematoma is one of the more common injuries of The nose is the most prominent structure on the face
the external ear. A significant deformity may result from and is commonly traumatized. Many injuries result in
improper initial management (Fig. 21-32). Many initial fractures to the bony structure, with or without soft tissue
treatments, such as needle aspiration or simple incision, involvement. As in the treatment of any bone fractures,
tend to be unsuccessful and require several attempts the underlying bones must be repaired before soft tissue
because of the reaccumulation of fluid despite meticu- wounds are closed. The bone and cartilage substructure
lous dressing application. Fibrosis and new haphazard of the external nose are covered by muscle, subcutane-
cartilage may develop if the hematoma is not completely ous tissue, and skin and have an internal lining of mucous
drained. Simple compression sutures yield superior membranes and glandular structures. Like other
Auriculotemporal a mucosal flap should be designed to cover the area, at

nerve least on one side.144
Lacerations of the skin of the nose should be closed
after inspection and débridement with 6-0 nylon or other
nonabsorbable sutures. Partial avulsions and through
and through lacerations should be closed by suturing the
mucosal layer with fine absorbable sutures, placing the
knots so that they are in the nasal cavity. Key sutures
should be used to align landmarks to ensure proper
orientation, especially about the nasal rim. Repair should
then continue with approximation of the cartilage with
5-0 chromic sutures and closure of the skin with 6-0 nylon
X X sutures. Because of the thick sebaceous skin over the
nasal tip and high content of bacteria, suture abscesses
X X
are common and the skin is prone to developing scars.5,144
Sutures should be removed after 4 days and reinforced
Lesser
occipital
with adhesive strips (Fig. 21-35).
nerve Avulsive wounds of the nose may require skin grafts.
Skin grafts are ideally done with full-thickness postauricu-
lar grafts, which give the best possible match of color and
Greater texture. Split-thickness skin grafts can be used if neces-
auricular sary and are best obtained from exposed body areas, such
nerve as the neck or forearm.13 Davis and Shaheen19 noted that
almost 50% of composite grafts will fail even in ideal
FIGURE 21-33 Ear block. The dots are the site of needle conditions; these grafts should be used only if the follow-
placement. A suggested trajectory for the needle (arrows) is ing conditions apply:
shown for placing the anesthetic in relation to the major nerves 1. The wound edges are cleanly cut and viable.
that innervate the ear. This method will not anesthetize the 2. There is no prospect of infection.
external canal adequately and must be augmented (X) if it is 3. Primary repair is not delayed.
necessary to include this area. 4. No part of the graft is more than 0.5 cm from the
cut edge of the wound.
5. All bleeding is controlled.
Abscess formation in the nasal septum is rare. If an
infection develops, it is usually from S. aureus invasion of
structures on the face, the entire nose has an excellent a nasal septal hematoma following nasal trauma. Both
blood supply and most lacerations, wounds, and incisions hematoma and nasal septal abscess formation can lead
of the skin of the nose heal readily and rapidly.144 Exami- to cartilage destruction, with severe functional and cos-
nation of the internal nose requires a nasal speculum, metic sequelae, consisting of septal deformity, perfora-
excellent lighting, and suction. Anesthesia with a 4% or tion, and saddle nose deformity. A hematoma of the
10% cocaine solution and lidocaine with epinephrine nasal septum will separate the mucoperichondrial blood
may be necessary for an adequate examination. The supply from the septal cartilage. Cartilage necrosis results
mucosa is inspected for evidence of lacerations, and within 3 days from ischemia and pressure but can rapidly
exposure of the cartilage is noted (Fig. 21-34). The septal occur with abscess formation within 24 hours.146-148 Poten-
cartilage should be evaluated for displacement, buckling, tially life-threatening complications from the spread of
and possible fracture. The septum must be assessed for infection include osteomyelitis, orbital and intracranial
the presence of hematoma, which would appear as a abscesses, meningitis, and cavernous sinus thrombosis.
boggy blue elevation of the mucosa.145 Once diagnosed, The typical clinical presentation includes nasal
a septal hematoma should be evacuated through small obstruction from a tender swelling of the anterior nasal
mucosal incisions or by needle aspiration. A running 4-0 septum. When two applicator sticks are pushed against
chromic suture is placed through and through the the septum bilaterally, the septum should feel firm. If a
septum to prevent recurrence.136 If untreated, the septal hematoma is present, a soft fluctuant consistency will be
hematoma may become infected and septic necrosis of noted. Prompt drainage of a nasal septal hematoma not
the cartilage is possible. With destruction and collapse of only prevents abscess formation but also prevents carti-
the septum, the nose loses its supporting framework, lage destruction that can occur even without infection.
resulting in retraction of the columella and saddling of Drainage and antibiotic therapy minimize the damage
the middle third. The septum may also become thick caused by a septal hematoma, but treatment does not
secondary to subperichondrial fibrosis.13 reverse the damage to the cartilage. Needle aspiration or
Mucosal tears may be associated with bone fractures staggered incisions are made bilaterally in a dependent
or penetrating objects. Suturing should be attempted location to prevent septal perforation. Penrose drains,
with thin absorbable sutures. Exposed septal cartilage nasal packing, or both, are used to prevent the reaccu-
does not pose any difficulty as long as the mucosa is intact mulation of blood or pus. An alternative is application of
on the other side of the septum. If the cartilage is divided, a septal stent that consists of two pieces of Silastic
A
B
D
FIGURE 21-34 A, An injury to the nose with a large laceration through the skin and mucosal tissue. B, The mucosal tears were repaired
with thin absorbable sutures. Exposed septal cartilage does not pose any difficulty as long as the mucosa is intact on the other side
of the septum. If the cartilage is divided, a mucosal flap should be designed to cover the area at least on one side. C, The lacerations
of the skin of the nose were closed after inspection and débridement with 6-0 sutures and a splint placed to prevent hematoma
formation (D).
A B
C D
FIGURE 21-35
For legend see opposite page
E F
FIGURE 21-35 , cont’d A-D, Through and through lacerations should be closed by suturing the mucosal layer with fine absorbable
sutures, placing the knots so that they are in the nasal cavity. Key sutures should be used to align landmarks to ensure proper
orientation, especially about the nasal rim. Repair should then continue with approximation of the cartilage with 5-0 chromic sutures and
closure of the skin with 6-0 nylon sutures. Because of the thick sebaceous skin over the nasal tip and high content of bacteria, suture
abscesses are common and the skin is prone to developing scars. Sutures should be removed after 4 days and reinforced with adhesive
strips. E, F, Fracture of the nasal bones with concomitant laceration. The nasal fractures were reduced, the nose was packed, and the
laceration was closed in layers.
Infratrochlear
nerve
External
nasal
nerve
Infraorbital
nerve
FIGURE 21-36 Field block of the nose. The sites of needle insertion (dots) and line of infiltration (arrows) are shown in relation to the
sensory nerves of the face.
material placed bilaterally against the septal wall. These lidocaine and phenylephrine (Neo-Synephrine) soaked
stents are secured by large, trans-septal Prolene sutures in cotton rolls, which are packed into the nares bilaterally.
passed through both Silastic stents and septum in a hori- Next, 1% to 2% lidocaine in 1 : 100,000 epinephrine is
zontal mattress fashion. Stents may be combined with injected bilaterally at the nasal bridge to block external
nasal packing and removed in 7 to 10 days.147,149 branches of the anterior ethmoid and supratrochlear
Anesthesia (Fig. 21-36) may be achieved with 10% nerves. Infiltration with lidocaine or bupivacaine at the
cocaine in 1 : 10,000 epinephrine or a 1 : 1 mixture of 4% vestibule, ala, and floor of the nose will block external
Posterior
lateral nasal
branches of
Anterior lateral nasal branch sphenopalatine
External nasal branch artery
of anterior ethmoidal Anterior septal branch
Sphenopalatine
artery artery
Posterior septal branch of

sphenopalatine artery
Alar branches of
lateral nasal
branch
(of facial artery)
Maxillary
artery Nasal septal branch
of superior labial
External carotid branch (of facial
artery artery)
Lesser palatine foramen and artery
Greater palatine foramen and artery

Lateral wall of nasal cavity
FIGURE 21-37 Blood supply to the lateral nasal complex. (Netter illustration from www.netterimages.com; © Elsevier Inc. All rights reserved.)
nasal branches of the infraorbital nerve. A standard infra- excessive cautery on both sides of the nasal septum
orbital nerve block is also beneficial. Avoid solutions with because septal perforation or exposure of the cartilage
vasoconstrictors injected near the septal cartilage so as may result. Cauterization with silver nitrate and packing
not to compromise the blood supply.150 Any intranasal usually stops most anterior nosebleeds. Placement of an
mucosal laceration should be repaired and the nasal anterior nasal pack, an 8.0-cm Merocel or 10-cm Pope
cavity packed to assist in preventing any post-traumatic nasal pack, may be useful if the bleeding persists. The
nasal adhesions. Lacerations involving skin overlying the most common method of anterior nasal packing is per-
nose are common. Superficial lacerations can be treated formed by the insertion of 0.5-inch petroleum jelly (Vase-
with adhesive tape to prevent suture marks. Deeper lac- line) gauze soaked in antibiotic ointment in a layered
erations require layered closure. Cartilage does not always manner (Fig. 21-38). Careful packing will allow tampon-
require suture repair, but if it is unstable or has to be ade of the bleeding areas. This packing can be left in
aligned, a fine absorbable suture, such as 5-0 fast-absorbing place for 2 to 5 days; the patient should receive broad-
gut suture, is recommended. Use of a limited number of spectrum antibiotic coverage.
sutures in cartilage is desirable. Skin sutures should be If the patient has a posterior nosebleed, these efforts
removed from the nose in 3 to 5 days and adhesive tape will be useless. The most practical definition of a poste-
should be used to maximize the cosmetic result. rior nosebleed is epistaxis that cannot be treated with an
Nasal bleeding from trauma usually stops spontane- anterior nasal pack. Inspection of the posterior pharynx
ously without requiring therapeutic intervention. On often reveals bright red blood that the patient may be
rare occasions, treatment may be necessary. Anterior epi- coughing up frequently. Posterior nasal packing is then
staxis is more common than posterior nosebleed and indicated. There are several methods for packing a pos-
usually involves hemorrhage from Kiesselbach’s area, terior nosebleed. A reliable method uses a Foley catheter.
also referred to as Little’s area (Fig. 21-37). Packing this First, the nose is adequately anesthetized. As described
area with cotton soaked in phenylephrine and 4% lido- earlier, the patient is sedated with an IV agent. Next, a
caine will provide hemostasis and some topical anesthe- Foley catheter is inserted into the offending naris until
sia, and often will be effective. A nasal speculum should it is seen in the oropharynx. Approximately 10 mL of
be used to visualize the areas of bleeding that persist and sterile water or normal saline is used to inflate the cuff
have to be cauterized. When using electrocautery or of the Foley catheter, with firm tension applied on the
silver nitrate, caution must be exercised to avoid catheter to secure it in the posterior nasopharynx. Next,
A B
FIGURE 21-38 Correct technique for

anterior packing of the nose. A, The
gauze is gripped 4 to 6 cm from the
end. B, The first layer is placed along
the floor of the nose. C, D, Subsequent
layering of the gauze packing. (From
Roberts J, Hedges J: Clinical
procedures in emergency medicine, ed
5, Saunders, Philadelphia, 2010.) C D
B
FIGURE 21-39 The Foley catheter is an effective tool used in the management of posterior epistaxis. A, It is placed in the nares and
inflated to tamponade the posterior nasopharynx. The nose is then packed with gauze in a layered manner to provide adequate
hemostasis. B, Another alternative is a commercially available packing device in which posterior and anterior balloons are used to pack
a posterior nosebleed. (From Roberts J, Hedges J: Clinical procedures in emergency medicine, ed 5, Saunders, Philadelphia, 2010.)
0.5-inch petroleum jelly gauze is packed into the naris Minneapolis]). This double-balloon tampon is placed
around the catheter. In the contralateral naris, 0.5-inch along the floor of the nasal cavity and a smaller posterior
petroleum jelly gauze is packed to prevent septal trauma. balloon is inflated with saline to occlude the nasopharynx.
An umbilical clamp is then used to secure the catheter The larger anterior balloon is then inflated to create pres-
in the desired position by applying it at the level of the sure to control hemostasis (see Fig. 24-39B). Although
entrance of the catheter into the nose (Fig. 21-39A). patients may find this method more uncomfortable, it is
The patient should be given IV antibiotics and neces- useful when emergent control of hemorrhage is
sary pain medication after admission. The balloon on the necessary.151
catheter may be decompressed in 3 days, allowing for
assessment of hemorrhage. If successful hemostasis has EYEBROW
been attained, the Foley catheter and packing can be Reconstruction of the eyebrow is extremely difficult and
removed before patient discharge. Another common transplants to the eyebrows are not always cosmetically
method of posterior nasal packing is achieved with a satisfying100 (Fig. 21-40). Therefore, efforts to repair eye-
silicone dual-cuffed catheter (Epistat [Medtronic, brows without resultant distortion or defects are
C
FIGURE 21-40 A-C, The eyebrow is maintained and the laceration is closed in an interrupted fashion, with good cosmetic result.
important. The eyebrow should not be shaved but should to assess for global injury and defects in vision. Even if
be lightly clipped if necessary to assist the surgeon in no defects are initially apparent, early baseline records
proper alignment of the eyebrow. The wound should be are necessary.
inspected and underlying fractures of the frontal sinus As in any surgical procedure, a detailed understand-
or supraorbital rim repaired before closure. As little ing of the anatomy of the region is necessary to assist in
tissue as possible should be removed and sutured into the proper repair of traumatic injuries to the eyelids. In
place. If nonvital tissue must be removed, incisions order, from the skin to the conjunctival layer, the eyelids
should be made parallel to the hair follicles to injure as are composed of the skin, alveolar tissue, orbicularis
few as possible. Special care should also be taken to avoid oculi muscle, tarsus, septum orbitale, tarsal (meibomian)
tight constricting sutures in the area, because hair folli- glands, and conjunctiva.153 The lid margin is formed by
cles are sensitive to decreases in blood flow.5,145 the junction of the skin and mucous membrane and is
The muscular layer should be closed with fine absorb- delineated by a gray line. The superior tarsus is of a
able sutures to prevent spreading of the tissue and scar semilunar shape to conform to the configuration of the
formation. The skin should be approximated with 6-0 globe; it assists in keeping the conjunctival mucosa intact
nylon sutures. Vertical displacements that may develop with the cornea. The tarsal plates are long thin plates of
can usually be corrected with a Z-plasty procedure, and connective tissue that also aid in maintaining the form
horizontal displacements can be corrected with scar revi- and support of the eyelid.154
sion and realignment of the parts. These procedures The levator muscle inserts into the skin of the upper
should be performed 6 to 12 months following the acci- lid and upper margin of the tarsus and is responsible for
dent, after the scar tissue has softened.152 elevation of the upper lid (Fig. 21-41). The muscular
layer over the tarsus is also anchored to the medial and
EYELID lateral aspects of the orbit by the medial and lateral
In the treatment of injuries to the eyelid, it is important canthal ligaments. The orbital septum is peripheral to
to restore not only the appearance of the individual but the tarsus and forms a fibrous sheet attached to the peri-
also, and more importantly, the vital function of the osteum about the circumference of the orbital rim. The
structure. The major function of the eyelid is to protect septum maintains the orbital contents in the proper
the globe and prevent drying of the cornea and adjacent position.153,154
tissue. Eyelids aid in removal of tears through the cana- Lacerations of the eyelids can be divided into two
licular system. With any type of injury to the orbit, eyelids, categories, wounds that involve the lid margin and those
and globe, an ophthalmology consultation is mandatory that do not. Simple lacerations that do not involve the
A B
C D
FIGURE 21-41 A, B, Injury to the upper eyelid. Disruption of the upper lid margin disrupts the superior tarsal plates, which are long thin
plates of connective tissue that also aid in maintaining the form and support of the eyelid. The levator muscle inserts into the skin of the
upper lid and the upper margin of the tarsus and is responsible for elevation of the upper lid. C, D, Lacerations of the upper eyelid must
be explored to identify damage to the levator muscle. At the point at which the levator attaches to the superior portion of the tarsus, an
upper lid fold is normally created. If the fold is violated, it should be restored by repair of the muscle-tarsus junction and suture of the
subcutaneous layer to the deep structures. Sutures should be removed in 48 to 72 hours to prevent suture tracks of epithelium.
margin should be closed primarily. Following evaluation between the conjunctival mucosa and skin).136 Three 6-0
for possible injury to the orbit, globe, and punctal and nylon sutures should be placed at the marginal rim to
canalicular systems, débridement with minimum tissue align and properly orient these structures on either side
removal should be accomplished. Lacerations should be of the laceration. The sutures should not be tied. Fine
closed in layers, restoring the integrity and orientation absorbable sutures are placed to close the fascial border,
of the skin, muscle, tarsal, and conjunctival layers. Deep but no other deep sutures are placed because of the risk
sutures are not recommended in the lower eyelid because of ectropion in the lower lid. A slight eversion of the lid
the orbital septum may be inadvertently sutured, creat- margin must be obtained with the marginal sutures to
ing a cicatricial ectropion as the wound heals.136 Lacera- allow for wound contraction of the lid margin. The trans-
tions of the upper eyelid must be explored to identify marginal sutures at the gray line and lash line are left
damage to the levator muscle. At the point at which the long and are secured to the skin surface to prevent
levator attaches to the superior portion of the tarsus, an corneal abrasion.153
upper lid fold is normally created. If the fold is violated, Avulsive injuries to the eyelids are treated with full-
it should be restored by repair of the muscle-tarsus junc- thickness skin grafts from the postauricular region or the
tion and suture of the subcutaneous layer to the deep other upper eyelid.154 With avulsive injuries of the lid
structures. Sutures should be removed in 48 to 72 hours margins, carefully placed pedicled tissue will usually be
to prevent suture tracks of epithelium.153 maintained because of the excellent blood supply in the
Marginal lacerations must be repaired carefully and region. Full-thickness eyelid avulsions of less than 25%
accurately to prevent functional and cosmetic defects. of the lid length can be approximated primarily as a
The most common identifiable structures are the lash simple laceration.5 Lateral canthotomy to dissect the skin
line, meibomian gland orifices, and gray line (junction and conjunctiva free from the lateral canthal tendon,
Facial nerve Temporal

temporofacial branch
division
Zygomatic
branch
Posterior
auricular nerve
Buccal
branches
Facial nerve
cervicofacial
division Parotid
duct
Parotid gland Marginal

mandibular
branches
Nerve to
digastric and
stylohyoid Cervical
muscles branch
FIGURE 21-42 Lacerations to the parotid duct frequently damage the buccal branch of the facial nerve because of the close
approximation of the two structures.
free all structures between the conjunctiva and the skin, The patient should be instructed to look up and down,
and allow for release of horizontal tension can be used. because this maneuver will aid in identification of the
Ordinarily, 5 to 10 mm may be gained in lid length in structure. The aponeurosis should be reapproximated to
the horizontal direction.153 Larger defects require grafts the distal cut edge or tarsal plate with interrupted 5-0
or flaps, such as an Abbe-type rotational flap from the Vicryl sutures in a horizontal mattress fashion. Lacerated
unaffected eyelid.136 skin edges are then reapproximated with 7-0 nylon or 6-0
Injuries to the conjunctiva require no treatment if fast-absorbing gut sutures. No attempt should be made
they are small. Large lacerations or punctures may to close the orbital septum.
require fine absorbable sutures to control the tissue.
Corneal abrasions are commonly associated with facial
trauma. Pain and irritation of the injured eye with a ORAL MUCOSA AND TONGUE
sensation of a foreign body present in the eye are Lacerations of the oral mucosa and tongue should be
common complaints. Fluorescein dye testing and slit- inspected, especially for pieces of teeth or restorations,
lamp examination will confirm the damage to the and débrided as for other wounds. The wounds should
cornea. Treatment with cycloplegics, ophthalmic antibiotic be thoroughly irrigated with normal saline and sutured
ointments that do not contain corticosteroids, and patch- loosely. Mucosal wounds should be sutured with 3-0 or
ing usually relieves discomfort while the injury heals. 4-0 chromic gut suture. Deep lacerations should be
Because of rare but devastating infections (e.g., Pseudo- closed in layers, with chromic gut sutures in the muscle
monas), patients with corneal abrasions should be referred layers to prevent formation of a hematoma. The tongue
to an ophthalmologist within 24 hours. should be closed in layers, with 4-0 Vicryl (dyed) sutures
Povidone-iodine (Betadine) solutions should be used in the superficial layers.
to prepare the wound for closure of lid lacerations. The tongue has a rich blood supply and injuries to the
Tissue débridement is discouraged. The use of 6-0 silk or tongue or the floor of the mouth may cause serious hem-
fast-absorbing 6-0 gut sutures at the lid margin and skin orrhage that could threatens the airway. The airway may
and 7-0 Vicryl interrupted sutures at the tarsal plate is become compromised some time after trauma to the
recommended.155 A transverse laceration of the upper tongue or lacerations of the floor of the mouth if veins
lid may completely sever the levator aponeurosis and are damaged, resulting in swelling of the tongue into the
Müller’s muscle from their attachments to the tarsal oropharynx.108,110
plate. A profound ptosis with minimal levator function
will appear. The wound has to be inspected with the SALIVARY GLANDS AND DUCTS
patient under local anesthesia; in most patients, the With injuries to the parotid area, an understanding of
orbital septum has also been violated. If it has not, the the anatomy is essential to proper treatment (Figs. 21-42
septum should be incised and orbital fat allowed to pro- and 21-43). The facial nerve exits the stylomastoid
lapse forward. Proper identification of orbital fat is foramen, where it divides into five branches within the
important for establishing a landmark. The fat is retracted substance of the gland. The temporal and zygomatic
superiorly and the underlying aponeurosis identified. branches run over the zygomatic arch, the buccal branch
A
B
A B
C D
FIGURE 21-43 The parotid duct is typically found along the plane from the tragus of the ear to the middle of the upper lip.
courses over the superficial aspect of the masseter muscle disfigurement. A rich anastomotic network of the
along with the parotid duct, the mandibular branch branches of the nerve allows frequent return of function
crosses superficially to the facial vessels at the angle of in this area. Repair of the forehead and mandibular
the mandible, and the cervical branch runs down the branches should be considered because cross innerva-
neck. The parotid gland is a single-lobed gland, with tion in these areas is less predictable.
superficial and deep portions of the gland determined Injuries to the parotid or submandibular gland should
by their relationship with the seventh cranial nerve. The be evaluated and repaired, if possible. Injuries to the
superficial part of the gland is lateral to the facial nerve parotid or submandibular ducts must also be assessed. If
and extends anteriorly to the border of the masseter the duct has been transected, repair around a thin poly-
muscle. The deep portion, which comprises approxi- ethylene tube is necessary. From the anterior border of
mately 20% of the gland, lies medial to the nerve in the the gland, the parotid duct extends forward approxi-
retromandibular fossa. The parotid duct exits the gland mately 1 cm below the zygoma. The location of the duct
anteriorly, runs along the superficial portion of the mason the face may be visualized as the middle third of a
seter muscle, and penetrates the buccinator to enter the line from the tragus of the ear to the middle of the upper
oral cavity opposite the upper second molar. The pres- lip. The duct is approximately 4 to 6 cm in length and
ence of multiple structures in such a small region explains 5 mm in diameter. The parotid (Stensen) duct runs
the high morbidity associated with these injuries. Treat- transversely through the buccinator muscle to empty into
ment of a parotid duct injury depends on the site of the the oral cavity at the buccal mucosa, directly across from
injury. If the injury is anterior to the masseter and the the maxillary second molar. Lacerations involving the
distal portion of the duct cannot be located, the duct parotid duct frequently damage the buccal branch of the
may be drained directly into the mouth. If the injury is facial nerve because of close approximation of the two
over the masseter muscle, the distal and proximal por- structures.
tions may be connected using a stent. If the injury is When the parotid duct has been lacerated, both ends
within the parotid gland, treatment should include of the duct must be located and sutured together. The
closure of the parotid capsule and application of a pres- distal portion of the severed duct is usually located first
sure dressing. by placing a lacrimal duct probe or polyethylene cannula
Injuries distal to the parotid gland and medial to the through the Stensen’s duct orifice in the mucosal wall of
lateral canthus of the eye rarely result in severe the oral cavity, just lateral to the second maxillary molar,
and passing the probe through the laceration site. The develops and allows the duct to drain. Scarring with
proximal segment can then be located by expressing obstruction of the duct may eventually require reestab-
saliva from the parotid gland. A Silastic catheter should lishment of the duct opening. Chronic obstruction or
be placed through the severed segments and repair inflammation is usually best treated with removal of the
should be made over the catheter. The repair should be submandibular gland.
done with 6-0 nylon interrupted sutures. Approximately
2 cm of stent should extend from the orifice, and the LACRIMAL APPARATUS
stent should be secured to the oral mucosa with one or Tears produced by the lacrimal gland drain across the
two nonabsorbable sutures. The Silastic stent should surface of the cornea to the medial portion of the eye,
remain in place for 5 to 7 days and the patient should be where they enter the puncta of the upper and lower lid
given sialagogues, such as lemon drops, to prevent scar margins and proceed to the canaliculi in the nasolacri-
formation at the anastomosis site.19,136 mal apparatus. The tears then drain into the inferior
After repair of the duct, the overlying soft tissue is meatus of the nose. More than 50% of the tear drainage
closed in layers to prevent formation of a fistulous tract volume is normally evacuated through the inferior
and a sialocele. If a sialocele does form, it should be canaliculus; when this pathway is traumatically inter-
treated with aspiration and a pressure dressing over the rupted, it is important that it be repaired, when possible
area to eliminate fluid collection. (Fig. 21-44).
A swelling over the course of the duct that slowly Any lacerations of the medial third of the lower lid
increases in size after trauma to the area may be sugges- should immediately raise the suspicion of injury to the
tive of an injury to the duct that was not detected during inferior canaliculus. Establishing hemostasis of the lac-
the initial examination. If the diagnosis is made within eration is mandatory for finding the injury. The canalicu-
48 hours of the injury, an exploratory operation with lus is a fairly large white-walled tube and may be located
repair is indicated.19 With injury to the salivary ductal by placing a lacrimal duct probe through the punctum
system, prophylactic antibiotics, such as penicillin or and into the wound. The canaliculus begins at the
cephalothin, should be used.136 punctum and proceeds perpendicular to the eyelid
The submandibular duct runs laterally and superiorly margin for approximately 2 mm and then turns medially
from the gland to its orifice in the oral cavity behind the and proceeds to the nasolacrimal apparatus. Magnifying
mandibular incisors. The mandibular duct is approxi- loupes of 2× or 3× power should be available to help
mately 5 cm long and courses near the lingual nerve locate the lacerated ends of the canaliculus. Another
before the nerve enters the tongue. A small polyethylene method of locating the lacerated canaliculus is to infil-
catheter is placed in the orifice and through the distal trate the upper canaliculus with air and instill sterile
segment. The proximal segment is located by massage of water or saline solution into the laceration line, allowing
the gland, so that saliva from the transected duct is the liquid to pool. Air will pass through the canalicular
found. The catheter is then advanced into the proximal apparatus and bubble through the saline or water, dem-
segment. Several 4-0 chromic sutures should be placed onstrating the site of the laceration.
to secure the transected ends of the duct about the cath-
eter. The catheter should then be cut in the oral cavity
and secured to the mucosal tissue by sutures. The cath-
eter should remain in place for 5 to 7 days and removed
Lacrimal gland Superior lacrimal
only after ensuring that the duct will remain patent punctum
without the catheter. Lacrimal sac
Lacerations of the parotid gland that occur without
major ductal lacerations do not require any special treat-
ment, other than the routine management and repair of
the soft tissue injury. Drain placement, however, may be
necessary. Permanent fistulas are rare in parotid glandu-
lar lacerations in the absence of major duct involvement.
Lacerations of the gland frequently result in delayed
fluid accumulation, even after drain removal, and the Inferior lacrimal
fluid collection may be treated with intermittent aspira- punctum
tion, compression, and reinsertion of a drain.156,157 Nasolacrimal
If the parotid duct cannot be repaired after traumatic duct
laceration, several treatment choices are available. Liga-
tion of the duct is an option that will produce a tempo-
rary swelling and may develop as a chronic source of
infection. If possible, the proximal duct stump should be Inferior meatus
mobilized and diverted into the mouth in the orophar- and turbinate
ynx. Irradiation of the gland to destroy its function is a
last resort. All these options are less desirable than
primary repair.
Repair of a lacerated submandibular duct is usually
unnecessary because a fistula into the mouth usually FIGURE 21-44 Anatomy of the nasolacrimal system.
When lacerated ends of the canaliculus have been layers are skin (S), subcutaneous tissue (C), aponeurosis
located, they can be repaired using a Veirs stainless steel layer (A), loose subepicranial space (L), and pericranial
rod wedged onto black silk. The rod is passed through layer (P).32
the punctum into the laceration site and then into the The thickness of the epidermis and dermis of the scalp
medial portion of the canaliculus to align the cut ends. varies from 4 to 8 mm, so the scalp is one of the thicker
The laceration is stabilized with small chromic gut sutures regions of the body; only the back, soles, and palms are
and the rod is left in place for 4 to 6 weeks. The free end
of the silk material of the Veirs rod is tied into place to
help stabilize the rod and is used to retrieve it at the time Scalp vessels and nerves
of removal.
Through and through margin injuries to the eyelid Supratrochlear nerve Supratrochlear artery
must be repaired in at least three layers to prevent notch- CN V1
ing as healing progresses. The deep layer contains the Supraorbital nerve Supraorbital artery
conjunctiva and tarsus and should be closed with 4-0 or
5-0 chromic gut interrupted sutures; the knots should be Zygomaticotemporal Superficial
tied into the wound so that they do not irritate the nerve (CN V2) temporal artery
cornea. The middle layer is the orbicularis oculi muscle,
which is closed with interrupted 5-0 chromic gut sutures, Auriculotemporal
and then the skin is finally closed. Great care should be nerve (CN V3)
taken to approximate the tarsus and ciliary margin accu-
rately. Once these structures have been sutured, the
remainder of the eyelid can generally be properly
repaired without difficulty. Any laceration involving the
medial portion of the upper or lower eyelid should be
presumed to involve the lacrimal canaliculi until proved
otherwise. Because the dense fibrous tissue of the tarsal Lesser occipital
plate is notably stronger than the medial canthal tendon, nerve (C2)
an avulsing force placed anywhere along the lid margin Posterior
Greater occipital auricular
will preferentially tear the medial soft tissue, causing dis- nerve (C2, C3) artery
ruption of the lacrimal apparatus.
Third occipital Occipital
SCALP nerve (C3) artery
The scalp and forehead are portions of the same highly
vascularized anatomic unit responsible for protection of FIGURE 21-45 Approximate location of the arteries and sensory
the skull (Fig. 21-45). They consist of five layers, which nerves that course through the dense connective tissue layer of
can best be remembered by the mnemonic SCALP (Fig. the scalp. (From Ellis H: Anatomy of head injury. Surgery (Oxford)
21-46). In order, from the skin to the cranial bone, the 25:505, 2007.)
Connective tissue (dense) Skin

Aponeurotic
layer
S
C
Skin Dense connective tissue Aponeurotic layer
A
Pericranium
Bone Pericranium Loose connective tissue
Loose connective
tissue
FIGURE 21-46 The layers of the scalp can be remembered by the mnemonic SCALP: Skin, Connective tissue, Aponeurotic layer, Loose
connective tissue, and Periosteal or Pericranial layer. (From Aehlert BJ: Paramedic practice today, St. Louis, 2009, Elsevier.)
thicker.32 The subcutaneous layer has many large vessels

that anastomose freely. Because this layer is so inelastic,
the blood vessels minimally contract when severed and
tend to bleed easily. Thus, large amounts of blood can
quickly be lost.99
The aponeurosis layer consists of the galea aponeuro-
tica, which connects the paired occipital muscles and
paired frontal muscles. The galea is a tough inelastic
tissue that is attached firmly to the skin and subcutaneous
layers and moves freely over the subepicranial space
below.19 The subepicranial space lies between the galea
aponeurotica and pericranium. It is traversed by small
arteries and emissary veins connecting the scalp veins A
with the venous sinuses of the skull. Infections and
thrombosis in this layer may be passed to the cranium or
sinuses via these vessels.32
The pericranium is very vascular and can be easily
stripped from the cranium. The pericranium will accept
a free graft readily because of its excellent vascularity.
The outer table of the skull will not accept a free graft,
so the pericranium is therefore extremely important in
any avulsive injury to the scalp.19 Avulsed scalp flaps are
replaced if the tissue is not badly damaged, and most
survive. Free graft survival depends on the presence of
the pericranium over the skull.
Injuries to the scalp should be evaluated for possible B
accompanying skull fractures and intracranial trauma. A
simple laceration should be treated like other lacerations FIGURE 21-47 A, B, Oblique laceration through the scalp on the
forehead, with the pericranium intact. The laceration is closed
on the face, with evaluation, hemostasis, débridement,
primarily in layers.
and primary closure. It is unnecessary to shave the hair
from the region, but scissors should be used to trim the
hair in the area around the laceration. Closure is easy if closure with flap procedures is indicated.19 The flap pro-
the scalp defect is less than 2.5 cm wide. If larger defects cedures used with scalp defects include advancement
are encountered, flaps should be used. (Fig. 21-47).116 flaps, transpositional flaps, rotation-advancement flaps,
With avulsion of the skin of the scalp, the examiner and microvascular free scalp flaps.13,99
must not only carefully ascertain the status of the peri-
cranium, but also look for evidence of fractures of the Hair Apposition Technique
cranium. As with other avulsive defects of the face, A technique of treating scalp lacerations has been termed
healing by secondary granulation must be prevented the hair apposition technique (HAT).158 After standard
because of the cosmetic and functional defects that result cleaning and débridement, hair on both sides of a lacera-
from excess scar formation and contracture. The scalp tion is apposed with a single twist. It is then held into
offers unique challenges because the cranial bones position with tissue adhesives. Severely contaminated
depend on the pericranial tissue for their blood supply.32 wounds, actively bleeding wounds, and patients with hair
The scalp has an excellent blood supply in the subcutane- strands shorter than 3 cm may not be suitable for this
ous tissue and pericranial layers that support avulsed technique. In comparison with standard suturing,
tissue, skin grafts, and various flaps. patients were found to have less scarring, lower pain
If the pericranial tissue is intact and the cranium has scores, shorter procedure times, less wound breakdown,
not been fractured, defects in the scalp that cannot be fewer overall complications, and greater satisfaction.159
closed primarily should be covered with a split-thickness The authors concluded that HAT is equally acceptable
skin graft. After stabilization and healing of the defect, and perhaps superior to standard suturing for closing
the area can be reconstructed by various advancement or suitable scalp lacerations. This procedure also avoids
rotational flaps to bring similar tissue into the defect, clipping or shaving of hair (to be avoided to limit infec-
with or without atraumatic tissue expansion. Tissue tion rate) to improve visualization and access for sutur-
expansion is an alternative for the closure of wound ing. However, in full-thickness wounds, only the superficial
defects because it provides donor tissue of the same margin of the skin may be apposed. There is potential
color, texture, and thickness, with minimal scar forma- for creation of dead space, which can increase complica-
tion and minor donor site morbidity.98 Tissue expansion tions such as infection and wound breakdown. Also,
involves developing donor tissue without depriving the there may be a temptation to avoid the use of local anes-
donor site of tissue. thetics, which may limit adequate cleaning and débride-
If the pericranium has been lost, the exposed cortical ment.160 In conclusion, in small superficial scalp wounds
cranial bone will not support a skin graft. When bone is in the appropriate clinical situation, the HAT technique
exposed in large avulsive injuries of the scalp, primary may be desirable.
A B C
FIGURE 21-48 A-C, Laceration involving the eyelid, cheek, and intraoral structures. The laceration is sutured from the inside out. Intraoral
closure should take place before the extraoral facial closure. The lacrimal apparatus is identified and repaired about a Silastic catheter.
Advancement Flaps transplant anastomosed to the superficial temporal artery

Advancement of the scalp into defect wounds is difficult and vein and covered with a free split-thickness skin graft,
because the galea aponeurotica is thick and not very and Ohmori has described the use of a microsurgical free
elastic and does not stretch under traction. The flap must scalp transfer, which permits the grafted scalp to have a
be widely undermined in the subepicranial space; mul- natural hair direction at the recipient site.21 Four types
tiple longitudinal incisions are made in the galea parallel of free flaps based on the superficial temporal, posterior
to the skin margin to facilitate closure of the defect. Split- auricular, and occipital vessels have been described.
thickness skin grafts should then be placed over the Reconstruction with microvascular free flaps is seldom
exposed pericranium. indicated in emergency situations.
If the pericranium has been destroyed and small scalp
Transpositional Flaps defects cannot be covered with local flaps, burr holes
Transpositional flaps involve the transfer of tissue from should be made through the outer table until pinpoint
one section to the defect, with acceptance of the fact that bleeding is found in the bone. A split-thickness skin graft
a secondary defect will be left in the donor area.19 The can be placed over the bleeding bone. If the grafted skin
donor area is usually in a less aesthetic region, such as is lost or the outer table of cranial bone undergoes
the occipital area of the head, and is covered with a skin necrosis, an osteotome or burr should be used to expose
graft. the diploe and a split-thickness skin graft should be
reapplied.21
Rotation-Advancement Flaps
A rotation-advancement of local flaps to cover defects is SCAR FORMATION
the treatment of choice when the pericranium has been
destroyed.21 To assist with stretching of the tissue, the Hypertrophic contracted scars are produced when
galea should be released with multiple incisions parallel inflammation is present in healing wounds (Figs. 21-48
to the longer axis of the flaps. Orticochea116 has devised a and 21-49). The main factors responsible for inflamma-
technique for closing cutaneous defects of the scalp with tion within wound surfaces are contamination, foreign
a three-flap procedure that mobilizes large flaps based on bodies, hematoma formation, crush injury, devitalized
the superficial temporal, occipital, posterior auricular, necrotic tissue, dead space, and operative trauma99
and supraorbital arteries, which supply blood to the (Table 21-6). Hypertrophic scars are often mistaken for
scalp.99 These studies described the cutaneous covering of keloids (Table 21-7). Because they are histologically
the skull and used five different applications of the three- indistinguishable, the clinical picture and medical
flap rotation-advancement technique for reconstruction history are the only clues to diagnosis. Keloids are true
of the forehead, right temporal region, left temporal benign tumors that extend into skin that was not
region, central region of the skull, and nape of the neck. involved in the original wound. Keloids are less common
than hypertrophic scars. They are the result of an over-
Microvascular Flaps active production of fibrous tissue during wound
In 1972, McLean and Buncke described a microsurgical healing, perhaps caused by increased tension around
reconstruction of a bare cranial defect with a free omental the wound margins. Keloids are defined as scars within
C
FIGURE 21-49 A-C, Significant laceration to the eyelid and cheek region. Careful débridement and examination must be done to identify
important structures such as the parotid duct and facial nerve. Structures must be repaired primarily and the wound closed in layers.
TABLE 21-6 Factors That Increase Scarring and Compromise Wound Healing
Contributing Factors Methods to Minimize Scarring

Direction of wound (i.e., perpendicular to lines of static and Layered closure; proper direction in elective incisions of
dynamic skin tension) wound
Infection necessitating removal of sutures, resulting in healing Proper wound preparation; irrigation, débridement, and use of
by secondary intention and a wide scar delayed closure in contraindicated wounds
Wide scar secondary to tension Layered closure; proper splinting and elevation
Suture marks Remove all pericuticular sutures within 7 days.
Uneven wound edges, resulting in magnification of shadows Careful, even approximation of scar by wound edges and top
layer closure to prevent differential swelling of edges
Inversion of wound edges Meticulous placement of sutures or use of horizontal mattress
sutures
Tattooing secondary to retained dirt or foreign body Proper wound preparation and débridement
Tissue necrosis Use of corner sutures on flaps, splinting, and elevation of
wounds with marginal circulation or venous return; excise
nonviable wound edges before closure
Compromised healing secondary to hematoma Use of proper conforming dressing and splints
Hyperpigmentation of scar or abraded skin Use of no. 15 or higher SPF sunblock for 6 mo
Superimposition of blood clots between healing wound edges Proper hemostasis and closure; H2O2 frequent swabbing;
proper application of compressive dressings
Failure to align anatomic structures properly, such vermilion Meticulous closure and alignment; marking as or placement of
border alignment suture before distortion of wound edges with local
anesthetic; use of field block
TABLE 21-7 Comparison of Abnormal Scar Formation
Keloid Hypertrophic Scar Widespread Scar

Genetics Significant familial Less familial incidence Not inherited
predilection
Race Blacks more than whites Less race-related Not ethnic
Sex Females more than males Equal gender ratio Unknown
Age Most common at Any, but mostly <20 yr Any age
10-30 yr of age
Borders Outgrows its boundaries Remains within wound Wide, flat, often depressed
boundaries
Natural history Months after injury, rarely Soon after injury, subsides Within 6 mo of injury
subsides with time
Location Mostly face, earlobe, Across flexor surfaces Arms, legs, and abdomen
anterior chest
Etiology Possible autoimmune Tension and timing of closure Tension and mobility of
phenomenon edges
Treatment Often worse after surgery Improves with correct surgery Scar excision or layered
and/or pressure closure
Adapted from Brody GS, Peng ST, Landel RF: The etiology of hypertrophic scar contracture: Another view. Plast Reconstr Surg 67:678, 1981.
the skin that grow beyond the confines of the original raised, and purplish because of the increased number
wound and tend to be darker than the normal skin, and size of capillaries, collagen, and fibroblasts. The final
whereas hypertrophic scars are raised scars that remain phase of wound repair, the maturation phase, involves
within the boundaries of the wound.90 Certain individu- resorption of excess collagen, decreased number of
als are predisposed to keloid formation and the patient fibroblasts, and a decrease in the number or size of capil-
usually can report a history of keloid formation. Keloids laries. This phase may last for 6 months to 2 years and,
occur more frequently in younger age groups in dark- during this phase, the scar contracts and widens and may
skinned individuals and in areas of thick skin rather undergo hypertrophy or form a keloid3,162-164 (Fig. 21-50).
than in areas in which the skin is thin. The incidence of Hypertrophic scars are usually self-limited and, over
keloids in dark-skinned persons is estimated to be 15 to time, soften, fade, and flatten. Scars should be revised
20 times that of light-skinned individuals. secondarily only after they have undergone maximal
An abnormality in melanocyte-stimulating hormone maturation for as long as 12 months.3,165 If a scar crosses
(MSH) may be responsible. Keloid growth is increased the favorable lines of tension lines that follow underlying
during puberty and pregnancy, when production of MSH muscle contraction on the face, tension on the skin
is increased. Infection may also promote the develop- wound margins will tend to pull the wound margins
ment of keloids at sites of skin injury. A family predisposi- apart. Poor operative technique is generally the cause of
tion is apparent; however, the exact cause of keloids is hypertrophic scars. Uneven closure of wounds, failure to
unknown. Patients who tend to form keloids usually close the wound in layers and relieve tension at the
produce reactions at other sites, such as vaccination sites. wound margin, and improper débridement and prepara-
Keloids generally form in areas of increased skin tension tion of the wound before closure all result in excessive
in individuals. scar formation.5
Approximately 12 hours following injury, epithelial In general, wounds that are within favorable lines on
migration begins. In primary closed wounds, complete the face heal without incident. If the scar is noticeable
epithelialization can occur within 48 hours. If wound and less than 2 cm in length, the scar tissue can usually
margins are open, secondary repair begins with migra- be totally excised and the wound simply closed primarily.
tion of epithelial cells from the margin. Epithelial cells If the scar is longer than 2 cm and is easily visible, the
will not cover necrotic tissue or highly inflamed tissue. scar line should be broken up from a straight line into
Epithelial cells can migrate from 1 to 3 cm, but closure multiple small segments to break the scar line visually
occurs after 5 to 7 days by the process of contracture of and alter the forces of tension on the wound margin to
the wound margins.161 limit contracture164 (Fig. 21-51). Broken line closure
The contracture of facial wounds should be prevented techniques include the W-plasty, zigzag-plasty, and
because the resultant scar usually leaves a considerable Z-plasty.3,21,99
functional and cosmetic defect. Wound contracture is The W-plasty involves excision of the scar tissue with
caused by fibroblasts that migrate to the wound margin multiple small triangles, with as many incisions made
from surrounding tissue and rapidly synthesize collagen within the favorable lines of tension as possible. The base
at the wound margin. Rapid collagen synthesis lasts 2 to and apex of the triangles should be perpendicular to the
4 weeks. The immature scar tissue is usually irregular, scar line. The incisions should also be made
A B
FIGURE 21-50 A, Dog bites to the head and neck region are common reasons for emergency room visits, and patients can have significant
injury to the soft tissue and also fractures of underlying bone and dentoalveolar structures. Proper antibiotic coverage and tetanus control
are important with animal bite wounds. The wounds should be thoroughly débrided and irrigated. Most laceration and tear wounds can be
closed primarily, but puncture-type wounds and wounds with excessive crushing of the tissue that requires considerable débridement
should be delayed for several days before definitive treatment. Wounds that have had significant crushing injury or heal by secondary
intention may develop significant scarring. B, 3 months following injury, the immature scar tissue is irregular, raised, and purplish because of
increased vascularity, collagen, and fibroblasts. Maturation of the scar may require 6 to 24 months as the scar softens, fades, and flattens.
Scars should be revised secondarily only after the tissue has undergone maximal maturation for as long as 12 months.
perpendicular to the skin to allow for even closure. The The Z-plasty should be used for scars that are more
wound margins should be undermined and meticulously than 40 degrees from the line of tension because the
closed in layers.99,164 technique can change the axis of the scar, relieve the
The zigzag-plasty gives better results for breaking up tension in the tissue of the area, and prevent linear scar
linear scars because of the more random nature of the contracture.99 The W-plasty and zigzag-plasty procedures,
scar line (Fig. 21-52). The zigzag-plasty consists of a series along with simple excision of small wounds, are indicated
of rectangles and squares between the triangles of the for scar revision of most facial wounds.164
W-plasty. The procedure requires more operative time Combination therapy of surgical excision of the scar
and technique but tends to camouflage the scar line tissue with corticosteroid injections and pressure dress-
better.164 The wound margins should be undermined and ings is the mainstay of successful treatment. Surgical exci-
closed meticulously in layers. sion with primary skin closure and no additional therapy
The Z-plasty was first described by Horner (1837) and results in recurrence in more than 50% of patients. With
further developed by Denonvilliers (1854) for correction the development of a hypertrophic or keloid scar, the
and alteration of scars to a more favorable position.99 It patient should be instructed to massage the scar at least
can alter the direction of scars across the lines of tension three to four times daily with a corticosteroid cream. If
to fall more closely within the favorable lines. The Z-plasty the scar develops into a keloid, steroid injections should
is a local transpositional flap consisting of a central limb, be initiated (Table 21-8). Farrior3 has recommended a
with limbs extending from each end in opposite direc- preoperative regimen of triamcinolone acetonide
tions at an angle from 40 to 60 degrees. The change in (Kenalog-40), 40 mg/mL, and lidocaine 2%, 1 : 100,000
direction of the central limb depends on the size of the epinephrine times, one dose, followed by interlesional
angles of the Z-plasty. If both angles of the Z-plasty are injections of triamcinolone mixed with lidocaine 1%,
60 degrees, the central limb will rotate 90 degrees when 1 : 100,000 epinephrine at a 1 : 4 dilution at a 3-week inter-
the flaps are transposed. Smaller angles cause less trans- val for three injections. The injections should be made
position. The Z-plasty also increases scar length by up to evenly throughout the lesion; improvement may be seen
200%.164 during this period with steroid therapy alone.
A B
C D
FIGURE 21-51 A-C, A large scalp laceration associated with a motor vehicle accident in which the patient suffered significant intracranial
and neurologic injuries. The scalp wound was débrided and closed primarily with an understanding that the wounds would have to be
revised once the patient had recovered from her neurologic injuries. D, Several months following the initial accident, the patient had
a large scar and hair loss. E, F, The scar tissue was excised with multiple small triangles, with the base and apex of the triangles
perpendicular to the scar line. The incisions are made perpendicular to the skin to allow for even closure and the wound margins
undermined and meticulously closed in layers. G, H, 3 months after repair of the scar.
G
following removal, steroid injections should continue on

25% a biweekly basis for 2 months. If no hyperplastic changes
30°
increase are noted, the steroid injections should be tapered off
over 6 months.3,164
In patients with a tendency to form hypertrophic
scars, the application of a pressure dressing and splinting
may be preventive. A firm pressure dressing may disrupt
50% the synthesis of collagen by decreasing circulation to the
45°
increase area. It may take months of splinting and pressure to aid
in the prevention of hypertrophic scars.166
BURNS
Each year, in the United States, approximately 2 million
75% individuals experience burns severe enough to require
60°
increase
medical attention. Approximately 100,000 require hospi-
talization and 6,000 to 20,000 die as a result of complica-
tions of burn injury.167 Burn injuries can be categorized
FIGURE 21-52 The classic Z-plasty has limbs with a 60-degree into thermal (flame and scalding), chemical, radiation,
angle from the vertical portion. Changing this angle will alter the and electrical types. Children younger than 5 years are
amount the scar length will increase. particularly prone to burn injuries.168 Electrical burns
caused by high-voltage electrical current are unique
because the underlying tissue destruction is frequently
TABLE 21-8 Steroid Injection Regimens for Treatment of more extensive than the skin injury. Low-voltage electri-
Keloids cal current results in potentially reversible physiologic
Medication Dosage changes, such as arrhythmias, without notable damage to
the skin and underlying tissue. The exception to this rule
Betamethasone acetate– Preoperative administration
is the electrical burn to the mouth, which is usually
sodium phosphate and 1% of 1-5 mL around the
lidocaine mixed in equal circumference of the keloid;
caused by a 120-V, 60-cycle alternating current.169 Chemi-
volumes no postoperative injection cals continue to produce local skin damage as long as
given they are in contact with the skin. Acids denature tissue
by coagulation necrosis, with protein precipitation. The
Triamcinolone acetonide Preoperative local
(5 mg/mL) mixed with equal administration of 1-5 mL,
wounds may initially appear to be deeper than they actu-
volume of 1% lidocaine with followed by 0.5-1.0 mL every
ally are. Alkalies cause liquefaction necrosis. Generally,
epinephrine (1 : 100,000) 2-4 wk postoperatively alkali burns are more serious than acid burns because
the alkali penetrates much deeper into the tissue, pro-
Triamcinolone acetonide 0.2 mL given as an
ducing progressive necrosis for several hours after
(40 mg/mL), given only when intralesional injection every
signs of excessive scarring 3 wk for 3 mo
contact. The severity of radiation burns, such as sunburn,
develop is related to time of exposure and wavelength character-
istics, which determine penetration.
Triamcinolone acetonide 1 mL injected every 2 wk,
The resuscitation of a burn patient should follow the
(10 mg/mL) mixed with equal for a total of four injections
volume of 2% lidocaine preoperatively; repeat the
same systematic evaluation as that for patients with other
same dose at surgery and
types of trauma, including primary and secondary surveys
every 2-3 wk, for a total of followed by definitive care. The most common cause of
four injections postoperatively head and neck burns is flame or flash burns. It is particu-
larly important with thermal injury of the head and neck
Adapted from Zuber TJ, DeWitt DE: Earlobe keloids. Am Fam Physician to consider inhalational injury. Inhalational injury with
49:1835, 1994.
resulting hypoxia is the most common cause of death
during the first hour after the burn.170 When the patient
After 3 months without acceptable improvement, the history and physical examination suggest a possible inha-
lesion should be excised. The excision should be made lational injury, fiberoptic nasopharyngoscopy is indicated
just within the margin of the keloid to prevent creation to evaluate the upper airway.
of a new tissue reaction. An intralesional injection of the The following factors and signs suggest inhalational
triamcinolone solution should be given before excision injury171:
of the lesion to also inhibit tissue reaction. The wound 1. History of confinement at a burning building
margins are slightly undermined to limit wound surface 2. History of exposure to an explosion
tension. The wound is closed in layers, with deep syn- 3. History of decreased level of consciousness
thetic absorbable sutures, subcutaneous polypropylene 4. Carbon deposits around the mouth or oropharynx
sutures, and multiple adhesive skin tapes to minimize 5. Inflammatory changes of the oropharynx
wound tension. The suture and skin tapes should remain 6. Carbonaceous sputum
for 3 to 4 weeks; triamcinolone injections should begin 7. Singed facial hair
2 weeks postoperatively. If hyperplastic changes occur 8. Respiratory distress
lacks blisters, and is painful to touch. These burns usually

BOX 21-3 American Burn Association: Grading System cause no permanent injury and resolve in 3 to 6 days.168
for Injury Severity Desquamation or exfoliation of the superficial epidermis
is common 3 to 5 days after injury.
MINOR BURNS Second-degree or partial-thickness burns are classified
• First- and second-degree burns that cover <15% of body
as superficial or deep. Superficial partial-thickness burns
surface area in adults and <10% in children <6 yr
are typically bright red or mottled, have a moist surface
• Third-degree burns covering <2% of the body surface
area in adults
caused by oozing of serous fluid from damaged tissue,
frequently form bullae, and are exquisitely painful. Pres-
MODERATE BURNS sure over the affected area causing blanching will be
• Second-degree burns that cover 15% -25% of body surface followed by rapid capillary refill. Because the epidermis
area in adults and more than 10%-20% in children and outer dermis are affected, epithelial elements are
• Third-degree burns that cover <10% of body surface area retained. Healing usually occurs with minimal scarring
MAJOR BURNS in 10 to 21 days.175 First-degree burns, by definition, do
• Second-degree burns covering >20%-25% of body not form bullae; however, because blisters may take 12 to
surface area in adults and 20% in children 24 hours to develop, those initially appearing as first-
• Third-degree burns that cover at least 10% of body degree burns may later be diagnosed as superficial
surface area second-degree burns.167 Deep partial-thickness burns are
• Burns of the hands, face, eyes, ears, feet, or perineum caused by immersion in hot fluids or exposure to flame
• Inhalation burns and are dark red or yellow-white, with a moist surface.
• Electrical burns Sensation to pressure remains over the wound but not to
• Burns complicated by fracture or major trauma pinprick because of damage of the superficial cutaneous
• In general, all burns in infants and older adults nerve endings. Only the epidermal cells lining the hair
• Burns in which patient is a poor risk because of preexist- follicles and sweat glands remain and serve to reepithe-
ing conditions, head injury, cerebrovascular accidents,
lialize the damaged skin surface. These burns heal in 3
psychiatric disabilities, or closed-space injuries
to 9 weeks and are predisposed to hypertrophic scar
Adapted from American Burn Association: Appendix B to hospital
formation. Thus, they are usually treated with excision of
resources document. Guidelines for service standards and severity eschar and autologous skin grafting.
classifications in the treatment of burn injury. Bull Am Coll Surg 69:24, In third-degree or full-thickness burns, the epidermis
1984; and from Griglak MJ: Thermal injury. Emerg Med Clin North Am and entire dermis are damaged. Electricity, concentrated
10:369, 1992. chemicals, and prolonged contact with hot objects,
liquid, and flame frequently cause full-thickness burns.
These wounds are dry and appear pearly white or charred,
Another immediate concern is carbon monoxide poi- or resemble parchment. Resurfacing and grafting are
soning caused by smoke inhalation. The most common necessary for wound closure. The necessity for analgesia
cause of death in fires is because of the accumulation of in burn patients is generally inversely proportional to the
carbon monoxide; carbon monoxide poisoning should depth of the burn. Cutaneous afferent nerve endings are
be considered in any burn patient. Carbon monoxide has completely destroyed in full-thickness burns, resulting in
an affinity for hemoglobin 200 times that of oxygen and minimal pain. However, partial-thickness burns, particu-
reversibly displaces oxygen on the oxygen- hemoglobin larly superficial partial-thickness burns, are usually
dissociation curve. The half-life of carboxyhemoglobin is painful.
4 to 5 hours in room air. In an individual breathing 100% In burns of the head and neck, massive facial edema
oxygen, the half-life is reduced to 45 to 60 minutes.172 may result from even minor burns because of the general
Therefore, it is prudent to administer oxygen to all laxity of the skin in these areas. If deep full-thickness
patients with a history of exposure to excessive smoke. injury is present with inelastic necrotic tissue, edema
The severity of burn injuries is related to the body formation may be directed toward internal structures.
surface area involved and depth of the wound. The Upper airway obstruction may occur suddenly and should
amount of body surface area involved can be estimated be anticipated.175
by using the rule of nines. Any patient with burns cover- Only after full examination of the total body surface
ing more than 20% to 25% of their total body area area and depth of the burn can treatment alternatives be
requires support with IV fluids, Foley catheter to monitor considered. Although various areas of the country have
urine output, and placement of a nasogastric tube slightly different requirements, the following conditions
because of the risk of intestinal ileus.* warrant transferring patients to a specialized burn
After resuscitation and stabilization of the patient, the facility167,169,172,176:
wounds are evaluated for extent and depth. Typically, 1. Second- and third-degree burns on more than 10%
burn wounds are classified as first-, second-, and third- of body surface area
degree burns (Box 21-3). First-degree burns (e.g., 2. Second- and third-degree burns on the face, hands,
sunburn) are the most superficial and involve the outer genitalia, or perineum, or over major joints
epithelium, sparing the dermis. The skin becomes ery- 3. Third-degree burns on more than 5% of the body
thematous because of local vasodilation, remains dry, surface area
4. Electrical burns
*References 167,168,170,171, 173-175. 5. Inhalation injury
6. Circumferential burns of any extremity occlusive dressing,176 which may be used with or without
7. Suspected child abuse topical antibiotics. It allows for wound protection and
The anatomic units in the head and neck region have good hygiene and allows the wearing of clothing. Early
different qualities that influence the outcome of a burn treatment of burns of the head and neck includes cleans-
injury. For example, the hair follicles of the scalp and ing, débridement of disrupted blisters, and application
beard extend deep into the underlying dermis; thereof moist dressings to prevent large eschar formation.
fore, epithelial repair is more likely. Nasal burns, which When necrotic debris or eschar persists despite these
occur in 70% of facial burns,169 tend to be partial-thickness moist dressing changes, the use of wet to dry dressings
burns because of the skin thickness and rich vascular should be initiated until healthy granulation tissue
supply. The thin skin of the eyelids predisposes them to appears to serve as a graft recipient bed. Removal of the
full-thickness burn injury. The exposed position of the dry dressing aids in débridement of the dry coagulum
ears results in more than 90% of patients with burns of and necrotic debris.169 Wounds of the head and neck can
the head and neck also sustaining burns of the ear,169 also be treated with the open method, in which no dress-
which are usually full-thickness injuries. ing covers the wound. Topical antibiotic cream is applied
Successful treatment of small burns (2% to 3% of the in a 1 8-inch layer over the burn and washed and reapplied
body surface area) is often accomplished with the use of twice daily. For a more detailed discussion of burns, see
cold water soaks. These can reduce the pain of partial- Chapter 28.
thickness burns and, if instituted within 10 to 15 minutes
of injury, may reduce the extent of tissue damage.168
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106. Torumi DM, O’Grady K: Surgical tissue adhesives used in D, Georgiade NG, editors: Pediatric plastic surgery, St. Louis, 1984,
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154. Kraissl CJ: The selection of appropriate lines for elective surgical 168. Finkelstein JC, Schwartz SB, Madden MR, et al: Pediatric burns:
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Oculoplastic surgery, Philadelphia, 1992, JB Lippincott. neck. Otolaryngol Clin North Am 17:361, 1984.
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157. Gottlieb RJ, Samford JS: Conservative treatment of post-traumatic 171. Eddy CA, et al: Trauma and burns. In Lawrence PF, editor: Essen-
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158. Hock MO, Ooi SB, Saw SM, et al: A randomized controlled trial 172. Griglak MJ: Thermal injury. Emerg Med Clin North Am 10:369, 1992.
comparing the hair apposition technique with tissue glue and 173. Waynock JP, Pruitt BA: Burn wound care. Adv Surg 23:261, 1990.
standard suturing in scalp lacerations. Ann Emerg Med 40:19, 2002. 174. Braen GR: Thermal injury. In Rosen P, Barkin RM, editors: Emer-
159. Brosnahan J: Treatment of scalp lacerations with hair apposition gency medicine: concepts and clinical practice, ed 3, St. Louis, 1992,
technique reduced scarring, pain, and procedure duration when Mosby.
compared with suturing. Evid Based Nurs 6:17, 2002. 175. Burgess MC: Initial management of a patient with extensive burn
160. Singer AJ: Hair apposition for scalp lacerations. Ann Emerg Med injury. Crit Care Nurs Clin North Am 3:165, 1991.
40:27, 2002. 176. O’Neil JA: Burns: Office evaluation and management. Prim Care
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Plastic surgery of the head and neck, New York, 1987, Churchill 177. Eilert JB, McKinney PW, Conn J, Jr, et al: Polyglycolic acid syn-
Livingstone. thetic absorbable sutures. Am J Surg 121:561, 1971.
CHAPTER
22 Secondary Revision of Soft Tissue Injury

Michael R. Markiewicz
| R. Bryan Bell
OUTLINE
Soft Tissue Wound Healing Distortion of Mobile Landmarks
Principles of Wound Management Recurrent Scar Widening
Preoperative Consultation Recurrent Scar Contracture
Scar Analysis Specific Types of Scars
Incision Placement Depressed Scar
Facial Aesthetic Units Electric Burns
Scar Type, Pattern, and Color Eyelid Ectropion
Scar Location Hypertrophic Scars and Keloids
Sun-Reactive Skin Type Classification Resurfacing Procedures
Skin and Aging Preoperative Considerations
Timing of Scar Revision Patient Preparation
Surgical Options Specific Techniques
General Principles of Linear Scar Revision General Postoperative Care for All Ablative Techniques
Procedures Adjunctive Scar Revision Techniques
Complications Tissue Expansion
Hematoma Steroids
Infection Filler Materials
Necrosis Botox
Hyperpigmentation Summery
S
carring is a natural progression of healing following fibroblasts, resulting in granulation tissue. Epithelializa-
soft tissue injury.1-3 The primary and immediate section may be completed in 24 to 48 hours in primarily
ondary management of head and neck wounds will closed wounds or be delayed for as long as 3 to 5 days in
inevitably affect the long-term aesthetic and functional wounds healing by secondary intention The final phase
outcomes of the resulting scar. Therefore, meticulous of wound healing is the maturation phase, during
planning is needed from the initial patient encounter to which the scar gains strength and volume and erythema
ensure successful outcomes in scar healing, maturation, decreases. Complete scar maturation and final tensile
and revision. This chapter will review the evaluation and strength generally take 12 to 18 months (Fig. 22-2).
management of various post-traumatic scarring, with an In any wound, even one with adequate primary closure,
emphasis on commonly encountered clinical scenarios. the gap between wound edges is temporarily repaired in
It is meant to provide the reader with a literature-based the form of a clot consisting of platelets engrossed in a
rationale for treatment. mesh of cross-linked fibrin fibers derived from fibrino-
gen cleaved by thrombin. The platelet clot serves as a
SOFT TISSUE WOUND HEALING reservoir of cytokines and growth factors that are released
as platelets degranulate. Growth factors and cytokines
A basic understanding of wound healing is needed recruit inflammatory cells, fibroblasts, and capillary
because of its relevance to scar formation and subse- ingrowth to the wound site, which invade the clot to
quent effects on revision.3-5 Wound healing is classified form granulation tissue, leading to contraction of
into three main phases (Fig. 22-1). These include the wound margins. A connective tissue scar remains when
immediate inflammatory phase (1 to 3 days), which is wounds are closed by secondary intention—the larger
characterized by a vascular and inflammatory response the wound gap, the wider the connective tissue scar.
including local vasoconstriction for the first 5 to 10 Scar consists of a poorly constructed collagen matrix
minutes followed by a local vasodilatory response. The in dense parallel bundles, which is contrasted to the
inflammatory phase takes place the first few days after efficiently cross-linked meshwork of collagen in the
injury, during which wound strength relies mainly on the native dermis. It occurs in three phases—epithelialization
fibrin clot. The second phase, the proliferation phase (3 migration, collagenization, and angiogenesis–granulation
to 12 days), begins within 24 hours after injury and is tissue formation. Epithelialization occurs by migration of
characterized by the recruitment of blood vessels and keratinocytes over the dermis and under the clot (Fig.
566
Secondary Revision of Soft Tissue Injury CHAPTER 22 567
Vasoconstriction
Vasodilation Inflammatory phase
Cellular response
Proliferative phase
Reepithelial-
ization
Fibroplasia: collagen synthesis
Wound contraction
Maturation / remodeling phase

Scar: collagen remodeling
Injury 30 minutes 1 day 1 week 2 weeks 3 weeks 6 months 1 year

FIGURE 22-1 Phases of inflammation.
100
80
Tensile strength*
60
40
20
0
1 2 3 4 5 6 7 8 9 10
Time after wounding (weeks)
*Percent of normal unwounded skin
FIGURE 22-2 Maximum scar tensile strength is obtained

approximately 12 to 18 months following injury. (Adapted from A
Goslin JB: Wound healing for the dermatologic surgeon.
J Dermatol Surg Oncol 14:959–972, 1988.)
22-3), which is facilitated by growth factors such as epi-

dermal growth factor (EGF) and transforming growth
factor α (TGF-α).6-8 Once a monolayer of keratinocytes
covers the denuded wound surface, epithelial migration
ceases and a new stratified epidermis with underlying
basal lamina is reestablished from the margins of the
wound inward. All aspects of a skin flap rarely touch
along all the length of the wound; migration is aided by
contraction of the underlying connective tissue. Within
3 to 4 days of injury, dermal fibroblasts around the wound
begin to proliferate and lay down a collagen-rich matrix,
a process modulated by platelet-derived growth factor
(PDGF) and transforming growth factor β (TGF-β).9-12
Finally, angiogenesis of the wound and the incorporation B
of pink, capillary-filled granulation tissue is mediated by FIGURE 22-3 A, A leading front of basal epithelial cells divides and
fibroblast growth factor 2 (FGF2) and vascular endothe- migrates beneath a dried clot. B, Contact inhibition and further
lial growth factor (VEGF) released at the site of the differentiation and epithelial stratification.
wound.13 Connective tissue contraction ultimately closes
embryonic and adult wounds. The major difference
between scar-free healing and scar formation is that a initial thorough removal of foreign bodies, débridement,
scar-free wound site has significantly less inflammation and cleansing of the wound with copious pulsatile irriga-
present.5 tion. Formal scrubbing of the wound may be undertaken
if necessary but should be done sparingly to spare further
PRINCIPLES OF WOUND MANAGEMENT damage to soft tissues. All devitalized soft tissue should
be débrided and excised and sharp healthy wound
General principles of wound management should always margins should be obtained to facilitate closure, with
be followed in the traumatic setting. These include an minimal scarring.14 Devitalized tissue increases the local
inflammatory response and subsequent scarring. Undi-

luted hydrogen peroxide use in open wounds should be
avoided because it inhibits wound healing and may cause
tissue necrosis. Normal saline with or without bacitracin
is the preferred irrigant for soft tissue trauma. Although
delayed closure may be necessary in some wounds caused
by edema and/or high-velocity injuries such as gunshot
wounds, in wounds with a significant amount of devital-
ized tissue, or because of other, more urgent medical and
surgical interventions that precede the treatment of head
and neck injuries, primary closure should be attempted,
if feasible. In the case of avulsed tissue or the inability to
reapproximate local tissue under minimal tension, local
flaps, regional flaps, or free tissue transfer may be needed
to restore tissues adequately to previous form and func-
tion.15 Wounds should be closed in layers, if possible, to
place minimum tension on the superficial skin closure
and aid in the eversion of skin edges to minimize scar
widening.16 Tension across a wound decreases blood flow, FIGURE 22-4 The effects of a moist occlusion dressing on
which leads to necrosis of wound edges and increased stimulating more rapid epithelialization (left) than under a dried clot
connective tissue growth in the proliferation phase, and (right). (From Brenner MJ, Perro SA: Recontouring, resurfacing,
and scar revision in skin cancer reconstruction. Facial Plast Surg
to elongation of scars in the remodeling phase.17,18
Clin N AM 7:469–487, 2009.)
Skin flaps should be appropriately undermined so that
wound edges can be everted, which will minimize scar
depression.19 A review comparing the use of tissue adhesives versus
Meticulous attention to detail and gentle tissue han- standard wound closure in patients with traumatic lacera-
dling are important to optimize wound healing and mini- tions found that pain and procedure time were signifi-
mize scarring.1 A multivariate analysis has shown that cantly reduced in the tissue adhesive group and wound
characteristics associated with suboptimal cosmetic dehiscence and erythema were significantly reduced in
appearance following laceration and surgical incision the standard wound closure group; however, there was
closure are associated tissue trauma, use of electrocau- no difference in final cosmesis or scar appearance
tery, incomplete wound edge apposition, and increased between the two groups.27
wound width (healing by secondary intention).20 If per- Desiccated and crusted wounds heal slower than those
manent sutures are used for wound closure, they should kept moist.28 Epithelial migration follows a path of mois-
be removed in 5 days or less to prevent track marks. ture and humidity, even if this route is longer (Fig. 22-4).
Another option is to use fast, resorbing plain gut suture This often requires more energy expenditure by the cell.
(5.0 to 6.0). In a study that compared 5.0 or 6.0 nylon In addition, an apoptosis-mediated decrease in granula-
sutures versus plain gut sutures for skin closure in a tion tissue has been shown to occur in vitro in flaps that
population of pediatric patients who suffered lacera- are covered postoperatively.29 Therefore, occlusive dress-
tions, no difference in infection or wound dehiscence ings and antibiotic ointment use are recommended so
was found between the two groups; however, slightly that epithelial migration proceeds in a direct and effi-
better cosmesis was found in the plain gut suture group.21 cient manner. The use of occlusive or semiocclusive
Similar studies,22 including a meta-analysis,23 have con- dressings has also been advocated as a means of promot-
firmed these results, demonstrating no difference in ing wound healing. Commercially available dressings,
long-term cosmesis, scar hypertrophy, infection rate, such as Tegaderm (3M), Opsite (Smith & Nephew,
wound dehiscence, and wound erythema or edema London), or similar polyurethane dressings minimize
between lacerations closed with nylon versus plain gut the amount of atmospheric oxygen that is absorbed
suture. For scalp incision and laceration repair, the use directly through an open wound30,31 and have been
of staples as an alternative to suturing has been demon- shown to decrease epithelial closure time by as much as
strated in a randomized control trial to reduce proce- 50%.28,31-33 The moist environment is optimal for epithe-
dure time significantly while not demonstrating any lial migration, with minimization of connective tissue
difference in cosmesis by a blinded physician at 1 week formation, therefore expediting healing and reducing
and 6 to 18 months postrepair.24 scar formation. These effects, however, have not been
Adhesive bandages such as Steri-Strips (3M, Maple- verified in a randomized control trial.34 Antibiotic oint-
wood, Minn) should be used to reduce wound tension at ment should be applied to the wound until epithelializa-
the time of closure and to reduce the need for long-term tion occurs. Bacteria delay healing by direct cell damage,
suture placement in those wounds under increased prolonging the inflammatory phase of wound healing by
tension. The use of 2-octyl cyanoacrylate–based fast- competing for oxygen; therefore, in addition to provid-
acting skin adhesives has been shown to be just as ing a moist environment, antibiotic ointment is benefi-
effective as Steri-Strips in reducing hypertrophic scar for- cial for reducing bacterial colonization.35
mation,25 although other study results have demonstrated Wounds should be cleaned daily during the immedi-
superior cosmesis in wounds dressed with Steri-Strips.26 ate postoperative period using a mixture of 50%
hydrogen peroxide and 50% water. Sunblock should be scars, has shown only to improve scar color while not
applied to the area of wound closure to reduce irritation having an effect on scar height.55
and minimize the inflammatory response. The patient
should be instructed to massage the wound once epithe- PREOPERATIVE CONSULTATION
lialization occurs using a simple base cream twice a day,
10 minutes at a time.36,37 The effects of scar massage, Detailed explanation of possible and realistic outcomes
however, have been questioned.38 In addition, silicone at the initial encounter will help circumvent any unrea-
sheets or gels may be used after epithelialization occurs sonable expectations that the patient might have and
and may assist in better scar maturation of hypertrophic prepare the patient for the reality that further proce-
and keloid scars.39-44 Although a barrier, silicone sheets dures will be needed. Although the surgeon may have a
do allow the passage of oxygen. It has been shown in an good idea of which scar revision procedure the patient
animal model that silicone sheets cause hydration of will need at the time of initial repair, it may not be until
keratinocytes within the stratum corneum of the epider- weeks to months later, after scar maturation occurs, that
mis, which has a suppressive effect on the metabolism of the surgeon will be able to formulate a definitive treat-
underlying fibroblasts and results in decreased capillary ment plan. Depressed scars tend to contract initially and
activity, hyperemia, and collagen deposition, and there- then relax as they mature, whereas hypertrophic scars
fore decreases dermal thickness and subsequent scar and keloids will often grow as the patient ages. On
hypertrophy.45 Oxygen tension, pressure, or silicone follow-up examination, the surgeon should note scar
leakage into dermis, however, has not been shown to be tension and adjacent tissue laxity of the scar while
mechanisms for silicone effectiveness.46-49 Furthermore, attempting to predict the outcome of tissue rearrange-
silicone sheets have been found to improve pigmenta- ment. In addition, the patient’s medical history should
tion, vascularity, and reduce the height of scars after 3 be revisited because much may be left out in the emer-
months of postoperative use.50,51 Reduction of pain and gent setting. Hereditary, vascular, metabolic, and immune
pruritus has also been demonstrated to be a benefit of deficiencies may be detrimental to wound healing.
silicone sheets, but these benefits are not seen until after Finally, the patient must be compliant with postoperative
6 months of use.52 In a study that used the Vancouver care. This not only includes local care to the wound, but
Scar Scale to assess the effects of silicone gel, silicone gel maintaining proper nutrition, because vitamin and trace
sheets, and allantoin in improving postburn scarring less mineral deficiencies such as deficiencies of vitamin A, C,
than 6 months from injury, the investigators found no E, zinc, and iron can be detrimental to wound healing.31,56
significant difference in the silicone gel and gel sheet
group, but there was a significant difference in improve- SCAR ANALYSIS
ment when comparing the allantoin groups with the sili-
cone sheet and silicone gels group.53 All three groups The purpose of scar analysis is to use a reliable and valid
showed a significant improvement 6 months from base- measure for quick and efficient scar assessment, which
line. The effects of silicone sheet use have been shown requires that the surgeon have a firm understanding of
to last up to 6 months after removal; therefore, their scar terminology (Table 22-1).57 Documentation of a
benefits are maintained once they are discontinued54 standardized assessment is necessary for developing a
Onion extract, another popular topical treatment for treatment plan and for serial evaluations. Photographic
TABLE 22-1 Scar Terminology
Scar Classification Features

Mature scar A light-colored, flat scar.
Immature scar A red, sometimes itchy or painful, and slightly elevated scar in the process of remodeling. Many
of these will mature normally over time, become flat, and assume a pigmentation that is similar
to the surrounding skin, although they can be paler or slightly darker.
Linear hypertrophic (e.g., A red, raised, sometimes itchy scar confined to the border of the original surgical incision. This
surgical or traumatic) scar usually occurs within weeks after surgery. These scars may increase in size rapidly for 3-6 mo
and then, after a static phase, begin to regress. They generally mature to have an elevated,
slightly ropelike appearance with increased width, which is variable. The full maturation process
may take up to 2 yr.
Widespread hypertrophic (e.g., A widespread, red, raised, sometimes itchy scar that remains within the borders of the burn
burn) scar injury.
Minor keloid A focally raised itchy scar extending over normal tissue. This may develop up to 1 yr after injury
and does not regress on its own. Simple surgical excision is often followed by recurrence. There
may be a genetic abnormality involved in keloid scarring. Typical sites include earlobes.
Major keloid A large, raised (>0.5 cm) scar, possibly painful or pruritic and extending over normal tissue. This
often results from minor trauma and can continue to spread over years.
Adapted from Mustoe TA, Cooter RD, Gold MH, et al: International clinical recommendations on scar management. Plast Reconstr Surg 110:560–571 ,
2002.
assessment using standardized lighting, spacing, posi- Vancouver scale, but relies on patient opinion (Table
tioning, camera settings, and background is beneficial 22-3).70 A number of other subjective and objective assess-
for initially assessing and serially tracking the progress of ment tools and devices have been reported in the
the scar maturation.58-65 Imaging software can be used to literature.71-76 Most indices include the clinical assess-
analyze, measure, and follow scars and can aid in surgical ment of vascularization, pigmentation, thickness, surface,
planning by almost performing the surgery before the pliability, size, reflection, distortion, texture, functional
actual procedure.66 Immediate preoperative and postop- deficits, and pain. These characteristics are often a clue
erative photographs should be taken.67 It is useful to to the cause of the scar. For example, postinflammatory
review photographs after the patient has left. It is then hyperpigmentation is often seen in scars associated with
that the surgeon will often notice subtle abnormalities acne, inherited and acquired diseases, temperature
that could affect the management of the scar. Also, pho-
tographs will document changes in following appoint-
ments often overlooked by the patient and surgeon.
Several factors must be considered when developing BOX 22-1 Factors Influencing Selection of Technique in
a treatment plan for scar revision, such as scar width, Scar Revision
length, relationship to relaxed skin tension lines (RSTLs),
neighboring anatomic landmark distortion, tissue loss, Medical comorbidities
scar type, patient age and race, scar location (visible Scar width
versus nonvisible with clothing), skin type (Fitzpatrick), Scar length
Relationship to RSTLs
tissue tension and laxity, and local tissue reservoirs (Box
Distortion of anatomic landmarks
22-1). Figure 22-5 illustrates a basic template for the
Tissue or volume deficit
surgeon to use for scar revision, but this must be tailored Type of scar
to the specific patient and scar. Age of patient
The most widely used scarring index is the Vancouver Race of patient
Scar Scale, which gives the surgeon an objective measure Patient expectations
of burn scars and assists in prognosis and management. Scar location
Although some have described it as a valid research tool Skin type (Fitzpatrick)
with good interrater reliability (Table 22-2),68 others have Local tissue laxity
not.69 Another scale, the patient and observer scar assess- Adjacent tissue reservoir
ment, has an objective component comparable to the
Scar revision algorithm
Scar
Hypertrophic Wide or
Scar maturation
or keloid malpositioned
Excise Moderate width Large width

Large Small
Distorted landmark Serial excision Local flap or graft

Excision Steroid injection No
or interferon Yes
Within RSTL
No
Pressure
or radiation Yes
Reposition scar Scar contracted
or gel sheeting
Yes
> 1 cm No Z-plasty
Depressed Effacement
G-broken line
Slight elevation or W-plasty
Collagen injection
Alloderm Dermabrasion or
Fat/dermis graft Shave excision laser resurfacing
FIGURE 22-5 Flow diagram for management of optimal scar revision. (Adapted from Thomas JR. Facial scars. In Thomas JR, Holt GR,
editors: Facial scars: Incision, revision, and camouflage, St. Louis, 1989, CV Mosby.)
extremes, sites of allergic reaction, radiation, and sun

TABLE 22-2 Vancouver Scar Scale exposure.77 Hypopigmentation often has iatrogenic
causes, such as chemical peel, dermabrasion, laser resur-
Scar Characteristic Rating facing or, with burns, trauma and infection.78,79
Vascularity Scar contour exists on a continuum, from the
Normal 0
depressed scar to the hypertrophic scar and keloid.
Hypertrophic scars typically remain confined to the
Pink 1
borders of the inciting injury and usually retain their
Red 2 shape, whereas keloids are defined as scars that extend
Purple 3 beyond the borders of the original wound, do not regress
Pigmentation spontaneously, and tend to recur following excision.80
Normal 0 Keloids present a special problem in treatment (see
Hypopigmentation 1 later). Scar depression often results from excessive
tension across the wound. Scar texture and reflection are
Mixed 2
mainly concerns of aesthetics. Scar contracture may have
Hyperpigmentation 3 functional and aesthetic ramifications in the head and
Pliability neck. Pertinent to the craniomaxillofacial skeleton, scar
Normal 0 tethering to underlying fascia, muscle, or bone may
Supple 1 occur, resulting in aesthetic and functional deficits,
Yielding 2 mainly the failure to animate or move the face and neck.
Firm 3
Painful scars, especially those associated with burns,
can severely debilitate the patient. The patient may
Ropes 4
present with allodynia, hyperesthesia, hypoesthesia, or
Contracture 5 dysesthesia, often caused by tissue adhesion, surround
Height soft tissue damage, underlying skeletal damage, or
Flat 0 neuroma or perineural scar formation. An increase in
<2 mm 1 nociceptive nerve fibers following burn injury is associ-
2-5 mm 2 ated with increased cutaneous innervation and increased
density of certain neuropeptides, and may be responsible
<5 mm 3
for chronic pain in patients with burns.81-83 Excision of
TABLE 22-3 Patient and Observer Scar Assessment Scale
OBSERVER SCAR ASSESSMENT SCALE

Normal Skin 1 2 3 4 5 6 7 8 9 10 Worst Scar Imaginable
Vascularization          
Pigmentation           Hypo 
Mix 
Hyper 
Thickness          
Relief          
Pliability          
Total score, Observer Scar Scale

PATIENT SCAR ASSESSMENT SCALE
No, no Complaints 1 2 3 4 5 6 7 8 9 10 Yes, Worst Imaginable
Is the scar painful?          
Is the scar itching?          
No, As Normal Skin 1 2 3 4 5 6 7 8 9 10 Yes, Very Different
Is the color of the scar different?          
Is the scar more stiff?
Is the thickness of the scar different?          
Is the scar irregular?          
Total score, Patient Scar Scale

Adapted from Draaijers LJ, Tempelman FR, Botman YA, et al: The patient and observer scar assessment scale: A reliable and feasible tool for scar
evaluation. Plast Reconstr Surg 113:1960–1965, 2004.
this tissue, in addition to reconstruction using local, skin incisions for the next century. Langer’s studies were,
regional, or distant flaps, may relieve pain in some however, limited because they were performed in cadav-
patients. Scars in the midline are less likely to produce ers, showing the effects of rigor mortis. Kraissl et al pre-
pain, but may cause more scarring because of increased ferred lines perpendicular to the action of the underlying
tension.84 muscle.87-89 Borges has studied this concept in vivo and
Elevated scars present in different patterns, depend- distinguished lines that follow furrows when the skin is
ing on the thickness and integrity of the remaining relaxed from those that are produced by pinching the
dermal wound edges. Hypertrophic scars are dome- skin, and found that these lines are distinct from wrin-
shaped and have a thin epidermis, whereas partially avul- kles, creases, and Langer’s lines and that the number of
sive or oblique wounds result in contraction at the base lines and spacing varies among individuals.90,91 Numer-
of the wound, creating an elevated and inclined scar. As ous other lines of tension have been described in the past
the scar matures, wound edges of different dermal thick- by Cox, Webster, Stark, and Ogilvie, Kocher, and Kazan-
ness and elevation result in elevated scars with gradual jian, among others.87,92 These lines of tension would be
step-offs; misaligned wound edges of the same dermal called Borges’ lines, or RSTLs. They follow furrows
thickness produce elevated scars with abrupt step-offs. formed on relaxed skin. It has been demonstrated that
Depressed scars may be related to underlying tissue loss placing incisions in the direction of RSTLs will produce
or to increased tension across the wound, resulting in more aesthetic outcomes with minimal scarring. RSTLs
atrophy of the underlying dermis, which results in a and wrinkles caused by aging may not be in the same
smooth and shiny scar. location. Wrinkles are the change in overlying skin as a
result of muscle pull over time. Conversely, RSTLs of the
INCISION PLACEMENT face often run perpendicular to the underlying muscle
Understanding of the natural lines of tension of the head and, in the neck, they usually run perpendicular to areas
and neck is imperative for proper placement of skin inci- of flexion (i.e., RSTLs run horizontally on the forehead,
sions and to optimize final scar appearance (Fig. 22-6). perpendicular to the vertical frontalis muscle). Examples
Dupuytren first observed that an oval wound was created of wrinkles that do not coincide with RSTLs include gla-
when a round instrument punctured the skin.85 Karl bellar lines, crow’s feet, and bunny lines. An exception
Langer, an anatomist, further studied this change in to this rule is in the area of the circular orbicularis oculi
facial skin configuration in cadavers in rigor mortis and underlying the eyelids, where RSTLs run horizontal and
postulated that intrinsic skin tension occurred along pre- parallel to the muscle because of the rigid scaffold of the
dictable lines of cleavage.86 Later called Langer’s lines, tarsal plate. In older patients, RSTLs often run parallel
these lines of tension became the basis for elective facial with the natural creases and wrinkles of the face. RSTLs
are determined by having the patient go through a series
of facial expressions (e.g., smile, frown, laugh, squint)
and then pinching the skin. The line where the longest
straightest line results is the RSTL.93 RSTLS should be
determined prior to administration of local anesthesia.
The lines of maximum extensibility (LMEs), also
known as antitension lines (ATLs), run perpendicular to
RSTLs. When incisions are placed perpendicular to
RSTLs, an S-shaped scar will develop. Pinching the skin
perpendicular to RSTLs produces humps; incisions par-
allel to this plane should be avoided. When the areas is
too distorted for assessment, the contralateral side may
be used.94 Incisions made parallel to the RSTL will
produce a narrow scar under minimal tension, as opposed
to those placed parallel to the LME or ATL, which will
be under maximum tension and will have a significant
propensity to widen and produce broad unsightly scars.
A major factor in deciding to undertake scar revision is
whether scars are located perpendicular to RSTLs or in
ATLs. Note that the ultimate goal of scar revision is to
orient the scar parallel to RSTLs.
FACIAL AESTHETIC UNITS

In trauma and reconstructive facial surgery, the face can
be divided into facial aesthetic units.95 Gonzales-Ulloa
initially described 14 aesthetic units.96-99 These include
the forehead, right and left cheeks, nose, right and left
upper lids, right and left lower lids, right and left ears,
FIGURE 22-6 The relaxed skin tension lines of the face. (From upper lip, lower lip, mental region, and the neck (Fig.
Kaminer M, Arndt K, Dover J, et al: Atlas of cosmetic surgery, ed 22-7). These aesthetic units can be further classified into
2, St. Louis, 2009 Saunders.) subunits based on skin thickness, color, elasticity, and
1B 1A 1A
1C 1B 1C
3B 3B
3C 3D 3C 3D
3A 2 3A
4B 2
4A 4B
8 8 4A
5 5
4C 5C 4D 4C 5C
4D 6B 6B
6A 6A
7
7
9 9
A B
2C 5B 5A 5B
2D 2D 5C
FIGURE 22-7 A, Frontal and profile (B) views of the
6B face. C-E, Nasal, lip, and ear units of the face,
2F 2A 2F
6A respectively. 1, Forehead. Subunits—A, central;
2E 2E
2B B, lateral; C, eyebrow. 2, Nasal. Subunits—A, tip;
C
D B, columellar; C, dorsal; D, right and left dorsal
side wall; E, right and left lateral alar base; F, right
and left alar side wall. 3, Periorbital. Subunits—
A, lower eyelid; B, upper eyelid; C, lateral canthal;
8A 8C
8B
D, medial canthal. 4, Cheek units. Subunits—
A, medial; B, zygomatic; C, lateral; D, buccal.
8D
5, Upper lip unit. Subunits—A, philtrum; B, lateral;
C, mucosal. 6, Lower lip. Subunits—A, central;
B, mucosal. 7, Mental. 8, Auricular. Subunits—
8E A, helical; B, antihelical; C, triangular fossa;
E D, conchal; E, lobe. 9, Neck.
underlying structural support. Additional subunits within When planning excisional scar revision, care should
each facial unit have been described that delineate be taken to limit the revision to within one facial unit.
natural break lines that allow the surgeon to conceal a For example, when revising a scar of the cheek, the
scar or skin graft placement100 (Fig. 22-7). For example, revised procedure should not encroach on the upper lip
the nose can be broken down into the nasal bridge, side- or lower eyelid unit. Facial units are important in onco-
wall, tip, ala, soft triangle, and columella.101 The upper logic skin resection and in regard to tissue avulsion in
lip is divided into the philtrum column, nostril sill, alar trauma, when it is important to remove the entire unit
base, and nasolabial crease102 Placement of incisions at or subunit, even if extension of the incision is necessary.
the seams of these units or subunits, or at facial midline The subsequent reconstruction, whether it be local or
will produce the least perceivable scars. regional flaps or free tissue transfer, should span the
The division of facial aesthetic units is based on natural entire facial unit or subunit. When the avulsed or excised
breaks formed by shadows, folds, hair, and on skin thick- area of tissue encompasses an entire unit and subunit,
ness, color, and texture. Facial restoration should respect the final outcome blends with surrounding tissues and is
the boundaries of facial units and subunits. Any restora- less conspicuous.1,102
tion that includes two or more units may result in aes-
thetic and functional deficits; superior cosmetic results SCAR TYPE, PATTERN, AND COLOR
are often obtained when treatment is rendered to an It is important for the surgeon to consider the type and
entire aesthetic unit rather than to an isolated scar within pattern of scar when considering surgical revision, which
a unit. An example would be when planning for derm- also may give an indication about the type and extent of
abrasion as revision treatment to a scar of the nose. In injury. For example, flat, linear, or curved scars often
this case, the entire nasal unit should be treated to mini- result from low-energy injuries and are more easily
mize the perception of residual scarring and the final treated than depressed scars and scars resulting from
scar will blend better with the adjacent units and not high-energy avulsive tissue loss. Wide scars caused by
appear as a stand-alone patch. increased wound tension or tissue loss are often flat and
faded and are difficult to treat because of a texture mis-

match with surrounding tissues. These scars often need TABLE 22-4 Fitzpatrick Classification of Sun-Reactive
reexcision and closure. Some hypertrophic scars or Skin Type
keloids may benefit from excision or other nonsurgical Skin Type Skin Color Sunburn Tan
treatment such as intralesional steroid injection, chemo- I White Always Never
therapy, cryotherapy, radiation, laser, or silicone sheet II White Usually With difficulty
treatment.80 Atrophic or volume-depleted scars often
III White Mild Average
result from wounds not closed primarily, in stellate scars,
with inappropriate approximation of wound edges in IV Moderate Rarely Easy
primary closure, or in deep abrasions. These scars often brown
require dermal fillers, including autogenous materials V Dark brown Very rarely Very easily
such as fat transfer103,104 and synthetic fillers.1 VI Black Never Always
Scar camouflage is difficult in widened scars because
of their smooth shiny surface, which reflects light differ-
ently than adjacent tissues. Similarly, scars that cross mul-
tiple facial units and subunits are challenging to treat SKIN AND AGING
because they are usually have varying skin texture, thick- A patient’s age will often guide the surgeon to the timing
ness, and histologic makeup. For example, nasal skin is and type of treatment chosen for scar revision. Older
different than skin of surrounding facial subunits con- patients should be evaluated for the risks versus benefit
taining a thicker dermis and higher density of sebaceous in any surgical procedure in the context of complex
glands; therefore, the nearest skin is the best donor for medical comorbidities. Glogau has developed a classifica-
reconstruction.101 tion for skin wrinkling related to aging as a guide to
Red scars are often immature and turn whiter than treatment for each skin type (Table 22-5). This should be
surrounding tissues once fully matured. Erythematous taken into consideration before undertaking scar revi-
scars seen in the early stages of scar maturation are not sion procedures, because skin resurfacing techniques
good candidates for revision unless the redness is con- can be chosen to match the depth of wrinkles and degree
fined to the scar itself. The color of white scars may be of wrinkling.110
the only concern of the patient; these are often treated It has been recommended that children have a higher
successfully with tattooing, making them appear similar tendency for scar widening than adults and should
to surrounding skin. undergo scar revision after puberty because of a pro-
longed and exuberant inflammatory response, increased
SCAR LOCATION skin tension, diminished skin and dermal thickness, and
The location of the scar should be considered before higher concentration of collagen and elastin,.111 Chil-
developing a treatment plan for scar revision. Facial units dren past the age of puberty are more likely to cooperate
such as the forehead and nose are well supported by the with treatment and postoperative care than their younger
underlying skeleton and tend to result in better out- counterparts. Severe psychological or functional impair-
comes than other facial units. Areas with multiple vectors ment secondary to scar formation, however, may warrant
of muscle pull, such as the medial canthus, lateral cheek, earlier treatment.
and submandibular area, often result in suboptimal out-
comes. Scars with similar adjacent local skin color, thick- TIMING OF SCAR REVISION
ness, and texture that are easy to mobilize and transfer
without distorting the donor site area are likely to have Experience has shown that in general, the appearance of
better outcomes. A discussion of specific local and most scars tends to improve spontaneously after a period
regional flaps is beyond the discussion of this chapter. of maturation during the first year after injury, after
which time the appearance of the scar stabilizes and
SUN-REACTIVE SKIN TYPE CLASSIFICATION surgical revision may be considered.112,113 However, scars
Fitzpatrick developed the sun-reactive skin type classifica- oriented perpendicular to RSTLs or those associated
tion to describe the degree of skin reaction after sun with functional impairment may be revised earlier than
exposure105-107 (Table 22-4). Although developed as a 1 year on an individualized basis.114,115
guide for the treatment of skin rejuvenation procedures, Early scar revision may be undertaken as early as 4
this classification scheme is useful when choosing the weeks when there is severe functional impairment, such
correct management of the traumatic scar. Patients with as salivary and lacrimal gland obstruction, lip incompe-
a higher classification will often experience inflamma- tence, or lagophthalmos with corneal exposure. Early
tory changes such as dyspigmentation after soft tissue scar revision may also be advisable in well-localized scars
injury. Although hyperpigmentation is usually tempo- sustained from low-energy injuries in which adjacent skin
rary, hypopigmentation is often the permanent result of damage is minimal. Although a delay in scar revision of
a mature scar. Furthermore, patients with a very fair skin at least 6 months is generally recommended for most
(Fitzpatrick classification type I or II) will often respond adult scars, high-energy injuries may continue to remodel
better to laser resurfacing, whereas patients with very and mature over a longer period of time, and delay for
dark skin (Fitzpatrick type IV or V) may benefit from 12 months may be advisable.116
more conservative treatment, such as superficial chemi- Interventions such as dermabrasion and shave exci-
cal peels and scar excision.108,109 sion may be performed as soon as 4 weeks from the initial
TABLE 22-5 Glogau Classification of Photoaging
Group Classification Typical Age (yr) Description Skin Characteristics

I Mild 28-35 No wrinkles Early photoaging, mild pigmentary changes no keratosis, minimal
wrinkles, minimal or no makeup
II Moderate 35-50 Wrinkles in motion Early to moderate photoaging, early senile lentigines visible, keratoses
palpable but not visible, parallel smile lines beginning to appear, usually
wears some foundation
III Advanced 50-60 Wrinkles at rest Advanced photoaging, obvious dyschromia, telangiectasia visible
keratosis, wrinkles even when not moving, always wears heavy
foundation
IV Severe ≥60 Only wrinkles Severe photoaging, yellow-gray color of skin, prior skin malignancies,
wrinkled throughout, no normal skin patient age, cannot wear
makeup—“cakes and cracks”
or regional flaps, or free tissue transfer may be indicated

BOX 22-2 Steps in Scar Revision if neighboring tissue reservoirs are deficient or if ana-
tomic structures and landmarks would be distorted by
closure.
1. Shave excision (for elevated scars)
• Serial scar excision GENERAL PRINCIPLES OF LINEAR SCAR REVISION
2. Tissue rearrangement The first step in any scar revision procedure is to examine
• W-plasty skin thickness, elasticity, texture, hair growth, and RSTLs.
• Z-plasty A fine-tipped marking pen should be used to plan the
• Geometric broken line closure incision, which should be measured and remeasured as
3. Surface retreatment many times as necessary before the skin is incised. Care
• Dermabrasion/microdermabrasion should be taken to avoid excess tension or forceps com-
• Chemical peels pression at wound edges because this might cause tissue
• Laser (CO2,2, erbium : YAG, 585-nm flashlamp-pumped slough because of compromised blood flow to flap
PDL)
margins and distort adjacent landmarks, ultimately
causing hypertrophic or widened scars.
Most facial incisions may be made with a no. 15 or no.
wound repair, based on the high level of fibroblastic 11 blade on a no. 9 knife handle. The no. 11 blade is the
activity during this period. Because dermabrasion itself most useful for straight cuts; these should be made per-
causes erythema, early intervention may overlap with ery- pendicular to the skin in a sawing-type motion, with the
thema from initial repair, leading to less total time of tip of the blade used to make initial incision. The handle
erythema for the patient. For hypertrophic scars and of the blade is then brought down toward the skin so that
keloids, steroid injections may be considered as early as the belly of the blade cuts the middle part of the incision.
3 weeks and may be given at the time of scar revision. Finally, the blade handle is brought up again so that the
Cigarette smoking, isotretinoin, and vitamin E use are tip finishes the incision. This technique ensures that skin
injurious to wounds and scar revision should be delayed and subcutaneous layers are incised evenly throughout
until they have been discontinued.117 the entire incision. If incising a scar, the blade should be
beveled outward (Fig. 22-8A). This aids in creating a
SURGICAL OPTIONS plane for undermining skin, allowing eversion of the
wound edges and minimizing scar depression. The skin
Scar revision can be broken down into three different at the ends and sides of the incision should then be
treatment modalities—scar excision, tissue rearrange- undermined with a no. 15 blade or curved scissors at least
ment, and surface treatment (Box 22-2). The selection 2 cm in the subdermal plane to avoid motor nerves of
of treatment should be based on the individual scar and the face (see Fig. 22-8B). Undermining the scalp will not
on the needs and expectations of the patient. For aid in closure because of the tensile strength of the galea
example, conservative treatment may be warranted for a aponeurosis. Galeotomies, however, may assist with mobi-
demanding patient with unrealistic expectations. Narrow lization and eversion of scalp tissue.
scars parallel to RSTLs may have distracting features such Primary closure should be achieved, whenever possi-
as surface discoloration and texture irregularities. These ble. Healing by secondary intention may be advisable in
scars will often benefit from surface treatments. Longer some cases, however, such as the lateral canthi of the
scars, which vary more than 35 degree from neighboring eyes, where skin is thin and well-contoured and is subject
RSTLs and have a local tissue reservoir, may be improved to constant motion because of lid closure. To avoid
with tissue rearrangement such as W-plasty or geometric bunching (dog ear) at wound edges, the principle of
broken line excision and closure (GBLC). Z-plasty, local halving should be used, whereby the first suture is placed
Beveled Principles of halving

Vertical
1 2
3 4
Beveling outward from lesion when creating skin incision
A
A
Undermining skin with skin
hook and no. 15 blade
Equalizing length of edges with a Burow’s triangle
1 2
3 4
Undermining skin with forceps

and scissors
B
FIGURE 22-9 A, The principle of halving is used to avoid a
standing cone deformity at the end of the incision. B, When an
incision is not of equal skin flap proportion at both ends, a triangle
is removed from the longer skin flap and closed primarily, making
skin flaps of equal size.
B
FIGURE 22-8 A, Beveling the blade outward when excising a scar.
B, Undermining skin should be done with a skin hook and no. 15
blade or forceps and scissors.
tubing or swabs may be placed under the knots of the
vertical mattress to minimize tension (see Fig. 22-10C).
at the center of the incision and the next two are placed A simple interrupted (see Fig. 22-10D) or, preferably, a
at the center of the remaining halves (Fig. 22-9A). Con- Gilles half- buried corner stitch should be used (see Fig.
tinuing this down the length of the skin margins will 22-10E) for tacking wound corners, The Gilles half-
close the wound with equal tension and eversion through- buried stich is performed by placing a subcutaneous
out. When incisions are not of equal length and shape, suture in the corner flap, finishing transcutaneously in
the principle of equalizing edges should be used (see Fig. the opposing skin edge. The most useful stitch for reliev-
22-9B). In this technique, a Burow’s triangle is removed ing skin tension and everting wound edges, however, is
from the longer skin flap and closed primarily to make the running buried subcuticular stich. However, care
the two primary skin flaps equal in length. must be taken to avoid tension and skin edge vascular
Meticulous attention to proper suturing technique is compromise ( see Fig. 22-10F). It should be noted that a
important for successful outcomes. A simple stitch pro- running subcuticular suture does not relieve tension
vides minimal wound eversion and scant relief of wound from wound edges like a simple subcuticular stich. Pref-
tension, and should be avoided in the face. Alternatively, erably, a monofilament absorbable suture on a small half-
a mattress suturing technique is best for ensuring a curved reverse cutting needle should be used. The stich
tension-free wound closure, with eversion of the skin should be placed while everting the skin edge with a skin
edges. The suture needle should be angled outward from hook at the middle finger of the surgeon and reaching
the skin edge and the knot tied as far as possible from the suture back under the dermis 2 to 3 mm from the
the wound (Fig. 22-10A). The vertical mattress suture is wound edge. The knot should be buried. The skin should
performed by placing the innermost suture first while then be closed with fast-absorbing gut or monofilament
holding up the wound edge, causing eversion of the skin to align the depth of the two skin flaps. Skin staples
flap. The wide suture should be thrown next. There are provide wound eversion, are positioned above the level
two types of vertical mattress sutures, the Donati and of the skin when placed, and are useful for scalp and
Allgower types (see Fig. 22-10B). Bolsters of silicone neck defect closure (see Fig. 22-10G).
Vertical mattress suture Vertical mattress suture

(Donati type) (Allgöwer type)
B C
Corner stitch Corner stitch Subcuticular
D E F
Staple
G
FIGURE 22-10 A, For simple sutures, the needle should be inserted at an outward angle from the incision, with the knot tied as far away
from the incision as possible. B, To create more eversion of skin edges in a vertical mattress suture, a bolster may be placed between
the knot and the skin (C). D, To create maximum skin eversion, the Gilles half-buried stich is recommended. E, However, a simple
interrupted corner stich may be used for a triangular skin flap. F, A subcuticular stich is useful for creating skin eversion. G, Staples
provide good wound eversion for scalp and neck closure.
3 : 1 to limit dog ears (Fig. 22-11). It may be straight or

PROCEDURES crescent-shaped, but should always follow a long axis
Scar Excision parallel to RSTLs and be limited to scars shorter than
The fusiform, or elliptical, incision is the most common 2 cm.115,118,119 The only exception to this is the lower
incision used in the head and neck. It should be placed eyelid, where a crescent-shaped incision may leave an
within the RSTL, with a length-to-width ratio of 2.5 : 1 to unsightly scar. It should be used for short anti-RSTL
FIGURE 22-12 A, The skin edges at the end of the fusiform

incision should be no more than 30 degrees apart. B, If a larger
FIGURE 22-11 Fusiform, or elliptical, excisions are useful for small
angle is used, the risk of a standing cone deformity is more likely.
scars that lie parallel to RSTLs.
(From Robinson J, Hanke CW, Siegel D, et al: Surgery of the skin,
ed 2, Philadelphia, 2010, Mosby.)
scars, achieving a more favorable reorientation of the

lesion, or for short but widened or depressed scars. Inter-
nal angles of the planned excision may not exceed 30
degrees (Fig. 22-12).
An abundance of subcutaneous tissue in present in
areas such as the ear and nose because of loose cartilage,
which leads to loss of surface definition and results in
unpredictable wound healing. In these areas, the surgeon
may choose to debulk, inject steroids, or use local skin
flaps to obtain an optimal result as an alternative to stan-
dard incisions. Furthermore, the standard elliptical exci-
sion may lead to bunching or a standing cone deformity
at the end of a wound, which results from rotation of skin
around a pivot point. These can be predicted and pre-
vented by the excision of excess tissue parallel to RSTLs FIGURE 22-13 An M-plasty may be used to decrease the length of
(Burow’s triangle) that allows the cone to lie flat (see Fig. the incision needed, but requires additional incisions. (From
22-9B). If a shorter incision is needed, an M-plasty can Kaminer M, Arndt K, Dover J, et al: Atlas of cosmetic surgery, ed
be created at the end of the incision to decrease the 2, St. Louis, 2009 Saunders.)
volume of healthy tissue removal, with the additional
incisions functioning as Burow’s triangles (Fig. 22-13).
The limbs of an M-plasty should be less than 30 degrees creep, which involves elongation of the skin from con-
to avoid cone deformities; closure is performed using a stant tension over time.120 This is distinguished from bio-
V-Y maneuver. This shortens the scar length along its logic creep, which involves the generation of skin from
central axis and should be used when a longer fusiform constant tension over time and only occurs with tissue
excision would encroach along a landmark, such as the expansion techniques.121
lateral cantus or the vermillion. The compromise is that Initially described by Morestin,122 the technique of
an M-plasty requires additional incisions. serial excision is especially useful for larger scars closed
primarily with a skin graft, as well as burn injuries, and
Serial Excision uses the skin’s ability to stretch and accommodate. Serial
Serial excision is a technique that can be used when a excisions can be used to move scars to or away from a
scar is too large to allow closure of the surrounding skin more or less conspicuous facial unit or area, such as junc-
in one stage. Serial excision allows for the recruitment tions of facial units, hair lines, or RSTLs. Its goal is to
of adjacent skin through a process called mechanical recruit adjacent normal tissue to cover a defect in stages.
Skin
tension
lines
a
b
a'
Scar
b'
Outline of
W-Plasty
FIGURE 22-14 A W-plasty may be used for scars with a long axis more than 35 degrees from the RSTLs.
Serial excision should only be used on scars without 22-15). The benefit of this technique is that it will break
any suspicion of malignancy and should be performed up a long scar into smaller ones that are more aligned
as early as possible, because scar elasticity decreases with parallel to RSTLs, thus improving its overall appearance.
time. All incisions should be kept within the previous scar This technique is indicated for long scars with a long axis
and wounds should be undermined and closed under more than 35 degrees from the RSTL; it is particularly
minimal tension. useful to camouflage vertical linear scars of the forehead
The initial excision removes an ellipse from within the and temples, linear horizontal scars of the chin and
body of the scar, or from along one of its edges. Wound cheeks, and scars located along a wrinkle. W-plasty is
margins are undermined and a portion of the scar is optimal around nonanimated facial units such as the
excised after advancement and the wound is closed.123 forehead (Fig. 22-16), but is contraindicated for scars
The skin of the wound is allowed to stretch for 8 to 12 with a long axis less than 30 degrees from the RSTL, and
weeks and then the procedure is repeated. For the last should be avoided around the eyelids, nose, vermillion,
excision, the remaining scar is excised and native skin and neck (Fig. 22-17).130 Furthermore, the use of W-plasty
margins are approximated in a straight line, W-plasty, or is not recommended in the presence of excess tissue
broken line closure. One drawback of this technique is tension or distorted landmarks, and in scars involving
that it may lead to wide and atrophied scars caused by two different skin types, such the cheek and lower eyelid.
the tension across the wound.124 A variety of other serial Advantages of the W-plasty technique include reduced
excision techniques have been described in the litera- tension and simple design and execution, and it can be
ture.120,125-127 One technique divides the initial scar into used for nonlinear scars. Unlike a Z-plasty, it does not
four segments along RSTLs; two of the opposing seg- lengthen a scar. For long linear scars, a GBLC is prefer-
ments are excised. The remaining flaps are advanced in able to the W-plasty, because the repeating W pattern is
a sigmoid-shaped ellipse and the remaining incision is readily noticeable by the eye.
closed in a Z pattern. This is repeated as needed and a Technique. Standard marking for a W-plasty is shown
fusiform excision is used to for final closure. in Figure 22-18. The patient’s skin should be thoroughly
cleaned and degreased with alcohol or acetone to remove
W-Plasty surface oils and should be allowed to dry completely
Borges initially proposed the running W-plasty, so-named before marking the skin to prevent smearing of the ink.
for it resemblance to the letter W128,129 (Figs. 22-14 and Then, 1-cm segments are marked perpendicular to the
A B
C D
FIGURE 22-15 Reconstruction of post-traumatic scalp avulsion with secondary cicatricial alopecia, brow asymmetry, and hairline
deformity. Patient was managed with tissue expansion, W-plasty excision, local rotation-advancement flaps, and brow lift. A, Preoperative
appearance. B, Tissue expander in place. C, Outline of W-plasty. D, Postoperative appearance 1 year following surgery.
A B
FIGURE 22-16 Depressed post-traumatic forehead scar in 27-year-old woman treated with W-plasty excision. A, Preoperative
appearance. B, 1 year postoperatively.
long axis of the scar and the limbs are drawn using these
marks and the RSTLs as a guide. The ideal length of
W-plasty limbs should be approximately 5 to 8 mm. If the
limbs are smaller than this, they become more noticeable
and the goal of camouflaging is lost. Limbs longer than
7 mm become aesthetically unsightly. After prepping and
draping the area, and atraumatically injecting local anes-
W
thetic, a no. 11 blade is used to excise the limbs. The
limbs are incised in a punch manner, directing the tip of
the blade toward the scar to help prevent undesired
Z Z damage to healthy tissue. No part of the pattern should
Z Z cross the scar. A running set of triangles, alternating with
their base toward and away from the scar, should be
drawn out. The angle between limbs should be between
W W 50 and 60 degrees and oriented as closely as possible to
Z Z
the RSTLs. Wider angles will not appreciate the elasticity
throughout the excision seen with more acute angles.
Z
Narrower angles compromise blood supply to the tip of
the triangle. To avoid a repeating pattern, the surgeon
W should slightly vary each triangle. Each proposed limb
incision should be marked as close to the scar as possible
to minimize tissue loss. Triangles along the scar should
have their points facing the midbase of the triangles on
the other side. It is easiest to begin marking each incision
centrally on one side of the scar and then its counterpart
on the other side of the scar in sequence. Unlike doing
all of one side and then the other, this maintains wound
tension and allows more efficient excision. This should
FIGURE 22-17 W-plasty (W) should be used around nonanimated continue toward the end of the incision, finishing with a
facial areas, whereas Z-plasty (Z) is more appropriate around small right triangle with its base perpendicular to the
mobile facial landmarks. long axis at the end of the scar. Incision design in this
manner will create a 30-degree closing angle of the
wound and help minimize a standing cone deformity.
Hemostasis should be obtained before closure. In
longer wounds, it may be useful to place several tempo-
W-plasty rary skin sutures to align flap edges before placing dermal
sutures. Often, a fusiform incision may be needed at the
end of a W-plasty to reorient any anti-RSTL lines that
have formed during closure or to excise any standing
cone deformity.131 It is essential to evert wound edges at
the dermal layer with interrupted absorbable sutures
placed at the midpoint of the tips of each point of the
triangles (Fig. 22-19). Alternatively, running subcuticular
monofilament absorbable sutures may be used. Skin may
be closed with running absorbable or nonabsorbable
sutures, with careful attention to evert wound edges.
Postoperative wound care (see earlier) should be used.
To prevent scar widening, Steri-Strips may be placed
across the wound for 4 to 6 weeks after surgery because
wound tensile strength progressively increases during
this period. Dermabrasion or laser resurfacing may
usually be performed 6 to 8 weeks after the W-plasty
surgery to blend the scar with adjacent tissues.132
Z-Plasty
There is debate in the literature about who reported the
Relaxed skin tension lines first Z-plasty. Many credit Denonvilliers with describing
A B the first Z-plasty in 1854 for a case of lower eyelid ectro-
pion in a patient following a shrapnel injury.133 Others
FIGURE 22-18 A, Markings for W-plasty should be in 1-cm argue that the first true Z-plasty was reported by Berger
segments drawn perpendicular to the long axis of the scar, with in 1904.134 The goal of Z-plasty is to take a scar perpen-
limbs drawn parallel to RSTLs (B). dicular to RSTLs and align the axis of the central
Scar tissue balance for optimizing flap rotation and lengthening

and for tension-free closure while limiting flap tip necro-
sis and the possibility of a standing cone deformity at
final closure. The smaller the angle between the central
and peripheral limbs, the less chance that the resultant
scar will lengthen and a smaller amount of rotation will
be achieved. Also, the chance of necrosis of the skin flap
A tip increases as the angle decreases. Therefore, the angle
should never be less than 30 degrees. With a larger angle,
more flap rotation and longer resulting scar length is
achieved; however, with larger angles, more tension is
placed on the wound at closure and may cause a standing
cone deformity. Angles that exceed 70 degree are more
likely to result in a standing cone deformity. Increase in
scar length is usually less than predicted. This angle,
B however, can vary between 30 and 90 degrees. Generally,
30-degree Z-plasty achieves a 25% increase in length of
the axis to the central limb, a 45-degree Z-plasty achieves
a 50% increase, and a 60-degree Z-plasty achieves a 75%
increase (Fig. 22-23).
Technique. Z-plasties should be planned and marked
ahead of surgery, if possible, using a set of Castroviejo
calipers.142 If the central diagonal scar is wide, it should
be preserved and transposed rather than excised to
prevent recurrent scar widening. Similar to the W-plasty,
C a no. 11 blade should be used in a punchlike fashion to
create skin flaps, moving from side to side and undermin-
ing each flap, as described earlier. Like other techniques,
eversion of wound edges and management of the stand-
ing goal deformity will optimize wound esthetics. Closure
should be started with tension-free placement of inter-
rupted, subcuticular, dermal absorbable monofilament
sutures, with eversion of the dermis. Skin is then closed
D using horizontal mattress, or running locked absorbable
FIGURE 22-19 A, The scar is excised and undermined down to gut, or nonabsorbable monofilament sutures. Like previ-
the level of the subcutaneous layer (B). C, D, The dermis is ous techniques, wound edges should be held with skin
approximated, with eversion of its edges. hooks with only minimal tension, not forceps. Hemosta-
sis must be achieved before closure and appropriate post-
operative care should be used (see earlier).143
Many variations of the traditional Z-plasty have been
diagonal limb parallel to RSTLs (Fig. 22-20). Then, using described. Standard Z-plasty is often referred to as the
triangular flaps, a contracted or webbed scar can be stereometric Z-plasty because it will often alter tissue
lengthened, a depressed scar may be leveled, or a long depths, producing elevations and depressions. Roggen-
scar may be divided into multiple shorter segments. Its dorf144 has described a planimetric Z-plasty that produces
use is optimal around the mobile parts of the head and scar lengthening without the surface irregularities accom-
neck, such as the eye,135 ear,136 lip,137,138 nose,139 and intra- panying the traditional Z-plasty.145 The planimetric
oral mucosa scars caused by trauma and tissue loss (Fig. Z-plasty include 75-degree transposition angles, a central
22-21; see Fig. 22-17). limb half the length of the lateral limbs, and a geometric
Unlike the actual letter Z, which has a diagonal longer pattern area of excision to eliminate excess scar tissue.
than the other shorter limbs, the traditional Z-plasty has Using this technique, the peripheral arms are longer
three limbs of equal length, with the central diagonal than the central limb, which is compensated for with two
representing the original scar to be revised.140 It is ideal excisions on either end of those arms. making the angles
for revision of the scar that runs parallel to ATL (see Fig. more obtuse than with a standard Z-plasty (Fig. 22-24).
22-20B and C). Its primary purposes are simply to rotate The technique can be adapted to local skin conditions,
the long axis of the scar to a favorable position within deepithelialized excess skin can be buried to provide
the RSTL, lengthen a contracted scar, and align mis- underlying wound support, and scar line can be varied
aligned scars around important facial landmarks. The more easily, as needed, than with a traditional Z-plasty,
peripheral limbs are parallel and the angles of diver- giving the surgeon more variety.
gence from the diagonal should be equal and lie as close A multiple Z-plasty is a useful scar revision for the
to RSTLs as possible. The peripheral limbs should be of trapdoor or gouge defect, curved depressed scars, when
equal length and at an angle of 60 degrees from the there is inadequate tissue for a large Z-plasty or when the
central limb (Fig. 22-22).141 This angle will give the best arms of a single Z-plasty would encroach on another
Relaxed X
skin Y
tension
lines
Scar
X
Y
A B
X
Y
C
FIGURE 22-20 A, A Z-plasty is designed so that the central limb (the scar) of the Z-plasty (B) is reoriented to a plane parallel with
RSTLs (C).
FIGURE 22-21 Hypertrophic scar with lower

lip retraction. A Z-plasty is used to excise
and reorient the scar to elevate the
lower lip and improve lip competence.
A, Preoperative appearance. B, 8 weeks
A B
postoperative appearance.
FIGURE 22-22 A, Peripheral arms designed at an angle of 60 degrees from the central limb will give the best balance for optimizing flap
rotation and lengthening (B) and tension-free closure while limiting flap tip necrosis and the possibility of a standing cone deformity at
final closure (C). (From Robinson J: Surgery of the skin, St. Louis, 2006, Mosby)
25% Scar
30°
increase
E (excision
area)
50%
45°
increase
75° 75°
E (excision
75% area)
60°
increase
FIGURE 22-23 In general, as the angle between the peripheral and

central limb increases, so does the length of the resulting scar.
FIGURE 22-24 Planimetric Z-plasty. This includes 75-degree
transposition angles, a central limb half the length of the lateral
limbs, and a geometric pattern area of excision to eliminate
facial subunit (Figs. 22-25 and 22-26). This technique has excess scar tissue.
less tension on closure and less surface depression, eleva-
tion, and lateral distortion. It may provide even more
scar lengthening and camouflage than the traditional of more scars. This may be avoided by using serial
Z-plasty because of the smaller peripheral limbs used. Z-plasties for oblique scars of equal dimensions. Serial
The surface depression, elevation, and lateral distortion Z-plasties can be arranged in continuity or can also be
seen with a large, single-unit Z-plasty are lessened when interrupted. These are particularly useful in situations in
multiple units are used. Multiple small Z-plasty units which there is not enough surrounding tissue for trans-
may achieve additional scar lengthening and result in position if one large Z-plasty were to be designed.143,146
improved scar camouflage as compared with a single For final closure, an elliptical or fusiform excision may
Z-plasty. A drawback of multiple Z-plasties is the creation be preferred to a Z-plasty if the original scar is close to
Existing scar a
perpendicular
to RSTLs a
b
b
c c
d d
Relaxed skin
tension lines A e
e
A
c
c b
d
b
d
e
f
b d
c
a
a
a e e
B
B
FIGURE 22-27 Various combinations of Z-plasties and fusiform
Alternate limbs of excisions may be used, depending on the relationship of the
Z-plasty oriented defect to the orientation of the RSTLs. A, Two fusiform excisions
along RSTLs
and three Z-plasties are used for defects perpendicular to RSTLs.
de
f B, One fusiform excision and four Z-plasties are used for defects
bc
a parallel to RSTLs.
being parallel to an RSTL; this technique that will avoid

C triangular flaps with very acute angles and probable skin
FIGURE 22-25 A, B, Multiple Z-plasties may be designed with the
necrosis. Borges has described a combination Z-plasty
peripheral limbs at acute angles to the central limb, reorienting
and fusiform excision for U-shaped or semicircular trap-
multiple segments of the central limb to RSTLs of the face (C). door deformities.94 Segments of the scar parallel to
(From Arndt K: Procedures in cosmetic dermatology series: Scar RSTLs will benefit from fusiform excisions, whereas seg-
revision, Philadelphia, 2006, WB Saunders.) ments oblique or perpendicular to RSTLs benefit from
Z-plasty. An example of this technique would include two
fusiform excisions and three Z-plasties for defects per-
pendicular to RSTLs (Fig. 22-27A), or one fusiform exci-
sion and four Z-plasties for defects parallel to RSTLs (see
Fig. 22-27B).
A variation of this technique has been described in
which the distortion of small angled flaps is overcome by
converting a two-flap Z-plasty to a four-flap Z-plasty.147 It
is especially useful in the webbed and functionally con-
tracted neck. This technique involves marking a 120-
degree angle Z-plasty and dividing each flap into two
flaps, creating four equal 60-degree triangle flaps. This
then allows for maximum lengthening of the scar without
sacrificing ease of closure (Fig. 22-28). Before dividing a
two-flap Z-plasty, the surgeon must make sure that the
initial flaps are of large enough angles. Dividing flaps of
questionable size may compromise blood supply and can
result in necrosis to the flap tip. In general, 60 degrees
should be the smallest angle used.
To gain maximum length of the final scar, another set
of modifications has been described. This includes a
90-degree four-flap Z-plasty, lengthening the scar by up
to 111%, and a 120-degree four-flap Z-plasty, lengthening
the scar by 164%.148 Alternatively, a 90-degree six-flap
Z-plasty achieves 180% of flap lengthening (Fig. 22-29).
The surgeon should begin with a simple 90-degree
Z-plasty. If excess tension is encountered on transposi-
tion, converting to a four-flap Z-plasty is advisable. The
FIGURE 22-26 Final closure of multiple Z-plasties will reorient the six-flap Z-plasty may be considered when more length is
divided central limb to the RSTLs. (From Canale ST, Beaty JH, desired and performed after a four-flap Z-plasty is marked
editors: Campbell’s operative orthopaedics, ed 11, Philadelphia, and incised, or even after a 90-degree Z-plasty is designed,
2008, Mosby.) regardless of tension encountered.
b’
b’
d d
a
c’ c’
b a
d’
d’
c
b
a’ c
a’
A B
b’
b b b’
c’ c’
c d c
d’ d’
a
a
a’ a’
C D
FIGURE 22-28 Two 120-degree angle Z-plasties are divided into two flaps, creating four equal 60-degree triangle flaps, which maximizes
the lengthening of the scar without sacrificing ease of closure.
5 3
5 5
1 3
2 4
4
3 1 1
4 2
6 6
6 2
FIGURE 22-29 The peripheral arms of the six-flap Z-plasty may be up to 90 degrees from the central limb and may achieve up to 180%
of scar lengthening.
FIGURE 22-30 Vertical scar band of the

neck following neck dissection and
pectoralis major muscle flap reconstruction
treated with Z-plasty to lengthen tissue and
improve mobility. A, Preoperative
A B
appearance. B, Postoperative appearance.
FIGURE 22-31 The GBLC technique is used for scars parallel to ATLs. The random pattern renders the scar less conspicuous. (From
Arndt K: Procedures in cosmetic dermatology series: Scar revision, Philadelphia, 2006, WB Saunders.)
As an alternative to standard two-dimensional Geometric Broken Line Closure

Z-plasties, a three-dimensional technique may be used. The regular repeating pattern of the W-plasty can detract
These types of Z-plasties are especially useful in the from its value in scar camouflage, especially in longer
webbed neck (Fig. 22-30).149 They can turn a cleft into a scars. Initially described by Webster, the GBLC is similar
peak or depress hypertrophic tissue by incorporating to a W-plasty but relies on creating a combination of
tissue wedges into the transposed flaps. Several three- various geometric shapes (e.g., crescents, squares, trian-
dimensional Z-plasties have been described, including a gles, rectangles, trapezoids) along a scar, with corre-
five-flap technique-s such as Converse’s double-opposing sponding shapes on the opposite side to allow for precise
Z-plasty, Numanoglu’s paired five-flap Z-plasty, or Mus- closure, orienting most of the scar more parallel with
tarde’s jumping man flap. Building on these flaps is a RSTLs (Fig. 22-31).153,154 In general, W-plasty and GBLC
modification by Hirschowitz that combines a five-flap techniques are identical, with similar indications and
Z-plasty with a V-Y advancement.150-152 contraindications. The resulting pattern from GBLC is
less predictable to the observer and thus is less noticeable

than that of a W-plasty. In general, rectangles and squares HEMATOMA
produce superior results when kept small and as parallel The prevention of hematoma begins with the initial
to RSTLs as possible. Crescent shapes may result in small preoperative visit, obtaining a comprehensive medical
trapdoor defects and should be used minimally in the history, history of medication, vital signs, social history,
incision design. Each shaped segment should be between psychological status, and normal activity schedule.156
5 to 7 mm in length. Smaller segments will resemble a Patients on medications affecting the coagulation cascade
straight line, whereas larger ones will result in a more or platelet function, such as acetylsalicylic acid or warfa-
unsightly scar. rin (Coumadin), are at high risk for hematoma forma-
There are several drawbacks to the GBLC technique. tion within the first 14 days after surgery.157,158 Patients
As compared with the W-plasty, it is conceptually more with cardiovascular comorbidities may forget that they
difficult to design, is significantly more time-consuming, are taking these medications. A thorough history of
and it lacks usefulness for curved scars. In addition, by bruising and bleeding should be obtained.159 Other risk
nature of the design, some segments of the resulting scar factors for hematoma include excessive alcohol intake
will be at 90 degree to the RSTLs. Some investigators and poorly controlled hypertension. These factors
have questioned whether the outcome from GLBC is should be identified and the risks and benefits of surgery
actually more aesthetically pleasing than from W-plasty.155 discussed with patient. Intraoperative factors associated
Like the W-plasty, this technique should not be used for with hematoma formation include hemodynamic
scars less than 30 degrees to RSTLs; these scars are better instability and poor wound hemostasis. Postoperative
treated with a simple fusiform excision. factors associated with hematoma formation include
Technique. Preparation for GBLC is the same as for increased postoperative activity, nausea, and vomiting
previously described techniques; incision design is the and retching.
same as for a W-plasty, except geometric shapes instead Prior to wound closure, the wound bed and skin flaps
of running W are marked out. A random pattern of geo- should be examined for any bleeding and meticulous
metric shapes, with most being rectangles and squares, hemostasis should be obtained using local techniques,
are marked on one side of the incision and then the such as ligation of vessels and electrocautery. Surgical
other to allow the original side to key into the opposing clip placement should be avoided in the face because of
side on closure. The shapes should not exceed 7 mm in the risk of their expulsion. All dead space should be
length in the case of rectangles, triangles, or squares or eliminated by compressive closure of all wound layers.
diameter in the case of crescents or circles. The design Drains should be used whenever dead space is suspected.
is finalized by placement of a right triangle at each end Finally, pressure dressings should be used to minimize
of the scar to produce a 30-degree closing angle of the dead space formation edema from fluid accumulation.
wound, minimizing a standing cone deformity. Wounds Small hematomas may be treated with needle aspira-
should be closed with technique identical to that de tion,156 whereas large hematoma should undergo formal
scribed for a W-plasty. Wound care after surgery and wound exploration and all sources of bleeding should be
planned dermabrasion are the same as for a W-plasty. identified and stopped. Failure to treat hematomas in
Similar to patients undergoing W-plasty, patients under- promptly may result in infection, skin flap necrosis, and
going GBLC should be warned that they will experience increased scarring.
moderate to severe erythema for several months before
the scar will turn pale. Dermabrasion should be planned INFECTION
as early as 6 weeks postoperatively, just after the prolifera- Like hematoma, prevention is the best form of treatment
tive phase of wound healing and just before scar contrac- for infection. A thorough medical history that includes
ture begins.115,117,119 questions about immunologic disease and immunosup-
pressive medications should be performed in the preop-
COMPLICATIONS erative period. Infection following scar revision is rare
and follows the rate seen with other cosmetic head and
Scar revision requires meticulous planning, precision, neck procedures.160,161 Redundant tissue, electrocautery
patient cooperation, and surgical skill. Even when all char, and excess suture may act as a foreign body and
these factors are present, errors may occur; therefore, it become a nidus for infection in patients.162 When sterility
is imperative that the surgeon optimize the patient’s is compromised, such as in procedures in which the oral
chance for success. Diagnostic, planning, and execution mucosa is breached, lip and ear procedures, skin flaps
errors can result in catastrophic results following scar on the nose, skin grafts, patients with extensive inflam-
revision. The most common complications include matory skin disease, or a surgical site infection is present,
hematoma, infection, necrosis, hyperpigmentation, dis- administration of antibiotics should be considered.163,164
tortion of facial landmarks and their function, and recur- Hematoma and seroma are also risk factors for infection,
rent scar widening or contracture. Because of not only so dead space should be eliminated using the techniques
the functional and aesthetic results, but also the psycho- described earlier. The type of prep used for surgery has
logical repercussions of these adverse outcomes, the been questioned with conflicting opinions about the
surgeon is encouraged to try to prevent any unforeseen superiority of chlorhexidine- based preps165 versus
complications from occurring. Inevitably, it is not the povidone-iodine.166 Swenson and Sawyer have concluded
complication, but its management that will predict the that the use of alcohol is key for preventing surgical site
final outcome. infections, regardless of the product used.167
the treatment of hyperpigmentation.196,197 Ablative non-

NECROSIS surgical treatments include chemical peels such as
Fortunately, gross necrosis of skin following scar revision glycolic acid, salicylic acid, trichloroacetic acid, and Jess-
procedures is rare. Minor necrosis of skin flaps edges is ner’s solution; laser therapy such as blue light pho-
not uncommon. This can be avoided using the tech- todynamic therapy, fractional photothermolysis, and
niques described earlier. It results from skin flaps with neodymium-doped (Nd):YAG (yttrium- aluminum-
vascular compromise, including poorly designed skin garnet) laser have also been shown to be effective in
flaps such as small skin flaps or flaps designed without treating hyperpigmentation.
consideration for an adequate blood supply, skin flaps
without a broad enough base, excessive suturing of skin DISTORTION OF MOBILE LANDMARKS
flaps, and placing too much tension on a wound at final Trauma to mobile landmarks such as the lips, eyelids, or
closure.168 In addition, complications such as hematoma nose is not uncommon; scar revision is often difficult
formation from inadequate hemostasis or inadequate because of the constant muscle pull, tension, and motion
drain place and infection can also initiate skin flap necro- present. Unless there is a preexisting vertical asymmetry,
sis.169,170 Inadequate wound undermining and closure at revision in a vertical vector should be avoided. Treatment
the dermal level will help decrease wound dehiscence must be tailored to the patient. In general, W-plasty
and necrosis. Medical problems such as Raynaud’s disease should be avoided. Z-plasty is the preferred treatment
may contribute to wound-healing difficulties and skin around the eyelids, nose, vermilion, and neck because of
necrosis.171 In a landmark study by Saran et al, it was excess tissue tension in these areas.135,137-139
concluded that a single cigarette reduces mean blood
flow velocity to the fingers by 42%.172 Smokers have a RECURRENT SCAR WIDENING
higher incidence of skin flap necrosis,173-178 which has Scar widening will often take place within several months
been demonstrated to be caused by the effects of nico- after injury and may occur in a scar that appears to be
tine, a vasoconstrictor, on local capillary blood flow.179 healing without difficulty.198 It occurs when opposing
Local exposure to noradrenaline does not seem to affect forces such as muscle pull, elastic forces of skin, and
the incidence of skin flap necrosis.180 In the trauma external pressure are applied to newly formed collagen
patient, previous embolization of major vessels caused by before it reaches final maturity. It may take several
uncontrollable bleeding may compromise skin flaps in months before completion of collagen maturation.199
scar revision.181 Demographic factors associated with scar widening
Topical agents such as nifedipine, trolamine, and salic- include increased age and race. Location of the scar and
ylate have been found to help salvage failing necrotic amount of volume loss have severe implications on
skin flaps. However, the efficacy of these agents needs to scar widening. For example, scars around facial land-
be explored further.182 Other agents have been described marks in constant motion or those under constant
for skin flap salvage.183 Leech therapy has been shown to tension because of loss of local tissues are at risk for scar
be beneficial in the treatment of skin necrosis secondary widening. Patients should be screened for heritable
to venous congestion,184-193 but its use is also associated collagen diseases such as Ehlers-Danlos syndrome, osteo-
with complications such as Aeromonas spp. infections and genesis imperfect, cutis laxa, Marfan’s syndrome, homo-
anemia that might require a blood transfusion.194 The cystinuria, Menkes syndrome, focal dermal hypoplasia,
surgical treatment of gross skin necrosis involves débride- tuberous sclerosis, familial cutaneous collagenoma, and
ment of all compromised tissue, allowing the remaining epidermolysis bullosa, because these will contribute to
wound to heal by secondary intention. To minimize con- postoperative scar widening. When it occurs, the cause
tracture, earlier skin graft placement, a local or regional of scar widening must be determined to manage the
flap, or even free tissue transfer may be performed to deformity correctly.200
limit long-term aesthetic and functional impairment. Although there are many therapies available for hyper-
trophic scarring,201-203 there are no time- proven interven-
HYPERPIGMENTATION tions available to correct scar widening. Wide and
Sun exposure is the most common cause of hyperpig- hypertrophic scars resulting from straight linear incisions
mentation following scar revision. Hyperpigmentation are difficult to treat surgically. The most common cause
caused by sun exposure is readily preventable; all patients of scar widening is from excess skin tension caused by
should be educated to wear sunblock and protective tissue volume loss. These defects are best treated with
clothing for the first 8 weeks following surgery. First- line tissue transfer in the form of local, regional, or free tissue
treatment for hyperpigmentation includes the tyrosinase flaps, because excision and manipulation techniques
inhibitor 4% hydroquinone, twice daily.195 Hydroqui- such as fusiform scar excision, Z-plasty, or W-plasty often
none acts by blocking tyrosinase from developing melanin result in recurrent scar widening and increased scar
precursors for the production of new melanin. Essen- length. In an attempt to provide support to skin edges in
tially, it blocks new pigment formation as the new epider- the widened scar, Millard has advocated leaving a base of
mis heals following a procedure. Secondary topical scar tissue and suturing wound edges to the base to
treatments include topical retinoids such as tretinoin, diminish opposing skin flap forces on each other.204 In
adapalene, tazarotene, mequinol, azelaic acid, kojic this technique, the area of scar is deepithelialized and
acid, and arbutin.195 Over-the-counter remedies such then incised on one side down to subcutaneous tissue
as soy, licorice extracts, niacinamide, N-acetylglucosamine, (Fig. 22-32A). Using a curved scissors, the healthy wound
and green tea have been shown to be beneficial in edge away from scar is undermined to at least double the
A B C D
FIGURE 22-32 A, The epithelium of the scar is excised, leaving an exposed dermal sheet. B, A vertical incision is made through one edge
of the dermal sheet, undermining that skin edge slightly more than the width of the scar. C, The dermal scar sheet is now undermined
for a greater distance in the opposite direction (see broken line in cross-sectional view). D, An incision on the bias (diagonal) is made at
the opposite edge and carried partially through the dermis to provide an edge equal to the opposite side.
width of the scar (see Fig. 22-32B). The dermal scar sheet including a single advancement, bilateral advancement,
is then undermined in the opposite direction (see Fig. and rotational, sliding, bilobed, and rhomboid flaps.217
22-32C). An incision at a diagonal is made at the opposite Scar release will often result in tissue loss and may
skin edge and carried partially through dermis to provide cause tethering of skin to deep tissues, such as bone or
an edge equal to the opposite side (see Fig. 22-32D). The muscle, severely limiting function. These scars are often
dermal scar sheet is then advanced and sutured subcuta- caused by trauma, burns, or infection and will ultimately
neously, taking tension off the new surface closure that need tissue transfer in the form of a graft or flap. Small
is now sutured in a staggered location away from the areas of scar contracture may be released with minimally
deep closure. In the case of a depressed scar, the scarred invasive procedures such as subcision (subcutaneous
dermal sheet may be advanced to fill the defect. Wilson incisionless surgery) and subsequent injection with
has shown good success with this technique in a series of autogenous or nonautogenous fillers. Scar subcision is
patients undergoing revision surgery for widened scars.199 used to treat contracted, atrophic, or depressed scars or
deep wrinkles.218-221 It should be attempted before using
RECURRENT SCAR CONTRACTURE any filler material. It is most commonly done with a
Scar contracture of the head and neck is an especially needle that acts as a scalpel and releases fibrotic strands
difficult problem because of the aesthetic changes and within a scar, elevating the surface of the scar. Briefly, the
functional disability that it may cause in the patient. needle is introduced at an angle into the skin and then
These types of scars are especially common in post- manipulated back and forth in a lateral motion to break
traumatic and burn patients. Scar release incisions should any fibrous bands. The placement of the needle should
be placed in facial unit or subunit borders to aid in the be meticulously planned in an orientation parallel to the
aesthetic placement of skin grafts. Scar release may be underside of the dermis, because the sharp cutting edge
performed by fusiform excision, Z-plasty, W-plasty, or is a threat to deeper vital head and neck structures. Care
straight line incision. must be taken by the surgeon not to rotate the needle,
Smaller areas of contracted scar may be treated by the so that its triangular tip stays horizontal to the skin
Y-V skin flap, avoiding the need for grafting.205-213 A single surface. This procedure should be avoided in the preau-
or running Y-V flap will result in scar lengthening without ricular, temporal, and mandibular areas to avoid injuries
flap transposition. The stem of the Y must be placed to the facial nerve and major vessels. Some standard
perpendicular to RSTLs. The scar release occurs at the principles include the following: individual scars should
stem of the Y and skin is then advanced, creating a be treated using separate, multiple puncture sites and,
V-shaped defect. The triangular flap of healthy skin is when multiple scars are treated, the most dependent one
advanced to fill the defects (Fig. 22-33). Alternatively, a should be treated first. This procedure may be repeated
V-Y release may be performed, in which a V is incised and multiple times, with 3 weeks between sessions, and the
the tissue inside the V is advanced and used to bulk up procedure should be ideally performed before a weekend
an area and lengthen the long axis of the scar (Fig. or holiday for working patients.222 Following subcision,
22-34).214-216 Other simple local skin flaps may be used, there is an organization of blood in the induced dermal
Running plasty
Single flap Y-V plasty Double arrows represent length gained
FIGURE 22-33 The V-Y flap can be used in single (A)

A or multiple (B) units.
A B C
FIGURE 22-34 A, A scar is lengthened by making a V-shaped incision in the area of contraction. B, The flap is then advanced in the
direction of the arrow. C, The final closure resembles the letter Y.
pocket, followed by connective tissue formation and restoring bulk to the subcutaneous and dermal soft tissue
collagenization. Patients should be counseled about tem- structures. Dermal restoration may be achieved by col-
porary hematoma formation and bluish discoloration lagen injection, including bovine (Zyderm, Zyplast,
that will occur. This procedure has the advantage that Inamed, Santa Barbara, Calif) and autologous dermal
it can be done in the outpatient setting under local collagen (Autologen, Collagenesis Corporation, Bever-
anesthesia. ley, Mass) or, less commonly, by steroid injection.223 Sub-
cutaneous restoration of facial contour defect may be
done with autologous fat transplantation,103,104,224-226
SPECIFIC TYPES OF SCARS although some have reported conflicting long-term
results using these techniques.227 Other options for soft
DEPRESSED SCAR tissue augmentation include autogenous dermal fat
Scar depression usually occurs secondary to loss or grafts and acellular dermal grafts (AlloDerm, LifeCell,
atrophy of subcutaneous or dermal layers, and therefore Branchburg, NJ). These materials may result in a
is not amenable to traditional surgical techniques (see longer lasting improvement of depressed facial scars but
earlier). Management of the depressed scar involves they are implantable rather than injectable and may be
Extended C-shaped incision and release for medial eyelid ectropion
A B
FIGURE 22-35 A, Extended C-shaped incision and release for medial eyelid ectropion (B).
technically more difficult to use.228 The use of these mate- lamella, which consists of the skin of the eyelid and orbi-
rials will be discussed later in the chapter. Previously cularis muscle. It usually occurs as a result of facial trauma
described minimally invasive techniques, such as subci- and may be associated with orbital fractures, facial burns,
sion, are also useful for the management of depressed or chronic dermatitis, or as an iatrogenic result of exces-
scars.218 sive skin excision during cosmetic blepharoplasty. It may
involve the upper or lower eye lids, or both. It may be
ELECTRIC BURNS medial or lateral and may shorten the eyelid vertically or
The treatment of electrical burns is challenging because horizontally, or both. In general, the goal of ectropion
the resulting scar often spreads from the skin at the point repair is to restore the original size and position of dis-
of contact to the periphery and generally has an indis- torted tissues and to replace lost tissue with similar
tinct end point of collateral damage.229 In the head and tissue.240 Anterior lamellar reconstruction is best achieved
neck region, these scars often occur when a child sucks using full-thickness skin grafts or local skin flaps.
on the female end or junction of an extension cord, or Extrinsic medial ectropion may be caused by scarring
when a child chews on the end of a poorly insulated wire. of the nasal dorsum, resulting in anterior and medial pull
Generated by a temperature of up to 2500 to 3000° C of the medial canthus. The result is epicanthal folding,
(≈4500° to 5400° F), electrical burns initially appear as a exposure of the cornea, and epiphora. Scar release in
grayish-white coagulated lesion with an erythematous this area involves a C-shaped excision of scar tissue from
rim. After 2 to 4 weeks, an eschar will slough off, leaving the upper and lower eyelids and lateral nose (Fig. 22-35).
an ulcerated area. This area will slowly be replaced by The resulting defect is then grafted with a full- thickness
fibrous connective tissue and undergo maturation. In skin graft. Skin over the nose adjacent to the release inci-
addition to unsightly scarring, fibrosis and scar contrac- sion should be undermined to allow maximal release; the
ture may occur with head and neck burns, which can be periosteum overlying the frontal process of the maxilla
debilitating to the patient by causing trismus, dysphagia, is excised to allow for graft adherence to bone. The use
dysarthria, or changes in facial expression. of a full-thickness skin graft is preferred here to minimize
Early splint therapy is important to relieve and prevent contracture. In addition, medial canthopexy may be per-
microstomia for patients with perioral burns. Patients will formed, if needed.241
often need multiple débridements of scar tissue.230-236 As with other mobile facial landmarks, the Z-plasty is
The initial surgical goal is to line up the vermilion. Then, optimal for treating scarring around the eye and should
if possible, fusiform scar excision or Z-plasty may be per- be considered for the treatment of lateral ectropion (Fig.
formed. Z-plasties may be used extraorally and intraorally 22-36). The advantage of the Z-plasty is that it transposes
to relive contracture and lengthen scars. Dermabrasion retracted lower eyelid tissue superiorly and posteriorly,
of skin may follow to relieve any skin surface resulting in better adaptation of the lid margin to the
irregularities. globe (Fig. 22-37).133,242
Intrinsic contracture of either eyelid and associated
EYELID ECTROPION vertical shortening may be approached with a supracili-
There are several types of eyelid ectropion, including ary or subciliary incision.243 The incision should extend
congenital, senile, neurogenic, and cicatricial.237-239 Cica- just short of the lateral and medial canthi. Skin flaps are
tricial ectropion results from scarring of the anterior raised and the upper or lower eyelid is approximated.
The skin flap is then undermined and the underlying position of the lid crease may be limited by the position
stable pretarsal orbicularis oculi is used as a graft bed. A of the incision. The eyelids may be separated immedi-
full-thickness skin graft is applied in the area of tissue ately or in a delayed fashion. If indicated, a C-shaped
loss. The advantage of this technique is that the tarsus release of skin can be combined with the approach.241
acts as a splint, limiting contraction of the graft, and the Unlike upper eye lid ectropion, which usually is caused
by scarring in the forehead and temples and is generally
repaired with scar release and grafting, lower eye lid
ectropion repair is more complex. Restoration of its
underlying tissues is crucial to prevent recurrence. The
lower eyelid has almost no excess tissue, so only a small
degree of scarring may cause retraction of the lower
eyelid.244 A number of techniques have been described
to correct lower eyelid ectropion. Management should be
tailored to the specific injury (Fig. 22-38). One approach
involves subperiosteal release of all extrinsic and intrinsic
components, with mobilization of the lower eyelid and
grafting as necessary. A subciliary incision with a lateral
canthotomy is performed, occasionally combined with a
transoral vestibular approach, which facilitates subperi-
osteal dissection from the zygomatic arch to the pyriform
rim, down to the alveolus. After release of the lower
eyelid, a middle lamellar graft harvested from the hard
palate or conchal bowel is secured superficially and infe-
riorly to the tarsal plate, if necessary. The orbicularis oris
is then dissected, redraped over the lower eyelid, and
sutured to the lateral orbital rim and lateral nasal wall.
Medial and lateral canthopexy is completed, and a skin
graft is placed.245,246 If skin is missing, a variety of local
skin flaps may be used in lieu of skin grafts .242,247,248 In
addition, autologous or allogenic dermis–only grafts may
be used for the correction of lower lid retraction in which
a spacer is needed but stiffness is not a concern. These
FIGURE 22-36 Z-plasty for lateral lower eyelid ectropion, grafts are associated with low donor site morbidity, but
transposing the retracted lower eyelid tissue superiorly and may undergo more contracture than split-thickness skin
posteriorly, and acquiring better adaptation of the lid margin to grafts. The drawback of acellular allogenic dermis grafts
the globe. is that they are associated with significantly more
A B C
FIGURE 22-37 Post-traumatic cicatricial ectropion, managed with scar excision and primary skin grafting with Z-plasty and lateral
canthopexy. A, Initial post-traumatic appearance, age 8 years. B, Preoperative appearance, age 13 years. C, 1 year postsurgery, age 14
years.
FIGURE 22-38 Lower eyelid ectropion and

retraction following repair of comminuted
orbital fracture and associated periorbital
lacerations. Ectropion repair consisted of
transconjunctival cantholysis and
orbitotomy, removal of previously placed
hardware, subperiosteal midface lift, and
lateral canthopexy. A, Preoperative
A B
appearance; B, 6 months postoperatively.
contracture than full-thickness skin grafts and are show Radiation therapy with or without surgical excision
significant degration by 4 months postoperatively.249,250 has been advocated for the treatment of keloids. One
For conjunctival reconstruction, the use of amniotic reported protocol has called for keloids of the earlobe
membrane transplantation has been described, with to receive 10 Gy in two fractions over 2 days, and other
some success.251,252 The advantages of these grafts over sites of the head and neck to receive 15 Gy in three
oral mucosa grafts include less donor site morbidity and fractions over 3 days. Surgical excision is performed and
the structural arrangement of collagen and lamina is adjuvant radiation therapy is initiated on postoperative
similar to that of the conjunctiva, providing an excellent day 1 or 2. The reported recurrence rate with this proto-
scaffold for proliferating conjunctival cells. col was 14% at 18 months of follow-up. A side effect of
this procedure is hyperpigmentation of the irradiated
HYPERTROPHIC SCARS AND KELOIDS area. To prevent this complication, investigators have
Keloids are defined as scars that extend beyond the edges recommended that steroid ointments be applied to the
of the original wound or incision, invading surrounding surgical site, reducing the radiation dose, or increasing
normal tissue,253,254 and affect an estimated 1.5% to 4.5% the time between radiation sessions.264 Malignant trans-
of the population.255 Hypertrophic scars, on the other formation is rare but has been reported.
hand, are elevated scars that remain within the original The use of lasers has been advocated for the treatment
tissue injury site.256,257 Both hypertrophic scars and keloids of keloids and hypertrophic scars. Although the argon,
result from alterations in normal cutaneous wound CO2,265,266 and Nd : YAG lasers267,268 have been found to be
healing that include the proliferation of the dermal of little benefit, the flashlamp-pumped pulsed dye laser
tissue and excess deposition of fibroblast-derived extra- (PDL) has shown good results, with significant improve-
cellular matrix (ECM).258-260 In normal wounds, there is ments in contour, texture, color, pliability, and pain relief
a decrease in cellularity mediated by apoptosis during and minimal side effects.57,269-271 Early PDL treatment may
the transition from granulation to scar tissue. In hyper- fundamentally change the physiology of wound healing
trophic scars, however, granulation tissue does not regress by reducing scare microcirculation and preventing excess
and alpha smooth muscle actin-expressing myofibro- scar formation.272,273
blasts produce excess ECM, resulting in a red, raised Intralesional corticosteroid injection is a common
rigid scar.261,262 These scars may develop only weeks after treatment modality for keloids and hypertrophic scars.274
injury. Dark-skinned individuals are at increased risk for It has been shown to reduce scar volume significantly and
keloid formation, with the earlobe and cheek being the increase scar pliability and height while reducing symp-
areas usually affected.263 Keloids may be symptomatic and toms such as pruritus and pain in the patient with
cause pain, but hypertrophic scars may be painless and keloids.57,275 It works by three primary mechanisms: (1) by
fade over time. suppressing inflammation by inhibiting leukocyte and
Surgical excision of keloids is characterized by recur- monocyte migration and phagocytosis; (2) by causing
rence and is generally avoided in the absence of pain or vasoconstriction, therefore reducing the delivery of
dysfunction.80 If excision is performed, care should be oxygen and nutrients to the wound bed; and (3) by exhib-
taken so that the tissue is handled in an atraumatic iting an antibiotic effect on keratinocytes and fibroblasts,
manner, using skin hooks to minimize trauma to skin slowing reepithelialization and new collagen forma-
flaps, and results in a layered, tension-free closure. tion.276 Insoluble triamcinolone acetonide (10 to 40 mg/
mL) is the most common steroid used in scar treatment.268 imiquimod, tacrolimus, onion, adhesive tape support,
The use of a topical and/or local anesthetic is recom- vitamin E, and massage.256,264,269 Pressure garments have
mended prior to injection. The steroid is ideally injected been popular in the past, but studies have shown these
into the superior dermal layer, the papillary dermis, which treatments to be minimally effective.306 Furthermore,
is where steroids promote collagenase activity. Injections their use is associated with problems such as nonadher-
may be repeated twice monthly and may be combined ence, patient discomfort, eczema, rashes, pruritus, and
with surgical excision. Following surgical excision and ulceration from excessive pressure and friction.307
primary closure, steroid may be injected into the wound Massage of the scar has also been advocated as a
and its edges.277 Side effects include short-term hypopig- method of minimizing scar prominence. Keloids and
mentation and injection pain.57,278 Long-term side effects hypertrophic scars contain a considerable amount of
include skin and subcutaneous fat atrophy, telangiecta- ground substance, which is composed of glycoproteins
sias, scar widening, and rebound effects.279 Topical ste- and glycosaminoglycans. This ground substance is fluid
roids have not been shown to be effective for the treatment and can be displaced by pressure; therefore, massage of
of hypertrophic scars or keloids.280,281 these scars can reduce swelling from a reduction in ground
Silicone gel has shown some success in the treatment substance. The reported benefits of massage include
of hypertrophic scars and keloids. First used in the increased scar pliability and decreased scar banding308;
1960s,282 and rediscovered in the 1980s253,283-285 for the however, there is little evidence to support these find-
management of burn scars, silicone materials, including ings.309 Scar massage appears to have little to no effect on
creams, gel sheets, Silastic sheets, and garments, have the vascularity, pliability, and height of the hypertrophic
become popular for the prevention and treatment of hyper- scar but it has been shown to reduce pain and itching.310,311
trophic scarring and burns. Their use has been shown to Emerging nonsurgical therapies are being developed
reduce scar height and hardness, and increase scar pli- that exploit an association of TGF-β with hypertrophic
ability; they may be used for several years after injury.47,49,286- scar formation57,312,313 in an effort to alter the scar forma-
288
The usefulness of silicone sheeting may be greatest in tion cascade. Cryotherapy with liquid nitrogen causes
children because it is noninvasive and painless. Better ischemic necrosis and has shown to improve or com-
effects have been shown with early treatment and their pletely regress keloids in significantly 51% to 74% of
use should be started 2 weeks after wound healing. Treat- patients after two or more sessions.274,314-316 To avoid
ment usually lasts 6 to 12 months; patients are advised to potential drawbacks of classic cryotherapy, such as skin
wear the silicone material for the entire day and only atrophy, pain, and hyperpigmentation, intralesional
remove it for cleaning. Each sheet lasts 2 to 3 weeks and needle therapy has been developed and shown to be
the adherent types seem to work better than others.279 effective in the alleviation of symptoms.
A review and meta-analysis has assessed the effects of Shave excision has been shown to be an effective treat-
silicone sheeting in preventing and treating hypertro- ment for keloids317,318 and may be considered in elevated
phic scars and keloids following surgery, using the pooled scars.319 The purpose of shave excision is to flatten the
results of randomized controlled trials (RCTs).289 The scar so that it is level with surrounding tissues, making it
investigators found that silicone sheeting reduces the less noticeable. It may be performed with a scalpel or a
incidence of keloid and scar formation by approximately razor blade (Fig. 22-39). The wound is allowed to heal by
55% in patients prone to scarring following surgery when secondary intention. It can be combined with dermabra-
compared with no treatment, and that silicone sheeting sion or laser resurfacing. It has been found to be an
produces a significant reduction in scar thickness while exceptionally effective treatment when combined with
significantly improving scar color. However, it was noted 5% imiquimod cream for keloids of the ear. Following
that most of the RCTs studied were of poor quality and shave excision, patients are treated with imiquimod 5%
possibly biased. Although most research has focused on cream nightly for 2 weeks and then three times weekly
the efficacy of gel sheets, semiliquid gels have also been under occlusion for 1 month. Shave excision is associated
evaluated. Their advantage is that they are composed with complications such as a high rate of recurrence, scar
of a clear material that adapts to the underlying skin, depression, and hyperpigmentation.320 Mustoe et al have
producing a more inconspicuous appearance than the provided an algorithm for the management of various
sheets.253 Silicone gel may be used for 12 to 24 hours, types of hypertrophic scars57 (Fig. 22-40).
washed off, and reapplied.290 Because silicone sheets have Despite much interest and a century of work on the
a water vaporization rate lower than that of skin, water problem of keloids and hypertrophic scarring, results of
accumulation may cause skin maceration.291 Other com- treatment remain generally unsatisfying. A meta-analysis
plications include pruritus, skin breakdown, skin rash, a by Leventhal et al has concluded that all currently avail-
foul smell from the gel pad, and poor durability of the able treatments for keloids and hypertrophic scars dem-
sheet.282,292 onstrate only minimal improvement when compared
Other nonsurgical options for keloids and hypertro- with no treatment.80 In addition, they found no differ-
phic scars include dermatography,268,274 intradermal epi- ence in scar improvement among any of the treatment
catechin gallate injections,293 the ThermaCool TC system, modalities assessed.
which uses radiofrequency waves (Thermage, Hayward,
Calif),294 adhesive tape support, subdermal injection of RESURFACING PROCEDURES
interferon-α2b (IFN-α2b),295,296 verapamil,296,297 hyal-
uronic acid,298-300 5-fluorouracil,301,302 collagenase,303 bleo- Facial skin resurfacing is performed to treat scarring
mycin,304 madecassol and alpha Centella cream,305 above the skin level, scars with an irregular surface area,
Syringe
A B
No. 15 blade scalpel
Forceps
E
FIGURE 22-39 A, An elevated scar should be anesthetized with local anesthesia at the periphery of the lesion and, using a scalpel or
razor blade (C) and forceps (D), the lesions is excised (E). (From Nouri K, Leal-Khouri S: Techniques in dermatologic surgery, St. Louis,
2003, Mosby,)
acne scars, and scars resulting from abrasions and tattoos combination of 14% salicylic acid, 14% lactic acid, and
caused by debris remaining in tissues following primary 14% resorcinol in an alcohol solution, known today as
repair. However, they may also be used to blend depressed Jessner’s solution.321
scars with surrounding normal tissue by reducing the In general, for larger treatment areas, the entire facial
height of adjacent normal tissue. Skin resurfacing proce- subunit, unit, or face should be treated to blend final
dures treat lesions no deeper than the boundary of the color and texture. These procedures are best performed
epidermis and dermis and aim to produce a smoother early in the healing process, from 6 to 9 weeks after tissue
scar that blends in with surrounding tissues. injury, because during this time there is a high degree of
The concept of facial skin resurfacing was used by the intrinsic fibroblastic activity. When treating nonfacial
ancient Egyptians as a procedure whereby they used skin, the surgeon should always be cautious and conser-
lactic and alpha-hydroxy acids to produce from sour vative with all ablative techniques because the lack of
milk, which was applied to the skin as a way to restore its pilosebaceous units outside the face and upper neck
youthful appearance321; the same concept was used later reduce the regenerative capabilities of skin throughout
in the French revolution, when aged wine was used for other areas of the body. There are a variety of resurfacing
the same purpose.322 The most significant innovation in procedures currently in use (see Box 22-2), generally
the modern era of facial resurfacing was developed by classified according to the depth of tissue affected—
Max Jessner, who reported the application of a superficial, medium, or deep. Superficial resurfacing
Scar
Classification
Immature Linear hyper-

Major high Widespread burn
hypertrophic trophic (surgical/ Minor keloid
risk keloid hypertrophic
(red, slightly traumatic) scar (red/raised)
(dark/raised) scar (red/raised)
raised) (red/raised, itchy)
Apply prevention Silicone gel sheeting (2 months)

algorithm. Progress
to treatment as a
hypertrophic scar
Initial Steroid injections 2.5 - 20 mg/mL (face)
if erythema
management 20-40 mg/mL (body). Repeat monthly.
continues for more
than 1 month
Localized pressure therapy if possible Speciality

(duration 3-12 months) burns unit
Pressure Pressure
Specific wavelength laser therapy
therapy garments and/or
silicone gel
sheeting
Secondary Surgery with adjunctive silicone gel (duration 6-12
management sheeting (two months) months)
Department specializing in scar therapy

Combination / Monotherapy
Primarily: steroids, silicones, pressure therapy, surgery/grafting
Occasionally: cryotherapy, radiotherapy, laser, other therapies
FIGURE 22-40 Algorithm for the treatment of scars. (Adapted from Mustoe TA, Cooter RD, Gold MH, et al: International clinical
recommendations on scar management. Plast Reconstr Surg 110:560–571, 2002.)
affects the papillary dermis, medium-depth resurfacing hypopigmentation regardless of the procedure. An
affects the upper reticular dermis, and deep tissue resur- erbium (Er):YAG laser may be better suited for types V
facing affects the midreticular dermis. and VI skin types because it is associated with less thermal
damage.325 The degree of photoaging should be consid-
PREOPERATIVE CONSIDERATIONS ered. The Glogau classification (see earlier, Table 22-5)
The patient’s Fitzpatrick skin type and response to sun provides a measure of photoaging that occurs as a result
exposure should be considered prior to facial of exposure to ultraviolet light (UV) radiation, specifi-
resurfacing.105-107,276,323 Hypo- and hyperpigmentation cally UVB (290 to 320 nm) and UVA (320 to 400 nm),
changes are rarely associated with skin types I and II; with wavelengths that penetrate the dermis and cause
therefore, all types of facial resurfacing procedures are photodamage.110,326 Resorption of elastin and collagen
considered safe in these patients. However, patients with leads to a prominent epidermis that rests on a thin
type I or II skin are usually best treated with lasers. Some damaged epidermis, resulting in wrinkle formation.
type III or IV patents may benefit from a medium-depth A complete medical history should be obtained and a
chemical peel. Before treating types IV to VI patients, the physical examination performed on any patient consid-
selected procedure should be performed as a test spot at ered for facial resurfacing. Patients with medical comor-
the hairline to assess pigment changes prior to a defini- bidities, such as systemic lupus erythematosus, active
tive procedure.324 The data regarding the appropriate herpetic infections, Ehlers-Danlos syndrome, sclero-
treatment for type V or VI patients is conflicting because derma, vitiligo, discoid lupus, and ectodermal dysplasia,
they are always at risk for hyperpigmentation and/or are at an increased risk of scarring following facial
resurfacing.325 Patients with lupus in particular are at III or IV skin may also be pretreated with a modified
increased risk for developing Koebner reactions follow- Kligman formula (0.1% tretinoin, 4% hydroquinone,
ing a resurfacing procedure.327,328 Immunocompromised and 0.1% triamcinolone) twice daily for 6 weeks in an
patients such as those with human immunodeficiency effort to minimize the risk of pigment change.349,350 This
virus (HIV) infection or those undergoing chemother- regimen is usually resumed in 2 to 3 weeks postopera-
apy are at increased risk for developing postoperative tively. If the formula is too irritating, kojic acid can be
infections.329 Patients who have received chemotherapy substituted for hydroquinone.332,333
or radiation to skin in the past should not have surgery The patient should be advised to wear comfortable
until 6 months after therapy to ensure that dermal col- clothing on the day of the procedure. The patient should
lagen remodeling is complete. In addition, patients with remove all makeup and then wash the face and neck with
previous radiation therapy may have chronic dermatitis, an antibacterial soap such as chlorhexidine gluconate
which decreases the body’s ability to heal.330 Previous (Hibiclens). Preoperative photographs should be taken.
areas of radiation should be examined for intact hair If lasers are being used, the appropriate eyewear should
growth. The presence of hair usually correlates with be applied. For chemical peels, moist gauze should be
enough pilosebaceous glands for adequate healing after applied to both eyes and the skin should be scrubbed
medium or deep chemical peels. with acetone or other cleanser for 2 to 3 minutes to
A complete medication history is also crucial to deter- remove the stratum corneum and allow deep penetra-
mine in the patient undergoing resurfacing. Women tion. Petrolatum or other ointment is then applied with
taking birth control pills or supplemental hormones are a cotton-tipped applicator to the deep grooves or rhyt-
at increased risk for hyperpigmentation. Patients with a ides (wrinkles) of the face to prevent chemical buildup
history of isotretinoin are at increased risk for postpro- in these areas. A fan blowing on the patient will decrease
cedure scarring following ablative procedures because patient discomfort throughout this process.
the drug is thought to shut down the pilosebaceous unit
(sebostatic), which is necessary for reepithelialization,
and may contribute to delayed wound healing. It is also SPECIFIC TECHNIQUES
thought to cause loss of collagenase function, which will Chemical Peels
cause increased fibrosis and scarring.331 If patients taking Of all resurfacing procedures, chemical peels may offer
isotretinoin complain of dry skin or anhidrosis, treat- the least benefit for post-traumatic scarring. Because of
ment should be avoided for at least 6 months to 2 the irregularities of the scar, it is hard to control the
years.325,332-335 The use of vitamin E should be noted and depth of penetration using chemical peels. This tech-
its use should be discontinued prior to resurfacing. Medi- nique, however, may be a useful adjunct for blending the
cations that affect the coagulation cascade such as aspirin margins of a scar previously treated by surgical revision,
or warfarin should also be discontinued if not otherwise dermabrasion, or laser therapy.
medically contraindicated. Chemical peeling is the application of a chemical
Patients undergoing perioral resurfacing treatment or exfoliant to the epidermis and dermis for removal of
those with a history of herpes infection should receive superficial lesions. Its goal is to improve the texture of
antiviral chemoprophylaxis. This is especially important skin and remove irregularities. New epidermal growth is
in trauma patients because they are at an increased stimulated by removal of the stratum corneum with more
stress level and increased risk for viral activation. Patients superficial chemical peels. Medium chemical peels stim-
undergoing CO2 laser resurfacing are at increased risk ulate an inflammatory response, leading to new collagen
for herpes infection. Patients may be prescribed valacy- formation in the deep reticular dermis; deep chemical
clovir, 500 mg twice daily, acyclovir, 400 mg three times peels stimulate ground substance formation.351 Fitzpat-
daily, or famciclovir, 250 mg twice daily.336 Prophylaxis rick skin types I and II patients have little risk for dyspig-
should be initiated at least 24 hours before the proce- mentation, whereas type III or VI skin has an increased
dure and continued for 2 weeks, or until reepithelializa- risk for hyper- or hypopigmentation following a chemical
tion is complete. Because the virus only creates lesions peel.352,353 Pigment changes are usually not of concern
in the epidermis in the early stages of wound healing, for superficial chemical peels, but have a higher inci-
herpetic lesions will manifest as superficial erosive dence in medium and deep chemical peels. Specific
ulcers.337-339 It is best to avoid ablative procedures during areas at risk include the lips and eyelids. Patients with
the summer because there is an increased risk of postin- extensive photodamage may require stronger chemical
flammatory hyperpigmentation caused by UV damage.340 peels with greater frequency.
After skin preparation, the chemical to be used is
PATIENT PREPARATION applied with one or two cotton-tipped applicators, gauze,
Topical tretinoin has been shown to be efficacious in large swabs, or a fan-shaped sable hair brush in a rapid
the treatment of photodamaged skin by increasing type and uniform manner for approximately 1 minute. It can
I collagen formation and inhibiting collagenase,341-346 be done superior to inferior, or medial to lateral, and
and it potentiates the effects of superficial chemical should be applied to the following facial units—the man-
peels and hydroquinone in melasma treatment.347 Pre- dible, chin, temples, upper lip, cheeks, glabella, nose,
treatment with topical tretinoin in the form of 0.1% and forehead—taking care to feather the chemical into
tretinoin cream for 2 weeks prior to 35% trichloroacetic the hair and jawline. Increasing pressure and number of
acid (TCA) peels has been shown to enhance the applications increase the depth of penetration. Frosting
healing time as well.348 Patients with Fitzpatrick type of the skin often occurs and is an indication of the
evenness of the peel. Duration of chemical contact is 14 g salicylic acid in 95% ethanol to make a total of
determined by the condition being treated, patient toler- 100 mL.321,362,363 It is useful for the treatment of dyspig-
ance, desired depth, and/or predetermined end point. mentations of the head and neck. In the immediate 2 to
Skin pretreated with tretinoin will frost faster, whereas 3 days after application, pigmented tissue may appear
photodamaged and highly sebaceous skin frost slower. hyperpigmented, with peeling and flaking up to 7 days
Types of Chemical Peels. Chemical peeling agents can after treatment. After standard application, Jessner’s
be categorized based on their depth of penetration. They solution is neutralized by its chemical reaction with epi-
are classified as superficial, medium, or deep. dermal proteins. Superficial chemical peels can be per-
Superficial Chemical Peels. Superficial chemical peels formed with one to ten coats of Jessner’s solution, applied
work by exfoliating down to the level of the stratum as three coats per session in 5- to 15-minute intervals.
corneum (Table 22-6). They are of little use in the post- Other superficial chemical peels include beta-hydroxy
traumatic setting and usually need to be applied more acid, salicylic acid (o-hydroxybenzoic acid), and resor-
than once for desired effects. Alpha-hydroxy acids (AHAs; cinol (m-dihydroxybenzene); however, their use in post-
e.g., glycolic [2-hydroxyethanoic] acid and lactic traumatic scarring is limited.
[2-hydroxypropanoic] acid) are naturally occurring com- Medium Chemical Peels. Medium-depth chemical
pounds that cause epidermolysis with discohesion of the peeling agents penetrate and destroy the epidermis, pap-
keratinocytes of the stratum corneum; they are commonly illary dermis and, in some cases, the reticular dermis.
used for superficial chemical peels.354-356 Strength and Medium-depth peeling agents are most useful for treat-
depth are dependent on the amount of buffering or neu- ing fine rhytides, hyperpigmentation, actinic keratosis,
tralization of AHA. Therefore, a solution of 30% glycolic dyschromias, Fitzpatrick type 2 photoaging, acne scars,
acid in a buffered solution may be equivalent to 15% gly- and depressed scars. Medium peels are optimal for
colic acid in a more acidic pH preparation. Immediate blending photoaged skin after deep chemical peels and
neutralization of AHA should take place after frosting, laser resurfacing. Unlike superficial chemical peels, only
followed by a water rinse. This may be repeated weekly or one treatment session is often necessary. Recovery time
monthly until desired results are obtained. Typical AHA is usually 7 to 10 days. In addition to the agents described
regimens include applying glycolic acid at a concentra- earlier, pyruvic acid, an alpha-keto acid that converts to
tion of 30% to 50% for 1 to 2 minutes. For a deeper super- lactic acid, is useful for medium-depth chemical peels.364
ficial peel, glycolic acid at a concentration of 50% to 70% It works by epidermal lysis and penetrates the dermis in
is applied for a duration of 2 to 20 minutes may be used. 1 to 2 minutes. Water may add comfort but does not
TCA is a useful treatment for superficial problems neutralize the pyruvic acid. Edema and erythema will be
such as melasma, superficial acne scarring, actinic kera- present following its application, with crusting that will
tosis, rhytides, and postinflammatory hyperpigmentation last approximately 10 days. TCA at a concentration of
associated with trauma.357-361 It works by causing coagula- 50% is associated with complications such as scarring.
tion necrosis of epidermal and dermal proteins. Depth Therefore, combinations of agents are commonly used
of penetration varies with concentration. The desired for medium chemical peels, such as the following: 70%
concentration is obtained by mixing TCA crystals with glycolic acid for 3 to 30 minutes, followed by 35% TCA365;
100 mL of distilled water. For example, 15 g of TCA crys- Jessner’s solution followed by 35% TCA366,367; solid CO2
tals mixed with 10 mL of distilled water makes A 15% followed by 35% to 50% TCA or pyruvic acid363; and
TCA solution. The solution may be stored in a dark glass Jessner’s solution and glycolic acid (Box 22-3).368 Medium-
bottle for up to 6 months. After standard application, depth chemical peels may be combined with CO2 laser
neutralization with a cool water mist should take place therapy, which reduces healing time and minimizes resid-
after a frost appears. Reapplication may take place, with ual scarring.369 Within approximately 3 months after a
35 minutes between coats. For a very superficial peel, medium-depth chemical peel, thick bands of elastic
TCA at a concentration of 10% applied for 1 to 2 minutes fibers are evident in the mid to upper dermis.370 In addi-
may be used. For a deeper superficial peel, TCA at a tion, there is an increase in glycosaminoglycans and
concentration of 10% to 30% for 1 to 2 minutes may be ground substance in the dermal matrix, which hydrates
used. Concentrations may be increased by 5% with each and thickens the matrix-inhibiting wrinkling. Dermal
application and may be used weekly to monthly for
desired effect.
Jessner’s solution, which is also known as the Combes
formula consists of 14 g resorcinol, 14 g lactic acid, and
BOX 22-3 Agents Used for Medium Chemical Peels
Combination of Either:
TABLE 22-6 Agents Used for Superficial Chemical Peels • 35% TCA and Jessner’s solution
• 35% TCA and solid CO2
Agent Concentration Mechanism of Action
• 35% TCA and 70% glycolic acid
TCA 10%-30% Protein precipitation 89% phenol*
Jessner’s solution Standard formula Keratolysis TCA, 50% concentration†
Glycolic acid 30%-70% Epidermolysis
*Mainly used for deep chemical peels.
Salicylic acid 5%-15% Keratolysis †
Rarely used because of scarring.
collagen is not finished reorganizing for 60 to 90 days; Infection, which may be bacterial, viral, or fungal, may
therefore, repeat medium-depth chemical peels should result in prolonged formation of granulation tissue.
not be done for at least 3 months after the initial session. Symptoms of a postpeeling infection include fever, pain,
Deep Chemical Peels. Deep peeling agents cause and discharge. Infections may lead to significant scarring
destruction of epidermis, papillary dermis, and extend and, when suspected, the skin should be cultured and
into the reticular dermis. The primary agents used in treated without delay. Milia, or small inclusion cysts, may
deep peels are TCA at a concentration higher than 50% occur during healing and are best treated with extraction
and phenol (carbolic acid). The latter agent penetrates using a no. 11 blade. Preoperative and postoperative
to the midreticular dermis. Baker et al have used a com- tretinoin has been shown to reduce the incidence of
bination of 3 mL of 88% phenol, 2 mL of water, 8 drops milia formation.346
of hexachlorophene (Septisol) liquid soap, and 3 drops
of croton oil for deep chemical peels.371,372 Histologically, Dermabrasion and Microdermabrasion
phenol-treated skin shows a thicker, more organized Dermabrasion and microdermabrasion work by mechani-
connective tissue in the dermis, and a finer network of cally removing the epidermis along with the papillary or
elastic fibers than normal skin, which contributes to less upper reticular layer of the dermis and are considered as
wrinkles.373-375 Phenol is cardiotoxic, hepatotoxic, and medium to deep resurfacing procedures.377,378 They may
nephrotoxic and is contraindicated in patients with be used as soon as 6 weeks following injury, with almost
cardiac arrhythmias.376 Preoperative electrocardiogra- complete disappearance of some scars treated at this time,
phy, complete blood count, and electrolyte panel should and have similar outcomes to the use of lasers for the
be performed before planning a phenol peel. treatment of perioral rhytides but are associated with less
To reduce toxicity, perioperative IV fluids are admin- postoperative crusting and more rapid reepithelialization
istered to the patient undergoing a phenol peel. The of the skin.379,380 They work by increasing the density of
phenol is applied until a frost appears. Each facial unit types I and III collagen and TGF-β in the papillary dermis
should be treated 10 to 15 minutes apart, for a total treat- and reorienting collagen to a more parallel plane to the
ment time of 1 hour. Immediately following the pro axis of the epidermis, which arises from the deeper, less
cedure, a dusky erythema will develop over the initial photodamaged cells.381-384 In addition, upregulation of
12 hours, with an accentuation of pigmented lesions tenascin expression throughout the papillary dermis and
and exudative crusting forms. This crusting should be an increase in a6b4 integrin subunits of keratinocytes of
débrided with soaks, compresses, or occlusive salves. The the stratum spinosum are seen on histologic examina-
goal is to remove the crust and prevent it from hardening tion.385 They have been shown to be equally or more effec-
to form a scab. Reepithelialization after a phenol chemi- tive than 5-fluorouracil (5-FU) in the treatment of actinic
cal peel begins after 3 days and continues until 14 days keratosis and other premalignant lesions.346,386
postoperative. Erythema may be present for 2 to 4 Indications for dermabrasion related to trauma
months. Neoangiogenesis and new collagen formation include the treatment of post-traumatic keloids, and
may take place for up to 4 months during the final stages hypertrophic or depressed scars378 Dermabrasion is con-
of fibroplasia. Patients should wait at least 1 year before traindicated in patients with a history of abnormal wound
undergoing another session. Common risks of the pro- healing, hypertrophic scarring, recent isotretinoin treat-
cedure include scarring, and hypopigmentation. ment, deep thermal injury, active herpes simplex or
Postoperative Care. Following epithelialization, patients human papilloma virus infection, and congenital ecto-
should use a moisturizer twice daily to prevent scarring. dermal defects.387 As with chemical peels, because of
Patients should be advised not to rupture any blisters or sebaceous gland atrophy, patients with a history of
pick any crusts. For major crusting, topical bacitracin or isotretinoin use may be at increased risk for scarring.331,388
bacitracin–polymyxin B (Polysporin) should be applied However, there have been reports of patients undergoing
twice daily. Aspirin and nonsteroidal anti-inflammatory dermabrasion following isotretinoin use without any
drugs (NSAIDs) should be avoided for up to 1 week after adverse effects,345,389 and laboratory studies have failed to
surgery. Erythema may last up to 4 weeks. For patients show any side effects of isotretinoin with regard to col-
with significant edema, 2.5% cortisone cream may assist lagen synthesis or fibroblast activity of the skin. Patients
with recovery. Tretinoin should be resumed 1 week after should be informed about the risks and benefits of derm-
a chemical peel. Sun block that prevents exposure to abrasion therapy and combination with other scar revi-
UVB and UVA should be used to prevent pigmentation sion techniques should be considered.390
abnormalities and further photoaging for at least the first The technique of mechanical dermabrasion includes
month following a chemical peel. After 1 month, the using a diamond fraise or wire brush burr, moved in a
daily use of a sunblock, SPF 15 to 30, is recommended. direction perpendicular to the rotating burr with a
Complications. Complications following chemical peel courser grit penetrating deeper than finer grit. It can be
usually stem from injury to the epidermis and dermis. performed using local anesthesia, nerve blocks, and/or
Hyperpigmentation may last several weeks, but treatment cryogenic freezing. Freezing the skin to −40° C (−40° F)
with tretinoin may reduce the duration. Patients with in 25 seconds produces a firm, anesthetized, bloodless
Fitzpatrick type IV or V skin and those exposed to sun surface, without distorting skin contours. The disadvan-
are at increased risk for hyperpigmentation. They are tages of freezing, however, is that it is technique-sensitive,
best treated with hydroquinone, which is especially useful with thermal injury resulting from temperatures lower
in the treatment of dyschromias in Fitzpatrick types III than 30° C inducing a frostbite type wound, leading to
and IV patients. hypopigmentation. If too much pressure is placed on the
skin with the operating handpiece sloughing of the skin Complications. Postoperative edema will usually resolve
may ensue. As an alternative to freezing, local anesthesia in 4 to 6 weeks. Complications following dermabrasion
tumescence may be used as an aid to increase skin turgor include milia, rebound oil production, and acne forma-
and rigidity to abrade.391 For larger areas, to reduce the tion, but these are usually transient. Infection, hyperpig-
risk of lidocaine toxicity, lidocaine diluted in saline, epi- mentation, persistent erythema, and scarring are also
nephrine, and bicarbonate may be used in a larger unforeseen potential risks of dermabrasion. Scarring
volume. For depressed scars, it may be helpful to paint may be operator- or patient-dependent. Histologic changes
the area with 1% gentian violet so that dermabrasion can following dermabrasion are similar to that of a deep
be carried to the greatest depth of the scar. Gentian violet chemical peel or CO2 laser treatment.395,396 Clinically,
combined with daily petrolatum dressings is also useful lasers penetrate the same depth as a phenol deep chemi-
after dermabrasion for tattoo removal, causing the cal peel and dermabrasion.397 However, when compared
pigment to leach out of the wound. This creates an with chemical peels one study has found that derm-
inflammatory response–stimulated phagocytosis of the abraded skin may be less stiff at 6-month follow-up.398 In
remaining pigment. addition, patients undergoing dermabrasion may heal
The treatment should be planned in the order of significantly faster, with less erythema, than when treated
cosmetic units performed, moving from unit to unit with with CO2 laser.
taut skin tension placed on the skin by the assistant, and Microdermabrasion. Microdermabrasion involves the
using a 4 × 4 gauze soaked in 2% lidocaine with 1 : 000,000 frictional resurfacing of the epidermis and dermis by
epinephrine, with mild pressure on treated sites for circulating a stream of aluminum oxide crystals that are
hemostasis. The surgeon may begin centrally beside the pulled and blown across the skin. Other types of granules
nose, working outward and moving from just below may be used, but aluminum oxide is the most common.
the jawline up to the infraorbital area and posterior to This is useful for post-traumatic scars; patients may see
the preauricular area. Unabraded skin such as the eye- beneficial results in as little as four treatments.399 Skin
brows and first few centimeters of hair may be treated biopsies taken in patients who have undergone multiple
with 35% TCA for an even blending of the dermabrasion. aluminum oxide microdermabrasion demonstrate a
The end point for dermabrasion is the development of thicker epidermis and dermis, more hyalinization of the
uniform pinpoint bleeding, which will emanate from the papillary dermis, and more newly deposited collagen and
papillary dermis. However, some may use the superficial elastic fibers when compared with controls.381,382
reticular dermis as an end point because dermabrasion Clinically, patients show improvement in dyschromias,
at this level is less likely to produce superficial scarring. actinic changes, and fine rhytides when compared with
This level is apparent by the transition between the controls.
appearance of white parallel bands and the protrusion Before the procedure, the skin should be cleansed in
of short white fibers.392 At this level, a yellowish appear- a similar manner as for chemical peeling. No anesthesia
ance resulting from the sebaceous glands at the border is required. Each facial unit should be treated one at a
between the reticular and papillary dermis may be time. Patients may cleanse the skin and resume wearing
present.337 This endpoint may be used for more signifi- makeup and normal activities immediately after the
cant scars, however carries the risk of further scarring. procedure. As with dermabrasion, the skin should be sta-
Postoperative Care. Following hemostasis, a topical bilized with firm pressure. A potential concern of micro-
antibiotic, followed by a nonadherent dressing, absor- dermabrasion is a resulting granulomatous response from
bent gauze layer, and more rigid stabilizing layer outside deep dermal penetration of the aluminum oxide crystals;
should be applied. Patients should keep the head ele- however, this reaction has not been seen in the clinical
vated; ice packs are recommended. Patients with a history setting.399
of herpes simplex infection should begin prophylaxis 24
hours preoperatively and continue for 5 days postopera- Lasers
tively. Patients should be advised to soak their face twice Light amplification by stimulated emission of radiation
daily and not pick at any crusts. Epithelialization follow- (LASER) works by emitting electromagnetic radiation in
ing dermabrasion takes approximately 7 days. Following the form of a stream of photons that travels at the speed
healing after dermabrasion, the area may be blended of light. Lasers used clinically emit radiation in a fixed
with surrounding tissues using superficial dermabrasion spectrum of wavelengths (Table 22-7). Materials used
or a chemical peel. As with chemical peels, the applica- include dye, crystal, gas, or other media. They require an
tion of 0.5% tretinoin for several weeks before and after energy source in the form of radiation, electric current,
dermabrasion has been shown to accelerate wound or flashlamp, which emits the electrons at an excited,
healing in the postoperative period.346 In addition, the higher energy level. After returning to their steady state
use of occlusive dressings in dermabraded wounds has orbits, electrons release quantums of energy in the form
been shown to increase healing time by up to 40% and of photons traveling at a certain wavelength; this stimu-
may have a positive effect on collagen synthesis when lates other electrons to release photons that travel along
compared with wounds left open to air.393 Pain is also an optical axis, reflecting back and forth, and causing a
reduced with the use of occlusive dressings.394 In patients cascading effect of energy and photon release. The result-
with a history of dyschromia, topical hydroquinone and ing light is amplified and a laser beam is produced.
tretinoin may be started, with 1% hydrocortisone being Lasers allow the surgeon to select a wavelength for a
added for patients with persistent hyperpigmentation. particular targeted tissue, or chromophore. The two
The skin appears normal skin in approximately 1 month. most commonly used lasers in facial resurfacing are the
areas can tolerate deeper resurfacing, whereas other

TABLE 22-7 Lasers and Their Clinical Applications areas such as the jawline and other sharp demarcations
should undergo one pass or lighter resurfacing.
Laser Wavelength (nm) Indications CO2 lasers were the first lasers available for skin reju-
CO2 10,600 Resurfacing, atrophic venation, first being reported by Patel in 1964.402 This
scars type of laser is most useful for the correction of severe
Er : YAG 2,940 Resurfacing, atrophic photodamaged skin, sebaceous hyperplasia, fine or mod-
scars erate rhytides, and dyschromias. The mechanism of
action is by causing thermal injury and subsequent vapor-
Long pulsed ruby 694 Hair removal
ization of the dermis and epidermis, thereby leading to
Long pulsed 755 Hair removal collagen coagulation and shrinking. New collagen pro-
alexandrite
duction continues for up to 2 to 3 months postopera-
Long pulsed diode 800 Hair removal tively. The continuous pulse CO2 laser works at a
Long pulsed 1064 Hair removal wavelength of 10,600 nm, vaporizing approximately 50
Nd : YAG µm of tissue.323,403,404 However, it can also can result in up
Q-s Nd : YAG 1064 Pigmented skin, to 100 µm of thermal injury, which causes erythema,
lesion, or tattoo pigment changes, and scarring. The superpulsed CO2
Q-s ruby 694 Pigmented skin, laser use higher peak powers and shorter pulse duration
lesion, or tattoo to minimize collateral thermal injury while maximizing
Q-s alexandrite 755 Pigmented skin, tissue ablation. The ultrapulse CO2 laser, reported by
lesion, or tattoo Fitzpatrick in 1993, has an even shorter pulse duration
Pulsed dye 510 Pigmented skin, (1000 microseconds) than the superpulsed CO2 laser,
lesion, or tattoo leaving behind as little as 50 µm of adjacent thermal
Q-s Nd : YAG 532 Pigmented skin,
damage. Reepithelialization following CO2 laser resurfac-
(frequency- doubled) lesion, or tattoo
ing takes place in approximately 7 to 14 days. Erythema,
KTP which is typical after CO2 laser treatment, tends to fade
over 1 to 6 months.338
Argon-pumped 577, 585 Vascular lesions
tunable dye
The Er : YAG has a wavelength of approximately
2940 nm and has a higher affinity for water than CO2
Flashlamp-pumped 585 Vascular lesions,
lasers, so most of its energy is focused on water vaporiza-
dye hypertrophic scars
tion, minimizing thermal damage and tissue debris.338 It
Pulsed Nd : YAG 532 Vascular lesions produces a more superficial ablation with less postopera-
(frequency-doubled) tive erythema and a shorter recovery phase than other
KTP lasers. It is useful for treating moderate to severe rhyti-
dosis associated, with moderate to severe photodamage,
and has been shown to stimulate collagen formation.404
It has an ablation depth of 10 to 40 µm and leaves a zone
of thermal spread less than 50 µm, which is less than that
CO2 and Er : YAG lasers, which are absorbed by water. of the CO2 laser. This leaves most patients with superior
Water constitutes 90% of the epidermis, so CO2 and cosmetic results with fewer side effects, such as scarring
Er : YAG are optimal for skin resurfacing procedures. and erythema. Complete reepithelialization takes place
Unfortunately, although the targeted chromophore may in 4 to 10 days; postoperative erythema usually resolves
absorb a particular wavelength, so may adjacent chromo- in 4 weeks. The use of the Er : YAG laser is most beneficial
phores. All laser energy is converted to heat in a process for Fitzpatrick types IV to VI skin and may be used as an
called photothermolysis, causing damage to adjacent adjunct in vaporizing the area of thermal necrosis follow-
tissue by heat dissipation, or thermal bleed. Type 1 col- ing ultrapulse CO2 resurfacing, resulting in faster healing
lagen denatures at 70° C (158° F); therefore, the underly- and less erythema in these areas.405 The CO2 and Er : YAG
ing dermis is susceptible to collateral thermal damage, lasers have also been combined, optimizing the advan-
which may lead to scarring. tages of both lasers.406-408 These include the precision and
Histologically, skin treated with lasers looks similar to low thermal ablation of the Er : YAG laser and deep abla-
skin treated with phenol. It demonstrates a zone of tissue tion of the CO2 laser.
vaporization and ablation of the epithelium, with an adja- The 585-nm flashlamp-pumped PDL is indicated for
cent area of a collateral basophilic zone of thermal hypertrophic scarring and keloids. It is especially useful
necrosis of the dermis. An initial pass of the laser will be in post-traumatic injuries, resulting in less recurrent scar
absorbed by the water in the epidermis but because of formation while significantly improving scar contour,
the low water content of the collagen of the dermis and height, pruritus, texture, color, and pliability.57,267,269-273,409
subsequent less absorption, more heat is produced, In addition, PDL reduces scar microcirculation, subse-
causing thermal injury with each successive pass.400,401 quently preventing excess scar formation. Its mechanism
Following laser resurfacing, regeneration of epithelium of action is by acting on hemoglobin-containing struc-
and elastic fiber in the papillary dermis occurs and gly- tures, rather than directly ablating scar tissue.
coprotein tenascin is expressed as new collagen. Facial Lasers should be used in accordance with the safety
units such as the cheeks, chin, forehead, and perioral standards of the American National Standards Institute
(ANSI).410 These include the use of protective eyewear prolonged erythema beyond 1 month, and contact
for the patient, surgeon, and staff, nonflammable drapes, dermatitis.421-423 Infections should be suspected when
smoke evacuator, and laser masks. It is safe to use an there is increased pruritus, burning, or pain in the first
aqueous-based solution for skin preparation; alcohol- 3 postoperative days.338,418 Gram staining, Tzanck smear,
based preparations should be avoided. Laser resurfacing or immunofluorescence and potassium hydroxide exam-
may be performed using general, regional, local, or ination should be done by direct smear of the areas in
topical anesthesia, or sedation. Preoperatively, pretreat- question, when indicated. Any occlusive dressing should
ment with hydroquinone, tretinoin, or glycolic acid has be removed and empirical antibiotic treatment begun,
been shown to reduce postradiation side effects, such as including gram-negative coverage and antiviral, and anti-
hyperpigmentation.411 It is important to know the end fungal therapy; this should not be delayed because of the
points with laser resurfacing. For CO2 laser resurfacing, significant long-term effects of infection. Prolonged ery-
a pink color may be seen once the papillary dermis is thema with skin thickening should be treated with intra-
entered. The use of saline gauze to remove vaporized lesional injections with triamcinolone, 5-fluorouracil,276
skin between passes is helpful for visualizing the full or a combination of both. Dermabrasion and CO2 laser
depth of treatment. Because of the hourglass shape of resurfacing should not be used in the lower two thirds
the pilosebaceous gland, pores increase in diameter as of the face because this area contains fewer adnexal
the level of ablation deepens. Variations in the thickness structures and has a higher chance of scarring. Extreme
of skin among individuals and the facial subunit of each caution should be used when considering resurfacing
individual require the surgeon to pay attention con- around the upper neck and jawline.
stantly to the laser settings with each pass and movement
to a different subunit.
Postoperative Care. Immediately following laser resur- GENERAL POSTOPERATIVE CARE FOR ALL
facing, cool gauze soaked with topical lidocaine should ABLATIVE TECHNIQUES
be applied. In the postoperative period, a semiocclusive
dressing should be used for 3 days and has been shown Postoperative care for specific procedures is discussed
to reduce pain and decrease the duration of reepitheli- earlier in this chapter. In general, occlusive dressings are
alization to as little as 5 days.412-416 Antiviral prophylaxis recommended for almost all wounds. As noted, reepithe-
should be continued for 7 to 10 days and any preopera- lialization is enhanced in a moist environment.5 Wounds
tive antibiotics, if used, may be discontinued. Antifungal with excess crusting and scarring heal more slowly than
prophylaxis with fluconazole has not been used routinely wound meticulously kept clean because epithelium
for ablative procedures; however, some believe that it travels along the most hydrated route28 (Fig. 22-40).
should be recommended to patients with a history of Granulation tissue formation is also hastened in a moist
oral, vaginal, or nail candidiasis. After reepithelialization environment.29 Therefore, occlusive dressings and anti-
is complete, sun should be avoided for 2 to 3 months. In biotic ointment use are recommended so that epithelial
patients with severe postoperative edema, corticosteroids migration proceeds in directly and efficiently. Antibiotic
have shown to be of benefit and skin moisturizers should ointment should be applied following surgical scar revi-
be used after reepithelialization. sion procedures,34 reducing pain, infection, and scar-
Complications. Excess passes of the laser will lead to an ring.424,425 Antibiotic ointment, however, may be associated
unintended depth of tissue penetration, which leads to with a higher incidence of contact dermatitis. A cold
significant scarring; this typically occurs in the area of compress on postoperative day 1 may be used. Once
excessive thermal injury or infection. Areas that remain initial healing is complete, patients should be instructed
persistently red for longer than 3 weeks should raise to use a soapless cleanser to wash the face for the next 2
concern for infection.417 These areas usually appear months. Patients may resume wearing makeup once
dusky red or red-purple, rather than the bright red ini- reepithelialization has occurred. Sunblock (SPF > 30) is
tially seen following resurfacing. For progressive scar- recommended for at least 1 year and encouraged indefi-
ring, 585-nm flashlamp-pumped PDL therapy can be nitely following resurfacing to minimize the risk of
performed every 4 weeks.418 hyperpigmentation and skin cancer. Hydroquinone is a
A variety of laser systems use a computerized scanner useful adjunct to prevent and/or treat hyperpigmenta-
generator, allowing large surface areas to be scanned in tion. This can usually be started as soon as 2 to 3 weeks
a systematic manner and minimizing overuse of the laser postresurfacing.
in one area.419 It is not uncommon to see a 2- to 6-week
period of hyperpigmentation following laser resurfacing,
especially in Fitzpatrick skin types IV to VI. Topical ste- ADJUNCTIVE SCAR REVISION PROCEDURES
roids used two or three times daily, tretinoin, or hydro-
quinone may be beneficial for treating pigmented skin. TISSUE EXPANSION
Hypopigmentation that results after laser resurfacing is Tissue expansion is indicated for scars that cannot be
often unpredictable and permanent. As depth of injury revised by immediate local or regional flap techniques
increases, more melanocytes in hair-bearing areas are without causing significant donor site morbidity and is
destroyed.417 This occurs in 10 % to 30% of patients and especially useful for post-traumatic avulsive defects sus-
is usually difficult to treat.420 taining significant tissue loss. It is most often used for the
Other side effects include acneiform eruption, herpes scalp and forehead because of the inelasticity of tissue in
simplex outbreak, bacterial infection, yeast infection, these areas. In general, the goal of tissue expansion is to
increase the size of normal tissue enough to cover a local discussion of tissue expander placement is beyond the
scarred defect. scope of this chapter.
Unlike serial scar excision, which relies on mechanical In general, incisions should be made in normal healthy
creep and tissue elongation, tissue expansion works by skin, just adjacent to the scarred area and preferably
biologic creep and tissue generation. It was popularized radial to the implant to minimize wound dehiscence.
by Radovan for mastectomy reconstruction.426 Expansion Passive placement of the implant into the cavity is essen-
of the skin results in the creation of a new epidermal tial. It should be placed within the subcutaneous plane,
layer, with thinning of the dermis and subcutaneous in the subgaleal plane in the scalp and just above the
tissues. Hair follicle morphology will remain the same, platysma in the neck. Only normal tissue should be
which is a critical advantage of scalp expansion.427 Alter- expanded and the scar should remain the same size, with
natives to tissue expansion include full- and partial- the ultimate goal of scar excision. In general, inflation
thickness skin grafting, serial scar excision, and the use of the implant begins 1 to 2 weeks after placement and
of local regional and distal flaps; however, tissue expan- increased in size at 1- to 2-week intervals. Expansion
sion can be used alone or in combination with these should not take place in the presence of excess pain or
techniques. Tissue expansion has the benefits of main- blanching on follow-up.429 When more rapid expansion
taining identical color, texture, thickness, and hair- sequences are used, it is advisable to use local pulse
bearing aspect of skin, and improves the vascularization oximetry to monitor for tissue hypoxia.433 As a general
of the native tissue bed. This proliferation of blood rule, tissue should be expanded at least 2.5 to 3 times the
vessels increases the survivability of flaps raised in desired size to allow for recoil and tension-free final
expanded tissue by 117% over flaps raised in nonex- closure after scar excision.441,442 Although lower in elastic-
panded tissue.428 Disadvantages of tissue expansion ity than neighboring skin, expanded skin may be rotated,
include the need for multiple operations, longer dura- transposed, or advanced. It is not recommended to
tion of treatment, making the patient live longer with the excise the capsule that develops during expansion
deformity, and loss of skin elasticity, along with implant because of its rich vascularity. It may, however, be scored,
capsule formation. Also, wounds treated by tissue expan- advance, and rotated. The patient should be informed
sion may experience delayed contracture of expanded that expanded skin will usually soften and skin character-
tissue; this may be associated with sensation changes of istics such as color and texture will improve usually 3
the overlying skin.429-433 months after final expansion.443
Tissue expanders should not be placed in areas of scar,
atrophied skin, or irradiated skin because of the increased STEROIDS
risk of skin breakdown and necrosis in these areas.434 Intralesional steroid injections are useful for the treat-
Complications include wound dehiscence, port failure, ment of keloids and hypertrophic scars (see earlier).276
implant exposure, seroma formation, implant rupture, They are also useful in reducing scar volume and height,
and infection.429,431 These might be avoided by using mul- pruritus, edema, and erythema and increasing scar pli-
tiple drains, avoiding custom implant use because they ability,57,274,275 and are a useful adjunct to surgical scar
tend to deflate, and using more than one expander if revision. They may be started as soon as 2 weeks postop-
space allows. In addition, expanded skin of the neck eratively.277 The most commonly used agent is insoluble
should not be advanced past the mandibular border. This triamcinolone acetonide (10 to 40 mg/mL).268 There are
could lead to scar widening, lower eyelid ectropion, or few short-term side effects; long-term side effects include
lip ectropion. Skin expanded in the neck and cheek tissue atrophy leading to skin thinning and widen-
region should not cross multiple facial units because dif- ing.57,278,279 Injections may be repeated every 3 to 4 weeks
ferences in skin characteristics may result in unsightly until the desired effect is achieved, but the dosage must
outcomes and be associated with more complications. be adjusted if side effects develop.444
Normal unexpanded cheek tissue is ultimately the best
donor for scar revision of the cheek and skin overlying FILLER MATERIALS
the mandibular body and inferior border. Inferior Filler materials are used to replace tissues below the epi-
advancement of expanded cheek skin is associated with dermis, such as dermal collagen or subcutaneous tissue.445-
447
a much lower risk of ectropion than superior advance- They are used to treat a variety of defects, most notably
ment than tissue of the upper facial third. Advancement the depressed scar. Xenograft fillers such as injectable
or rotational flaps used in the neck should be performed bovine collagen (Zyderm, Zyplast), which is derived from
with the neck in extension because this decreases skin cowhide and is the purified suspension of bovine dermal
tension. collagen, may be used. The antigenic potential of the
Ideally, if tissue expansion is needed, it is combined material is reduced by 95% to 98% in a series of purifica-
with other revision techniques, such as free tissue trans- tion steps.448 When these materials are used, , the double
fer,435 skin resurfacing,436 serial scar excision,437 Z-plasty,438 skin test may be performed 4 weeks apart to test patient
and W-plasty.439 Variations include endoscopic tissue sensitivity. This is done by injecting 0.1 mL of the mate-
expander placement, which allows for placement of rial in the volar forearm; if erythema or induration devel-
expanders away from the site of interest, using small inci- ops, the material should not be used. The skin test is
sions to reduce the risk of wound dehiscence.440 positive in approximately 3% of patients.449 Zyplast is col-
Technique. There are a variety of customized and stan- lagen cross-linked with glutaraldehyde which is longer
dardized implants of various sizes and shapes that can be lasting and less reactive than Zyderm, which is placed
used in the head and neck region. However, a detailed within the dermis.444 Long-term complications of bovine
dermal fillers include local skin necrosis, granulomatous microlipoinjection, overcorrection should be done
reactions,446,450,451 and abscess formation.452-454 Other because of expected absorption.480
popular nonhuman filler materials include gelatin matrix Other permanent materials such as expanded polytet-
implants455 and hyaluronic acid fillers, such as hylan B456- rafluorethylene (e-PTFE; Gore-Tex, WL Gore, Flagstaff,
458
and Restylane (Medicis Aesthetics, Scottsdale, Ariz),481-483 may be used as permanent fillers in facial
Ariz).459-461 augmentation and are extremely useful in the lips
Allograft fillers include AlloDerm and/or Cymetra because they will not resorb, like other implants.484
(LifeCell). AlloDerm is available as sheets and Cymetra However, these materials are associated with side effects
as the injectable form. For post-traumatic lip scarring such as extrusion into surrounding tissue layers, espe-
secondary to deficient tissue volume, AlloDerm may be cially in the upper lip because of complex motions, with
used by creating a submucosal tunnel along the antero- the resulting implant creating a capsule of fibrosis around
inferior aspect of the lip, pulling the appropriate-sized it.485 Other synthetic permanent materials used as fillers
piece of AlloDerm through. AlloDerm may also be in the head and neck region include liquid silicone,486
injected in areas of minor defects. Although silicone is polymethylmethacrylate (PMMA),487 and a biphasic
no longer approved for use in the face, other allogenic polymer (Bioplastique).488 Although silicone has shown
fillers that may be used include homologous injectable to be inert, PMMA and Bioplastique have been associated
collagen.462 However, more studies are needed to evalu- with side effects such as granuloma formation.489-491
ate the usefulness of this material.
First described for ophthalmologic procedures,463 BOTOX
autologous dermal grafts are useful after subcision and Botulinum toxin is used for simple facial wrinkles, bleph-
undermining of scars for preventing reattachment of the arospasm, and post-traumatic muscle contraction. It
anchoring fibrous bands from the overlying skin. Dermal weakens or paralyzes muscle by binding to presynaptic
grafts should be used 2 to 6 weeks after subcision.464 cholinergic terminals and blocking the release of acetyl-
Optimal donor sites include the postauricular dermal choline at the neuromuscular junction.492 It comes in two
tissue because of its inconspicuous nature. Side effects different preparations, onabotulinumtoxinA (BTX-A)
include hematoma formation, infection, edema, pain, and rimabotulinumtoxin B (BTX-B). BTX-B is useful for
and graft migration. Grafts will mature to final size in 1 the treatment of cervical dystonias493,494 and facial
to 6 months.465 Other but less used autologous fillers spasm.495,496. BTX-A injections are useful for a variety of
include cultured human fibroblasts466-469 and autologous procedures, including the treatment of wrinkles,497 mas-
injectable collagen470-472; however, few clinical studies ticator muscle hypertrophy,498 temporomandibular disor-
have been carried out on the use of these materials. ders,499 salivary secretion disorders,500 facial nerve palsy,501
Autografts such as autologous fat graft or injection and post-traumatic scars secondary to significant muscle
may be used for severely depressed scars. These are espe- contraction.502,503
cially useful for post-traumatic defects and scarring. Botulism toxin is useful in combination with resurfac-
However, their effects are unpredictable and patients ing procedures and dermal fillers. The resulting decrease
may experience a 45% weight loss within 1 year.473 Fat in muscle pull allows for new collagen formation in areas
grafts harvested surgically maintain volume better than of treatment. In addition, BTX-A injection lengthens the
those suctioned474,475 and, because of expected absorp- duration of effect of injectable dermal fillers. Its effects
tion, overcorrection of defects by 30% to 50% is recom- are noticeable 2 to 3 days after injection, with maximal
mended.476,477 Microlipoinjection is performed by first weakness occurring 1 to 2 weeks after injection. Although
using a tumescent local anesthesia technique and then BTX-A permanently impairs neuromuscular junctions,
harvesting with a blunt-tipped microcannula or syringe. repair of muscle, axonal sprouting, and production of
After serosanguineous material is separated, the fat is new neuromuscular junctions limit its effects to 3 to 6
then washed with sterile saline. After injection, the fat is months. It is available in a vial form and must be recon-
massaged to a smooth fill. This technique is useful for stituted with sterile, nonpreserved saline prior to IM
the treatment of defects around glabellar furrows, lips, injection. Each vial contains 100 units of Clostridium
melolabial and nasolabial folds, hemifacial atrophy, or botulinum toxin type A, 0.5 mg of human albumin, and
post-traumatic head and neck scarring. As a method to 0.9 mg of sodium chloride. The 100 units of Botox
restore natural skin layers, subcutaneous fat may be used (Allergan Irvine, Calif) are significantly below the
to restore lost subcutaneous tissue and dermal fillers may median lethal dose (LD50) in an average 70-kg (150-lb)
be used to restore the deficient dermis. The epidermis human.
may then be restored as described earlier. Lipocytic Complications of Botox injection are usually revers-
dermal augmentation is a modification of fat injection; ible. These include ptosis after glabellar injection; as a
the remaining intracellular fibrous setae following adipo- result of migration of the toxin through the orbital
cyte rupture and triglyceride removal is used as collagen septum, affecting the levator muscle,504 eyebrow drop-
filler.478,479 This seems to be beneficial for atrophy around ping following forehead injection may occur. Other com-
the mouth and subcutaneous scars. The process involves plications include bruising, asymmetry, dysphagia, neck
freezing harvested fat in liquid nitrogen and then rapid weakness, perioral droop, and diplopia from lateral
thawing in warm water. The supernate is then centri- rectus involvement. Permanent side effects include globe
fuged to remove the remaining triglycerides. This mate- perforation, lagophthalmos, and keratosis. Treatment of
rial has been shown to be equal to Zyplast in lid ptosis includes eye drops consisting of 0.5% apracloni-
longevity for the treatment of atrophic skin and, like dine (Iopidine) to stimulate Müller’s muscle.505
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and histologic findings. Arch Facial Plast Surg 2:48–52, 2000. 496. Tousi B, Perumal JS, Ahuja K, et al: Effects of botulinum toxin-B
472. Fagien S: Facial soft-tissue augmentation with injectable autolo- (BTX-B) injections for hemifacial spasm. Parkinsonism Relat Disord
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477. Pinski KS, Coleman WP, 3rd: Microlipoinjection and autologous 2011.
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478. See reference 477. ment for drooling saliva in PD. Neurology 54:244–247, 2000.
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480. Henke CW, Coleman WP: Collagen filler substances. In Coleman 502. Gassner HG, Brissett AE, Otley CC, et al: Botulinum toxin to
WP, Hanke CW, Alt TH, Asken S, editors: Cosmetic surgery of the improve facial wound healing: A prospective, blinded, placebo-
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ence. Ann Plast Surg 32:457–462, 1994.
CHAPTER
Management of Human and
23
Animal Bites
Mark R. Stevens
| Hany A. Emam
| Larry Cunningham, Jr.
OUTLINE
Incidence of Bites Surgical Management
Human Bites Postsurgical Management
Animal Bites Forensic Bite Mark Recognition, Evidence, and Analysis
Pathophysiology Bite Mark Recognition
Human Bites Bite Mark Evidence
Animal Bites Bite Mark Analysis
Treatment of Bite Injuries
Initial Presentation
Antibiotic Prophylaxis
H
uman and animal bites are relatively common abuse, burglary, and kidnapping.10 The incidence of
occurrences and clinicians should have an human bite infections ranges from 4% of facial injuries
understanding of the incidence, pathophysiol- to 50% of bites to the hand.5,13-16 Human bites more com-
ogy, virology, bacteriology, surgical and medical therapy, monly become infected than dog or cat bites.2,17
and proper sequence of treatment to provide compre-
hensive care for patients with these potentially compli- ANIMAL BITES
cated injuries. An understanding of possible injury Approximately 4.5 million persons are bitten by animals
demographics and microbiology of common bite injuries each year; 15% of these will seek treatment from health-
assists the practitioner in developing a clinical pathway care providers.1,6,9,18 Many of these wounds go unreported
to aid in the decision making process regarding medical because some injuries may appear innocuous or because
and surgical treatment. Forensic bite mark examination of social concerns. The overwhelming offender is the
continues to play an important role in criminal investiga- domesticated dog (85% to 90%), followed distantly by
tion, along with an understanding of DNA-based evi- the domesticated cat (6% to 8%). In 2001, an estimated
dence gathering and criminal identification. 368,245 patients were treated for dog bite–related inju-
ries in hospital emergency departments.19 Wild animals,
INCIDENCE OF BITES including skunks, raccoons, bats, foxes, and others,
account for less than 6%. Other domesticated animals,
HUMAN BITES including horses, cattle, and sheep, account for less than
3% of these bites. The rate of injury is higher among boys
Human bites are the third most common bite injuries than girls; most victims are between 5 and 14 years of age,
following dog and cat bites; it is likely that 50% of the but many are younger than 5 years (Table 23-1).20-23
U.S. population will have been bitten by a human or Injury severity scales of children who are admitted to
animal during their lifetime.1-3 It has been estimated that the hospital with dog bite injuries range from 1 to 25,
as many as 150,000 human bites of humans occur annu- with an average of 4 ± 5; the head and neck area is
ally but go unreported.4 This estimate includes bites to involved in almost 70% of these injuries.* This is in con-
the hand that occur when an assailant punches a victim trast to adult victims, who suffer only 5% to 15% of
in the teeth. The population of human bite victims is animal bites to the head and neck19,26,27 (Fig. 23-1).
usually between 20 and 30 years of age.5 Males are affected As many as 50% of dog bites may be reported as
more frequently than are females.6-8 “unprovoked” (a possible indication of rabies infection),
Human bite injuries can be found in almost any ana- and more than 80% of these injuries involved the family’s
tomic location, including the face and head, upper and or a neighbor’s pet.18 Breeds most often involved included
lower extremities, breasts, lips, cheeks, nose, ears, pit bulls (25%), golden retrievers (12%), Labrador
abdomen and thorax, and genitalia; more than 50% retrievers (12%), Chow Chows (10%), German shep-
occur to the hands and are clenched fist injuries.4,6,9-12 herds (10%), Rottweilers (10%), and Doberman pin-
Human bites are generally inflicted as a result of inter- schers (5%) (Table 23-2).
personal violence and are typically associated with
murder or attempted murder, rape, sexual assault, child *References 6, 9, 18-20, 24, and 25.
615
TABLE 23-1 Number, Percentage, and Rate* of Nonfatal Dog Bite–Related Injuries 2001
Characteristic No. (%)† Rate (95% Cl‡)

AGE GROUP (YR)
0-4 48,153 (13.3) 253.8 (218.9-288.7)
5-9 56,146 (15.2) 278.2 (234.8-321.6)
10-14 49,326 (13.4) 236.2 (203.1-269.4)
5-19 27,820 (7.6) 137.3 (108.6-166.0)
20-24 26,161 (7.1) 133.0 (105.9-160.2)
25-34 45,133 (12.3) 114.0 (99.2-128.7)
35-44 46,658 (12.7) 103.6 (89.1-118.2)
45-54 32,613 (8.9) 83.2 (72.4-94.0)
55-64 16,185 (4.4) 64.0 (49.5-78.4)
≥65 19,005 (5.2) 53.9 (45.5-62.2)
Unknown 25§ — —
GENDER
Male 202,735 (55.1) 145.0 (126.5-163.5)
Female 165,510 (44.9) 114.2 (103.8-124.5)
TREATMENT MONTH
January 21,994 (6.0) 7.7 (5.7-9.7)
February 24,945 (6.8) 8.8 (6.4-11.1)
March 27,511 (7.5) 9.7 (7.3-12.1)
April 36,108 (9.8) 12.7 (10.1-15.3)
May 34,284 (9.3) 12.0 (9.8-14.2)
June 34,742 (9.4) 12.2 (11.3-13.1)
July 40,828 (11.1) 14.3 (11.3-17.4)
August 34,716 (9.4) 12.2 (10.9-13.5)
September 32,983 (9.0) 11.6 (9.6-13.6)
October 27,372 (7.4) 9.6 (7.3-11.9)
November 25,011 (6.8) 8.8 (7.2-10.4)
December 27,749 (7.5) 9.7 (7.9-11.6)
WORK-RELATED
Yes 16,526 (4.5) 5.8 (4.1-7.5)
No 350,554 (95.2) 123.1 (109.9-136.3)
Unknown 1,165 (0.3)§ — —
BODY PART INJURED
Head, neck 83,946 (22.8) 29.5 (26.0-32.9)
Face 55,867 (15.2) 19.6 (17.0-22.2)
Mouth 17,029 (4.6) 6.0 (5.2-6.8)
Ear 5,475 (1.5) 1.9 (1.4-2.5)
Head 3,669 (1.0) 1.3 (0.8-1.8)
Other (neck, eyeball) 1,906 (0.5) 0.7 (0.3-1.0)
Upper trunk (includes shoulder) 5,036 (1.4) 1.8 (1.2-2.3)
Lower trunk 14,432 (3.9) 5.1 (3.8-6.4)
Arm/Hand 166,756 (45.3) 58.6 (54.2-62.9)
Hand 66,969 (18.2) 23.5 (20.6-26.4)
Lower arm 45,482 (12.4) 16.0 (14.7-17.3)
Finger 34,787 (9.4) 12.2 (10.3-14.1)
Upper arm 8,645 (2.3) 3.0 (2.3-3.7)
Wrist 8,029 (2.2) 2.8 (2.2-3.4)
Elbow 2,843 (0.8) 1.0 (0.7-1.3)
Leg/Foot 94,848 (25.8) 33.3 (26.2-40.4)
Lower leg 54,388 (14.8) 19.1 (14.3-23.9)
Upper leg 25,379 (6.9) 8.9 (7.3-10.5)
Knee 5,317 (1.4) 1.9 (1.3-2.5)
Foot/Toe 5,063 (1.4) 1.8 (0.9-2.6)
Ankle 4,700 (1.3) 1.7 (1.1-2.2)
Other 2,328 (0.6)§ — —
Unknown 899 (0.2)§ — —
DIAGNOSIS
Contusion, abrasion, 22,016 (6.0) 7.7 (5.7-9.7)
Hematoma
Laceration 90,926 (24.7) 31.9 (27.3-36.5)
Puncture 148,180 (40.2) 52.0 (34.1-70.0)
Fracture/Dislocation 1,386 (0.4) 0.5 (0.2-0.8)
Amputation/Avulsion/Crush 2,854 (0.8) 1.0 (0.7-1.4)
Cellulitis/Infection 5,559 (1.5) 2.0 (1.0-2.9)
Unspecified dog bite/Other 97,324 (26.4) 34.2 (20.4-48.0)
DISPOSITION
Treated and released 361,692 (98.2) 127.0 (113.3-140.7)
Hospitalized, observed, transferred 5,921 (1.6) 2.1 (1.6-2.6)
Unknown 631 (0.2)§ — —
Total 366,245 (100.0) 129.3 (115.9-142.7)
*Per 100,000 population. These bites were treated in U.S. hospital emergency departments, by selected characteristics.
†
Numbers might not sum to total because of rounding.
‡
Confidence Interval.
§
Estimate might be unstable because the coefficient of variation is >30%.
From Centers for Disease Control and Prevention (CDC): Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, 2001. MMWR
Morb Mortal Wkly Rep 52:605–610, 2003.
Management of Human and Animal Bites CHAPTER 23 617
0.4 1.0 1.6 0.8

100 4.9 BOX 23-1 Common Microorganisms Transmitted by
90 19.6 30.8
Human Bites
27.0 31.5
80 AEROBIC AND FACULTATIVE
Other/unknown
70 30.4
ISOLATES ANAEROBIC ISOLATES
2.8
Percentage
60 Leg/foot Acinetobacter spp. Bacteroides fragilis group

50 36.6
Arm/hand Corynebacterium spp. B. oralis
7.5 55.4
40 64.9
Eikenella corrodens B. urealyticus
Trunk
30 Enterococcus spp. Bifidobacterium spp.
10.6 Head/neck
20 41.5 Haemophilus influenzae Eubacterium spp.
10 19.7 4.1 H. parainfluenzae Fusobacterium nucleatum
8.9
0 Klebsiella pneumoniae F. neorophorum
0–4 5–9 10 –14 15 Neisseria spp. Peptostreptococcus
Age group (years) Nocardia spp. asaccharolyticus
FIGURE 23-1 Percentage of nonfatal dog bite–related injuries Proteus spp. P. magnus
treated in U.S. hospital emergency departments, by primary body Pseudomonas Peptococcus niger
part affected and age group—National Electronic Injury Staphylococcus aureus Prevotella melaninogenica
Surveillance System All Injury Program, United States, 2001. (Data
S. epidermidis P. intermedia
from Centers for Disease Control and Prevention [CDC]: Nonfatal
dog bite-related injuries treated in hospital emergency Streptococcus Veillonella spp.
departments—United States, 2001. MMWR Morb Mortal Wkly α-hemolytic
Rep 52:605–610, 2003.) γ-hemolytic
Group A β-hemolytic
Non–group A β -hemolytic
TABLE 23-2 Dog Bite Injuries by Breed of Dog OTHER RARE PATHOGENS
Breed Bite Injuries (% of all Bite Injuries) Hepatitis B virus
Pit bulls 25 Herpes simplex virus
Golden retrievers 12 Human immunodeficiency virus
Labrador retrievers 12 Mycobacterium tuberculosis
Chows 10 Treponema pallidum
German shepherds 10
Rottweilers 10
Doberman pinschers <5
incisors shear, canines tend to puncture and molars
Data from Gandhi RR, Liebman MA, Stafford BL, Stafford PW: Dog bite crush. Thus, human bites can penetrate, avulse, and
injuries in children: A preliminary survey. Am Surg 65:863–864, 1999. crush the tissue. These injuries are contaminated by a
wide range of microorganisms (Box 23-1).*
More than 42 different species of bacteria have been
reported in human saliva. Consideration must be given
There were 1164 deaths caused by nonvenomous to all normal oral flora and common pathogens in the
animals from 1979 through 1990.28 From 1995 to 1996, treatment of these contaminated crush injuries. Although
279 human deaths occurred as a result of dog attacks.29 the amount and type of inoculum may be minimal in the
During 1997 and 1998, at least 27 dog bite–related fatali- case of pristine dentition, they are of significant concern
ties occurred.30 Although some deaths involved hunters in the neglected mouth. More than 190 species have
who were attacked by large animals, such as bears, most been isolated when gingivitis or periodontitis is present.
of the deaths were caused by large domesticated dogs, The most common bacteria associated with human bite
especially Pit bulls, Rottweilers, and German shepherds.23 infections include Streptococcus, Staphylococcus aureus,
The most frequent reason for death is exsanguinating Eikenella, Prevotella, Peptostreptococcus, Fusobacterium, and
hemorrhage. The victims are usually infants (60%) or Candida spp. Immunocompromised patients, alcoholics,
older individuals.20 and diabetics are at a higher risk for infection by human
bites. Other transmissible human diseases that are of
concern include herpes, hepatitis B, hepatitis C, tuber-
PATHOPHYSIOLOGY culosis, and syphilis.37,38 Acquired immunodeficiency syn-
drome (AIDS) transmitted by saliva is considered to be
HUMAN BITES of low or no risk, according to the Centers for Disease
When humans chew, they generate forces in the range
of 1.6 to 26.7 kg.31-34 Maximum molar bite forces range
from a low of 1 kg to a high of 443 kg. Although human *References 6, 9, 11, 12, 35, and 36.
A B
FIGURE 23-2 The long, thin, sharp teeth of the domesticated cat tend to cause puncture injuries, which are more frequently associated
with infections.
A
B
FIGURE 23-3 A, B, Shorter, rounder, blunter teeth tend to penetrate and crush, as in the case of the domesticated dog. (B from Boyd J,
Paterson C: Colour atlas of clinical anatomy of the dog and cat, London, 2001, Mosby.)
Control and Prevention (CDC). However, a number of performed to prevent missing critical injuries, especially
case reports have listed a human bite as the likely in infants, children, and older adults (Fig. 23-5).
event responsible for transmission of AIDS infection A list of microorganisms from all animal bite sources
and the use of postexposure prophylaxis has been is presented in Box 23-2.* No species seems to be associ-
advocated.2,39,40 ated with any particular type of bacterial variant, except
that animal bites differ from human bites in the presence
ANIMAL BITES of Pasteurella multocida in as many as 50% to 75% of cases
The force delivered by an animal’s jaw when biting can of infection. Consistent with the heterogeneity observed
be as high as 1800 psi.41,42 This can result in devitalized between feline and canine oropharyngeal Pasteurella
tissue caused by crushing, tearing, avulsion, or a combi- strains, P. canis biotype 1 is the predominant isolate from
nation of all three. Furthermore, these wounds are con- dog bites, whereas P. multocida subsp. multocida and septica
taminated by a broad spectrum of microorganisms and have been isolated much more frequently from cat
can cause a wide range of zoonotic diseases. Sharp, thin, bites.49
long teeth more frequently cause puncture injuries, as in The aerobic bacteria most frequently associated with
the case of the domesticated cat6,20 (Fig. 23-2). Shorter, infected animal bites include alpha- and beta-hemolytic
blunter, rounder teeth frequently cause a combination streptococci (24% to 46%), S. aureus and S. epidermidis
of penetrating and crush injuries, as in the case of the (10% to 25%), and Escherichia coli, Pseudomonas, and
domesticated dog (Fig. 23-3). Flat teeth cause crush and Moraxella spp. (10% to 25%).† The most common
tear injuries, as in the case of the domesticated horse
(Fig. 23-4). Animal bites may cause fractures in addition *References 6, 9, 20, 35, 36, and 43-48.
to soft tissue injury, a thorough examination should be †
References 9, 35, 36, 43, 47, 48, and 50.
FIGURE 23-4 The domesticated horse has very flat incisors (A)
and molars (B) and is capable of causing significant crush injuries.
anaerobic bacteria isolated from infected animal bites

are the Bacteroides, Prevotella, and Fusobacterium spp. (13%
to 76%). Oral and environmental fungi may also con-
taminate bite wounds. Candida spp. have been isolated
from 8% of infected human bites, but their pathogenic
role remains unclear.51,52
Tetanus
Tetanus is caused by Clostridium tetani, a gram-positive, B
anaerobic rod. C. tetani spores are resistant to heat and
antiseptics and are found widely in soil and in the intes- FIGURE 23-5 A, Multiple scalp lacerations caused by a dog bite in
tinal tract of domestic animals, including dogs and cats. this young child. B, Injury extends to the subperiosteal plane.
Humans have also been known to harbor the organism.
The CDC has stated that 201 cases of tetanus were
reported from 1991 to 1994, with an annual incidence in a human was reported to the CDC during 2001. This
rate of 0.02 cases/100,000.53 There was a reported case viral disease is most frequently carried in wild animals
fatality rate of 25%. Of these injuries, 49% resulted from (especially bats, raccoons, and skunks). Domestic animals
puncture wounds, 20% from lacerations, and 12% from accounted for 6.7% of all rabid animals reported in the
abrasions. Only 5 patients reported injury by an animal. United States during 2001; these were mainly cats, dogs,
No bite injury should be considered clean or minor. and cattle. Vaccination of domestic animals, vaccination
Although the incidence of the tetanus may seem low, the programs targeting wildlife, and ongoing educational
high rate of mortality in patients who contract it makes programs have contributed to the very low incidence of
the treatment of tetanus a priority. If adequate history of rabies in humans. Approximately 20% of human cases
immunization cannot be elicited, the patient should be occur in the United States because of exposure abroad.
treated according to the Advisory Committee on Immu- Of the almost 80% of cases that occurred within the
nization Practices (Table 23-3).53 United States from 1990 to 2001, 92.3% of infected
persons were found to have viral variants associated with
Rabies bats.
The incidence of rabies has declined steadily since the The rabies virus is a bullet-shaped rhabdovirus.56 After
1950s.54 Approximately 36 cases have been reported in entering its new host, it travels to the central nervous
the United States since 1990.1,55 Only one case of rabies system through the peripheral nerves, proliferating in
BOX 23-2 Common Microorganisms Transmitted by TABLE 23-3 Summary Guide to Tetanus Prophylaxis in
Animal Bites Routine Wound Management
AEROBIC BACTERIA ANAEROBIC BACTERIA Clean, Minor All Other
Acinetobacter spp. Arachnia propionica Wounds Wounds*
Aeromonas hydrophila Bacteroides spp. (many History of adsorbed Td† TIG Td† TIG
Bacillus subtilis species) tetanus toxoid (doses)
Bordetella spp. Eubacterium spp. Unknown or <three‡ Yes No Yes Yes
Brucella canis Fusobacterium spp.
≥Three No§ No No¶ No
Capnocytophaga canimorsus Leptotrichia
Chromobacterium spp. Peptococcus *Such as, but not limited to, wounds contaminated with dirt, feces, soil,
Clostridium perfringens Peptostreptococcus spp. and saliva, puncture wounds; avulsions, and wounds resulting from mis-
siles, crushing, burns, and frostbite.
Corynebacterium spp. Propionibacterium acnes †
For children < 7 yr old; DTP (DT, if pertussis vaccine is contraindicated)
EF-4 Veillonella spp. is preferred to tetanus toxoid alone. For those ≥7 yr of age, Td is preferred
EF-7 to tetanus toxoid alone.
Eikenella corrodens OTHER RARE PATHOGENS ‡
If only three doses of fluid toxoid have been received, then a fourth dose
Enterobacter spp. Bartonella henselas of toxoid, preferably an adsorbed toxoid, should be given.
Flavobacterium spp. Clostridium tetani
§
Yes, if >10 yrs since last dose.
¶
Yes, if >5 yrs since last dose. (More frequent boosters are not needed
Haemophilus aphrophilus Francisella tularensis
and can accentuate side effects.)
Klebsiella Hepatitis B virus
Micrococcus spp. Rabies virus
Moraxella catarrhalis Herpes simplex virus
M. weaveri Leptospira spp. anyone with a bite, scratch, or mucous membrane contact
Moraxella spp. Rio Bravo virus with a bat.
Neisseria spp. Simian herpes B virus For victims at risk for rabies, management must begin
Pasteurella multocida (macaque monkeys only) immediately (Table 23-4); 20 IU/kg (0.133 mL/kg) of
Proteus mirabilis Spirillum minus rabies immune globin (RIG) should be administered.
Pseudomonas Streptobacillus moniliformis Most of the dose should be injected in and around the
Serratia marcescens Yersinia pestis site of the wound as much as possible, avoiding vascular
Staphylococcus aureus compromise. The remainder should be given IM.1,58
S. epidermidis Rabies vaccine should also be administered in five doses
S. saprophyticus IM on the day of the attack and on days 3, 7, 14, and 28
Streptococcus spp. after the attack.3,7,59 RIG should not be administered to
Weeksella zoohelcum patients who have been previously vaccinated, but they
should receive additional vaccine. Three inactivated
rabies vaccines are licensed for use in the United States.
the gray matter. It then spreads centrifugally to the sali- They are human diploid cell vaccine (HDCV), rabies
vary glands, adrenal glands, musculature, and heart. This vaccine absorbed (RVA), and purified chick embryo cell
mechanism accounts for the signs and symptoms associ- vaccine (PCEC).
ated with the different phases of the rabies infection.
There is a long incubation period in rabies, typically TREATMENT OF BITE INJURIES
lasting 20 to 90 days and rarely exceeding a year or
more.57 The prodromal phase usually ranges from 3 days Management of bite wounds to the face is not unlike
to 3 months, the excitement phase lasts from 3 months managing other trauma to the head and neck. Because
to 6 months, and the brainstem dysfunction phase ranges bite wounds can cause a wide variety of injuries, and
from 6 to 12 months. Symptoms of rabies in animals because they may not be isolated injuries, appropriate
include an unprovoked attack or bizarre behavior in attention to complete evaluation and adherence to
domestic animals. Signs of infection in humans include Advanced Trauma Life Support (ATLS) protocols is
symptoms of cerebral dysfunction, anxiety, confusion, important; plain film or computed tomography (CT)
and agitation, progressing to delirium, abnormal behav- scans should be ordered, when appropriate.60 Certain
ior, hallucinations, and insomnia. aspects of management of these wounds are slightly dif-
If the bite has been inflicted by a human, chipmunk, ferent. The following section will highlight these differ-
guinea pig, gerbil, hamster, squirrel, rat, mouse, rabbit, ences and offer a protocol for treatment.
or horse, there is little to no risk of rabies infection.1,55 If
the bite is from a healthy domesticated dog, cat, or ferret, INITIAL PRESENTATION
the animal should be confined and observed for 10 days. Whether inflicted by humans or animals, the basic prin-
Any sign of illness prompts sacrifice and testing of the ciples for the management of maxillofacial bite injuries
animal and postexposure prophylaxis for the victim. Any are the same. ATLS protocols should be followed. Cervi-
bite by a wild animal, such as a raccoon, skunk, fox, or cal spine immobilization and neurologic evaluation are
coyote is considered high risk and rabies prophylaxis particularly important because a large animal can grasp
must be given. Interestingly, bats are the most common the underlying cranium with its fangs and crush the
source of exposure to rabies in the United States. Cur- cranium of children and infants or shake them violently,
rently, postexposure prophylaxis is recommended for thereby injuring the cervical spine.61
TABLE 23-4 Rabies Postexposure Prophylaxis Guide—United States, 2008
Animal Type Evaluation and Disposition of Animal Postexposure Prophylaxis Recommendations

Dogs, cats, and ferrets Healthy and available for 10 days Persons should not begin prophylaxis
observation. unless animal develops clinical signs of
Rabid or suspected rabid. rabies.* Immediately vaccinate. Consult
Unknown (e.g., escaped). public health officials.
Skunks, raccoons, foxes and most other Regarded as rabid unless animal proven Consider immediate vaccination.
carnivores; bats negative by laboratory tests.†
Livestock, small rodents, Lagomorphs Consider individually. Consult public health officials. Bites of
(rabbits and hares), large rodents squirrels, hamsters, guinea pigs, gerbils,
(woodchucks and beavers), and other chipmunks, rats, mice, other small
mammals rodents, rabbits, and hares almost never
require antirabies postexposure
prophylaxis.
*During the 10-day observation period, begin postexposure prophylaxis at the first sign of rabies in a dog, cat, or ferret that has bitten someone. If the
animal exhibits clinical signs of rabies, it should be euthanized immediately and tested.
†
The animal should be euthanized and tested as soon as possible. Holding for observation is not recommended. Discontinue vaccine if immunofluores-
cence test results of the animal are negative.
After initial assessment and stabilization, a compre- listed in Box 23-1 should be considered. Large, random-
hensive head to toe examination should be performed. ized clinical trials comparing antibiotics in human and
This is followed by a thorough review of the past medical animal bites have not yet been carried out. Some studies
history of the victim, including the status of the patient’s have suggested that empirical therapy should be amoxi-
tetanus vaccination. The time of the bite and circum- cillin with clavulanic acid.11,50 Alternatives include fluoro-
stances surrounding the bite should be noted and quinolones, carbapenems, or combinations of clindamycin
whether the animal was wild or domestic, whether the and penicillin or second- or third-generation
attack was provoked or unprovoked, and the number of cephalosporins.35
bites and/or injuries.1,29 Antibiotic prophylaxis for animal bites continues to be
Once the secondary survey has been accomplished debated, with few well-designed prospective studies avail-
and a thorough history has been obtained, a complete able to shed any light on the controversy.44,62-64 Although
physical examination should be performed. All organ some studies have indicated that prophylactic antibiotics
systems should be evaluated. Wounds to the head, neck, make a difference in the incidence of infection, others
or thoracic inlet deserve special attention, with a particu- claim no efficacy. A review of randomized controlled
lar focus on the great vessels of the neck.41 If present, trials comparing antibiotics with placebos in mammalian
consideration should be given to special imaging tech- bites failed to show the effectiveness of prophylactic anti-
niques, such as CT angiography or magnetic resonance biotics for dog and cat bites in anatomic areas other than
imaging (MRI) angiography. The specialized structures the hand.63 Although documentation in support of pro-
of the face, including the parotid ducts, facial nerve, and phylactic antibiotics for animal bites was not found in this
nasolacrimal system, should be assessed individually. review, only eight publications were included in the study
Care should be taken to evaluate the globe and an oph- and only dogs were included in more than one study. It
thalmologic consultation should be obtained, if indi- seems clear that confirmatory research is necessary, but
cated (Fig. 23-6). it is prudent to consider the type of wound, its location,
A proposed classification of facial bite wounds, based and additional contamination or foreign bodies when
on the extent of injury, is presented in Table 23-5 (Figs. deciding on possible antibiotic use. Amoxicillin with cla-
23-7 to 23-9). vulanic acid is the drug of choice for prophylactic cover-
age.58 If the patient is allergic to penicillin, treatment
ANTIBIOTIC PROPHYLAXIS options include fluoroquinolones or clindamycin in
Human bites to humans have received considerable combination with second- or third-generation cephalo-
attention and a bad reputation. The reason for this is that sporins. Azithromycin is probably the most appropriate
most human bites affect the interphalangeal joints from choice for penicillin-allergic pregnant women or chil-
a clenched fist hitting human teeth when a punch is dren, for whom tetracyclines, fluoroquinolones, and
thrown.31,60 Oral flora is inoculated into the joint capsule. sulfa compounds are contraindicated.65
When the hand relaxes, the joint capsule becomes sealed.
A dark moist region that is rich in nutrients and contami- SURGICAL MANAGEMENT
nated with microorganisms is the result. Because many The primary focus in the management of bite wounds is
of these patients are unreliable, they infrequently seek thorough wound cleansing by high-pressure, pulsed irri-
care until well after an infection has developed. When gation with copious amounts of normal saline1,20,66 (Fig.
considering antibiotic prophylaxis, the microorganisms 23-10). Some have used povidone-iodine (Betadine)
A B
C D
FIGURE 23-6 A, B, These lacerations were the result of a dog bite to the face. C, D, Exploration of significant structures should be
performed when indicated. In this case, these would include the facial nerve, parotid duct, and the lacrimal system. Note that this injury
includes fractures of facial bones. CT scanning is indicated in this situation. (Courtesy Dr. Edward Ellis III.)
and debris must be removed. Wound infections caused

TABLE 23-5 Classification of Facial Bite Injuries by animal bites are typically of mixed flora and a wound
culture has been advocated58 (Fig. 23-11). Puncture
Type Clinical Findings wounds should be irrigated with the same solutions. This
I Superficial injury without muscle involvement (Fig. 23-7) can be facilitated by the use of a flexible angiocatheter
attached to a syringe, allowing access to the deepest part
IIA Deep injury with muscle involvement
of the wound. An alternative is to take a scalpel and
IIB Full-thickness injury of the cheek or lip with oral extend the puncture wound with two releasing incisions,
mucosal involvement (through and-through wound)
creating a laceration.20 This injury can then be irrigated
IIIA Deep injury with tissue defect (complete avulsion) more easily. Good wound cleansing is absolutely impera-
IIIB Deep avulsive injury exposing nasal or auricular tive. After the wound has been thoroughly cleansed, it
cartilage (Fig. 23-8) should again be inspected. With debris, dried clots, and
IVA Deep injury with severed facial nerve and/or parotid blood removed, better visualization is routinely afforded.
duct (Fig. 23-9) However, sustained high-pressure irrigation should be
IVB Deep injury with concomitant bone fracture avoided in areas containing loose areolar tissue, such as
From Stefanopoulos PK, Tarantzopoulou AD: Facial bite wounds: Man-
the eyelids or children’s cheeks, because this could cause
agement update. Int J Oral Maxillofac Surg 34:469–472, 2005. tissue disruption and excessive edema. In general, 250 to
500 mL of solution provides an adequate cleansing effect
for most facial bite wounds.67,68
After irrigation and reassessment, appropriate imaging
and/or hydrogen peroxide irrigation initially.22 If these techniques should be used if there is suggestion of a
are used, normal saline should be used for a third irriga- fracture. Hemorrhage should be controlled and necrotic
tion to remove any remaining povidone-iodine. Iodine tissue should be débrided. Specialized structures, such as
left in the wound can cause local tissue necrosis and the facial nerve, parotid duct, or nasolacrimal apparatus,
inflammation. Gross necrotic tissue, foreign bodies, dirt, should be repaired as indicated.
A B
FIGURE 23-7 A, Small dog bite, facial injury classification type I, with no muscle involvement. B, Small dog bite injury treated with primary
closure and topical antibiotics.
A B
C
FIGURE 23-8 A, Human bite facial injury classification type IIIB, demonstrating partial avulsion and exposure of underlying cartilage nasal
tip. B, Staged musculocutaneous dorsal nasal flap advancement, reconstructing the avulsed nasal tip. C, 4-week postoperative view of
nasal tip reconstruction.
A B
C
FIGURE 23-9 A, Large dog bite facial injury classification type IVA, demonstrating deep tissue injury in the region of the facial nerve and or
parotid duct. B, Large dog bite injury demonstrating primary closure with residual areas of tissue avulsion. C, Large dog bite injury 1 year
postoperative demonstrating scarring and soft tissue deformity and managed with intralesional steroids.
It has been recognized for at least 4 decades that resist infection well. Thus, in cases of deep bites to the
uncomplicated lacerations from bites to the face can be cheek, especially in children, antibiotic prophylaxis
closed primarily within the first 24 hours—the golden should be started as soon as possible after careful explo-
24-hour period—without fear of increased rates of ration and irrigation, usually with the first dose adminis-
infection.69-74 This also produces the most favorable aes- tered IV.
thetic results, although this opinion has been challenged, Puncture wounds should be left open or converted to
particularly in human bites to the face resulting in lacerations and then closed as described. Specialized
exposed cartilage.5 A layered closure should be per- techniques of wound pexis, skin grafts, and regional flaps
formed with the minimum number of deep resorbable should be considered when appropriate.21,25,75,76 Avulsed
sutures necessary to eliminate dead space and tension, tissue may require microvascular repair or tissue
followed by closure of the skin with nonresorbable mono- banking.77,78 Adherence to the principles of irrigation,
filament sutures.20 meticulous wound care, minimal débridement, and
Two additional factors pertaining to the face can primary closure can provide favorable results20,21,73 (Fig.
render the management of bite wounds in this area prob- 23-12; Box 23-3).
lematic. The first is a substantial risk of occult oral com-
munication with bite injuries of the cheek because of the POSTSURGICAL TREATMENT
nature of the animal occlusion. The second is the pres- Postsurgical management includes local wound care and
ence of the relatively avascular buccal fat pad, which is antibiotic therapy for 5 to 7 days after surgery.1 Depend-
well developed in children and, once exposed, does not ing on the type of attack and age of the victim, psychiatric
C
FIGURE 23-10 A, B, Pulsatile irrigation system—3-liter bags of saline are pumped through a handpiece that provides pulsation and
suction during wound irrigation. C, Use of the pulsatile irrigation system for wound cleansing.
or social counseling may be required. This is especially representational pattern of the oral structures.79 A human
true for children or victims of sexual assaults.4 Signs and bite mark, therefore, is a patterned injury to the skin
symptoms of infected wounds and even zoonotic diseases similar to a tool mark patterned injury. In most cases,
should remain a concern.58 Finally, scar revision and sec- human bite marks are associated with violent crimes,
ondary reconstruction can be considered as soon as 6 such as homicide, rape, sexual assault, child and spousal
months after the injury. abuse, and assault.10,80,81 With the violent nature in which
human bite marks are usually received, it is important
that medical and dental personnel, day care and nursing
FORENSIC BITE MARK RECOGNITION, home workers, teachers, criminal investigators, and
EVIDENCE, AND ANALYSIS medical examiners have proper training in the recogni-
tion of patterned injuries on the skin as possible bite
Bite mark evidence has been widely accepted by courts mark injuries.
in the United States for many years on the basis that the Knowledge of the anatomic location of human bite
human dentition is unique to each person. The convic- marks is pivotal for all who are involved with examining
tion of mass murderer Theodore Robert Bundy was the victims (living and deceased) of violent crimes.
secured by bite mark evidence and bite mark analysis Hospital-based studies of biting incidence have indicated
testimony (Bundy was executed in Florida on January 24, that the extremities, especially hands, are the most com-
1989). Bite mark evidence has become a powerful inves- monly bitten areas.4 However, information from coro-
tigational tool in the United States. However, bite mark ners’ data has suggested that bites are more commonly
evidence and analysis are not without controversy. This delivered to breasts. One study of 101 human bite mark
section will provide the practitioner with an overview of cases, using the Lexis legal database, has concluded that
bite mark recognition, evidence, and analysis. females were four times more likely to be bitten than
males and that bites occurred more frequently on breasts
BITE MARK RECOGNITION than on extremities.10
A cutaneous human bite mark, as defined by the Ameri- To recognize a human bite mark, one must be familiar
can Board of Forensic Odontology (ABFO), is an injury with the shape of this particular patterned injury on the
on the skin caused by contacting teeth that shows the skin. In general, skin is a poor impression medium for
A B
D
FIGURE 23-11 A-D, This purulent infection developed 1 week after treatment of this dog bite, despite pulsatile irrigation and IV antibiotics
during closure.
recording tooth imprints because of its rebounding and are described as having a dotted or broken line
nature over time. Therefore, the evidence that remains pattern (Fig. 23-13). Any distinguishing factor, trait, or
on the skin generally takes the form of bruising patterns. pattern in a given bite mark is referred to as a character-
Bite marks usually appear as oval or circular contusions istic of the mark. There are two categories, class charac-
or abrasions, with or without indentations or lacerations, teristics and individual characteristics.80
FIGURE 23-13 Human bite mark showing the circular pattern, with
the broken line bruising containing an area of central ecchymosis.
(From Swartz M: Textbook of physical diagnosis: History and
examination, ed 6, Philadelphia, 2010, Saunders.)
Class Characteristics
A class characteristic is a feature, trait, or pattern seen in,
or reflective of, a given group. Teeth are divided into
morphologic classes—incisors, canines, premolars, and
molars. Each class will represent a somewhat different
B pattern in the bite mark injury. Incisors, for example,
FIGURE 23-12 2-month postoperative results of the patient seen in usually produce linear or rectangular contusions, whereas
Figure 23-6. (Courtesy Dr. Edward Ellis III.) canines typically leave triangular bruises. Maxillary inci-
sors will produce larger patterns because of their size,
which helps distinguish the maxillary arch from the man-
dibular arch. Arch size differences are important in
determining whether a bite mark was produced by a
child or adult.
Individual Characteristics
BOX 23-3 Treatment Protocol For Common Facial An individual characteristic is a feature, trait, or pattern
Bite Wounds that represents a variation in the class characteristics.
1. Skin preparation; anesthesia Examples include but are not limited to rotations, frac-
2. Pressure irrigation; irrigation of puncture wounds tures, missing restorations, malalignment, and spacing
3. Resection of skin tags between marks. The number of discernible individual
4. Removal of visible foreign particles characteristics present in the bite mark is used to distin-
5. Suturing (exceptions listed below) guish between two different dentitions. The higher the
6. Consideration of tetanus prophylaxis number, the more distinctive the bite mark and the
7. Follow-up within 24 to 48 hours higher the confidence level that a particular suspect
ALSO RECOMMENDED: made a given bite mark.
• Normal saline irrigation (1% povidone-iodine should be
reserved for grossly contaminated wounds)
BITE MARK EVIDENCE
• Antibiotic prophylaxis Ordinarily, a forensic odontologist should be called on
• Culture of problematic wounds (failure to respond to to perform a preliminary examination when a human
initial antibiotic therapy or presence of serious infection) bite mark is suspected. Several basic questions must be
answered during this initial evaluation:
NOT RECOMMENDED:
• Routine debridement (if attempted, it should not exceed
1. Is the patterned injury a bite mark?
1 mm of tissue)
2. If the injury is a bite mark, did human teeth cause the
• Suturing in the presence of overt infection, gross edema, injury?
foreign bodies, or visible contamination (consider delayed 3. Is the bite mark consistent with the type of crime and
closure) time of occurrence?
• Culture of fresh uninfected wounds, because it depicts 4. Does the bite mark contain distinct or unique indi-
the polymicrobial flora of the wound rather than the caus- vidual characteristics of the biter’s teeth?
ative organisms of any subsequent infection Once it has been ascertained that the patterned injury
is a bite mark, it is important to determine that an animal
did not produce the bite mark. Domesticated animals

and wild animals, such as rats, may have access to a crime
scene. Typically, animal bites are V-shaped and have deep
lacerations, but do not contain areas of ecchymosis within
the confines of the bite mark. In contrast, human bites
are circular or elliptical, have superficial abrasions, and
commonly contain ecchymosis within the bite mark
injury secondary to positive pressure from closing the
teeth and damage to capillaries or to negative pressure
from sucking and tongue thrusting81 (see Fig. 23-13).
Intercanine distances less than 2.5 cm indicate that a
child may have caused the injury. Bite marks with inter-
canine distances more than 3 cm were likely caused by
adults.
Although bite marks are usually associated with violent
crimes, bite marks may occur at other times, such as FIGURE 23-14 ABFO no. 2 reference scale. (From Byard R, Corey
during sexual relations not associated with a crime. The T, Henderson C: Encyclopedia of forensic and legal medicine,
age of the bite mark must be consistent with the time of Kidlington, England, 2005, Academic Press.)
the crime occurrence to be used as evidence in the case.
The bite mark should contain enough individual charac-
teristics to allow the forensic dentist to prove or disprove blood group classification in their saliva. In addition,
a physical match to a suspect’s teeth with a high degree recovery of human DNA evidence is possible through
of confidence. At the conclusion of the preliminary swabbing the bite mark injury.85 Evidence is collected by
examination, it is the responsibility of the forensic odon- using the double-swab technique,86 which involves moist-
tologist to make a judgment about to the evidentiary ening the bite injury with a sterile cotton swab moistened
value for recovering and analyzing the bite mark.77 with sterile distilled water, followed by moisture removal
from the site with a second dry swab. Control swabbings
Bite Mark Evidence Recovery should be made on other areas far removed from the bite
After it has been decided to recover bite mark evidence mark.
from the victim, it must be collected expeditiously Impressions. After photographs and swabbings have
because the appearance of the bite mark starts to change been completed, impressions of the bite mark surface
quickly, especially on the living victim. Most forensic den- should be made when it appears that valuable informa-
tists follow a standard protocol for bite mark evidence tion will be provided (ABFO Bite Mark Analysis Guide-
recovery that includes photographing the bite mark, lines).79 All hair should be removed from the bite mark
swabbing the bite site, making impressions of the injury, location and the site washed, rinsed, and dried. A low
and obtaining tissue specimens. viscosity impression material (one that meets American
Photography. Extensive photographing of the bite Dental Association [ADA] specifications) is put on the
injury, before any manipulation, is generally the first step area and allowed to set completely. The impression mate-
in evidentiary collection. Color and black and white print rial must be reinforced with a rigid backing material to
film should be used. Color prints represent a realistic reproduce the anatomic contour accurately. Commonly
reproduction of the bite mark, whereas black and white used backing materials include dental stone, acrylic resin
prints tend to make the bite mark more evident.82 At tray material, thermoplastic tray material, and orthope-
times, color photographs may be considered inflamma- dic mesh.87 Once the selected backing material has set,
tory and not admitted into court as evidence, whereas the impression is poured in an ADA type IV dental stone,
black and white photographs are routinely admitted. using the manufacturer’s instructions. The master cast is
Because the bite mark injury appearance changes over used for court demonstrations and casts produced from
time, it is important to photograph the bite mark at subsequent pours are used for evaluation and analysis.
regular intervals, usually every 24 hours, for several days. Tissue Specimens. With approval from the medical
Photographs should be made with the lens plane par- examiner or coroner, bite mark injury patterns on
allel to the plane of the bite mark to decrease perspective deceased individuals may be excised for photography
distortion. This is a challenging task because most sur- with transillumination and preservation for future analy-
faces on the human body are curved. A scale should be sis and comparison.88 One technique for bite mark
used to estimate the amount of photographic distortion. removal is to use a custom-fabricated acrylic stabilizing
The ABFO no. 2 reference scale has been specifically ring and permanently attach it to the skin using cyano-
designed for this purpose and has been recommended acrylate and interrupted sutures.89 Vinyl polysiloxane
by the ABFO83,84 (Fig. 23-14). Photographs should be (VPS) impression material is injected on the surface of
made with and without the scale in place. The photo- the skin within the stabilization ring to serve as a backing
graph without the scale demonstrates to the court that it for the anatomic contour of the area to be excised. Once
does not cover any relevant evidence. the impression material is set, the entire complex (ring,
Swabbing. Swabbing the bite mark may provide valu- backing, and skin) is dissected and removed from the
able salivary trace evidence. Approximately 85% of the body. The entire specimen is placed in 10% buffered
general population are secretors who reveal their ABO formalin fixative for at least 10 hours. After fixation, the
VPS backing material may be removed while leaving the transparency, each tooth tracing is given its respective
ring and sutures intact. The tissue specimen should be tooth number (see Fig. 23-15B).
placed in a sealed plastic bag and stored in a refrigerator 3. The transparency is placed just short of exact super-
for future analysis. imposition over the 1 : 1 photograph of the bite mark
Protocol of Evidence Recovery. Before collecting evi- to view concordant points (matching points) of the
dence from a suspect, the forensic dentist must ensure suspect’s teeth with the bite mark (see Fig. 23-15C).
that the proper legal documentation has been obtained. 4. Exact superimposition of the acetate overlay of the
Extraoral photographs should include head and neck suspect’s teeth over the life-sized photograph of the
portrait and profile views. Intraoral photographs should bite mark is used to determine the degree of match
include the frontal view and lateral views at maximum (see Fig. 23-15D).
intercuspation (MI), maximum interincisal opening, The use of hand tracings from life-sized photographs
close-up of the anterior teeth in MI and protrusion, and and photocopies of the suspect’s dental stone casts has
occlusal views of the maxillary and mandibular arches. decreased over the years with the introduction of a more
The intraoral photographs should be made with and accurate, less subjective technique, the computer-
without the ABFO no. 2 reference scale in place. Other generated bite mark overlay.91
evidence to collect from the suspect would include an
extraoral and intraoral examination, salivary swab, blood Metric Analysis
sample, two impressions of each arch, and sample or test In addition to the fabrication of an overlay, careful
bites in various materials. inspection of the suspected biter’s teeth is necessary.
When the bite mark is located in an area accessible to With metric analysis, once casts and exemplars have been
the victim, impressions of the victim’s dentition and com- generated, each characteristic of the suspect’s teeth is
parison to the marks is advisable. On occasion, victims measured accurately using calipers and recorded.83 This
do bite themselves during the passion of an intense fight. includes the size of each tooth, intercanine distance, size
If an investigator fails to perform this task, the defense of any diastema, degree and direction of any rotated
often will bring forth this possibility to the embarrass- and/or malaligned teeth, and notation of any missing
ment of the prosecution. teeth. Each characteristic of the suspect’s teeth that is
registered in the bite mark will also undergo a similar
analysis. Then, there is a comparative analysis of the
BITE MARK ANALYSIS measurements recorded from the bite mark and that of
Human bite mark analysis is possibly the most challeng- the suspect’s teeth to determine the degree of match.
ing aspect of forensic odontology. Combining the subtle
nature of bite mark evidence with the highly subjective Results of Analysis
interpretation of this evidence is a major problem related After bite mark analysis and evaluation of other evidence,
to bite mark analysis. Because of this problem, differ- including DNA evidence, crime scene photographs, and
ences in expert opinions—even among board-certified written medical treatment reports, the forensic dentist
forensic dentists—should be expected during trial. must prepare a report of the bite mark analysis results
Comparative analysis involves the examination of the and form an opinion. The opinion may link a suspect to
bite mark evidence and comparison against suspect evi- the bite mark, exclude a suspect as the biter, or neither.82
dence to determine whether a positive identification is Specific bite mark terminology has been recommended
possible. There are many comparison methodologies by the ABFO to prevent miscommunication when used
used by forensic dentists in the analysis of bite mark as a conclusion in a report or testimony.79 The terms
evidence, including visual comparison, life size overlays, relate the degrees of certainty when describing the link
test bites (exemplars), digital bite mark overlays, scan- between the bite mark and suspect.
ning electron microscopy, and metric analysis. The most Although the conviction of a criminal based on bite
commonly used comparison methods involve some type mark evidence alone is extremely rare, bite mark evi-
of overlay technique and metric analysis. dence provides additional information in connecting a
suspect to a crime or an injury produced during a crime.
Fabrication of Bite Mark Overlays It is the bite mark evidence in conjunction with the other
Many methods for fabricating bite mark overlays have evidence that leads to a conviction. Bite mark analysis
been published.90-92 One technique is described as follows: continues to be a challenging yet fascinating and impor-
1. Life-sized (1 : 1) photographs are produced of the bite tant aspect of forensic odontology.
injury (Fig. 23-15A).
2. Once stone casts of the suspect’s teeth have been gen- SUMMARY
erated and duplicated, the incisal edges and cusp tips
are inked on the duplicate cast. Life-sized (1 : 1) pho- Human and animal bites are complicated wounds. They
tographs are made of the suspect’s casts, with a scale consist of crush injuries with punctures, lacerations, and
in place. Two Xs are placed on the photograph to avulsions that are contaminated by a plethora of micro-
serve as reference points. A transparent acetate sheet organisms. Underlying fractures and concomitant multi-
is placed over the life-sized photograph of the sus- organ systems injuries must not be overlooked. Antibiotic
pect’s cast and the incisal edges are traced and labeled. prophylaxis using amoxicillin with clavulanic acid is
The Xs are also traced to prevent the overlay from encouraged. Because these are neither clean nor minor
inadvertently being reversed. On the flip side of the wounds, tetanus prophylaxis must be considered. Rabies
A
B
C
D
FIGURE 23-15 A, Victim with a bite mark on torso. B, Photograph of the suspected biter’s cast with the mandibular teeth inked and
acetate overlay tracing. C, Acetate overlay tracing shown slightly above bite injury to visualize concordant points. D, Exact
superimposition of overlay on life-sized bite mark injury photograph. (Courtesy Dr. Douglas Damm.)
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Clin North Am 45:365–397, 2001. 1997.
CHAPTER
Diagnosis and Management of
24 Traumatic Salivary Gland Injuries
Brian Bast
| Norman J. Betts
| Michael P. Powers
OUTLINE
Anatomy Submandibular Gland Injuries
Parotid Gland and Duct Sublingual Gland Injuries
Submandibular Gland and Duct Parotid Gland Injuries
Sublingual Gland and Duct Isolated Glandular Injury
Minor Salivary Glands Ductal Injury
Mechanism of Salivary Gland and Ductal Injuries Management of Salivary Gland Injury Complications
Diagnosis of Salivary Gland Injuries Iatrogenic Injuries to the Salivary Gland
Treatment of Salivary Gland Injuries Parotid Sialocele and Fistula
Minor Salivary Gland Injuries Submandibular Gland Mucocele
T
rauma to the facial soft tissues and fractures of the underestimated in patients who have suffered significant
maxillofacial complex may involve the salivary or massive facial trauma. Thorough assessment and
structures, but the relative incidence of injury to proper management of these injuries can prevent costly
the salivary structures is low. Salivary gland injuries are and unpleasant sequelae as acute treatment is usually
usually associated with penetrating injuries or complex much less difficult than late management.5,6
fractures of the facial bones.1,2 Salivary gland trauma can
be classified as acute (blunt, lacerating, avulsion, or blast
injuries) or chronic (inflammatory damage associated ANATOMY
with infection, foreign bodies, sialoliths, or irradiation).
Management of salivary gland injuries may vary accord- PAROTID GLAND AND DUCT
ing to factors such as the mechanism of injury, site of The parotid gland is a unilobar structure with superficial
injury, degree of contamination, associated injuries, and and deep portions. These two segments of the gland are
general medical status of the patient. Lacerations in the connected by a small isthmus, within which lies the facial
cheek region posterior to the anterior border of the mas- nerve. The gland is encapsulated by a fascia formed by a
seter muscle along a plane from the tragus of the ear to splitting of the superficial layer of the deep cervical
the middle of the upper lip (Fig. 24-1) may involve the fascia. The bulk of the parotid gland overlies the ramus
parotid gland or duct, various branches of the facial of the mandible and is bounded superiorly by the zygoma
nerve, and the facial artery and veins. Soft tissue injury and anteriorly by the masseter while posteriorly abutting
in the floor of the mouth or beneath the mandible can the external auditory canal and the anterior superior
damage the submandibular or sublingual glands, their aspect of the sternocleidomastoid muscle. The parotid
associated ducts, or both. However, the incidence of tail curves posteriorly around the mandibular ramus and
injury to these salivary glands is lower than that for the is rarely involved in traumatic injury. The parotid duct,
parotid gland because of the protection of these salivary or Stensen’s duct, exits from the anterolateral portion of
structures by the body of the mandible. the gland and passes beyond the anterior border of the
Salivary gland injuries can be serious and frequently masseter muscle, parallel with a plane drawn from the
associated with long-term morbidity. Delay or failure to tragus of the ear to the midpoint of the upper lip.
diagnose may result in morbidity secondary to soft tissue Approximately 1 cm anterior to the anterior border of
scarring and disfigurement, sialocele, cutaneous fistula, the masseter muscle, the duct turns medially and pene-
or gustatory sweating associated with Frey’s syndrome.3,4 trates the buccal fat pad and buccinator muscle, opening
Surgical and nonsurgical approaches are used in the into the mouth at the level of the maxillary second molar.
treatment of salivary gland and ductal injuries. Nonsurgi- The facial nerve emerges from the stylomastoid foramen,
cal approaches are generally used only when the gland passes into the substance of the gland, and subdivides
parenchyma is contused but the ductal structures remain into multiple branches that emerge anteriorly from the
intact. Surgical techniques are used to repair extensive gland substance. Stensen’s duct is divided into the glan-
injuries. Unfortunately, injuries to the salivary glands dular portion, the proximal (masseteric) portion and a
and/or supporting structures are often overlooked or distal (buccal) portion.7 Generally, the buccal branch of
633
portion of the submandibular triangle. The gland lies

deep to the platysma muscle, bounded anteriorly and
inferiorly by the digastric muscle, the myohyoid muscle
deep, and the hypoglossus muscle posteriorly. The
greater part of the gland is superficial, but it folds around
the posterior border of the mylohyoid muscle so that a
small portion of the gland is found in the posterior floor
of the mouth. The facial artery is intimately associated
with the superficial portion of the gland. The subman-
dibular duct, or Wharton’s duct, arises from the deep
portion of the gland, is about 5 cm long, and has rela-
tively thin walls and a constricted orifice. The duct leaves
the submandibular triangle by passing above the poste-
rior border of the mylohyoid muscle traversing along the
floor of the mouth and opening in the anterior floor of
mouth. In the floor of the mouth, the duct passes from
lateral to medial on its way to the sublingual caruncle.
Here, the duct has an intimate relation to the lingual
nerve, which crosses it twice on its forward path (Fig.
24-2).9,10 The facial vein and artery are in close associa-
tion with the submandibular gland and generally lie just
posterior to the gland. The marginal branch of the facial
A nerve provides function to the depressor muscles of the
lower lip and runs over the fascia superficial to the facial
artery, facial vein, and gland and can extend to the most
inferior level of the gland.
SUBLINGUAL GLAND AND DUCT

The sublingual gland is the smallest of the three major
salivary glands. It is narrow and flattened and lies below
the mucosa bilaterally in the floor of the mouth, above the
mylohyoid muscle. About 12 small sublingual ducts (ducts
of Rivinus) emanate from the superior border of the
gland and open separately in the floor of the mouth.10-12
MINOR SALIVARY GLANDS

A discussion of the anatomy of salivary glands would not
be complete without mention of the minor salivary
glands. Minor salivary glands provide the bulk of lubrica-
B
tion for the mucosal surfaces of the oral cavity. These
FIGURE 24-1 A, A line drawn from the tragus of the ear to the glands are located throughout the oral cavity, with the
middle of the upper lip approximates the course of the parotid majority in the palate, the labial and buccal mucosae, the
duct. Injury to the parotid gland duct is usually located at or ventral surface of the tongue (Blandin and Nuhn’s
distal to the anterior border of the masseter muscle along this glands), and the alveololingual glands in the lateral floor
line. B, Facial laceration with high risk of injury to parotid gland of the mouth. These minor glands lack a well-developed
and duct. (Part A from Adams J, Barton E, Collings J, et al.: ductal system. Instead, these glands, which are located in
Emergency medicine, St. Louis, 2008, Saunders.) the submucosal layer, have short ducts that open directly
on the mucosal surface.10,13
the facial nerve can be found 5 to 10 mm below the
parotid duct as it exits the gland. The nerve and duct are
especially vulnerable to injury as they pass relatively MECHANISM OF SALIVARY GLAND AND
unprotected over the superficial surface of the masseter DUCTAL INJURIES
muscle and exit the anterior portion of the parotid gland
before descending within the fibers of the orbicularis oris Sharp penetrating trauma is the usual mechanism that
and buccinator muscles.4,8 Several vascular structures are results in acute injury to the salivary glands and sur-
associated with the parotid gland, including the retromo- rounding anatomical structures. Lewis and Knottenbelt
lar and external jugular veins and superficial temporal, have reported the incidence of parotid ductal injury as
external carotid, and facial arteries. 0.21% (33 of 15,419) of all trauma cases evaluated over
a 6-month interval, with most of these injuries being
SUBMANDIBULAR GLAND AND DUCT assaults with a knife or bottle.1 The most common cause
The submandibular gland lies below and in front of the of parotid gland injury is penetrating trauma from assault
angle of the mandible and occupies most of the posterior weapons or broken glass from a bottle or an automobile
Diagnosis and Management of Traumatic Salivary Gland Injuries CHAPTER 24 635
FIGURE 24-2 Anatomy of the floor of the mouth. Note the intimate relationship between the lingual nerve and submandibular duct. The
submandibular duct originates from the portion of the gland that folds around the posterior border of the mylohyoid muscle. (From
Liebgott B: The Anatomical basis of dentistry, ed 3, St. Louis, 2011, Mosby.)
windshield.3 The largest documentation of salivary gland physical examination often provide useful information
injury in the literature was reported by Morestin, who in the workup of possible salivary gland injury. Ques-
published his World War I experience with 62 parotid tions should be directed toward the presence of any sus-
gland injuries.14 Blunt or compressive injury to the sali- picious swelling or drainage from the wound that might
vary glands is rare, usually requires significant amount of represent saliva, as well as the effects of food if the
force that results in injury to the facial bones and facial patient is taking an oral diet. Any penetrating cheek
soft tissues, and typically is associated with motor vehicle injury has the potential to involve the parotid gland and
accidents (MVAs), but also has been reported from duct, the facial nerve, or all these structures. Figure 24-3
sports-related injuries, strangulation, blows from fists or demonstrates a useful anatomic classification of parotid
feet, and excessive manipulation.15,16 Blunt trauma may duct injuries first described by Van Sickels.7 Site A repre-
result in the formation of a parenchymal contusion, sents the most proximal portion of the duct, where it
hematoma, and sometimes a sialocele or a mucocele. emerges from the substance of the parotid gland to the
This type of injury usually involves the parotid gland posterior edge of the masseter muscle. Site B is directly
because of the protective nature of the mandible body over the masseter muscle. In this location, the duct is
for the submandibular and sublingual glands.17 However, relatively straight, superficial, and unprotected by any
rupture of major salivary glands can occur after blunt other overlying structure. Consequently, site B is the
force, even in the absence of a cutaneous defect or lac- most common location of duct injury and the easiest to
eration.15,18 The demographics of salivary gland injury repair.1 Lastly, site C represents the portion of the duct
are similar to those of other maxillofacial injuries in that distal to the anterior border of the masseter muscle,
the incidence is greater for men in the third decade of which subsequently dives into the substance of the buc-
life.1,3,19 In a collective review of 32 patients by Tachmes cinator muscle to terminate in the mouth adjacent to
et al, 56.3% of ductal injuries were acute, whereas the the maxillary second molar.
remainder appeared several days following the injury Parotid duct injuries are not easily diagnosed and are
with a sialocele, fistula, or both, often with associated often missed on initial examination.1,19 In addition, other
superinfection.2 severe traumatic injuries are often associated with parotid
duct injuries. Thus, delay in diagnosis of salivary injury
DIAGNOSIS OF SALIVARY GLAND INJURIES is common and, if diagnosis is made, immediate repair
is often postponed until the patient is stable.2,3 When the
The diagnosis of salivary gland injury starts with patient’s condition permits, the optimal sequence of
increased suspicion of a potential injury based on the treatment for suspected parotid gland ductal injury
location and mechanism of trauma. The history and should include the following20,21:
FIGURE 24-4 Lateral cephalometric image of a patient following a

parotid sialogram. Note the presence of the catheter in the parotid
duct orifice.
examination consists of attempting to identify collections

of clear fluid in the depths of the wound. The sensitivity
of this examination can be improved by pressing on the
A B C gland to express saliva into the field. When injuries are
suspected with the submandibular gland, an assessment
of tongue sensation and mobility may be helpful. Facial
nerve function can be assessed with a nerve stimulator to
help determine if the nerve is intact. Ductal injuries can
best be delineated by direct inspection following cannu-
FIGURE 24-3 Anatomic classification of parotid duct injuries first lation of the duct with a lacrimal probe from its distal
described by Van Sickels and Alexander. The path of the duct is oral opening. Retracting the cheek wall in an outward
divided into three regions—A, B, and C. The most common site direction, which straightens the sharp bend in the distal
of injury and the easiest to repair is in region B over the anterior duct, can facilitate cannulation of Stensen’s duct. Retro-
border of the masseter muscle. grade injection of methylene blue can be used to aid in
the diagnosis of ductal injury when inspection and
probing fail to locate the duct. The duct opening is
• Detailed history and physical examination. located intraorally and cannulated with a small gauged
• Complete otologic examination when injury to the angiocatheter. A small amount of methylene blue is
parotid gland is suspected. injected retrograde while observing the wound. Areas of
• Palpation of the skeletal support of the face and the extravasation can then be explored for ductal injury. A
temporomandibular joints. small amount should be injected because an excessive
• Functional testing of each branch of the facial nerve amount of dye in the wound can make for difficult evalu-
(the administration of local anesthetic should be ation and identification of stained anatomic land-
delayed until this examination is completed). marks.6,22,23 Saline, sterilized milk,24 or propofol solution
• Control of hemorrhage with pressure until adequate has been advocated to assess the integrity of the duct and
exploration of the wound under general anesthetic avoid the staining problems associated with the use of
can be attempted; blind attempts to control bleeding methylene blue.
should be avoided because the main blood vessels to Radiographic imaging can been used to support the
the parotid gland lie deep to the facial nerve. clinical suspicion of salivary gland and ductal injury. Mag-
• In deeply penetrating injuries to the parotid gland, netic resonance imaging (MRI) has been the standard
one must rule out injury to the carotid artery and a technique for imaging soft tissue pathology, including
thorough neurologic examination must be under- infections, but is not the study of choice for salivary gland
taken. Repeat examination is indicated if the patient trauma because it is difficult to delineate the integrity of
is intoxicated or unable to participate with the the ductal system. Sialography with a water-soluble con-
examiner. trast medium remains a highly sensitive test of ductal
• Emergent exploration of the wound if nerve or ductal abnormalities, with or without (Fig. 24-4) computed
injury is suspected. tomography (CT) imaging.13,17,25-27 Direct visualization of
Inspection of the injury and surrounding structures ductal filling under fluoroscopy can be useful, particu-
should be compared with the contralateral side for sym- larly using digital subtraction techniques. Cannulation of
metry. After control of hemorrhage, a complete the parotid duct is normally straightforward, but access
to the submandibular duct, especially in the trauma

patient, may be difficult and its use with possible sublin-
gual gland injury is not possible. Several authors have
argued that the study of sialography, although costly and
time-consuming, is important because it can delineate
the exact location of glandular and ductal injuries, which
has significant prognostic implications.1,3,28 Patients with
facial trauma may also have concomitant injuries that
prohibit transferring the patient to the radiology depart-
ment for a lengthy study. Sialography is best used in cases
that present some time after the traumatic event or in
which ductal injury may have been overlooked.23 Sialog-
raphy is also useful in the postoperative period to evalu-
ate the results of treatment. If cannulation of the duct is
unsuccessful, salivary gland function may be quantified
by time-activity curves with 99mTc-pertechnetate scintigra-
FIGURE 24-5 Atypical location of a mucocele (salivary
phy and may distinguish between the functioning,
extravasation phenomenon) on the ventral surface of the tongue.
obstructed, and nonfunctional gland.29 MRI sialography
A mucocele can occur anywhere minor salivary glands are
is an imaging technique using heavily T2-weighted present. They commonly occur following injury to the minor
sequences that is performed without the injection of a salivary gland duct, which leads to extravasation of saliva into the
contrast medium and is considered a noninvasive, pain- surrounding tissue.
less, and safe technique. Ductal injuries can be demon-
strated by MRI sialography, which is dependent on
stimulated ductal salivary flow as the contrast medium,
and correlates well with or even improves on conven- include intraoral lacerations of the duct, penetrating
tional sialography.24,30 trauma to the gland, trauma to the gland associated with
fracture of the mandibular body, or direct blunt trauma
TREATMENT OF SALIVARY GLAND INJURIES with fracture of the gland (usually seen following MVAs).
Complications may include salivary extravasation into
Specific recommendations on the management of ductal tissue, an expanding neck mass or, less commonly, cuta-
injury remain controversial. There is a consensus in the neous fistula formation.13,31 Treatment of parenchymal
literature that acute parotid injuries should be explored injuries usually consists of conservative management with
primarily and the injured structures repaired, if possible. pressure dressings and aspiration of any fluid collection.
The aims of primary repair of salivary gland injuries If significant damage to the gland is present or if conser-
should be the reapproximation of anatomic structures vative measures fail, excision of the gland is appropri-
and return of normal function. Nonsurgical manage- ate.28 The most frequent management for intraoral
ment of parotid duct injuries has been supported by lacerations of Wharton’s duct is marsupialization at the
Lewis and Knottenbelt, who reported their experience site of injury (Fig. 24-6). This is the treatment of choice
with 19 patients with a confirmed parotid duct injury. because primary repair of the duct is difficult and unnec-
Nine patients had an uncomplicated duct healing and essary and may result in secondary stricture formation.9
the remaining patients developed a sialocele or fistula
that eventually resolved without surgical management.1 SUBLINGUAL GLAND INJURIES
Injury to the sublingual gland is most commonly a result
MINOR SALIVARY GLAND INJURIES of blunt penetrating trauma in the floor of the mouth or
Most minor salivary gland injuries occur during penetrat- injury associated with fracture of the mandible in the
ing intraoral trauma. Appropriate treatment during the area of the sublingual glands. Again, the incidence is low
closure of intraoral lacerations includes the removal of because of the protective nature of the mandible.
any traumatized minor salivary glands within the wound. Depending on the severity of injury, repair consists of
Complications of such intraoral or labial injuries may primary closure of the wound or gland removal. The
result in mucus retention phenomena (or mucocele; Fig. most notable complication of this injury is ranula forma-
24-5) caused by extravasation of fluid into the surround- tion with treatment being gland excision or marsupializa-
ing tissue from injury to the duct of a minor salivary tion11,12,32,33 (Fig. 24-7).
gland. The treatment of this complication is accom-
plished by aggressive removal of the involved and sur- PAROTID GLAND INJURIES
rounding minor salivary glands and the associated Defining the extent of parotid gland injury is helpful for
fluid-filled cavity, followed by primary closure of the predicting the development of complications and dura-
mucosa.9,13 tion of healing. Consequently, it is useful to divide inju-
ries into those that involve only glandular tissue, those
SUBMANDIBULAR GLAND INJURIES that involve only the duct, and those that involve both
Direct injury to the submandibular gland parenchyma is the gland and the duct. Van Sickels has recommended
unusual because of the protective nature of the body of that injuries that occur over the glandular region be
the mandible and position of the gland. Typical injuries treated with closure of the capsule, those over the
FIGURE 24-6 Marsupialization of the submandibular duct

into the floor of the mouth in a more distal location
following traumatic injury to the distal duct.
A B
C D
FIGURE 24-7 A, Ranula in the right side of the floor of mouth. This patient experienced penetrating injury to the floor of the mouth
approximately 1 month before being seen by a physician. B, Initial incision with exposure of mucocele. C, Specimen containing
sublingual gland and mucocele. D, Exposure of lingual nerve and submandibular duct after removal of sublingual gland and mucocele.
A B
FIGURE 24-8 Injury to the parotid region involving only the glandular material. Note the circular form of the injury resulting from an assault
with a broken bottle. The wound is closed after careful attention to a layered closure, paying particular attention to the gland capsule. An
external pressure dressing will now be applied for 24 to 48 hours.
masseter muscle treated by direct repair of the duct, and injury and presentation, and presence of complications,
those anterior to the masseter treated by repair of the such as sialoceles or salivary fistulas. There are three
duct or creation of an intraoral fistula.7 Identifying the methods generally used to manage duct lacerations.
exact location of the ductal injury provides important Three categories of treatment include primary repair of
prognostic information (see Fig. 24-3).1,3 the duct with microsurgical anastomosis, diversion of sali-
vary flow by creation of an intraoral fistula, and suppres-
Isolated Glandular Injury sion of salivary gland function.23
Isolated glandular injury can be managed conservatively Controversy exists in the literature concerning the
without any surgical intervention other than suturing. acute management of known parotid duct injury. One
Thorough irrigation of the wound, débridement of side argues for exploration of the wound and primary
necrotic tissue, and layered primary closure of lacera- closure of lacerations to Stensen’s duct, stating that the
tions should be carried out, with closure of the gland complications of sialoceles, fistulas, and salivary cysts are
capsule being the most important. A pressure dressing great and preventable6,22 and, given the advancements in
often is applied to prevent a sialocele by attempting to microsurgical technique, good results may be achieved.35,36
direct the saliva back through the ductal system. Because Others believe that the hazards and inconvenience
of the potential for infection, these patients should be involved in immediate repair of parotid ductal injuries
placed on antibiotics. are not justified because complications such as sialocele
Primary management of glandular injury that includes and cutaneous fistula eventually heal with conservative
a major interparotid duct also involves a layered closure management.1,3
of the wound (Fig. 24-8), application of pressure dress- The most important factors in the primary surgical
ings, frequent recall with aspiration of any fluid accumu- management of parotid duct injury are the extent of
lation, and techniques to reduce salivary flow (i.e., NPO injury and anatomic location of the lesion. In a study by
and the administration of antisialagogues [e.g., prop- Parekh et al, conservative management of parotid inju-
antheline, 30 mg PO every 6 hours]). Oral intake is ries resulted in an average healing time of 10 days for
restricted as Enfers34 has demonstrated that resting lesions in regions A and B (see Fig. 24-3) when only
parotid secretions are negligible and the major impetus partial ductal injury was present. However, complete
for parotid salivary flow is gustatory and mechanical transection of the duct, whether in region B or C, resulted
stimulation. Lesions confined to the parenchyma or in a delayed healing time as long as 21.5 days with con-
minor ducts heal notably faster than glandular disrup- servative management.3
tion that includes a major intraparotid duct. For glandu- Localization of the site of ductal injury can provide
lar injuries that disrupt major intraparotid ducts, lack of important prognostic data and help determine the
oral stimulation has been shown to facilitate healing method of treatment. Lesions appearing in the proximal
significantly.3 portion of the duct or at the glandular-duct interface
have fewer associated complications and a more expedi-
Ductal Injury ent healing phase and therefore can be treated conser-
Acute trauma to the parotid gland rarely produces a vatively. In contrast, Parekh et al3 have indicated that
complicated surgical problem unless Stensen’s duct has disruption of the glandular-duct junction has the worst
been injured. When managing an injury to the parotid prognosis. Lewis and Knottenbelt noted in their study
duct, many factors must be considered, including the that only 2 of 9 patients with site A injuries (glandular
degree and anatomic location of the ductal damage, any injury only) have complications following conservative
associated facial nerve injury, time interval between therapy, whereas 8 of 10 patients with injuries in sites B
A B
C D
E F
FIGURE 24-9 Steps for primary repair of parotid duct laceration. A, The parotid duct severed at the anterior border of the masseter
muscle. B, A catheter is passed through the oral orifice of Stensen’s duct into the wound. C, The sharp bend in the duct just before it
penetrates into the oral cavity. D, Correctly placed intraoral finger pressure can straighten the duct to facilitate the threading of the
catheter. E, Direct anastomosis of the cut ends of the duct using the catheter as a splint. F, Appearance of the duct after primary
anastomosis with at least three sutures.
and C have complications.1 Overall, in their study, 47% parotid duct injuries, especially if they are located in
of ductal injuries healed without complication, 37% regions A and B.
had salivary fistulas, 21% had sialoceles, and 1 in 19 Most authors believe that the acute appearance of a
had an infection that resolved following antibiotic admin- parotid duct transection warrants immediate repair with
istration. However, all complications healed within 3 stenting.1,7,20,28,37
weeks without surgical intervention. These figures give Primary parotid duct repair should be sequenced as
credence to the conservative management of partial follows (Fig. 24-9):
FIGURE 24-10 Severe through-and-through laceration of the left FIGURE 24-12 Repair of the parotid duct with three small Prolene
cheek from the commissure of the mouth almost to the ear sutures following identification and cannulation of the proximal and
following a motor vehicle accident. distal portions of the lacerated duct.
FIGURE 24-13 Final layered closure of the wound before

FIGURE 24-11 Visualization of the entire laceration after careful application of an external pressure dressing.
débridement and control of hemostasis.
1. Functional testing of the facial nerve should be per-

formed before administration of local anesthetic. The
wound should be gently irrigated and débrided. Bleed-
ing should be controlled with pressure or surgical ties;
avoid electrocautery and blind clamping (Figs. 24-10
and 24-11).
2. The cheek wall should be retracted outward. This
maneuver straightens the angled course of the distal
parotid duct and permits easy passage of the catheter.
3. A 16-gauge Intracath stent is passed through the distal
portion of the duct from the oral orifice. If this is
impossible, and if the cut end of the distal portion of
the duct is visible in the wound, cannulation of the
duct can be performed through the wound. FIGURE 24-14 End of the catheter sutured in place intraorally in
4. Identification of the proximal portion of the duct is the left cheek. This catheter will be left in place for 10 to 14 days.
facilitated by massaging the gland to express saliva. The
proximal segment of the duct is then cannulated. to the buccal mucosa (Fig. 24-14), and an external
5. The severed ends of the duct are closed over the Intra- pressure dressing is applied for 24 to 48 hours. Anti-
cath, with at least three small nylon or Prolene sutures sialagogues (propantheline, 30 mg PO every 6 hours)
(Fig. 24-12). can be considered. The catheter is left in place for 10
6. The wound is closed in layers, with careful closure of to 14 days. During this time, the patient should receive
the gland capsule (Fig. 24-13). The catheter is sutured antibiotic therapy.7,22,28
7. A ductal defect larger than 1 cm may prevent direct of pain until the atrophy process is complete. A pressure
anastomosis, and an autogenous graft may be indi- dressing should be placed over the parotid gland to mini-
cated.35 Interpositional vein grafting in the repair of mize swelling and further promote gland atrophy; antisi-
Stensen’s duct has been reported.38 alogogue medications should be used to decrease
Unfortunately, no long-term study has looked at ductal salivary gland function.4,23 Concerns of facial asymmetry
patency or the incidence of parotid duct atrophy after following glandular atrophy have been demonstrated
primary repair. If ductal stricture occurs, balloon dilation not to be a long-term complication following parotid
can be performed to improve ductal patency.39 Postop- duct ligation.41
erative sialography or evaluation by sialoendoscopy may Some authors advocate a conservative approach and
be used to examine the intraductal anatomy after trauma believe that the biggest risk of delayed treatment of
to the gland and/or duct.35,40 ductal injuries is the development of a sialocele or sali-
If there has been extensive tissue loss and direct anas- vary fistula, which in most cases can be managed conser-
tomosis is not possible, the proximal parotid duct should vatively.1,3,28 The advantages of conservative management
be dissected free from the surrounding tissue to allow for of acute ductal injuries include safety and ease of treat-
surgical manipulation and diversion of the duct into the ment, less risk of facial nerve injury, no necessity for
oral cavity may be possible. The proximal portion of the special surgical skills, and the ability to manage these
duct is brought through the buccinator muscle and oral patients on an outpatient basis.
mucosa into the oral cavity. If the duct enters the oral Another factor essential for determining the method
cavity without tension, a catheter within the duct may not of treatment for parotid gland injuries is the presence of
be necessary and the duct can be sutured to the intraoral known facial nerve injury. The facial nerve can be injured
mucosa. Although use of a stent is not mandatory, a stent by transection or compression, or from a crushing injury.
may help reduce the incidence of ductal stenosis conse- In a compression or crushing injury, the functional
quent to developing granulation tissue and edema while deficit may be without anatomic disruption. Electrical
maintaining patency of the duct and permitting salivary nerve testing may be useful to evaluate nerve potential
flow.4 If the proximal duct cannot be advanced to enter and, in most cases, nonpenetrating injuries to the facial
into the oral cavity tension-free, a catheter can be inserted nerve can be managed conservatively with good results.42
into the proximal portion of the duct and secured to the Most authorities agree that the diagnosis of transected
oral mucosa to allow for secondary epithelization around facial nerve injury warrants immediate exploration and
the catheter and formation of an oral fistulous tract for repair of the nerve and duct in an operating room setting
drainage of the salivary flow. using microsurgical repair.1,2,5 Landau and Stewart28 have
With severe avulsion of the soft tissues or during reported a 20% incidence of facial nerve injury associ-
wound exploration, repair of the ductal injury is judged ated with isolated glandular injuries and a 55% incidence
to be impossible; the proximal portion of the duct should with parotid duct injuries. When a facial nerve injury
be ligated. The resulting salivary obstruction leads to occurs, the buccal branches are usually injured. This is
increased intraluminal pressure, which when transmitted because the buccal branches run parallel and just supe-
to the parotid parenchyma results in decreased perfusion rior to the duct and occasionally may even cross lateral
and eventual physiologic death of the gland.6,14,28 Although to the duct (Fig. 24-15). Severance of this nerve branch
effective, this process can result in temporary parotid causes drooping of the upper lip. To determine whether
inflammation and swelling, causing a significant amount a severed nerve branch should be repaired, the examiner
Facial nerve Temporal

temporofacial branch
division
Zygomatic
branch
Posterior
auricular nerve
Buccal
Facial nerve branches
cervicofacial
division Parotid
duct
Parotid gland Marginal
FIGURE 24-15 The relationship of the parotid mandibular
gland and duct to the branches of the facial branches
Nerve to
nerve. Note the close approximation of the digastric and
buccal branches of the facial nerve to the stylohyoid Cervical
parotid duct. muscles branch
should compare the site of injury with a line from the Clinical studies have investigated the use of botulinum
outer canthus of the eye to the gonial notch of the man- toxin at the site of a sialocele or fistula.45,46
dible. Branches distal to this line do not require repair; The use of antisialagogues alone to treat salivary inju-
however, careful attention to closure of the wound in ries has had mixed reviews in the literature. Antisiala-
layers is necessary to facilitate reestablishment of nerve gogue therapy is a useful adjunct when attempting to
function. For nerve injuries proximal to this line, isola- decrease salivary flow. Their use may aid in the closure
tion of the lacerated nerve stumps and primary repair of salivary fistulas; however, some authors report success
are indicated, including possible nerve graft from the only in injuries not involving major intraparotid ducts.
greater auricular or sural nerves. Their use alone may be questioned and the side effects
The detection of parotid duct injuries is frequently associated with their use can be problematic.
delayed. Delay allows for granulation tissue formation as In the past, radiation therapy was used to induce fibro-
well as scarring. Finding and repairing a duct in such a sis and atrophy of the gland. Approximately 1800 rad is
presentation may be difficult or impossible and more necessary to accomplish glandular atrophy. However,
conservative treatment modalities may be required. This there is a high failure rate in patients with ductal injuries,
is primarily because of the high incidence of severe mus- and more than 6 weeks is required for gland atrophy to
culoskeletal injuries associated with parotid injuries. occur following radiation therapy.3 The potential to
Management of these injuries takes precedence, often induce malignancy (thyroid cancer, skin cancer, or sali-
precluding definitive diagnosis and treatment of parotid vary gland neoplasms) has led to general abandonment
injuries in a timely fashion. Furthermore a definitive of this treatment method.6
diagnosis of ductal injury is often not made in the trauma Tympanic neurectomy (transtympanic sectioning of
bay, because an accurate diagnosis often requires patient Jacobson’s nerve) has a high failure rate. It has been
compliance and time-consuming procedures, such as shown that the use of this technique may not speed
local wound exploration and duct cannulation,28 cannu- recovery and bears a high potential morbidity of delayed
lation of the duct with injection of methylene blue dye,1 healing because glandular atrophy may take as long as 6
or the use of sialograms with or without associated CT months to occur.44,47,48
studies.3,25,43 Delay in the treatment of parotid injuries Superficial or total parotidectomy has been advocated
may be beneficial in certain patients in whom notable as a treatment method. However, the morbidity of this
hemorrhage or tissue distortion is present. In these procedure, especially in the presence of granulation
patients, local wound exploration may be associated with tissue and fibrosis, must be emphasized. This technique
a high risk of morbidity (e.g., facial nerve injury).44 has also largely been abandoned because approximately
75% of these patients experience some postoperative
facial palsy.44
The initial treatment for complications such as sialo-
MANAGEMENT OF SALIVARY GLAND cele and cutaneous fistula is conservative management,
INJURY COMPLICATIONS including pressure dressings, repeated aspirations,
limited intake by mouth, and the use of antisialagogues
The most common complications of major salivary gland to decrease salivary flow (Fig. 24-16).19,48 Landau and
injuries are a result of salivary fluid extravasation into the Stewart have reported uniform success using this conser-
tissue leading to a sialocele, a nonepithelialized fluid- vative treatment regimen in a prospective study of 14
filled cavity (through continuous salivary secretion patients with sialoceles or cutaneous fistulas.28 All the
without proper drainage),35 and finally to a salivary cyst, sialoceles and fistulas resolved within 14 days.49,50 Other
an epithelialized cavity filled with salivary secretions. authors have shown similar results.1,3,44,47 One study went
Occasionally, a cutaneous salivary fistula may be formed further in the delineation of conservative therapy by
from the extraoral flow of saliva from the injury site.6 An placing patients on a strict NPO regimen while adminis-
external parotid fistula can develop within the first week tering parenteral nutrition until the salivary lesion was
after injury. In contract, a sialocele tends to develop completely healed. The investigators found a significant
more slowly, presenting 8 to 14 days after parotid gland difference in the rate of healing when those on NPO
trauma.3 The duration of the complications and the status were compared with those allowed oral intake 5
prognosis are again directly attributed to the location days following repair. This method of treatment is suc-
and degree of the parotid injury, (i.e., parenchymal cessful because the parotid gland is kept in a resting state
versus ductal injury and partial versus complete ductal in which basal salivary flow rates are small. In addition to
transection).44 Ideally, one would confirm the presence the preceding, Epker and Burnette have advocated the
of salivary fluid in a sample of aspirate by determining insertion of a catheter via Stensen’s duct into the sialo-
the amylase level (>1000 U/liter), because these lesions cele, with intent to direct drainage intraorally.6 Studies
may be mistaken for hematoma or infection. of the treatment of selected salivary gland disorders with
Since secondary repair of the duct is difficult because local injections of botulinum toxin type A (Botox, Aller-
of the presence of granulation and scar tissue,6 the major gan, Irvine, Calif) has been encouraging. Botulinum
aim of therapy is to resolve the complication with toxin is an exotoxin of Clostridium botulinum. It prevents
glandular atrophy. In the past, methods such as antisiala- the release of acetylcholine at the cholinergic synapse in
gogue administration alone, radiation therapy, parasympa- salivary glands.51 Ellies et al have reported on ultrasound-
thetic denervation (tympanic neurectomy), and superficial guided administration of Botox into salivary glands in the
or total parotidectomy were used to accomplish this goal. treatment of hypersalivation.52 Significant suppression of
A B
FIGURE 24-16 A, Patient with a parotid fistula appearing approximately 10 days following conservative repair of parotid gland and duct
laceration. Note the drop of saliva from the fistula. B, Same patient 3 weeks after initiation of conservative treatment consisting of an
external pressure dressing, administration of oral antisialagogues, repeated aspirations, and restriction of oral intake. Note healing of the
fistula.
salivary gland function induced by botulinum toxin Frey’s syndrome (gustatory sweating) is thought to
begins 1 to 2 weeks after injection and can last for 3 to represent the aberrant regeneration of postganglionic
6 months. This allows time for healing of the salivary parasympathetic parotid nerve fibers, denervated during
gland function and resumption of normal salivary flow.53 the surgical procedure or the traumatic injury, as they
The success of conservative treatment of the complica- grow astray into the overlying skin and innervate the
tions of salivary injury suggests that surgical intervention sweat glands. Diagnosis can be made based on a history
should be considered only after conservative therapy fails. of gustatory sweating or by means of the starch iodine
Various surgical techniques are described in the litera- test, in which the affected skin is painted with iodine and
ture for refractory salivary fistulas and sialoceles, ranging dusted with starch. The patient is then given a sialogogue
from reexploration of the wound to identify and repair and the resultant sweating is manifest by the appearance
the parotid duct injury to techniques designed to redi- of black spots as the sweat interacts with the iodine.
rect the salivary secretions intraorally (create an intraoral Treatment options for Frey’s syndrome include the
fistula).19,50,54,55 With the exception of the last procedure, topical application of 2% glycopyrrolate cream, intra
all these techniques run the risk of complications, dermal injection of botulinum toxin, and tympanic
ranging from delayed or poor healing to facial nerve neurectomy.4
injury. In general, salivary gland injuries are an infrequent
Demetriades19 has described the technique of inter- occurrence. When they occur, they may be associated
nalization of salivary flow for the treatment of sialoceles with other severe injuries, which can lead to delayed
and fistulas. The procedure is performed with the patient diagnosis and treatment. It may be advisable to obtain a
under local or general anesthetic using an incision incor- sialogram if the patient is stable at the time, because the
porating the traumatic scar to gain access to the lesion. information derived from this diagnostic test can be
Next, blunt dissection is used to enter the floor of the important for determining the location and extent of
cystic cavity and then to perforate through the masseter injury and predicting the outcome of conservative treat-
muscle into the oral cavity. A Jacques catheter (size 6) is ment. If acute injury to the duct is detected, particularly
positioned so that one end is within the cavity and the when associated with a facial nerve injury, the wound
other exits through the oral mucosa where it is sutured should be explored and primary repair of the duct and
in place. When a true fistula is present, the epithelium- facial nerve accomplished. If diagnosis is delayed
lined tract must be excised. The skin wound is closed (usually with the appearance of a sialocele or fistula),
primarily in layers and a pressure dressing is applied. The conservative management should be used. In most cases,
intraoral drain is typically left in place for 10 days, oral this approach is successful. If conservative management
antibiotics are prescribed, and the patient receives a fails, surgical intervention should be used to promote
liquid diet. Invariably, the secretions decrease in the first healing.
5 to 7 days. The presumed cause of healing is scar forma-
tion within the cavity and duct, which results in glandular
atrophy. The advantages of this procedure over the IATROGENIC INJURIES TO THE
options described earlier are the ease of performance, SALIVARY GLAND
minimal surgical risk, and minor cost.19,22 A better prog-
nosis for the sialocele or salivary fistula is expected when Surgical approaches to the facial skeleton, particularly
the injury is a result of glandular disruption rather than approaches to the mandible, may bring the surgeon into
a duct-only injury.35 close proximity to the major salivary glands. Iatrogenic
A B
D
FIGURE 24-17 A, B, CT scans demonstrating left subcondylar fracture. C, Retromandibular inciscion. D, Postoperative panoramic
radiograph showing open reduction and internal fixation (ORIF) of mandibular fractures with anatomic reduction.
Continued
E F
G
FIGURE 24-17, cont’d E, Development of a parotid sialocele 2 weeks after surgery. F, Aspiration of sialocele. G, Resolution 1 month after
aspiration and pressure dressing.
injury to the glands during these procedures is a rare infection will often present with fever and leukocytosis,
possibility. It is important that the surgeon be able to which are absent in the sialocele. Aspiration of the sialo-
recognize and manage these injuries should they occur. cele reveals a straw-colored fluid. Laboratory tests would
confirm a high level of amylase. Management involves
PAROTID SIALOCELE AND FISTULA decompression with needle aspiration of the saliva, place-
The retromandibular incision initially described by ment of a pressure dressing, and starting the patient on
Hinds56 requires blunt dissection through the body of the an antisialagogue. Conservative management should
parotid gland. This incision provides excellent exposure continue until resolution of the swelling. This may take
for the open reduction and fixation of mandibular sub- 4 to 5 weeks and may involve repeated needle decom-
condylar fractures. Dissection through the parotid gland pressions59 (Fig. 24-17).
carries a slight risk of the development of parotid sialo-
cele or fistula.57 The reported incidence of parotid sialo- SUBMANDIBULAR GLAND MUCOCELE
cele and fistula associated with the retromandibular The submandibular or Risdon approach provides access
incision is between 2% and 8%. Careful dissection to the mandibular body, angle, and ramus. During this
through the gland and tight closure of the parotid dissection, the operator may encounter the submandibu-
capsule have been advocated as preventive measures to lar salivary gland deep to the platysma muscle while pro-
avoid this complication.58 gressing through the superficial layer of deep cervical
Diagnosis and management of a postoperative parotid fascia. During this dissection, the gland’s capsule may be
sialocele are often straightforward. Clinical presentation violated and the body of the gland injured. Submandibu-
would include a posterior neck swelling in the region of lar gland mucocele is a rare complication.60
the prior surgery. The differential diagnosis would The diagnosis of a submandibular gland mucocele is
include infection versus sialocele. The patient with an largely clinical. The differential diagnosis may include
C
FIGURE 24-18 A, 3 years post-ORIF right mandibular angle fracture. B, Submandibular swelling 3 years after ORIF mandibular angle
fracture. C, Axial CT scan showing fluid-filled collection in the submandibular space.
Continued
infection versus mucocele but could also include other with the associated gland. In some cases, it may prove
neck swellings. Aspiration of straw-colored fluid positive difficult to distinguish if the mucocele is associated with
for amylase coupled with a CT scan of the neck confirms the sublingual or submandibular gland. In these cases, it
the diagnosis. The treatment of a submandibular gland is recommended that both glands be removed as defini-
mucocele involves the removal of the mucocele along tive treatment61 (Fig. 24-18).
E
FIGURE 24-18, cont’d D, Aspiration of submandibular fluid collection (saliva). E, Excision of submandibular gland and mucocele.
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30. Jungehulsing M, Fischbach R, Schroder U, et al: Magnetic reso- 58. Yang L, Patil P: The retromandibular transparotid approach to
nance sialography. Otolaryngol Head Neck Surg 121:488, 1999. mandibular subcondylar fractures. Int J Oral Maxillofac Surg 41:494,
31. Singh B, Shaha A: Traumatic submandibular salivary gland fistula. 2012.
J Oral Maxillofac Surg 53:338, 1995. 59. Abramova L, Mann M, Hessler J, Sengelmann R: Iatrogenic patotid
32. Baurmash H: Marsupialization for treatment of oral ranula: A sialocele after excision of malignant melanoma of the cheek. Der-
second look at the procedure. J Oral Maxillofac Surg 50:1274, 1992. matol Surg 34:1584, 2008.
33. Mintz S, Barak S, Horowitz I: Carbon dioxide laser excision and 60. Ozturk K, Arbag H, Koroglu D, et al: Submandibular gland muco-
vaporization of non-plunging ranulas: A comparison of two treat- cele: Report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol
ment protocols. J Oral Maxillofac Surg 53:370, 1994. Endod 100:732, 2005.
34. Enfers BO: The parotid and submandibular secretions in man: 61. Anastassov G, Haiavy J, Solodnik P, et al: Submandibular gland
Quantitative record of normal and pathologic activity. Acta Otolar- mucocele diagnosis and management. Oral Surg Oral Med Oral
yngol 172:1, 1962. Pathol Oral Radiol Endod 89:159, 2000.
CHAPTER
Traumatic Injuries of the
25
Trigeminal Nerve
Michael Miloro
| Antonia Kolokythas
OUTLINE
Trigeminal Nerve Anatomy Third Molar Surgery
Macroanatomy Dental Implant Surgery
Microanatomy Maxillofacial Trauma
Trigeminal Nerve Imaging Orthognathic Surgery
Preoperative Risk Assessment Maxillofacial Pathology
Postinjury Assessment Endodontic and Chemical Injury
Postinjury Functional Assessment Clinical Neurosensory Testing
Classification of Trigeminal Nerve Injuries Microneurosurgery
Seddon Classification System Indications
Sunderland Classification System Microneurosurgery for Trigeminal Nerve Injuries
Axonal and Cellular Response to Injury Outcomes of Trigeminal Nerve Injury and Surgical Intervention
Mechanisms of Injury to the Trigeminal Nerve
Local Anesthetic Injection
T
he face and perioral regions are among the body injuries that are paramount for appropriate manage-
regions with the highest density of peripheral ment of these cases; and a description of microsurgery
nerve receptors; this feature makes neurologic dis- for trigeminal nerve repair and the expected outcomes.
turbances less tolerable in the head and neck than in The use of universally accepted terminology is crucial
other body parts. The trigeminal nerve is the largest when discussing nerve injuries. It is imperative that the
cranial nerve, with three main divisions including the appropriate terms be used to describe and document
ophthalmic, maxillary, and mandibular branches. The each case for communication among clinicians, determi-
trigeminal nerve is a mixed motor (special efferent and nation of management strategies, and medicolegal
proprioceptive) and sensory (general afferent) periph- reasons (Table 25-1). In addition, a detailed description,
eral nerve innervating the face, mouth, head, and neck including nerve mapping with illustrations of the region
regions. Injury to the peripheral branches of the trigemi- with associated sensory changes, should be documented
nal nerve can be devastating because of the effects on for each patient and used to quantify the initial presenta-
speech, deglutition, swallowing, mastication, and taste, as tion and, most importantly, to follow the progress of the
well as the impact on social interactions. Unfortunately, area of involvement (Fig. 25-1).
these injuries can occur rather easily from a traumatic
event or from several commonly performed procedures
in the maxillofacial region. Throughout their careers, TRIGEMINAL NERVE ANATOMY
oral and maxillofacial surgeons often encounter patients
with trigeminal nerve injuries and should be proficient MACROANATOMY
in diagnosing and managing these cases appropriately, Inferior Alveolar Nerve
because successful outcomes from nerve injuries are criti- The largest of the three branches of mandibular division
cally time-sensitive. In this chapter, the following topics of the trigeminal nerve (V3) descends between the
are presented: an overview of the anatomy of the periph- medial pterygoid muscle and medial ramus and enters
eral branches of the trigeminal nerve, relevant to trau- the mandible at the mandibular foramen (Fig. 25-2). At
matic injuries and surgical procedures in the maxillofacial the lingula (the bony landmark for the mandibular
region; an overview of nerve microanatomy to assist the foramina along the medial surface of the ramus), the
reader’s understanding of the events following injury and inferior alveolar nerve (IAN) has the largest diameter,
the nerve’s regenerative properties; the available imaging 2.4 ± 0.4 mm. At the mandibular foramen, the IAN diam-
modalities for risk assessment of nerve injury from com- eter is 2.0 ± 1.1 mm. The mental nerve exits the man-
monly performed maxillofacial procedures, along with dible at the mental foramen and the course of the bony
the possible mechanisms of injury from these proce- canal appears to be fairly predictable, based on cadaveric
dures; neurosensory testing modalities available for and conventional imaging studies.1-3 Proximally within
appropriate evaluation and classification of nerve the ramus, angle, and body region of the mandible,
650
Traumatic Injuries of the Trigeminal Nerve CHAPTER 25 651
between the mandibular foramen, where the IAN enters

TABLE 25-1 Select Terminology of Sensory Alterations the mandible to the second premolar region, the IAN
follows an S-shaped course. This is where the nerve is
Term Meaning most lateral in the third molar region and closest to the
Allodynia Pain because of a nonpainful stimulus buccal cortex. It then approaches the lingual plate in the
Analgesia Absence of pain from a painful stimulation
first molar region. Anteriorly, between the premolars,
the IAN returns toward the buccal cortex prior to exiting
Anesthesia Absence of any sensation from a painful
the mandible through the mental foramen.
or nonpainful stimulation
According to Cutright et al, the mental foramen was
Dysesthesia Abnormal sensation, spontaneous or found to be apical to the second premolar in approxi-
evoked, that is unpleasant mately 51% of cases; its distance from the midline was
Hyperalgesia Abnormal response to a painful stimulus slightly different between whites and blacks, averaging
Hyperesthesia Increased sensitivity to stimulation, 2.7 and 3.2 cm, respectively. It was noted that in whites
excludes special senses the foramen is located between the premolars, whereas
Hyperpathia Increased reaction to a (repetitive) in blacks it is located distal to the second molar. In addi-
stimulus. tion, the group noted small but significant differences
Hypoalgesia Diminished pain in response to a painful between males and females for the three foramina
stimulus (mental, infraorbital, and supraorbital).4 In the sagittal
Hypoesthesia Decreased sensitivity to stimulation, plane, the course of the IAN in the mandible begins
excludes special senses superiorly and lingually at the lingula, approximately
Neuralgia Pain in the distribution of a nerve or 10 mm from the sigmoid notch, and it reaches its lowest
nerves point at the first molar to second premolar region, with
the distance from the inferior border of the mandible of
Paresthesia An abnormal sensation, spontaneous or
evoked, that is not unpleasant
7.5 ± 1.0 mm, where it splits into the incisive and mental
nerve branches. The incisive dental branch continues
FIGURE 25-1 Facial photographs with the areas of involvement marked are useful for monitoring progression.
Mandibular nerve Nerves to

(CN V3) temporalis
Meningeal branch Masseteric

(nervus spinosus) nerve
Auriculotemporal Nerves to medial

nerve and lateral
pterygoid
Lateral
pterygoid
Parotid branch of Buccal

auriculotemporal nerve
nerve
Nerve to Medial
mylohyoid pterygoid
Lingual nerve
Inferior dental
nerves
Inferior alveolar
nerve
Mental nerve
Masseter
FIGURE 25-2 Regional anatomy demonstrating the peripheral trigeminal nerve system.
forward toward the incisors and the mental nerve ascends identified four branches (angular, medial inferior labial,
and loops backward for a variable distance (3 to 7 mm) to lateral inferior labial, and mental) and five branching
exit at the mental foramina through the buccal cortex.5,6 patterns. They believed that this information on the
In their study of the mandibular canal, de Oliviera branching could help the clinician to predict the area of
et al analyzed the bidimensional and tridimensional posi- sensory disturbance after injury of the mental nerve
tions of the canal via multiplanar computer tomography more accurately, depending on the cause and location.
(CT) morphometric analysis and provided useful average
distances of the canal to the buccal and lingual cortices, Lingual Nerve
inferior border, and alveolar ridge. The locations of the The lingual nerve (LN) branches from the posterior divi-
mandible for the measurements were selected to repre- sion of the third division of the trigeminal nerve, medial
sent areas of commonly performed maxillofacial proce- to the lateral pterygoid muscle. It is located medial to the
dures associated with high risk for nerve injury, specifically IAN and supplies sensory and special sensory function to
extraction of third molars, sagittal split osteotomy, and the anterior two thirds of the ipsilateral tongue, floor of
dental implant placement. They did not find significant the mouth, and lingual mandibular gingiva. The LN is
differences between the right and left sides, whereas in joined by the chorda tympani as it passes through the
edentulous patients the typical values were lower in pterygotympanic fissure, which provides taste (anterior
females than males and in older (from 51 to 75 years) two thirds of the tongue) and carries special visceral
than younger individuals (25 to 50 years).7 afferents (preganglionic parasympathetic fibers from the
The mental nerve, the continuation of the IAN after facial) to the submandibular and sublingual glands. Kim
it exits the mental foramen has two branches (range, one et al,11 in their study of the topographic relationship of
to four branches), with the largest being the labial branch the LN and IAN at the infratemporal fossa and paralin-
running on the orbicularis oris muscle fibers. A smaller gual space in 32 cadaveric hemisectioned heads, noted
mucosal branch runs posteriorly on the buccinator four patterns of furcation between the two nerves in
muscle fibers. The labial branch innervates the lip and relationship to the sigmoid notch and lingula (Table
chin mucosa and overlying skin, but it may reenter the 25-2). In addition, the group measured the distance of
mandible to innervate the mandibular incisors and even the bifurcation to stable bony landmarks, including the
cross the midline.8 The mucosal branch innervates the foramen ovale and hamulus. The bifurcation was identi-
buccal mucosa and gingiva of the mandible as far poste- fied to occur on average 14.3 mm (range, 7.8 to 24.1mm)
riorly as the first and second molar, where cross- inferior to the foramen and 16.5 mm superior to the tip
innervation with the buccal nerve may occur. Throughout of the hamulus (range, 4.9 to 24.3 mm). This variation
its course in the mandible, the IAN provides branches in the bifurcation patterns between the IAN and LN, as
for innervation of the mandibular teeth.9 Hu et al,10 in a well as the collateral nerve branches at the retromolar
study of the branching pattern of the mental nerve, region identified in 81.2% of the cases in their study, are
thought to contribute to the reported failure rate of At the second molar region, the LN crosses Wharton’s
mandibular anesthesia.12 duct from a lateral to medial direction, traversing below
The LN then passes into the pterygomandibular space the duct and hypoglossal nerve in the submandibular
between the ramus and medial pterygoid muscle, where triangle. The nerve in this location gives off the pregan-
it is surrounded by mesoneurial fat throughout its course. glionic parasympathetic fibers from the facial nerve to
It enters the oral cavity over the superior pharyngeal the submandibular ganglion. These fibers are transected
constrictor, styloglossus, and mylohyoid muscles at the during submandibular gland excision so that the gland
anterior border of the medial pterygoid muscle. As the can be released from the nerve. It has been reported that
nerve approaches the third molar region, it courses from the risk of LN injury during submandibular gland exci-
a more lateral to a more medial position following the sion or sialodochoplasty of Wharton’s duct ranges from
oblique flaring of the ramus. The exact location of the 1.4% to 4.8%, and the nerve is in danger from intraoral
LN at the third molar region has been studied exten- and extraoral approaches.21-24
sively, with some controversial findings among cadaveric After looping under Wharton’s duct, the LN passes
studies, clinical observation during third molar surgery, upward onto the genioglossus muscle and enters the oral
and high-resolution magnetic resonance imaging (MRI) tongue muscular substance. With the exception of one
with regard to its proximity to the mandible.13-20 Table or two large branches that proceed towards the tip of the
25-3 summarizes the reported distances and relationship tongue, all other branches to the tongue and adjacent
of the nerve to the mandible at the third molar region. lingual mucosa and gingiva are of small diameter (gener-
In this location, the nerve has a diameter from 2.0 to ally not >1 to 2 mm). The larger branches provide the
5.0 mm and may be round, oval, kidney-bean shaped, greatest density of innervation to the tip and medial por-
elliptical, or ribbon-like in cross section, with a predomi- tions of the anterior two thirds of the tongue, compared
nance of one shape versus another varying among with the posterolateral, dorsal, and ventral portions; this
studies.11,18,20 difference is developmentally driven.25
Buccal Nerve
TABLE 25-2 Types of Furcation Of Inferior Alveolar Nerve
And Lingual Nerve The buccal nerve (BN) is a branch of the mandibular
division of the trigeminal nerve that carries sensory fibers
Type of Furcation to the lower buccal, gingival, buccal sulcus, and cheek
Between IAN and Level of Furcation Between mucosa and may contribute to the cutaneous supply of
LN Sigmoid Notch and Lingula No. per Type
the cheek. The nerve travels between the two portions of
Type I Separation occurs above 65.6% (21/32) the lateral pterygoid muscle, beneath or through the
notch and inferior to otic lower part of the temporalis muscle deep to the mandi-
ganglion ble, and then crosses over the external oblique ridge at
Type II Separation occurs below 28% (8/32) the anterior border of the masseter muscle and merges
notch and at superior half of with the same branch of the facial nerve. This is where
distance between notch and the nerve crosses over the external oblique ridge that
lingula places it at risk for injury, most commonly from third
Type III Separation occurs below 3.1% (1/32) molar surgery. A rare variation that supports the IAN as
notch and at inferior half of the origin of the BN has been described by Turner, Singh,
distance between notch and and Jablonski et al, who identified the nerve exiting the
lingula mandible through a small foramen at the retromolar
Type IV Separation occurs in a 6.3% (2/32) fossa.26-29 As the nerve reaches the surface of the buccina-
plexiform pattern tor muscle, it divides into a superior division that supplies
Kim SY, Hu KS, Chung IH, et al: Topographic anatomy of the lingual nerve. the muscle and an inferior division that provides the
Surg Radiol Anat 26:128–135, 2004. sensory innervation of the mucosa, as noted earlier.
TABLE 25-3 Distances and Relationship of Lingual Nerve to Mandible at Third Molar Region
MEASUREMENT (MM) % of LN Above % of LN in Contact

Study No. of Nerves Vertical (mm) Horizontal (mm) Alveolar Crest With Lingual Plate
Kiesselbach and 34 cadaveric and 256 2.28 ± 1.96 0.58 ± 0.9 17.6 62
Chamberlain in vivo nerves
Pogrel et al 40 cadaveric nerves 8.32 ± 4.05 3.45 ± 1.48 15 0
Behnia et al 669 cadaveric nerves 3.01 ±0.42 2.06 ±1.10 14.05 23.27
Holzle and Wollfe 68 cadaveric nerves 7.83 ± 1.65 0.86 ± 1.00 8.82 57.4
Karakas et al 21 cadaveric nerves 9.56 ± 5.28 4.19 ± 1.99 4.7 0
Miloro et al 20 in vivo nerves 2.75 ± 1.00 2.53 ± 0.67 10 25
(evaluated by HR-MRI)
Hendy et al,28 in their study of the course and relation-

ships of the BN in 20 cadaveric specimens, noted the
following:
• The nerve was found to have four to eight major
branches, with a mean number of three branches m
ax
where it crosses the external oblique ridge.
• The nerve trunk was found to cross the ridge as
close as 3 mm from its deepest concavity of the
external oblique ridge in 70% of specimens(14 of
20). A
• In the remaining cases, the distance ranged between
7 to 12 mm below that point.
The authors postulated that the nerve is at risk from inci-
sions in this region, even if these are placed as far away
as 12 mm from the external oblique ridge. The variation
of the branching patterns of the nerve, in addition to the m
high mechanosensory threshold noted on the buccal ax
mucosa, may result in a small area of damage or in the
injury not being noticeable by the patient.30,31
Infraorbital Nerve
The infraorbital nerve (ION) is a major branch and is
the termination of the second division of the trigeminal B
nerve that emerges on the face via the infraorbital
foramen. The foramen is on average 2.7 cm from the FIGURE 25-3 Hematoxylin and eosin (A) and silver stain
facial midline and 6 to 8 mm from the inferior orbital (B) demonstrating the organization of a peripheral myelinated
rim. In males, the foramen is larger than in females, with nerve in longitudinal section in the area of a node of Ranvier
some differences in the distances from the midline and (arrow). Ax, axon; m, myelin.
infraorbital rim identified in anatomic studies.4,32 In the
study by Kazkayasi et al, a single foramen was found in the myelinated fiber, the ratio of nerve axons and
90% of cases, two canals in 5% and three canals in the Schwann cells is 1 : 1, whereas in the unmyelinated fiber
remaining 5%. The shape of the canal was found to be the Schwann cell envelops several axons. The membrane,
oval in 30%, round in 40%, and semilunar in 30% of or basal lamina, created by the Schwann cell as it wraps
cases.33 The ION enters the orbit via the inferior orbital around the axon and runs the entire length of the axon,
fissure and transverses the orbital floor in the infraorbital is called a band of Büngner (laminar myelin sheath) and
canal (IOC) for 22 mm. The canal may not be complete is crucial for the process of nerve regeneration. Although
because the cortical thickness of its roof ranges from 0.1 myelin may be destroyed during nerve injury, Schwann
to 6.0 mm; thus, the nerve may be exposed, without a cells survive and play a major supportive role in nerve
discrete superior bony wall. The combination of a groove recovery and repair. The length of the axon surrounded
and canal is found in 50% of cases and the remainder by a single Schwann cell is known as the internode and
demonstrate a complete canal.33 Racial and gender varia- the small area (0.3 to 2.0 µm) between the internodes,
tions have been reported in the location and shape of where the axon is not myelinated, is known as a node of
the foramen and in the length of the canal.32,34,35 After it Ranvier. In each node of Ranvier, certain ions diffuse,
exits the infraorbital foramen, four branches of the ION which causes nerve depolarization and repolarization
have been identified and correspond to the areas of the and allows for the conduction of nerve impulses
midface, nose, upper lip, and lower lid innervated by the along the nerve fiber. This event—of the conduction
nerve36 The ION is at risk for injury during approaches occurring only between the nodes of Ranvier (saltatory
for reconstruction of the orbitozygomaticomaxillary conduction)—is responsible for the rapid impulse trans-
complex following traumatic events and during maxillary mission noted in myelinated nerve fibers (up to 150 m/
orthognathic surgery. Orthognathic-related injuries are sec) compared with nonmyelinated nerve fibers (2 to
typically transient and reversible, but sensory changes 2.5 m/sec). Typically, unmyelinated axons are also
from entrapment of the nerve encountered in midface smaller in diameter, with diameters ranging from 0.15 to
trauma may cause more problematic, long-term neuro- 2.0 µm.
sensory changes. Collagen provides the framework that surrounds the
nerve and creates the structural architecture within the
MICROANATOMY nerve (Fig. 25-4). The endoneurium is the first organiza-
The microanatomy of all peripheral nerves is the same, tion of fine collagen fibers around each nerve fiber axon.
with sensory and motor nerves containing myelinated In the pre–electron microscopy era, this organization was
and unmyelinated fibers in a ratio of 1 : 4. The difference known as the Plenk-Laidlaw sheath or sheath of Key and
between the two types of fibers is the number of Schwann Retzius.37,38 Several bundles of endoneurial groups,
cells that surround each fiber with nodes of Ranvier that known as fascicles, are grouped together and surrounded
permit rapid saltatory nerve conduction (Fig. 25-3). In by a second layer of collagen fibers (and mesothelial
Endoneurium Perineurium Epineurium
Myelin
FIGURE 25-5 Schematic representation of vascular supply

between the layers of the connective tissue surrounding the axon
(red, arteries; blue, veins).
A
Epineurium TABLE 25-4 Number of Fascicles and Diameter of
Perineurium Branches of Trigeminal Nerve
No. of Fascicles
Endoneurium Nerve (mean) Cross-Sectional Area (mean)
IAN 9.4 to 21 ± 7.05 1.64 ± 0.27 mm2
(third molar region) (third molar region)
LN 8.5 to 10 ± 4.0 1.87 ± 0.38 mm2
Endoneurium A (third molar region) (third molar region)
MN 10.9 to 12 ± 3.58 1.18 ± 0.27 mm2
ION 5 to 6 ( in the IOC) 2 mm2 (in the IOC)
0.4 mm2 (after it exits the IOF)
A
B
FIGURE 25-4 A, Schematic representation of nerve organization.
B, Low-power cross section of polyfascicular nerve showing the oligofascicular pattern, containing only some (two to
organization of the nerve, with individual nerve fibers surrounded ten) fascicles (e.g., the labial branch of the mental
by endoneurium, fascicles surrounded by perineurium, and the nerve), and polyfascicular, with more than 10 fascicles of
investing epineurium. The mesoneurium is visible surrounding the different sizes (e.g., IAN, lingual, and buccal nerves).
entire nerve sheath at the periphery, with adipose tissue (upper The mean number of fascicles and cross-sectional area
left). A, perineurial and endoneurial blood vessels. (A from Patton for the trigeminal nerve branches decrease from the
K, Thibodeau G: Anatomy and physiology, ed 7, St. Louis, 2010, proximal to the distal nerve.39-42 Table 25-4 provides the
Mosby.) reported observations regarding fascicular number and
diameter for each branch of the trigeminal nerve.
cells), called the perineurium. The outer layer of con- A rich interconnecting vascular network of extrinsic
nective tissue supporting the nerve, along with some and intrinsic systems provides the blood supply for each
elastic fibers, creates the external or extrafascicular epi- neuron. The vessels reach the extrafascicular epineu-
neurium. Another layer of epineurium that invests the rium via the vasa nervosum after entering the mesoneu-
fascicles is known as internal epineurium. The epineurium and create a plexus that runs longitudinally at this
rium makes up 50% of the cross-sectional area of the level. The vessels continue their course toward the axon
nerve and provides some protection against compres- by passing in an oblique angle through the subsequent
sion. The final layer of connective tissue that is continu- connective tissue layers and forming a longitudinally
ous with the epineurium and surrounding tissue bed and running plexus during their course at each level. This
is responsible for allowing some freedom of movement configuration allows for the individual fascicles to have
of the nerve is known as the mesoneurium, or adventitia an independent and rich blood supply, analogous to an
of the nerve.37 individual nerve fiber43,44 (Fig. 25-5). This passage of the
Peripheral nerves are often distinguished based on vasculature, between the layers of connective tissue, may
their fascicular pattern, which may be of one of the fol- become an area of compromise within the intrafascicular
lowing three patterns—monofascicular pattern with layers; there are no associated draining lymphatics
only one large fascicle (e.g., the chorda tympani), running with the vascular plexuses.
TRIGEMINAL NERVE IMAGING objective radiologic findings with subjective, clinical

examination findings and thereby guide the need for
Objective, noninvasive, radiologic imaging modalities for surgical intervention and possibly aid in treatment plan-
the preoperative assessment of the patient at risk for ning (e.g., the need for an interpositional nerve graft).
nerve injury, as well as monitoring for the postinjury and
postrepair phases of neurosensory recovery, are highly
desirable.45 Radiologic assessment should be categorized PREOPERATIVE RISK ASSESSMENT
with regard to the timing of the imaging period—that is, Panoramic Radiography
preinjury, postinjury, and postrepair phases. Preinjury The preoperative assessment of the position of the infe-
assessment refers to the documentation of the in situ rior alveolar nerve during patient consultation has been
position of a nerve prior to any surgical intervention that routinely performed with the use of a panoramic radio-
places that nerve at risk for iatrogenic injury (e.g., third graph. Obviously, the information gained from this study
molar removal). Intraoperative monitoring of nerve is extremely limited because of the two-dimensional
function during a surgical procedure (e.g., sagittal split nature of the image, variable magnification of the bony
mandibular osteotomy) that involves a specific nerve may anatomy (for the inferior alveolar nerve), and complete
also be used, usually by a functional study of nerve con- inability to visualize the position of the lingual nerve.
duction and electrophysiologic status, such as somatosen- Valuable information can be obtained from the pan-
sory evoked potentials (SSEPs). oramic radiograph as a stand-alone imaging modality in
Postinjury imaging is divided into a primary phase regard to the relationship of the IAN in the vertical
(i.e., following nerve injury and allowing for spontaneous plane, but not in the horizontal dimension. The most
neurosensory recovery without microneurosurgical inter- useful aspect of the panoramic radiograph is for assess-
vention) and secondary phase (i.e., following surgical ing the increased potential for inferior alveolar nerve
nerve exploration and repair). Primary postinjury injury during third molar extraction based on the pres-
imaging may be clinically significant if it can correlate ence of several radiographic predictors46,47 (Fig. 25-6).
FIGURE 25-6 Panoramic radiographs showing examples of Rood radiographic predictors of root proximity to the inferior alveolar canal,
including root darkening, root narrowing, root deflection, loss of the superior white line of the canal, and diversion of the canal.
Other types of plain radiographs, such as periapical or minimal distortion compared to traditional plain films
anteroposterior films and lateral cephalograms, are not and by simpler acquisition compared to CT systems.54,55
routinely used for accurate preoperative routine risk Similar to panoramic radiography, CBCT can be used for
assessment for IAN injury. Superimposition and varia- preoperative risk assessment in various dentoalveolar
tions of magnification of the structures, based on their procedures (e.g., third molar surgery or dental implants
location, do not allow for reliable and reproducible and preprosthetic surgery).56-58 A major limitation
information to be obtained with plain films. Further- remains the inability to visualize the lingual nerve,
more, even if the IAN can be visualized in the third molar because no accurate soft tissue information can be
region, only a rough outline of tooth and root anatomy obtained with CBCT.
can be obtained, making these images of limited value
for nerve injury appraisal. High-Resolution Magnetic Resonance Imaging
MRI is the method of choice for visualization of all
Computed Tomography cranial nerves (CNs) and each nerve segment can be
The use of CT for the assessment of nerve injuries is seen and examined in detail with specific sequences.
limited. An evaluation of bone window attenuation Because of the complexity of the course and
images may indicate violation of the cortical outline of
the inferior alveolar canal, either from implant place-
ment or following facial trauma involving the posterior
mandible fracture (Fig. 25-7), but yields little informa-
tion regarding the condition of the nerve or neurovascu-
lar bundle.48 The use of soft tissue window images for the
lingual or inferior alveolar nerves is compromised by
poor-detail resolution, which precludes its routine appli-
cation for neural assessment. Furthermore, dental arti-
facts often pose severe limitations in obtaining accurate
information regarding the position of the LN to the
lingual cortex of the mandible in critical areas, even in
the soft tissue windows, and despite current high-
resolution image acquisition.
In 1998, CT cone beam (CBCT) technology, until
then used only in angiography, was used in the United
States as a potential imaging modality for the maxillo-
mandibular complex. The presurgical evaluation of the
impacted mandibular third molar relationship to the
IAN has gained popularity over CT scans and plain pan-
oramic radiographs among surgeons49-53 (Fig. 25-8). The
need for accurate imaging with the lowest possible dose
of radiation (following the ALARA rule—as low as rea-
sonably achievable) seems to be well satisfied with this
technology. CBCT provides the desired three-dimensional FIGURE 25-7 Coronal CT scan through a mandibular body fracture
representation of the anatomic location of interest with showing canal involvement.
FIGURE 25-8 Cone beam CT scan showing the proximity of the inferior alveolar canal to an impacted third molar, and three-dimensional
reconstruction of the scan to highlight the canal passing between the roots of the impacted third molar tooth.
surrounding anatomic structures, detailed examination Ultrasonography

of the CNs is made possible only with careful planning Several reports have described the use of ultrasound
and MRI technique selection. The imaging plane, coil (US) and high-resolution US technology, mainly for
selection, slice selection, in-plane resolution, and use of assessment of peripheral nerve lesions. This real-time
special techniques can be tailored based on the CN and advanced technology, with the currently available high-
segment of interest so that the highest quality image resolution probes, can offer compound imaging without
possible is obtained. The trigeminal nuclei (intra-axial), radiation and in a relatively inexpensive manner.
the cisternal (preganglionic), and Meckel’s cave (intra- Although US has not been used nor investigated as a
dural) segments, contain the motor and sensory compo- potential preoperative risk assessment tool for the tri-
nents of the trigeminal nerve and can be visualized with geminal nerve, it has been demonstrated to be valuable
high-resolution T1- or T2-weighted MR images. At the in identification and safe advancement of the needle in
anterior aspect of the gasserian ganglion, the sensory brachial plexus and sciatic nerve blocks.68 It would be
root divides into the ophthalmic, maxillary, and man- reasonable to anticipate limitations with the use of US in
dibular divisions, and each can be followed and exam- the examination of the IAN in the third molar region
ined separately based on their known course. The course because of the presence of bone and teeth. Visualization
of the lingual and inferior alveolar branches of the man- and documentation of the course and integrity of the
dibular division, after it exits from the oval foramen, can LN, on the other hand, should be relatively easy, requir-
be followed with high-resolution, contrast-enhanced, ing training and familiarity of the operator with the
T1-weighted (T1W) or T1W three-dimensional fast field regional anatomy.
echo (T1W 3D-FFE) sequences in the axial, coronal,
and sagittal or parasagittal planes.59-63 Although detailed POSTINJURY ASSESSMENT
information can be obtained with the use of MRI, Perhaps most clinical interest is in documenting the
routine presurgical evaluation of the route and integrity postinjury condition of nerves by objective means,
of the LN and/or IAN is not undertaken. Instead, MRI because the information gathered by clinical and radio-
is used as the preferred imaging modality for examina- logic examination could be used to aid in staging the
tion of the status of the CNs in the presence of a disease degree of neural injury. With increased image resolution,
process or injury.60,64-67 the precise degree of architectural disruption of the
In an attempt to document the in situ position of the nerve could be visualized and surgical intervention could
lingual nerve in the third molar region directly, without be planned. Also, this information could be used to docu-
surgical manipulation or tissue distortion artifact, high- ment the position of the injury prior to surgical explora-
resolution MRI (HR-MRI) has been studied. In one tion for repair. For example, this documentation could
study, 10 patients (20 sides) of healthy adult volunteers help avoid surgical nerve exploration in the third molar
without prior dental surgery were imaged using an region if the injury occurred in the pterygomandibular
HR-MRI sequence (PETRA [phase-encoded time reduc- space as a result of a mandibular block injection injury.
tion acquisition]) that enabled visualization of the lingual Finally, radiologic techniques could be used to monitor
nerve (Fig. 25-9). This study documented that the lingual neurosensory progression objectively in conjunction with
nerve position, although variable, is found to be superior the clinical examination, after nerve injury or in the
to the lingual crest in 10% of cases and in direct contact postrepair phase.
with the lingual plate in 25% of cases.18
Panoramic Radiography
The postsurgery assessment of the nerve-injured patient
usually includes a panoramic radiograph that may dem-
onstrate clinically significant findings. The presence of a
foreign body in the region of one or both nerves must
be ruled out; these may include metallic foreign bodies
from rotary instruments or amalgam particles from
Nerve neighboring teeth, as well as retained tooth or root frag-
ments following third molar surgery. The presence of an
iatrogenic surgical disturbance of the nerves may be indi-
cated by evidence of bone removal in proximity to the
inferior alveolar neurovascular bundle or LN (Fig. 25-10).
M3
However, a panoramic radiograph or any other plain film
is rarely used to monitor progression following injury or
repair.
Computed Tomography
Postoperative investigation of the surgical site for exami-
nation of the integrity of the IAN canal or the presence
of material, such as tooth or root fragments within the
FIGURE 25-9 High-resolution MRI showing a kidney-bean shaped canal, could be superior and more reliable with CT or
lingual nerve (Nerve) superior to the lingual crest, and in contact CBCT imaging than traditional panoramic imaging.
with the lingual plate in the third molar (M3) region. Direct investigation of the integrity of the LN cannot be
High-Resolution Magnetic Resonance Imaging

The application of the HR-MRI modality to the assess-
ment of the nerve postinjury is in its early trial phases.
Presumably, with improved resolution, a variety of ana-
tomic changes in the nerve may be visualized. First, a
change in nerve diameter may be visualized in cases of
nerve injury with Wallerian degeneration of the nerve
segment distal to the site of injury with an acute or
gradual decrease in nerve diameter. Second, an acute
change in nerve position may be seen—for example,
where the lingual nerve is retracted into the region of
the third molar socket, with the formation of a lateral
adhesive or exophytic neuromatous segment. Third, a
change in nerve shape may be seen—for example in a
case of a fusiform neuroma-in-continuity, where a change
in the shape of the nerve for a certain distance with
return to normal shape distal to the neuroma may be
FIGURE 25-10 Panorex following third molar removal showing the able to be visualized.70
presence of preoperative radiographic predictors of root proximity The application of HR-MRI to postinjury neural assess-
to the canal, and evidence of the use of a drill distal to the crown ment is hindered by several factors. The degree of image
of the extraction site, in a patient with right lingual nerve injury. resolution and magnification significantly limits precise
anatomic examination of the neural elements. The ability
to image the internal architecture of neural anatomy will
require dramatic improvements in resolution from cur-
reliably examined with either modality because of the rently available techniques. Also, although the lingual
limitations discussed earlier in the preoperative risk nerve lies within soft tissue and its course is unaccompa-
assessment section. Disruption of the lingual cortex of nied, the inferior alveolar nerve lies within a cortical
the mandible at the third molar region that may be noted bony conduit and is joined by an artery and a vein
in a postoperative panoramic radiograph and may imply throughout its course. Preliminary studies with HR-MRI
trauma to the LN in the region can be reviewed in more have allowed gross visualization of the lingual nerve
detail with CT or CBCT. Direct comparison of pre- and because it is the sole structure in the area, but examina-
postimages can be made, adding to the information gath- tion of the inferior alveolar nerve has been complicated
ered from the clinical examination and potentially assist- by the presence of the vessels, although attempts to atten-
ing in the decision for the need of exploration in the uate the image signal can overcome this problem (see
region. earlier section on magnetic resonance neurography).
Depending on the plane of image section, HR-MRI may
Magnetic Source Imaging miss several anatomic indicators of nerve injury. A trans-
One of the few objective radiologic studies that docu- verse (or coronal, in the case of the lingual nerve in the
ments inferior alveolar nerve injuries involves the use of third molar region) section of the nerve may not visualize
magnetic source imaging (MSI), which combines mag- a short discontinuity or abrupt alteration in the course
netoencephalography (MEG) and HR-MRI. MEG tech- of the nerve, depending on the distance between images.
nology uses magnetic fields to measure electrical brain This may be avoided with the use of a sagittal or longitu-
activity; it is influenced less by intervening soft tissues dinal image along the course of the nerve. However, this
than electroencephalography (EEG) and therefore pro- is difficult because the position of the nerve varies nor-
duces a more detailed image, with higher resolution. mally in the uninjured patient and may change signifi-
Similar to SSEPs, a stimulus is applied peripherally and cantly in the injured patient, thereby requiring patient
a signal is recorded centrally; this enables measurement repositioning or redirection of the imaging plane.71
of signal latency and amplitude. The information The use of noninvasive, lack of radiation exposure
obtained from MEG is combined with HR-MRI images to HR-MRI for the nerve-injured patient would provide the
produce a structural and functional magnetic source advantage of correlating the results of clinical neurosen-
image of a particular region of the brain. McDonald et sory testing and subjective patient evaluation with an
al69 used MSI on six patients with unilateral inferior alve- objective assessment of the anatomy of the injured nerve
olar nerve injury and have shown that MSI technology site. Although it may seem that a frank transection injury
may be able to differentiate various grades of nerve (Sunderland grade V; see later) might be visualized easily
injury. The findings on clinical and MSI examinations with HR-MRI, the less severe injuries (Sunderland III and
were correlated with surgical findings; neural continuity IV) could be extremely difficult to discern radiographi-
defects were identified as different radiographically from cally. Future study designs with HR-MRI include an
intact nerves. Despite some limitations of the study experimental group of postinjury patients who will
design (small n, lack of blinded examiners and surgeons, undergo clinical neurosensory testing and HR-MRI and
and other study designs flaws), there is potential for MSI then microneurosurgical nerve exploration and repair, if
to be applied in the postinjury and postrepair phases to indicated. This would allow correlation of postinjury
monitor the progression of neurosensory recovery. radiologic results and findings at the time of surgery to
determine the ability of HR-MRI to predict the actual the pig cadaver head. In the study by Olsen et al, the
degree of anatomic nerve injury accurately. HR-MRI iatrogenic injuries created were successfully categorized
might also prove useful in monitoring the progression of in 17 of 27 attempts once the examiners became familiar
anatomic neurosensory recovery (correlated with physi- with visualization of the LN. The major remaining limit-
ologic clinical signs and subjective symptoms) following ing factor in the use of US for this application is the lack
nerve injury and/or microneurosurgical repair.45 of training and familiarity with US technology and
imaging among surgeons. The possibility of incorporat-
Magnetic Resonance Neurography ing US for investigation of the integrity of LN postopera-
Following the application of MRI technology to blood tively, along with clinical evaluation, seems promising.
vessels (magnetic resonance angiography [MRA]), direct The potential for US examination in several subsequent
imaging of nerves with magnetic resonance neurography visits in a noninvasive manner, without the need for radi-
(MRN) was a logical progression. The MRN images are ation, additional cost, or discomfort with the ability to
obtained using axial, coronal, and longitudinal T1 and document findings of every examination for comparison
T2 image acquisition, with customized phased array coils and evaluation of progression, make this modality rea-
and imaging protocols. The application of MRN relies sonably valuable.
on its ability to distinguish nerves from surrounding
structures such as blood vessels, lymph nodes, ligaments, POSTINJURY FUNCTIONAL ASSESSMENT
adipose tissue, and ducts. This would allow isolation of Among the imaging modalities available, it should be
the IAN from the neighboring artery and vein contained evident that the only studies that could potentially con-
within the inferior alveolar bony canal. MRN studies tribute to the functional assessment of the post–nerve
to date have documented the ability to distinguish intra- repair are SSEPs, MSI, high-resolution functional MRI,
neural from perineural masses, demonstrate nerve con- MRN, and US technology. Success or failure of nerve
tinuity versus discontinuity at the fascicular level, and repair grafting or direct anastomosis can be assessed only
localize extraneural nerve compression prior to nerve after several months have elapsed and is typically based
exploration. on neurosensory examination, not imaging. The use of
Most research has focused on larger, peripheral motor MRN has proven to be valuable to evaluate the repair site
nerves, including the brachial plexus, sciatic, peroneal, for neuroma formation or problems with the sutures
and femoral nerves.61,65,72-75 One report has documented when there is no recovery following repair, and this
nerve compression and signal hyperintensity of an IAN imaging may indicate the need for early surgical inter-
in a patient with a lymphoma of the pterygomandibular vention. The few limitations posed by the presence of a
space. MRN has been able to document increased diam- hematoma in the early phases of nerve repair that were
eter of injured nerves, increased signal intensity, and initially discussed in the literature are no longer an issue
longitudinal variations associated with nerve injury and with the current advances in MRN imaging. Finally, nerve
recovery. There does not seem to be any correlation continuity after direct repair or interpositional grafting
between the amount of hyperintensity and degree of may be examined with US, but more details are possible
neural injury, and its significance has not yet been clearly with the use of MRN. Also, the major limitations with the
defined. The finding of signal hyperintensity has been use of US are the lack of training among surgeons and
demonstrated for a transient period following neural lack of familiarity with the acquired images for appropri-
anastomosis and distal to a nerve graft site. The remark- ate interpretation.
able ability of MRN to depict fascicular architecture is The current advances in MR imaging technology with
based on the difference in fluid composition of the high-resolution, functional, or metabolic-based images
neural elements. The fascicles contain a preponderance (BOLD [blood oxygenation level–dependent]) certainly
of endoneurial fluid and axoplasmic water, whereas the allow for detailed examination of the neural structures,
interfascicular space is largely composed of fibrofatty as well as associated pathology and nerve injury pat-
connective tissue. In a sense, these images may be able terns.76 Perhaps the main potential limitations with the
to define radiographically the histologic characteristics routine use of these advanced imaging modalities for
of different grades of nerve injuries set forth by Seddon the investigation of IAN and LN injury and recovery are
and Sunderland. Similarly, sequential images could be the cost associated with these studies and the lack of
used to monitor nerve recovery at the fascicular level. expertise of neuroradiologists and surgeons regarding
One of the most advantageous characteristics of MRN their interpretation and clinical significance.60,75,77-80
images is the ability to image the nerve in a longitudinal
plane. In a technique similar to that of MRA to image
the anatomy of an abdominal aortic aneurysm, these CLASSIFICATION OF TRIGEMINAL
MRN images can easily be assessed for variations in nerve NERVE INJURIES
anatomy, diameter, location, discontinuity, and signal
intensity, which may indicate areas of nerve injury and Several complex cellular events occurring in and around
thereby guide surgical intervention, as well as monitor the nerve structure are responsible for the response to
neurosensory recovery. nerve injury and are required for the regeneration and
restoration of neurosensory function. Two nerve injury
Ultrasonography classification schemes, Seddon and Sunderland, are
Recently, some promising findings were reported with described here. These provide for a correlation between
the use of US for visualization of the lingual trauma in clinical symptoms and histologic changes observed within
Axonotmesis
Neurapraxia
Neurotmesis
FIGURE 25-11 Seddon classification system including examples of neurapraxia, with nerve stretching, axonotmesis, with variable degrees
of axonal injury, and neurotmesis, with nerve transection.
5th Epineurium
1st
2nd 3rd 4th Perineurium
Endoneurium
Axon
FIGURE 25-12 Sunderland classification system showing the 5 degrees of nerve injury with progressive injury beginning with damage
confined within the endoneurium (first-degree injury) and extending outward to the perineurium (second degree), then through the
perineurium (third degree) and to the epineurium (fourth degree), and finally through the epineurium with discontinuity (fifth degree).
the nerve structure at the time of injury. Seddon’s clas- Axonotmesis involves axonal damage, corresponds to
sification is based on the time between injury and recov- Sunderland injuries degrees II to IV; variable degrees of
ery and degree of recovery, whereas Sunderland places demyelination and axonal injury and therefore sponta-
an emphasis on the specific histologic degree of damaged neous recovery vary significantly in this category of inju-
neural structures. ries. More details are provided in the following discussion
of Sunderland’s classification of nerve injuries. Finally,
SEDDON CLASSIFICATION SYSTEM neurotmesis implies complete or near-complete nerve
The Seddon classification system includes three levels of transection that includes epineurial discontinuity. Spon-
nerve injury (Fig. 25-11)—neuropraxia, axonotmesis, taneous recovery is unlikely, whereas neuroma formation
and neurotmesis.81 In neuropraxic injuries, the integrity may occur more commonly.
of the axon is maintained, and the injury indicates a local
conduction block from a transient anoxic event caused SUNDERLAND CLASSIFICATION SYSTEM
by acute vascular interruption of the epineurial or endo- Sunderland revised and further subclassified nerve inju-
neurial vasculature. Neuropraxia is usually the result of ries in 1951 and described a five-degree classification
a mild nerve manipulation, traction, or compression system (Sunderland’s I to V degrees of nerve injury)
injury; it is characterized by a reversible conduction based on histologic findings of the degree of nerve
block with a favorable outcome, with rapid and complete involvement82 (Fig. 25-12). A first-degree Sunderland
recovery within days to a few weeks of the event. injury is the same as Seddon’s neuropraxia described
No axonal degeneration occurs in neurapraxic injuries earlier, and was further divided by Sunderland into three
and damage is confined to the endoneurium only. types based on severity and recovery time. First-degree
TABLE 25-5 Classification of Nerve Injuries and Associated Findings
Injury type Histologic Findings Response Recovery Pattern Recovery Rate Treatment
First-degree Transient ischemia, Conduction block Complete Fast (hours to None indicated
(Seddon anoxia, ± segmental weeks)
neuropraxia) demyelination,
intrafascicular edema
Second-degree Axon and myelin Wallerian Complete Slow (weeks) None indicated
(Seddon axontmesis) interruption, (intact degeneration distal to
endoneurium, injury
perineurium and
epineurium)
Third-degree Injury involves Wallerian Variable Slow (weeks to Nerve exploration
endoneurium (intact degeneration and months) maybe considered
perineurium and some degree of
epineurium) neuron cell death
Fourth-degree Injury involves Wallerian None Spontaneous Microneurosurgery
endoneurium and degeneration, neuron recovery not
perineurium cell death, neuroma likely
formation,
intrafascicular fibrosis
Fifth-degree Complete nerve Wallerian None No spontaneous Microneurosurgery
(Seddon transection, degeneration, cell recovery possible
neurotmesis) continuity disruption death neuroma,
fibrosis
type I injury is the result of nerve manipulation that The fifth-degree injury in Sunderland’s classification
causes transient blood supply interruption that once system corresponds to Seddon’s neurotmesis, which
restored, allows for full sensory recovery after only a few implies a nerve transection, avulsion, or laceration of the
hours. First-degree type II injury involves intrafascicular nerve trunk, with complete disruption of all components
edema formation, from fluid exudate or transudate, of the nerve organization; there is little to no chance of
resulting from moderate traction or compression on the spontaneous recovery. Extensive fibrosis, neuroma for-
nerve. Sensory recovery follows edema resolution within mation, and/or neuropathic changes occur in these
a few days. First-degree type III injury results from more serious clinical situations and microneurosurgery is indi-
aggressive nerve manipulation and may involve segmen- cated. In cases of witnessed nerve transection, immediate
tal demyelination; recovery requires a few days to weeks.83 surgical intervention is required. Table 25-5 summarizes
Second-degree injuries involve axonal and myelin the types of injuries, corresponding histologic changes,
interruption but the intact endoneurium, epineurium, responses, recovery pattern, rate of recovery, and recom-
and perineurium allow for axonal regeneration. Recov- mended treatment.
ery is a relatively slow process and may take up to 1 year
for complete return to normal sensation, but is possible AXONAL AND CELLULAR RESPONSE TO INJURY
because of the intact supporting connective tissue struc- Nerve injury involves several events and variable
tures. These injuries are caused by traction or compres- responses, but the basic process of nerve healing remains
sion on the nerve. the same and involves a sequence of degeneration fol-
In third-degree injuries, the endoneurium is involved lowed by regeneration.84,85 Within hours after axonal
in the injury but the epineurium and perineurium injury, a series of events occurs at the primary site of
remain intact. The usual causes are the same as for first- injury, as well as at the distal and proximal portions of
and second-degree injuries, and some spontaneous the axon and cell body. The changes within the cell body
recovery is expected. However, complete recovery is not and the nerve fiber proximally depend on the proximity
likely and surgical exploration may be considered. of the injury to the cell body, as well as the severity of the
Fourth-degree injuries caused by traction, compres- injury. Within 6 hours of injury, the metabolic rate of the
sion, needle injection, or chemical injury lead to disrup- cell body increases significantly, resulting in edema and
tion of the endoneurium and perineurium; the migration of the nucleus toward the periphery of the cell
epineurium remains intact. These injuries are associated body and upregulation of the rough endoplasmic reticu-
with a poor potential for spontaneous recovery and a lum (Nissl substance), with increased protein synthesis
high probability of neuroma formation and intraneural that will be exported from the cell body toward the site
fibrosis. Surgical intervention is required for these inju- of injury. These events are collectively termed chromatoly-
ries, especially if there is no improvement within 3 sis and represent the histologic correlation of RNA and
months following injury. protein synthesis, a programmed event intended to
ensure cell survival that peaks within 14 to 21 days

following acute injury.86-94 Chromatolysis signals the
proliferation of perineural glial cells that along with
macrophages, phagocytes, and Schwann cells, begin the
clean-up process of cellular debris at the injury site.84,85,95
When the injury involves the axonal fibers (Sunder-
land grades II to V grade injuries), a series of molecular
and cellular events occur, simultaneously or consecu-
tively, and collectively result in Wallerian degeneration.96
These events occur throughout the distal nerve trunk
and the small portion of the proximal end close to the
injury site. The distal portion of the axon becomes edem-
atous so that its ends are sealed, whereas the myelin that
surrounds the axon breaks down into droplets.97 The
debris is phagocytosed by Schwann cells, which demon-
strate enhanced proliferation and activity; the recruited
macrophages also participate in this débridement
process. These events are a prerequisite for nerve regen-
eration to occur, initiated within hours of injury and
completed within 1 week following the nerve injury.98-104 A
Neural degeneration occurs in the distal and proximal
nerve ends so the final result is empty endoneurial tubes
that act as conduits for nerve regeneration; these tubes
are present up to the site of the injury.97,101,105-107
Proximally, the transected axon forms sprouts, or axo-
noplasmic extensions, that mimic the axon growth cones
observed during embryonic neural development. Several
substances produced by neural and supportive tissues are
required for these events to occur, which ultimately lead
to the growth and regeneration of the axon toward its
receptor target.100,108-111 Each axon may have as many as
50 collateral axonal sprouts. The high proliferative activ-
ity of the Schwann cells noted during these phases is
thought to be required for the production of new myelin
that will host the new axon. This theory has been recently
challenged by Yang et al,99 who demonstrated that B
Schwann cell proliferation may not be an absolute
FIGURE 25-13 A, Diagram of a fusiform neuroma-in-continuity.
requirement for nerve regeneration but that this is B, Clinical example of an inferior alveolar nerve neuroma-in-
achieved via existing Schwann cells that survive the insult, continuity at the apex of a mandibular first molar following
but do not divide. The regeneration is axon-driven and endodontic therapy with nerve injury.
axon-dependent, as opposed to a predominant Schwann
cell influence.
In any case, if these processes occur in the appropriate
chronologic order, spontaneous nerve regeneration will
be achieved. In cases in which there is interruption or
unfavorable sequencing of these events, the outcome will and the resultant nerve injury. For clean lacerations of
be failure of reinnervation of target receptors and pos- the nerve, primary repair is usually indicated but for
sible neuroma formation. Neuromas represent a disorga- avulsive-type injuries, a delayed primary repair is pre-
nized mass of collagen fibers and nerve sprouts that are ferred. A delayed primary repair is typically performed
randomly oriented.112-116 Neuromas can be of the follow- at 21 days following injury, which allows time for the area
ing types: amputation (stump neuroma); neuroma-in- of injury to become defined macroscopically. At 3 weeks’
continuity (central or fusiform neuroma, Fig. 25-13); or time, the levels of neurotrophic and neurotropic factors
lateral (lateral exophytic, or lateral adhesive neuroma, are at their highest and the nerve is most amenable to
Fig. 25-14). Neuromas may be painful or asymptomatic repair.
and histologic differentiation between the two clinical
scenarios is not possible. What appears to distinguish
painful and nonpainful neuromas appears to be their MECHANISMS OF INJURY TO THE
neurophysiologic properties, based on studies that have TRIGEMINAL NERVE
shown that neuromas may be sensitive to both mechani-
cal stimuli as well as activation of the sympathetic system Several commonly performed procedures in the maxil-
by chemical or physiologic manipulation.117-119 Finally, lofacial region are associated with potential injury to the
consideration must be given to the mechanism of injury terminal branches of the trigeminal nerve.
epineurium, has been associated with sensory changes

LOCAL ANESTHETIC INJECTION after mandibular blocks.125-128 Box 25-1 presents the con-
Injury to the IAN and LN is possible during the admin- clusions that can be made based on the current under-
istration of mandibular block local anesthesia. Interest- standing of injection-related nerve injuries. These cases
ingly, prolonged sensory alterations are rare, considering are usually associated with only a limited distribution of
the number of blocks administered daily by dental pro- neurosensory alteration, reflecting the small number of
fessionals. The ratio of injuries to injections has been fascicles insulted or involved in this type of injury.129
estimated as between 1 : 26,762 and 1 : 160,571 although
this may not represent the actual incidence, because not THIRD MOLAR SURGERY
all cases of sensory disturbances are reported.120,121 Harn Complications associated with third molar removal are
and Durham, in 1990, reported an incidence of transient the most common cause of trigeminal nerve injury
sensory disturbance of 3.62%, with only a 1.8% incidence reported and can occur during any stage of the actual
of long-term changes (>1 year duration).122 There are a procedure (Fig. 25-15), as well as during postoperative
number of proposed mechanisms that result in this care.130-134 The overall incidence of IAN injury during
injury and the exact cause remains unclear; in addition, third molar surgery is estimated between 0.41% and
there is no reliable way of avoiding these types of injuries. 7.5%, resulting in temporary sensory changes in 2% to
Direct penetration of the nerve by the needle, hematoma 6% and permanent disturbances in 0.5% to 2% of cases.
formation from vessel laceration, direct laceration of the Stretching or manipulation of the lingual nerve from
nerve from a barb on the tip of the needle after repeated tissue retraction during third molar surgery is reported
injections, needle contact with cortical bone, and chemi- to cause temporary sensory disturbances in rates from
cal injury from intraneural injection are reasonable 6.4% to as high as 15%, but less than 1% result in per-
possibilities.122-124 Direct toxicity of the local anesthetic manent changes.129,135-141 Several risk factors associated
solution (specifically, 4% articaine and 4% prilocaine), with an increased risk of IAN injury during this proce-
especially when deposited within the confines of the dure have been discussed in the literature. These include
BOX 25-1 Clinically Based Conclusions About Local

Anesthesia–Related Nerve Injuries
1. Not predictable, possibly preventable
2. Painful response on injection (electric shock sensation)
does not always accompany an injury
3. More common in female patients
4. More commonly result in dysesthesia than hypoesthesia
5. May follow a nonanatomic distribution (involvement of
more than one division of the trigeminal nerve) because
of segmental demyelination
6. More common with higher concentration anesthetic solu-
tions (e.g., 4% articaine)
7. Surgical exploration not indicated because of nature and
location of injury
A 8. Lingual nerve is more commonly affected than inferior
alveolar nerve
9. Spontaneous recovery usually occurs within 8 wk of injury
10. Less than one third of cases lasting longer than 8 wk
recover fully
11. Pharmacologic management indicated for unpleasant
sensations (dysesthesia)
B
FIGURE 25-15 Diagram showing possible iatrogenic injury of the
FIGURE 25-14 A, Diagram of a lateral exophytic neuroma. inferior alveolar nerve during extraction of a deeply impacted third
B, Clinical example of a lateral exophytic neuroma of the lingual molar. (From Hupp JR, Ellis E, Tucker MR: Contemporary oral and
nerve because of third molar removal. maxillofacial surgery, ed 5, St. Louis, 2008, Mosby.)
A B
C
FIGURE 25-16 A, Panorex showing root proximity to the inferior alveolar canal. B, Cone beam CT showing root proximity to the inferior
alveolar canal. C, Third molar following removal with a periodontal probe showing the location of the inferior alveolar neurovascular
bundle. Despite an attempt to section the tooth to avoid nerve injury, the nerve was transected during the extraction.
advanced age, female gender, tooth angulation, depth occurrence, with a 0% to 40% reported incidence of
and type of impaction, integrity of the lingual cortex, nerve injury caused by implant placement, depending on
complexity of the procedure, and surgeon experi- location (Fig. 25-17), and patient management can be
ence.142,143 Rood and Shehab, in 1990, described seven problematic.146,147 The IAN, in particular, is at risk in the
radiographic predictors of potential proximity of the molar region and anterior to the mental foramen, espe-
third molar to the IAN on panoramic radiographs that cially in edentulous patients, because of the associated
may be helpful in the decision making process regarding alveolar ridge resorption, in addition to the anterior
extraction versus more conservative approaches, such as extension, or genu, of the neurovascular bundle beyond
coronectomy or observation.47 These predictors include the foramen. These injuries can result from surgical
darkening, deflection or narrowing of the tooth root, exposure, during preparation of the osteotomy site, or at
diversion, narrowing or interruption of the white line the time of implant placement. Mechanical compression
of the IAN canal, and a dark or bifid root apex. The of the neurovascular bundle can result from overexten-
most significant radiographic findings of potential nerve sion and canal violation during the osteotomy that causes
injury included root darkening, root deflection, and infracture of the cortex of the canal at the site and direct
interruption of the white line of the canal. It is important pressure on the IAN (Fig. 25-18). Alternatively, bleeding
to note that subsequent studies have reported controver- within the canal from a laceration of the inferior alveolar
sial findings, both in support of and opposition to the vein or artery with an implant drill can cause pressure
value of these radiographic predictors in nerve injury144,145 similar to that of a compartment syndrome. Finally, direct
(Fig. 25-16). compression on the neurovascular bundle following res-
toration of the implant with mastication, or because of
DENTAL IMPLANT SURGERY prior clot formation and subsequent ectopic calcifica-
With the wide use of dental implants for dental rehabili- tion, may occur. Although extensive literature is available
tation worldwide, injury to the IAN is a fairly common regarding the use of modern imaging modalities for
FIGURE 25-19 Ramus graft procedure that places the inferior

alveolar nerve at risk for injury because of its lateral location in this
region of the mandible.
FIGURE 25-17 Diagram showing implant-related nerve injury that

can occur when the implant is in proximity to the closed canal
with possible bleeding, edema, and development of a
compartment syndrome that causes deleterious effects on the
nerve, even in the short term.
FIGURE 25-20 Genial bone graft harvest that may sacrifice the
incisive branch of the inferior alveolar nerve and result in
paresthesia to the anterior mandible dentition.
FIGURE 25-18 Panorex showing the distal implant placed within exact cause of the trauma and the need or lack thereof
the confines of the inferior alveolar canal in a patient with inferior for nerve canal exploration, as well as the timing and
alveolar nerve paresthesia. recognition of the occurrence.129,146,153-155
Procedures aimed at augmenting the alveolar bone
treatment planning in implant dentistry, data are lacking height in the posterior mandible or improving the site
on the most appropriate modality for nerve injury risk to facilitate implant placement, such as bone grafting,
assessment, as discussed earlier.3,147-152 distraction osteogenesis (DO), or IAN lateralization,
Management of these injuries is tailored individually carry their own risks for nerve injury. During bone har-
based on the mechanism of injury and may involve vesting from the mandibular ramus (Fig. 25-19) or chin
implant removal as soon as the injury is recognized, or region (Fig. 25-20), the IAN or mental nerves could be
the use of pharmacologic therapy, if indicated for dyses- inadvertently injured, especially when a large area
thesia. Immediate implant replacement with a shorter requires augmentation. When small, single, tooth-sized
implant, may be considered but is dependent on the grafts are harvested, and appropriate preoperative
radiographic examination of the area is undertaken, this found in 10% of single and 16% of multiple midface
risk appears to be minimal.156 The same branches of the fractures.172
trigeminal nerve are at risk during securing autogenous Reduction of fractures with alignment of segments
or allogenic bone graft material at the recipient site, and removal of loose bony segments that impinge on the
either from direct compression of the nerve from the nerve will assist in spontaneous neurosensory recovery.
graft or from hardware (e.g., plates and screws) used to Unfortunately, on occasion, the actual treatment of facial
secure the graft in place. DO, another method used for fractures may cause further injury to peripheral nerve
alveolar ridge height augmentation, may lead to nerve branches of the trigeminal nerve because of nerve retrac-
injury, again at the time of the osteotomy or directly from tion or from direct injury caused by inadvertent place-
to the device used for the distraction. The actual response ment of plates and screws.
of the IAN to the DO process has been studied in animal
models. It has been shown that several events occur at ORTHOGNATHIC SURGERY
the cellular level, including activation and proliferation Neurosensory alterations are common sequelae of
of Schwann cells, and a limited degree of axonal degen- orthognathic surgery for correction of dentofacial defor-
eration and regeneration. The result is minor nerve mities, especially mandibular procedures.173 During sagit-
injury that is reversible and has no long-term sequelae.157-159 tal split osteotomy (SSO), the neurovascular could be
Nerve lateralization for the facilitation of implant injured at several locations and during the various steps
placement is a viable option in select cases. With this of the procedure. These include during medial dissec-
approach, the lateral cortex of the mandible is removed tion at the lingula region, the actual osteotomy proce-
and the IAN is exposed and lateralized so that implants dure, or mobilization or fixation of the segments. If the
of adequate length can be placed (Fig. 25-21). The pro- IAN is found to be located in the proximal segment after
cedure inevitably causes some neural trauma, but the the osteotomy, it may need to be mobilized, which may
injury is “controlled” while the risk of compartment syn- cause further injury. The location of the IAN in relation-
drome is eliminated, along with the risk of direct injury ship to the inferior border of the mandible, ramus height,
to the neurovascular bundle from the implant placement dentofacial deformity to be corrected, and patient age
itself. The procedure is associated with a high incidence and gender have all been associated with various inci-
of neurosensory changes, with some permanent changes, dences of neurosensory disturbances.174-177 In addition,
but with excellent results in implant stability and success the incidence of neurosensory alterations during man-
and high patient satisfaction.160-166 If the nerve lateraliza- dibular orthognathic surgery has been found to increase
tion procedure requires release of the mental nerve from with intraoperative complications, usually unfavorable
the mental foramen, the incidence and degree of neuro- splits.178 Furthermore, IAN sensory alterations appear to
sensory dysfunction is increased over a transposition of occur more frequently with additional procedures e.g.,
the nerve posterior to, and not involving, the mental genioplasty in addition to SSO), but are transient; spon-
foramen. Recovery after nerve lateralization should be taneous full recovery is usually reported within 6 to 12
expected within 3 to 6 months, although up to 30% to months.173,179,180 Interestingly, a substantial difference has
40% of patients may experience long-term neurosensory been demonstrated between subjective and objective
dysfunction, especially older individuals.166 The use of findings regarding sensory alterations after SSO, with
piezosurgery in a cadaveric study (10 sheep mandibles normal sensation reported in 73.7% of osteotomy sites;
with 20 lateralizations) has found no disturbance of objective testing revealed normal sensation in only 34.2%
structures beyond the epineurium; the overall degree of of cases.181
injury was found to be less than when the procedure was During maxillary or midface procedures, the ION is
performed with conventional burrs.167 at risk for injury, usually because of soft tissue flap retrac-
tion rather than direct injury that results in sensory
MAXILLOFACIAL TRAUMA changes of the upper lip, cheeks, lateral aspect of nose,
Maxillofacial trauma and surgery for the correction of and infraorbital region. Based on the nature of the injury
facial injuries may result in disturbances of the periph- (e.g., traction, compression, or pressure), full recovery is
eral branches of the trigeminal nerve in the vicinity of expected and usually achieved without intervention.180
the traumatic injury. The overall incidence of neurosen- Segment fixation with plates and screws could theoreti-
sory impairment has been reported to be 70.9%. In cases cally cause direct injury to the ION or LN from bicortical
of nondisplaced fractures, the incidence was found to be screw overpenetration (Fig. 25-25), but this is easily
54.4%, whereas a significant increase was noted in dis- avoidable with adequate exposure, visualization, and pro-
placed fractures of 88.2%. As expected, cases of direct tection of the nerve.
injury had 100% neurologic impairment.168 Fractures of
the mandible may result in neurosensory alterations MAXILLOFACIAL PATHOLOGY
caused by laceration, traction, or compression of the IAN Several odontogenic and nonodontogenic benign cysts
from bony segment displacement (Fig. 25-22) or treat- and tumors may be found in the nerve-bearing segment
ment of the fracture with iatrogenic injury to the nerve of the mandible in intimate relationship with the IAN,
canal (Fig. 25-23). Similarly, midface fractures or soft often causing displacement of the canal; in some cases,
tissue trauma, lacerations, or avulsions may violate the the canal may be located within the pathologic entity
infraorbital canal and damage the ION, leading to tran- (Fig. 25-26). This also applies to tumors of the maxilla in
sient or permanent sensory alterations168-171 (Fig. 25-24). the vicinity of the IOC. Benign pathology usually is not
In the study by Kloss et al, hypoesthesia of the ION was associated with neurosensory disturbances, with the
R R L
A
C
FIGURE 25-21 A, Panorex showing posterior mandibular edentulism with insufficient bone height above the canal and inadequate
interocclusal clearance for implant placement. B, Nerve repositioning procedure results in a neurapraxic injury in a controlled fashion
during implant placement. C, Panorex showing bilateral inferior alveolar nerve repositioning with restored implants that engage the
superior and inferior borders of the posterior mandible for stability.
FIGURE 25-24 Intraoperative view compression of the terminal

branches of the right infraorbital nerve exiting from the infraorbital
FIGURE 25-22 Panorex showing an open, displaced, unfavorable formen in a patient with a displaced right zygomaticomaxillary
left mandible angle fracture. Note the displacement of the inferior complex fracture.
alveolar canal.
FIGURE 25-23 Panorex showing fixation of a right mandibular body

fracture with screws that penetrate the inferior alveolar canal in a
patient with right inferior alveolar nerve dysesthesia.
FIGURE 25-25 Posteroanterior skull film showing overpenetration

of the bicortical screws used to stabilize the sagittal split
exception of neural origin or vascular tumors originating osteotomies. This places the lingual nerve at risk for iatrogenic
from the involved neurovascular bundle (Fig. 25-27). On injury during orthognathic surgery.
the contrary, malignant lesions usually will be associated
with sensory changes early, as is the case with specific
pathology (e.g., adenoid cystic carcinoma with neurotro- pull-through procedures or use of adjuncts, such as enu-
pism), in cases of tumors with aggressive behavior, when cleation and curettage with cryotherapy, have been advo-
the IAC is invaded by the tumor, or the tumor has caused cated for some tumors in an effort to minimize morbidity
a pathologic mandible fracture (Fig. 25-28). Infectious associated with more aggressive treatment and perma-
processes are similarly associated with neurosensory nent neurosensory disturbances. These approaches
changes if they involve nerve-bearing areas of the jaws; remain somewhat controversial with regard to the associ-
these usually resolve spontaneous with resolution of the ated risk of recurrence, in addition to a conflict with the
infection (Fig. 25-29). basic oncologic principles for management of these
Treatment of maxillomandibular pathology often tumors.182-190 Acceptable outcomes, with complete neuro-
involves extensive bone and soft tissue resection that may sensory recovery after treatment of benign odontogenic
include the IAN, mental nerve (MN), or ION, resulting pathology with simple enucleation followed by cryother-
in permanent anesthesia in the distribution of the apy, have been reported in the literature and may be a
corresponding resected nerve. On occasion, nerve viable option in select cases.191-194
ENDODONTIC AND CHEMICAL INJURY

Endodontic therapy and periapical root surgery may
place the IAN at risk for injury. The nerve may be injured
by physical disruption with a file by overinstrumentation
of the canal(s), root resection, or apicoectomy proce-
dures, or by physical compression from extrusion of the
filling materials used (Fig. 25-30). The other mechanism
of injury is chemical neurotoxicity, which may result from
the use of certain root canal medications to treat the
canal(s). These types of IAN injuries may be caused by
mechanical or chemical factors, or both, and may result
in a foreign body reaction or granuloma formation in
the canal that could impede spontaneous neurosensory
recovery. Unfortunately, these injuries are difficult to
manage, with variable success following microneurosur-
gery, and a large proportion of these injuries may mani-
fest clinically as dysesthesia. For extrusion of potentially
neurotoxic root canal filling materials into the IAC,
FIGURE 25-26 Panorex of a keratocystic odontogenic tumor
prompt exploration, decompression, and débridement
causing displacement of the left inferior alveolar canal, and without
paresthesia.
of the foreign material may be beneficial in preventing
long-term sequelae.
A L
B L
FIGURE 25-27 A, Panorex of an arteriovenous malformation of the right mandible involving the inferior alveolar canal. B, Panorex of the
same patient following arteriography with embolization.
L
A
B L
FIGURE 25-28 A, Panorex of multiple myeloma involvement of the left mandibular body. B, Panorex of the same patient with progression
of the disease with a displaced unfavorable pathologic fracture of the left mandibular body, with resultant inferior alveolar nerve
paresthesia.
A B
FIGURE 25-29 A, Coronal cone beam CT showing Garre’s osteomyelitis of the mandible with buccal cortical perforation and proliferative
periostitis in a young patient involving the inferior alveolar canal with paresthesia. B, Sagittal cone beam CT of the same patient showing
the extent of involvement of the Garre’s osteomyelitis throughout the marrow involving the inferior alveolar canal.
Direction and 2-point discrimination

(Level A)
Normal Abnormal
Contact detection
(Level B)
Normal Abnormal
Mildly impaired
Pain sensitivity
FIGURE 25-30 Periapical film showing root canal filling material (Level C)
within the inferior alveolar canal in a patient with inferior alveolar
nerve dysesthesia.
Normal Abnormal
Moderately impaired Threshold

No response
In addition to root canal medications, other chemical Response
agents are potentially neurotoxic, such as tetracycline,
surgical (oxidized cellulose), and prolonged exposure of
Severely
the nerve to Carnoy’s solution (a solution of ferric chlo- impaired
Anesthetic
ride, glacial acetic acid, chloroform, and ethanol).
FIGURE 25-31 Clinical neurosensory testing algorithm. Level A
CLINICAL NEUROSENSORY TESTING testing (brush stroke direction and two-point discrimination) is
done first and, if normal, the examination is normal (Sunderland
A detailed history and clinical examination, along with first-degree injury). If level A testing is abnormal, level B testing
objective testing that includes the use of specific neuro- with contact detection is performed and, if normal, the
sensory tests (NSTs), pain questionnaires, and visual ana- examination indicates mild impairment (Sunderland second degree
logue scales, are crucial in the assessment of the patient injury). If abnormal, level C testing (pinprick and thermal
who has sustained trauma to the trigeminal nerve. Atten- discrimination) is done and, if normal, the examination indicates
tion to detail regarding the onset of symptoms, events moderate impairment (Sunderland third degree). If Level C is
associated with the current complaints, and any changes, abnormal, then the patient is either severely impaired (Sunderland
including worsening or improvement, require careful fourth degree), or with no response to testing, is considered
documentation and play a critical role in the treatment anesthetic (Sunderland fifth degree).
decision making process.129,170,195,196 Descriptive terms
used by the patient to qualify his or her symptoms need
to be documented in the chart exactly as stated by the
patient. performed in the same manner and sequence on each
In a critical evaluation of the accuracy of NSTs to occasion, in a quiet, calm, comfortable environment,
diagnose trigeminal nerve injuries accurately, Zuniga with the patient in a semireclined position. It is impor-
et al have demonstrated that for LN assessment, NSTs tant that the clinician explain in details the tests that will
have superior sensitivity and specificity compared with be performed and assure the patient that there will be
examination of the IAN. In addition, IAN findings were no pain involved. An uninvolved normal site should be
associated with a high incidence of false-positive and used to establish a baseline control and to demonstrate
false-negative results, 23% and 40%, respectively.197 This the tests about to be performed. Marking can be done
was subsequently supported in a recently published com- directly on the patient’s face with erasable markers, on
parison between clinical NSTs and current perception photographs obtained prior to testing, or on drawings on
threshold.198 NSTs should be performed for patients with standard recording forms, if available. If the marking is
neurosensory changes to determine the degree of sensory done directly on the face, the patient needs to be photo-
impairment, monitor recovery, and assist in decision graphed; all photographs, drawings, and forms must be
making in regard to the need for surgical intervention. kept in the records for documentation purposes and for
The clinical NST protocol involves mechanoreceptive future reference and comparison.
fiber testing performed first (two-point discrimination, The clinical neurosensory testing protocol (Fig. 25-31)
static light touch, directional discrimination, and vibra- begins with outlining the area of sensory disturbance or
tory sense), followed by nociceptive fiber testing (pain mapping, using brush stroke directional discrimination
stimuli and thermal discrimination). Testing should be to differentiate between the normal and affected areas.
Brush stroke directional discrimination is performed

with a camel hair or fine sable brush that is stroked across MICRONEUROSURGERY
the affected area at a constant rate and the patient is
asked to indicate the direction of movement. The correct INDICATIONS
number of responses out of 10 is recorded. Static two- Careful patient assessment and collection of information
point discrimination is performed next, using any device from neurosensory testing are crucial in the decision
that allows for measurement between two points; these making process for treatment recommendations, and
tips should be blunt, not sharp, which would stimulate specifically the need for surgical innervation (Box 25-2).
the nociceptive fibers. The closest distance that the With the exception of an observed nerve transection,
patient can discriminate two points versus one point is which requires immediate surgical repair, successful
recorded. If the findings at this level of testing, brush treatment of all other injuries requires a balance of
stroke and two-point discrimination (level A testing) are timing to allow for potential spontaneous recovery, but
normal responses, no further testing is required. The without delaying timely microsurgical intervention. The
patient NST is considered normal and the injury can be complex events surrounding nerve injury, with degenera-
classified as Sunderland first-degree injury. However, if tion and regeneration at various levels—distally, proxi-
the findings are abnormal, testing proceeds to the next mally, and centrally—make the timing of surgical
level. Level B testing involves contact detection and is intervention critical when it is indicated.204-207
performed with von Frey hairs or Semmes-Weinstein Clinical neurosensory testing, along with subjective
monofilaments of several diameters that reflect the stiff- findings, should guide and dictate appropriate treat-
ness of the filament and the force required to deflect it ment. When improvement is documented during
on contact. The narrowest filament consistently detected periodic nerve testing, surgery is not indicated. Micro-
by the patient that requires the least force to deflect is neurosurgery is also not indicated in cases of central
recorded for the control and involved sites. Both levels neuropathic pain or most cases of dysesthesia or unpleas-
A and B testing examine the integrity of the large myelin- ant sensations, and consideration should be given to
ated A alpha and A beta fiber types. If level B testing is pharmacologic management of these difficult clinical
normal, no further testing is required and the patient is scenarios. If persistent paresthesia is documented in sub-
considered mildly impaired, representing a Sunderland sequent visits, referral to a surgeon with expertise in
second-degree injury. If findings are abnormal at level B, microneurosurgery is prudent. Although there are
then testing proceeds to the next level, which involves several timing guidelines regarding surgical interven-
pinprick nociception and thermal discrimination and tion, the scientific evidence to support them is limited.208
evaluates smaller myelinated A delta fibers and unmy- It is generally accepted that prolonged delay may decrease
elinated C fibers. A 30-gauge needle, in the absence of a the success of microneurosurgical repair. Regardless of
pressure-sensitive device, can be used for pinprick testing, the exact timing, indications for microneurosurgery
with care not to cause injury to the skin or mucosa, and include a witnessed nerve transection, no improvement
an all or none response may be recorded. For thermal of significant hypoesthesia (>50% compared to control
discrimination, specialized Minnesota thermal discs are site), the presence of a foreign body, neuroma forma-
available, or simpler options such as ice or hot water on tion, progressive worsening of hypoesthesia or dysesthe-
a cotton swab can be used for suprathreshold thermal sia, and intolerable subjective hypoesthesia.209 Intervention
testing and has been shown to be valuable for assessment for LN paresthesia should be considered earlier (1 to 3
of iatrogenic injuries to the IAN and LN.199 Normal months postinjury) than for the IAN (3 to 6 months
responses at level C testing imply a moderate impairment postinjury), because the inferior alveolar canal provides
(Sunderland third-degree injury). Abnormal findings
may be consistent with severe impairment, with an
increased thermal threshold or decreased nociceptive
response (Sunderland fourth-degree injury), or lack of BOX 25-2 Indications and Contraindications to
response to pinprick or temperature with complete anes- Microneurosurgery
thesia (Sunderland fifth-degree injury).129 INDICATIONS
Pain as a result of nerve injury can be assessed specifi- Complete anesthesia
cally with a simple visual analogue scale or with a more <50% residual sensation (Sunderalnd III, IV, V)
complex McGill pain questionnaire that can also be used No improvement within 3 mo after injury
for the evaluation of altered sensation; it is a useful tool Observed nerve transection
for continuous monitoring of progress. Direct or indirect Early dysesthesia (neuroma formation)
injury to the LN may cause taste alteration, which can be Intolerable subjective paresthesia
a significant component of the patient’s subjective com- CONTRAINDICATIONS
plaints. Taste requires special testing that may involve the Continuing improvement in sensation
entire mouth or be localized, but it is generally difficult Late dysesthesia (especially IAN)
to assess taste alterations; there is poor correlation Central neuropathic pain
between the degree of injury and these changes, as well Complex regional pain syndrome
as response to surgical intervention.129,200-203 Taste can be Trigeminal neuralgia
evaluated with 5% saccharose (sweet), 5% saline (salt), Atypical facial pain
5% citric acid (sour), and 0.5% chinin hydrochloride Anesthesia dolorosa
(bitter).202
BOX 25-3 Recommended Time Frame for

Microneurosurgery (When Indicated)
Lingual nerve: 1-3 mo after injury
Inferior alveolar nerve: 3-6 mo after injury
a conduit to spontaneous nerve regeneration, whereas

the LN lies in soft tissue. This may explain why IAN inju-
ries have a higher rate of spontaneous recovery than LN
injuries (Box 25-3). Some studies have indicated that no
surgical intervention should be considered longer than
1 year postinjury because distal end-organ neurotization
is less likely. However, others have suggested that timing
is less important and improvement can be achieved when
microneurosurgery is performed after 12 months.129,209
MICRONEUROSURGERY FOR TRIGEMINAL

NERVE INJURIES
Microneurosurgical procedures are best performed in
the operating room under loop magnification or with an
operative microscope. Surgical exposure to assess the
IAN, LN, MN, and ION can be easily performed via
intraoral approaches and, in these cases, surgical loop
magnification may be more practical than a microscope.
There is a clear aesthetic benefit from intraoral
approaches that avoid incisions on the face and associ- FIGURE 25-32 Diagram showing surgical access for lingual nerve
ated potential scars or injury to other vital structures, but repair using a lingual gingival sulcus approach with posterolateral
may be more challenging based on the site of the injury.129 extension.
The more proximal the injury, the more challenging is
access; for example, an LN injury at the third molar
region is more challenging to repair than an IAN at the step and is termed external neurolysis (EN). For the LN,
mental foramen area. The individual patient’s anatomy, this may involve microdissection of the neurovascular
surgeon’s experience, mechanism of injury, and location bundle from surrounding scar tissue, whereas for the
of the injury are further considerations when deciding IAN it may imply the need for decortication of the IAC
the most appropriate surgical approach. and lateralization of the IAN. Separation of the nerve
The LN is approached intraorally via a paralingual or from scar tissue that may be responsible for restriction
lingual gingival sulcus incision (Fig. 25-32). The paralin- or compression leading to a conduction block and pre-
gual incision allows for a small incision and direct visual- vention of spontaneous recovery may be all that is
ization of the nerve, but may be more challenging to required. In cases of short duration of symptoms (<6
identify the nerve stumps after transection because of months), or if nerve compression from scarring is less
retraction into the soft tissues. The latter approach than 25% of the nerve diameter without neuroma forma-
involves a longer incision with anterior and posterior tion, EN may provide definitive treatment.129,209,212,213 EN
releases, but there is less risk of retraction of the nerve is performed under loop magnification and, once com-
endings during dissection.210 For the IAN (and MN), a pleted, an examination of the nerve is performed and
vestibular incision with identification of the MN and the need for addition intervention is determined. If
lateral decortication to expose a portion of the IAN are foreign material or bone or tooth fragments are identi-
usually adequate to mobilize the mental nerve for repair. fied, they should be removed at this stage.
In cases of restricted mouth opening, an extraoral Several injuries may cause intraneural scarring that
approach may be required. Once the mandible is results in neurologic deficits while nerve continuity is
accessed, the IAN is approached via lateral decortication maintained.214 In such cases, internal neurolysis (IN) is
techniques (Fig. 25-33).211 Access to the ION can be indicated, which requires opening of the epineurium for
accomplished transorally via a maxillary vestibular inci- fascicular examination. Because of the sparse amount of
sion at the time of maxillary or zygomaticomaxillary epineurium in the trigeminal nerve branches, this
complex fracture repair. Alternatively, a lower lid, trans- may lead to further fibrosis and iatrogenic scarring.
conjuctival, or subciliary incision may be more suitable Caution should be exercised when making the decision
and an osteotomy around the infraorbital canal may be to proceed with IN because it may cause worsening of
required for nerve isolation.39,210 the condition.129 Several types of IN are described based
Dissection of the nerve from the surrounding tissue on the exact tissue manipulation performed: epifas
bed for inspection and further manipulation is the next cicular epineurotomy, epifascicular, epineurectomy, and
A B
FIGURE 25-33 A, Diagram of techniques for inferior alveolar nerve access, including isolated decortication or a sagittal split osteotomy,
with extension to the mental foramen if necessary. B, Diagram of technique described by Miloro in 1995 for wide access to the inferior
alveolar nerve via a complete lateral decortication window that may be replaced to protect the nerve repair site.
intrafascicular epineurectomy that are of progressive repaired; scarred and necrotic nerve stumps are com-
complexity, involve tissue removal, and are of question- pletely removed at 1.0-mm resection increments until
able benefit for the trigeminal nerve system.208,209 normal tissue is encountered (Fig. 25-34). For a direct
In cases of neuroma formation, excision followed by neurorrhaphy, epineurial suturing with three or four 7.0
restoration of nerve continuity is required. Careful exam- or 8.0 nonreactive sutures (nylon) is adequate for the
ination under magnification of the nerve stumps to be trigeminal nerve (Fig. 25-35).215 Coaptation is the align-
anastomosed is crucial so that healthy nerve tissues are ment of individual fascicles during direct repair, but this
is difficult or impossible with a polyfascicular nerve, such

as the trigeminal.216,217 Nerve mobilization for tension-
free closure is critical and may require dissection in
proximal and distal directions (Fig. 25-36) or, addition-
ally, in the case of the IAN, sacrifice of the terminal
incisive branch to allow further release and mobilization
of the IAN.216
Cases of nerve injury that result in nerve continuity
defects, or prevent primary tension-free repair, will
require indirect repair, with interpositional grafting (Fig.
25-37). Traumatic avulsive injuries, pathologic conditions
involving the nerve, or extensive neuroma resection at
FIGURE 25-34 Diagram showing preparation of the nerve stump
the time of nerve repair are common reasons for these
with serial 1.0-mm resections to remove scar tissue (neuroma)
continuity defects of the nerve. When nerve mobilization
and ensure that normal healthy neural tissue is encountered prior is not adequate to allow tension-free primary repair,
to the neurorrhaphy procedure. Failure to débride the nerve interpositional grafts may be required. The donor site
stumps adequately will result in failure of neurosensory recovery. selection for a nerve graft depends on several factors,
including the diameter and fascicular pattern, correla-
tion of neural function, and donor site morbidity. Usual
donor sites for trigeminal nerve repair include the
greater auricular and sural nerves because of ease of
access and relatively low donor site morbidity, and anes-
thetic areas relatively tolerable.* In fact, the sural nerve
may be the preferred autogenous nerve graft because it
matches most closely with the diameter and fascicular
pattern of the trigeminal nerve system and results in an
area of minor donor site paresthesia (Fig. 25-38).218 The
greater auricular nerve diameter is almost 50% of that of
the trigeminal nerve and therefore its usefulness may be
limited to cable grafting (multiple grafts) for the trigemi-
nal nerve. Also, the harvest would result in a facial scar
as well as an area of deficit in the facial region that is less
tolerable to patients than the donor site deficit of the
lateral foot that results from sural nerve harvest.
FIGURE 25-35 Diagram showing direct neurorrhaphy with

epineurial sutures. *References 42, 129, 209, 210, and 217.
FIGURE 25-36 Clinical example of a left lingual

nerve neuroma (A) and following resection of
the neuroma and direct repair with epineurial
sutures (B).
A B
FIGURE 25-37 A, Clinical example of a discontinuity of the right inferior alveolar nerve following resection of a neuroma because of a third
molar injury (arrowhead wexel sponge; left). Autogenous sural nerve graft, 3 cm (right). B, Indirect graft repair of the right inferior alveolar
nerve continuity defect using the autogenous sural nerve graft with epineurial sutures.
A B
FIGURE 25-38 A, Clinical example of sural nerve harvest site posterior and superior to the lateral malleolus with identification of the lesser
saphenous vein (anterior) and the sural nerve (posterior). B, Donor site deficit mapped with marker 1 week following sural nerve harvest.
This area of paresthesia decreases significantly over time.
Alternatively, several other materials may be used for

indirect neurorrhaphy via entubulation techniques,
including alloplastic tubes (Silastic, expanded polytetra-
fluoroethylene, polyester, polyglycolic acid polymer),
vein grafts,219 and allogeneic nerve grafts (Fig. 25-39).
The use of alloplastic tubes is attractive because it elimi-
nates donor site morbidity. Unfortunately, there has been FIGURE 25-39 Diagram showing the principle of entubulation using
no consistency in the reported clinical outcomes with a conduit to guide neural regeneration in cases of nerve
these entubulation techniques, and therefore this is not discontinuity.
a standard technique for the management of trigeminal
nerve injuries with continuity defects. Vein grafting, on
the contrary, has been successfully used for this purpose, OUTCOMES OF TRIGEMINAL NERVE INJURY
with results comparable to primary repairs, especially in AND SURGICAL INTERVENTION
defects smaller than 5 mm.220-225 Following surgical inter-
vention, periodic follow-up with repeat NSTs to evaluate Injuries to the peripheral branches of the trigeminal
the response to treatment is required, and sensory reedu- nerve may be associated with impairment of speech,
cation exercises may be used to augment spontaneous taste, mastication, and impact on quality of life. Long-
neurosensory recovery. term effects of these injuries are not well documented in
the literature. In a recent effort to elucidate on this 7. de Oliveira Júnior MR, Saud AL, Fonseca DR, et al: Morphometri-
subject, Pogrel et al204 attempted to obtain information cal analysis of the human mandibular canal: A CT investigation.
Surg Radiol Anat 33:345–352, 2011.
from patients several years following nerve injury via a 8. Pogrel M, Smith R, Ahani R: Innervation of the mandibular inci-
telephone survey. Despite the poor 20% response rate, sors by the mental nerve. J Oral Maxillofac Surg 55:961–963, 1997.
patients did report long-term difficulties with jobs, rela- 9. Alantar A, Roche Y, Maman L, Carpentier P: The lower labial
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2011. 1995.
PART FOUR
Special Considerations
in the Management of
Traumatic Injuries
CHAPTER
Anesthetic Considerations in the Acutely
26
Injured Patient
Kyle J. Kramer
| Jeffrey D. Bennett
OUTLINE
Importance of the Airway in Maxillofacial Trauma Basic Principles of Management
Airway Examination and Management Patient Position
Initial Assessment Sedation and Analgesia Techniques
History Factors Affecting Anesthetic Strategies
Physical Examination Treatment of Specific Injuries
Injuries Affecting the Airway Postoperative Airway Support
Injuries Affecting Breathing Postoperative Sedation and Analgesia in the Intensive
Anesthetic Strategies Care Unit
Triage Mechanical Ventilation
F
ew situations are more challenging than the man- This chapter will focus on anesthetic and airway con-
agement of the acutely traumatized patient. It is the siderations in the management of the patient with oral
leading cause of death in individuals younger than and maxillofacial injuries. Many of the topics relevant to
45 years.1,2 Up to 75% of these deaths occur within hours anesthetic trauma management are presented in the
of injury. Effective management requires cooperation chapters pertaining to the assessment and evaluation of
and communication between a team of physicians. neurologic, thoracic, and abdominal injuries. This
The initial survey of the patient should occur imme- chapter will emphasize aspects that have significant anes-
diately on arrival to the health care facility and must thetic implications while minimizing repetition of the
assess if the patient is in an imminent life-threatening material presented elsewhere in this text.
condition. A systematic approach should be followed.
The Advanced Trauma Life Support (ATLS) protocol IMPORTANCE OF THE AIRWAY IN
describes a process of assessment and resuscitation that
involves the evaluation of airway patency, breathing, cir- MAXILLOFACIAL TRAUMA
culation, and neurologic function. For the critically
injured patient, the primary anesthetic responsibilities The patient presenting with maxillofacial trauma pres-
focus on assessing, maintaining, or obtaining an airway ents a potentially complex and emergent scenario. Of
and providing respiratory support. If the injury warrants, significant concern is the susceptibility of the airway to
surgical intervention will occur in the operating room. injury in association with trauma to the head and neck.
Anesthetic management in this phase of the patient’s Airway narrowing or obstruction can result from edema,
care will focus on drug selection to facilitate the surgical vascular congestion, or hemorrhage into the soft tissues
procedure. The anesthetic objective will be to achieve or fascial spaces. These processes are dynamic and
anxiolysis, analgesia, amnesia, and hemodynamic stabil- minimal; even an absence of early findings in the patient
ity. The selection of drugs may be modified secondary to with significant trauma does not ensure that such prob-
the injury and by the fact that resuscitation of the patient lems will not occur or not worsen. Fracture of the skeletal
may be ongoing. complex may also result in airway narrowing and/or
683
684 PART IV Special Considerations in the Management of Traumatic Injuries
distortion. This may be a direct result associated with the practitioner must also ensure that the examination
displacement of bony fragments or may be secondary to focuses beyond the maxillofacial injury, determining
the instability of bony segments with an unfavorable whether the patient has other injuries that increase the
effect on normal muscle function. Airway irritability may risk of respiratory complications or would benefit from
also occur secondary to hemorrhage within upper airway. ventilatory assistance.
This could contribute to airway obstruction, laryngo- The complexity of managing the airway in the trauma-
spasm, or aspiration. tized patient is that the decision to intubate may not be
Maxillofacial trauma may also impede the ability to clearly defined. There are patients who, on admission,
secure the airway. Trismus may occur secondary to will appear to be ventilating and oxygenating adequately,
edema, skeletal mechanical obstruction, or inflamma- but who will have less morbidity if the airway is con-
tion of the muscles of mastication. The cervical spine is trolled. Conversely, there are also patients in whom
susceptible to injury and, until an injury is ruled out, aggressive airway intervention on retrospect was contrib-
modifications in airway management will be dictated. utory to an adverse event.
HISTORY
AIRWAY EXAMINATION AND MANAGEMENT To provide optimal care, all patients should have a com-
plete medical history and physical examination. If the
INITIAL ASSESSMENT patient is in acute distress, there frequently is inadequate
The initial airway survey occurs immediately and consists time to perform such a complete history and physical
of making a gross observation. Is the patient breathing examination. Emergent resuscitation and surgery may
spontaneously? Does the patient have adequate exchange? need to proceed with little or no background information.
A negative response to either of these questions will Whatever information is available should be obtained
necessitate emergent intervention. The initial assessment expeditiously. Information about the past medical history
should also determine the patient’s adequacy of oxygen- or the events surrounding the injury may be ascertained
ation. Observation for cyanosis may not be evident sec- from the patient, family members, friends, or bystanders.
ondary to significant blood loss. Use of a pulse oximeter The emergency response personnel may also provide
to determine oxygen saturation may be difficult for information about the events surrounding the traumatic
numerous reasons, including cold extremities, decreased event. Information about the mechanism of the injury
perfusion, burns, and smoke inhalation. Centrally posi- may facilitate the diagnosis of associated clinical condi-
tioned probes should decrease the incidence of artifact tions. Information such as the death of another occupant
associated with cold extremities and decreased periph- of the vehicle may alert the practitioner to the potential
eral perfusion. An oxygen saturation above 92% on room for severe injuries that might otherwise go undetected.
air confers some degree of safety, but this has to be inter- The report of the use of shoulder belts may alert the
preted based on the specific situation. For example, the practitioner to blunt cervical injuries, such as a hema-
patient with a decreased hematocrit may reflect a satisfac- toma, that may displace the airway and produce pharyn-
tory oxygen saturation but in reality have a compromised geal and laryngeal congestion. A history of fire or smoke
oxygen content because of the diminished blood volume. in a closed space will raise concern about the potential
Rapidly obtained initial laboratory studies, such as arte- for airway injury.
rial blood gas (ABG) or venous blood gas (VBG), can Many trauma patients have major systemic diseases in
provide data useful for evaluating the adequacy of venti- addition to the injuries that currently brought them to
lation and oxygenation. The astute clinician will also look the hospital. These systemic diseases may directly affect
for subtle changes, such as irritability and agitation, that the patient’s care. Cardiovascular, pulmonary, hepatic, or
may be early signs of hypoxia. Apprehension and restless- renal disease may decrease the patient’s reserve and
ness may be suggestive of hypoxia as opposed to fear or increase the patient’s risk. Trauma patients frequently
anxiety caused by the ongoing events. As the hypoxia have histories of alcohol and illicit drug use. These drugs
worsens, this may progress to deteriorating levels of can cause various physiologic changes and interactions
altered consciousness, ultimately progressing to uncon- with anesthetic drugs. Their actions could affect preop-
sciousness. Maxillofacial trauma patients who demon- erative, intraoperative, and postoperative care.
strate an altered mental status, whether it be apprehension The trauma patient may also be pregnant. Pregnancy
or confusion, must also be considered in the differential in the traumatized patient presents special problems.
diagnosis to have a cerebral injury. The emergent need Changes in cardiovascular and respiratory parameters
to manage the airway will preclude the ability to evaluate can alter the patient’s response to anesthetic drugs.
the patient fully and assess the extent of the head and Additionally, many anesthetic drugs cross the placenta,
neck injuries. Management of the airway will thus neces- having adverse effects on the fetus, and thus may be
sitate the assumption of concomitant injuries and dictate contraindicated.
appropriate care. An additional factor that needs to be considered
If emergent intervention is not required, the examina- during the intake visit is patient maturity. The child or
tion must then identify injuries that may complicate or mentally impaired patient poses a unique challenge.
impede airway management. The examination must These individuals may lack the ability to cooperate. Tech-
identify injuries that although not initially of an emer- niques that may be selected for the typical adult patient
gent matter, may potentially worsen and result in adverse may need to be foregone for safety purposes because they
respiratory consequences at some future point. The require a degree of patient cooperation.
Anesthetic Considerations in the Acutely Injured Patient CHAPTER 26 685
irritability or cause laryngospasm, both of which impair

PHYSICAL EXAMINATION ventilation. Impaired reflexes in the obtunded patient or
significant hemorrhage may also lead to aspiration of
INJURIES AFFECTING THE AIRWAY blood. Patients are actually at more risk for aspirating
The anesthesiologist first inspects for injuries that blood than gastric contents. Vascular injury does not
decrease airway patency and impair the ability to venti- have to produce evident hemorrhage. A hematoma may
late and intubate the patient. Stridor, dyspnea, dyspho- cause a narrowing of the pharynx or superior-posterior
nia, dysphagia, odynophagia, or gurgling may be displacement of the tongue, which will lead to partial or
suggestive of obstruction or swelling of the airway. Cough- complete obstruction of the airway. The hematoma or
ing or hemoptysis may be associated with significant edema may also cause vascular congestion that com-
hemorrhage and an inability to maintain a patent airway. pounds the narrowing of the airway, contributing to
A muffled voice, hoarseness, or inability to speak may be respiratory distress. The edema or hematoma formation
suggestive of a laryngeal fracture. Subcutaneous emphy- may not necessarily be noted extraorally. The swelling
sema may be suggestive of a disruption of the airway. The may also take several hours to become clinically signifi-
physical examination of the maxillofacial region must cant and occlude the airway. An injury to the tongue
identify congenital abnormalities in addition to the fol- represents an example of this, in which the extent of
lowing: (1) displacement of teeth or oral appliances; (2) swelling may be unimpressive on initial examination,
hemorrhage; (3) soft tissue edema; (4) maxillofacial frac- with delayed edema causing airway obstruction. Hemor-
tures; (5) limited interincisal opening; (6) cervical spine rhage within soft tissue is more common with penetrat-
injury, instability, or hypomobility; and (7) burns and ing head and neck injuries as opposed to blunt injuries.
smoke inhalation. An extended examination must assess Another consideration with soft tissue injuries is the
for neurologic, ophthalmologic, thoracic, abdominal, potential distortion of the anatomy so that a mask fit
and orthopedic injuries, all of which may affect the anes- cannot be satisfactorily achieved.
thetic decisions that are made. Certain fractures of the maxillofacial complex have
The initial examination may be limited. Injuries may the potential to compromise the airway. Mandibular frac-
be missed during the primary assessment, both in the tures (e.g., bilateral parasymphyseal or condylar frac-
emergency department and operating room. Undiag- tures) can result in posterior displacement of the tongue
nosed cervical spine injuries, pneumothorax, or thora- and paraglottic soft tissue, resulting in partial or com-
coabdominal vascular injuries may cause significant plete respiratory obstruction. Establishment of a patent
intraoperative or postoperative morbidity or mortality. A airway can usually be achieved by traction on the anterior
secondary assessment or reexamination of the patient, mandibular segment and/or tongue, pulling either or
including a review of the radiographs and laboratory both forward, away from the posterior pharyngeal wall.
results before surgery if the patient is not immediately One method used to maintain anterior traction on the
operated on, or postoperatively, has been shown to diag- tongue is to place a heavy suture or towel clamp through
nose 90% of significant injuries missed during the initial the anterior midline of the tongue. The placement of the
examination.3 suture through the midline avoids injuring a vessel.
Reducing the fracture using maxillomandibular fixation
Maxillofacial Injury or interdental wires may also reduce the posterior dis-
Although unusual, teeth and/or associated structures placement of the tongue and paraglottic soft tissue, alle-
may be aspirated. These foreign objects may become viating the airway obstruction. The placement of a
lodged in the supraglottic, glottic, or laryngeal area, or nasopharyngeal or oropharyngeal airway may also assist
below the carina in the bronchi. A foreign object in the in establishing a patent airway when the tongue is dis-
supraglottic, glottic, or laryngeal area may cause partial placed posteriorly.
or complete obstruction. Immediate removal is indi- Le Fort fractures produce a disruption of the ptery-
cated. General anesthesia should be considered for the goid plates that may result in the posterior displacement
patient with a partial obstruction, because anything that of the maxilla. At the Le Fort I level, this may result in
causes agitation of the patient could result in movement, an anterior open bite but generally does not produce
resulting in a total obstruction. Alternatively, a foreign airway obstruction secondary to the skeletal displace-
object that is aspirated into a bronchus is an urgent situ- ment. The severity of the open bite, however, may cause
ation as opposed to an emergent situation. Maneuvers difficulty in achieving a satisfactory mask fit. Posterior
such as coughing should be avoided because they could and downward displacement of a Le Fort III fracture may
dislodge the object so that it becomes wedged above the result in obstruction of the nasopharynx. The disruption
carina, causing a complete as opposed to a partial obstruc- of the skeletal stability, with its associated effect on the
tion. The surgeon must also be cognizant that aspirated soft tissue of the pharynx, may contribute to obstruction
foreign objects are not always symptomatic. They fre- during negative pressure inspiration.4 Nasal fractures
quently are not considered and may be only incidentally may also cause nasopharyngeal obstruction. The hemor-
detected during laryngoscopy or evaluation of a chest rhage associated with a nasal fracture may be sufficient
radiograph, which should always be inspected for foreign to result in airway irritability and aspiration of blood.
material. Aspects of the examination seek to identify injuries
Maxillofacial injuries usually do not result in signifi- that may necessitate modifications in airway manage-
cant hemorrhage. However, in the traumatized patient, ment. A restricted interincisal opening may be seen with
hemorrhage into the airway may increase airway mandibular and midface trauma. The restricted
movement may be secondary to soft tissue edema, muscle collar, a cervical-head immobilizer, and a backboard.12
splinting, or mechanical bony obstruction. Frequently, it Rigid cervical collars by themselves limit rotation and
is secondary to pain and muscle splinting and should be lateral movement to only 50% of normal and flexion and
alleviated on induction of anesthesia. An actual mechani- extension to only 30% of normal and do not provide
cal limitation may exist. A condylar or high subcondylar adequate stabilization. An anesthetized or paralyzed
fracture of the mandible, the displacement of the zygo- patient should not remain on a backboard for a period
matic buttress or zygomatic arch so that either impinges exceeding 1 hour because of the risk for decubitus ulcers.
on the path of the coronoid process of the mandible, or Respiratory complications are common with cervical
significant edema may limit mandibular opening and is spine injuries. The extent of the respiratory derange-
not relieved with the induction of anesthesia. ment is associated with the level of the injury to the cervi-
Le Fort II and III fractures, along with naso-orbital- cal spine. Diaphragmatic paralysis occurs with injuries at
ethmoidal (NOE) fractures, may involve a fracture of the C4 or above. This will necessitate ventilatory support.
cribriform plate of the ethmoid bone or the medial wall Although injuries at C5 or below spare the phrenic nerve
of the orbit. The fracture of these bones creates the risk and therefore diaphragmatic breathing, expiratory
for the endotracheal tube to enter the cranium or orbit reserve may be adversely affected secondary to accessory
with nasal intubation. This is a relative contraindication muscle paresis. This may be further compounded by the
to nasotracheal intubation until a cranial base fracture respiratory depressant effects of alcohol and/or illicit
has been ruled out. There is also a potential risk for drugs and any concomitant injuries to the brain, chest,
bacteria or air to be forced into the cranial cavity with or abdomen. Respiratory function may also be impaired
positive-pressure ventilation.5 because of pulmonary edema. This is secondary to pul-
monary capillary damage and left ventricular dysfunction
Cervical Spine Injury associated with the acute transient hypertension that fre-
Cervical spine injury must be suspected in any patient quently follows a spinal cord injury.
with a maxillofacial injury. The incidence of cervical
injury in the presence of facial fractures has been Cervical Airway Injury
reported to be 1% to 6%.6-8 The higher percentage Injuries to the cervical airway may result from blunt or
is among patients who were involved in a motor penetrating trauma. The incidence of these injuries is
vehicle accident (MVA). The increased incidence prob- low. Blunt trauma to the airway from a direct blow to the
ably is secondary to the forces sustained in the MVA and cervical airway or from severe flexion-extension injuries
the associated hyperextension, hyperflexion, compres- may result in a thyroid, cricoid, or laryngeal cartilage
sion, and rotation of the cervical spine.9 However, no fracture, or laryngotracheal separation.13 A fracture of
definitive relationship has been found between the the thyroid cartilage is frequently associated with edema.
mechanism of injury and a specific maxillofacial or cervi- Stridor, dyspnea, dysphagia, odynophagia, or gurgling
cal spine injury. may be suggestive of swelling of the airway. A muffled
In the conscious patient, cervical spine injury is voice, hoarseness, or inability to speak may also be sug-
unlikely if the patient subjectively is without pain or par- gestive of a laryngeal fracture. A fracture of the cricoid
esthesia and objectively is without deformity or tender- cartilage is less common. It is frequently associated with
ness to palpation in a neutral position and during flexion an injury to the recurrent laryngeal nerve. Injury to this
and extension.10 If there is any positive finding, or if the nerve results in vocal cord paralysis. Vocal cord paralysis
patient is obtunded or not fully alert and able to concen- impairs the ability to protect the airway, which can lead
trate, further investigation is warranted. The pediatric to pulmonary aspiration. Although the incidence of a
patient may be unable to provide reliable information cricoid cartilage fracture is rarer, there is a mortality of
and a lower threshold for further investigation is war- 43% associated with this injury compared with 11% seen
ranted. In the unconscious patient, flaccid areflexia, loss with a thyroid fracture.14,15 Up to 70% of patients sustain-
of rectal sphincter tone, diaphragmatic breathing, and ing blunt airway trauma have a concurrent cervical spine
bradycardia are suggestive of a cervical spine injury. injury.16
If further investigation is required, the diagnosis of a
cervical injury is made radiographically. The examina- Thermal and Inhalation Injury
tion must be able to detect fractures and ligamentous Thermal and/or inhalation injury to the airway must
injuries. The examination must visualize all seven cervi- be suspected in any patient presenting with a history
cal vertebrae and the first thoracic vertebrae to be able of exposure to fire or smoke. Injury to the respiratory
to rule out a cervical injury. Fractures of the cervical system may extend from the mouth to the alveoli. The
spine are more reliably detected with a computed tomog- heat and noxious chemicals from exposure to fire
raphy (CT) scan compared with plain films (90% versus or smoke can produce upper airway edema, resulting
58%), but ligamentous injuries are more reliably detected in airway obstruction, periglottic edema, which poten-
with plain films compared with CT scans (93% versus tially impairs laryngeal function, resulting in compro-
54%).11 Immobilization of the neck in a neutral position mised protection of the lower airway, chemical injury,
is required until a definitive diagnosis is established, with resulting in impaired pulmonary gas exchange, and
the understanding that the urgency of the resuscitation carbon monoxide and cyanide toxicity. Patients with
may preclude the ability to obtain a definitive diagnosis facial burns or a history of being in an enclosed space
for several hours to days. The best method of immobiliza- with a fire or smoke have a high risk of developing
tion is achieved with a combination of a rigid cervical airway damage.
When the patient presents with a risk of thermal or toxicity. However, elevated levels in the patient without a
inhalation injury, the examination must include looking significant burn injury and with ventilatory correction
for signs such as facial burns, singed facial hair, and/or are more suggestive of cyanide toxicity.25 The mixed
carbonaceous debris in the nasal or oral secretions. venous partial pressure of oxygen is also elevated in these
These may be the only indications of potential respira- patients. Cardiac rhythm disturbances are also not
tory problems because some patients may not demon- uncommon in these patients. Cyanide levels above
strate respiratory dysfunction on initial presentation. 0.2 mg/liter are toxic and above 1 mg/liter are fatal.26
However, approximately 15% to 30% of burn patients Cyanide is hepatically metabolized, with a half-life of
develop some degree of respiratory dysfunction.17,18 less than 1 hour. Oxygen therapy, possibly with mecha
Other early physical findings include wheezing, cough, nical ventilation, is indicated and effective. HBO
dysphonia, and hoarseness. Upper airway edema, which therapy may have its indications but, considering the
may appear unremarkable initially, is an early contribut- relatively rapid elimination of cyanide, its practicality
ing factor to respiratory distress. Within 2 hours, it may may be limited. Specific pharmacologic therapies for
become notable, progressively worsening and necessitat- cyanide toxicity include sodium nitrate and thiosulfate.
ing intubation within 4 to 8 hours.19 The pediatric Thiosulfate increases the liver’s ability to metabolize
patient’s airway, with its relatively smaller diameter, is cyanide; sodium nitrate promotes the formation of
more susceptible to airway obstruction because any cyanomethemoglobinemia.
edema will have a more profound effect on airway
patency. Late complications, such as parenchymal lung
damage, may take several days to develop. INJURIES AFFECTING BREATHING
Periodic examination over the first 12 to 24 hours The traumatized patient may sustain multiple injuries.
should be done to assess the severity of the injury. Fiber Of specific concern to the anesthesiologist are those inju-
optic laryngoscopy and bronchoscopy will provide direct ries that affect respiratory function. Thoracic trauma
visualization of the periglottic region and lower airways, resulting in rib fractures, pneumothorax, and pulmonary
respectively. Serial ABGs and pulmonary function tests contusion potentially can result in respiratory
may also aid in assessing and differentiating upper from dysfunction.
lower airway obstruction and pulmonary injury.
Carbon monoxide and cyanide are products of com- Thoracic Trauma Injury
bustion; both cause tissue hypoxia. Hypoxia secondary to Rib fractures may be single or multiple. Ventilation may
carbon monoxide toxicity occurs because carbon mon- be impaired because of splinting secondary to intense
oxide has a 250 times greater affinity for hemoglobin pain. Fractures of three adjacent ribs are referred to as
compared with oxygen. This displaces oxygen from its a flail chest. This results in chest wall instability and is
hemoglobin binding site and results in a lower oxygen- associated with paradoxical chest wall movement, con-
carrying capacity and lower blood oxygen content. The tributing to respiratory insufficiency. Therapy entails
oxyhemoglobin dissociation curve is also shifted to the pain relief with analgesic administration. Continuous
left. The leftward shift of the oxyhemoglobin dissociation epidural analgesia directed to the thoracic segments has
curve results in less oxygen being released to the periph- been shown to be more beneficial than parenteral anal-
eral tissue.20 gesics.27 Respiratory insufficiency, despite analgesia,
Monitoring oxygen saturation by pulse oximetry is however, may require intubation and mechanical ventila-
inaccurate because these devices do not differentiate tion. Rib fractures may also produce pleural and abdomi-
between oxyhemoglobin and carboxyhemoglobin.21,22 nal injuries. Pleural injuries include a closed, open, and
Serum carboxyhemoglobin levels should be obtained to tension pneumothorax.
establish the actual level of carbon monoxide present. A small closed pneumothorax, in which the patient is
Carboxyhemoglobin levels less than 20% cause headache not to be anesthetized with positive-pressure ventilation,
and possible confusion. Carboxyhemoglobin levels may be treated with observation. Nitrous oxide, which is
between 20% and 40% present symptoms that include more soluble than oxygen and nitrogen, should not be
nausea, vomiting, disorientation, and visual impairment. administered because it will diffuse into the pleural cavity
Levels between 40% and 60% result in agitation, halluci- and significantly expand the pneumothorax. For the
nations, and coma, whereas levels greater than 60% are patient who will be intubated and ventilated with positive
fatal.23 The half-life of carboxyhemoglobin is 4 hours. pressure during a surgical procedure, thoracostomy
Oxygen therapy is indicated. The administration of 100% drainage should be performed. If not, the closed pneu-
oxygen can shorten the half-life of carboxyhemoglobin mothorax may be converted to a tension pneumothorax
to less than 1 hour. Hyperbaric oxygen (HBO) therapy as air is forced into the pleural space. A tension pneumo-
has been recommended for carboxyhemoglobin levels of thorax presents an immediate threat to the patient’s life.
30% or higher.24 Patients with neurologic symptoms Classic signs of a tension pneumothorax include hypo-
should be considered for HBO regardless of their car- tension, neck vein distention, tracheal deviation, and
boxyhemoglobin level. diminished breath sounds on the affected side. In the
Cyanide interferes with mitochondrial cytochrome acutely symptomatic patient, treatment involves the
function, resulting in tissue hypoxia. Nonspecific neuro- insertion of a 14-gauge catheter through the second
logic findings, including agitation and coma, are seen intercostal space at the midclavicular line.
with cyanide toxicity. Lactic acidosis is also found with An open pneumothorax also is an immediate threat
cyanide toxicity because it occurs with carbon monoxide to the patient’s life. The chest wound allows air to enter
the pleural cavity through the chest wall opening instead considered in the “cannot ventilate, cannot intubate”
of through the airways during spontaneous ventilation. patient in select situations. Although contraindicated in
Lung expansion and ventilation are poor, with resultant a patient with a full stomach, because it does not protect
hypoxia and hypercapnia. Treatment in the spontane- the trachea against gastric regurgitation and pulmonary
ously breathing individual entails placing an occlusive aspiration, it may provide a temporary airway and facili-
dressing, which is taped on three sides, over the wound. tate intubation. Importantly, the LMA protects the lower
This prevents air entry into the pleural cavity during airway against aspiration of pharyngeal blood and secre-
inspiration but allows air egress during expiration. An tions. Patients with maxillofacial injuries are more likely
occlusive dressing over the wound and a chest tube at to aspirate blood associated with the traumatic injury
another site should be used when positive-pressure ven- than gastric contents.28 Also, a large-gauge IV catheter
tilation is desired. (e.g., 12 or 14 gauge) can be used to provide a temporary
airway by performing a transtracheal jet ventilation. The
easiest site for needle insertion is the cricothyroid mem-
ANESTHETIC STRATEGIES brane, which may be difficult to locate depending on the
nature of the maxillofacial trauma. This technique is not
TRIAGE without risk and does require higher pressures to insuf-
The goal of triage is to classify patients into various cat- flate the lungs. However, this may provide the patient
egories, identifying the urgency and immediacy of treat- with sufficient oxygen until a more definitive airway can
ment. In regard to airway management, traumatized be established.
patients are divided into two categories: (1) those who Patients who are in acute respiratory distress will also
will require airway control as part of the resuscitation; require emergent airway intervention. These patients
and (2) those who will require semielective airway control may present with stridor, labored breathing, intercostal
at some point during hospitalization for surgical man retractions, and tracheal tug. Despite being alert, these
agement of the injury. Airway management as part of patients are fatigued. Also included are patients who are
resuscitation can be further categorized as emergent or unconscious, even though they may have adequate ven-
urgent. tilation. A primary purpose in intubating the uncon-
The patient categorized as requiring emergent airway scious and obtunded patient is to protect the airway, in
control is apneic or has total or near-total airway obstruc- addition to providing supplemental oxygen and support-
tion. This category of patient should be identified during ing ventilation.
the primary survey and requires immediate establish- Patients requiring urgent airway control are those who
ment of a patent airway. The quickest technique to secure present with conditions such as the following: airway nar-
the airway artificially is required. The possibility of a rowing secondary to hemorrhage, edema, or maxillofa-
cervical spine injury must be considered and appropriate cial skeletal instability; airway irritability secondary to
interventions taken to prevent a new neurologic injury hemorrhage; or thermal or inhalational airway injury.
or an exacerbation of a preexisting neurologic injury. These situations, although urgent, allow the practitioner
The initial intervention is to give positive-pressure venti- to proceed in an organized and deliberate but nonemer-
lation by mask with 100% oxygen. The mouth is inspected gent manner. Supplemental oxygen should be adminis-
and suctioned, with any foreign material removed before tered. A more complete medical history and physical
placing the mask. If ventilation is unsuccessful, a jaw examination may be obtained, including appropriate
thrust may be performed or an artificial airway may be cervical spine radiographs. Alternative intubating tech-
inserted, which may facilitate mask ventilation. Place- niques may be considered. Appropriate medications may
ment of an airway is not without potential risk. An oro- be administered, such as those to minimize the risk of
pharyngeal airway may stimulate the pharynx and gastric aspiration. The extent of injury may necessitate
precipitate gagging and coughing, which may cause an CT imaging. Monitoring and accessibility of the patient
increase in intracranial or intraocular pressure. The may be less in these remote environments, with the
upper body movement that may be associated with the potential for an adverse event. Consideration should be
gagging and coughing may cause further insult to a cervi- made to intubate a patient electively with occult, impend-
cal spine injury. Insertion of a nasopharyngeal airway ing respiratory impairment before sending the patient
must also be done cautiously in a patient suspected of for the CT scan.
having a base of skull fracture. It may also cause an epi-
staxis, which may further impair the airway. Distortion of
the soft tissue and unstable mandibular or maxillary frac- BASIC PRINCIPLES OF MANAGEMENT
tures may impair mask fit and compromise the ability to
provide positive-pressure ventilation. The clinician PATIENT POSITION
should remain cognizant of the urgency of the situation. The first principle in any emergency protocol is main-
Brain damage begins to occur as soon as 4 to 6 minutes taining or obtaining airway patency. Maxillofacial trauma
in the complete absence of inspired oxygen. If the may result in a notable disruption of soft and hard tissue,
attempt to ventilate the patient fails, laryngoscopy and which may compromise the patency of the airway. Con-
intubation under direct vision can be tried. As the anes- scious patients will seek out a position that optimizes
thesiologist is attempting the laryngoscopy and intuba- airway patency. When appropriate (e.g., the patient is not
tion, the trauma team should be preparing for a surgical at risk for a cervical spine injury), allow the patient to
airway. A laryngeal mask airway (LMA) may also be remain in that position.
objectives are that the patient: (1) be NPO; (2) have a

SEDATION AND ANALGESIA TECHNIQUES normal mandibular opening; (3) have a stable skeletal
Parenteral conscious sedation is capable of providing framework; and (4) have minimal soft tissue edema and
analgesia, anxiolysis, and amnesia. Although this can be distortion. A negative answer to any of these factors will
done safely, overly deep sedation may allow relaxation of necessitate a modification from standard induction and
the upper airway musculature, leading to airway obstruc- intubation.
tion, depression of the hypoxic or hypercapnic respira- Intubation may be attempted in an awake patient who
tory drive, and obtundation of the protective airway is not in respiratory distress. The awake patient has the
reflexes. Maxillofacial soft and hard tissue injuries may ability to protect his or her airway against pulmonary
increase the susceptibility to airway obstruction. The aspiration and maintain spontaneous ventilations. Secur-
administration of analgesic and sedative medication to ing the airway while the patient is awake may be consid-
these patients may result in muscular relaxation so that ered the safest technique when the initial evaluation of
the patient no longer compensates and airway patency is the patient suggests that ventilation or intubation may be
compromised. extremely difficult or impossible once anesthesia has been
induced. Awake intubation may also be considered as an
Induction of Anesthesia alternative to rapid sequence intubation in the patient
Pharmacologic management is frequently required in all with a full stomach. The alternative to an awake intubation
but the severely obtunded or comatose patient. If the in this situation is to establish a surgical airway. The airway
patient is hemodynamically stable, anesthesia may be can be secured surgically under local anesthesia only or
safely induced in any number of ways (e.g., inhalational in combination with minimal or moderate sedation.
mask, benzodiazepine, or barbiturate), but propofol is Success of an awake intubation is dependent on
frequently used. IV opioids and/or lidocaine are also patient comfort and cooperation. This includes explain-
advantageous in attenuating the stimulation that accom- ing the procedure to the patient. Sedation will improve
panies instrumentation of the airway and intubation. patient comfort and minimize potentially detrimental
Preventing exaggerated hypertensive responses is impor- hemodynamic fluctuations. Benzodiazepines and opioids
tant for numerous reasons, such as preventing dislodg- are an appropriate combination for sedation and analge-
ment of a hemostatic clot, possibly resulting in a sia. Benzodiazepines provide anxiolysis, sedation, and
hematoma leading to airway narrowing, and increasing amnesia. Opioids provide analgesia. Opioids should be
intracranial pressure. In the presence of hemodynamic used with caution because they have the greatest degree
instability, etomidate, benzodiazepine, or ketamine of respiratory depression for the amount of sedation
should be considered. Alternatively, smaller boluses of gained. Also, when combined with benzodiazepines, the
propofol given intermittently can also be used. The respiratory depressant effect of opioids is potentiated.
advantage of etomidate is that it has minimal cardiovas- Too deep a sedation may compromise the patient’s ability
cular depressant effects, specifically with regard to to maintain airway patency, satisfactory ventilation, and
causing the least vasodilatory effects. The advantage of oxygenation and protect the airway against pulmonary
ketamine is that it increases sympathetic activity, which aspiration. The safety of this technique is that benzodi-
produces a modest increase in blood pressure and heart azepines and opioids have specific antagonists. Opting to
rate. However, in the traumatized patient with high sym- administer benzodiazepines as the sole sedative agent
pathetic tone, ketamine may produce hypotension sec- can provide satisfactory operating conditions without the
ondary to its direct myocardial depressant effect. overt risk of opioid-induced respiratory depression.
Ketamine is contraindicated in the presence of head Intubation in the awake individual can be a stimulat-
injury because it increases intracranial pressure. ing process. Sympathetic stimulation can result in
A neuromuscular blocking agent is commonly admin- increased central venous pressure, which may result in
istered in conjunction with the induction agents. This an elevation in intracranial and/or intraocular pressure.
agent paralyzes the patient, enhancing the success and Furthermore, inadequate local anesthesia of the upper
safety of intubation by decreasing patient movement and airway can drastically impair the ability to secure the
adrenergic stimulation. In the severely hypovolemic or airway safely. Anesthetizing the upper airway can improve
obtunded patient, a neuromuscular blocking agent may patient comfort and lessen the stimulation associated
be indicated without the administration of the sedative with the procedure. The gag reflex can be effectively
or induction agent. Neuromuscular blockade should not controlled with a nerve block of the lingual branch of
be used if there is a concern that the patient may not be the glossopharyngeal nerve and/or the superior laryn-
able to be ventilated or intubated. If the anesthesiolo- geal nerve.29-31 Both these nerve blocks are relatively
gist’s concern is that of ventilation, mask ventilation simple techniques. The glossopharyngeal nerve block
should be attempted after sedative administration before requires the bilateral deposition of 1 to 2 mL of local
administration of the neuromuscular blocking agent. If anesthetic agent into the caudal portion of the tonsillar
the anesthesiologist’s concern is that of intubation, a pillar. The superior laryngeal nerve block is accom-
partial laryngoscopy may be performed to determine plished by deposition of 1 to 2 mL of local anesthetic
whether intubation may be accomplished after paralysis. agent into the hyothyroid membrane. Local anesthetic
agents can also be topically administered orally (as a
Awake Endotracheal Intubation swish) via a nebulizer or atomizer, or injected transtra-
Before using a general anesthetic, the practitioner must cheally. Transtracheal administration anesthetizes the
have the ability to control and protect the airway. Ideal mucosa of the trachea and upper airway. Anesthetizing
the airway while optimizing intubating conditions blunts esophageal occlusion between the cricoid cartilage and
the glottic and cough reflexes, increasing the patient’s cervical vertebrae. It has been shown to be effective in
susceptibility to aspiration. However, by combining preventing gastric regurgitation and gastric insufflation
several local anesthetic administration techniques with during anesthetic induction and positive-pressure venti-
moderate procedural sedation with a benzodiazepine lation. However, it is not without risk in the traumatized
alone, the airway can be safely and comfortably secured. patient. Cricoid pressure can theoretically displace a ver-
tebra of the cervical spine, potentially damaging the
FACTORS AFFECTING ANESTHETIC STRATEGIES spinal cord. The technique should be modified in the
Full Stomach patient with a suspected cervical spine fracture by sup-
Traumatic injuries are not planned. Therefore, it is porting the back of the neck with another hand.34 Cricoid
common for the patient to have recently consumed food. pressure is absolutely contraindicated in the patient with
Patients with altered levels of consciousness from intra- suspected laryngotracheal injury because it may produce
cranial injuries, alcohol, or drug intoxication will have complete airway occlusion.35,36
diminished protective airway reflexes. These patients Patient position may also be of some benefit. In the
may also be more prone to vomiting. Induction of anes- event of regurgitation, the Trendelenburg position is
thesia also results in the loss of protective reflexes; laryn- gravitationally favorable in preventing aspiration. This
goscopy and intubation may initiate regurgitation. Thus, position is generally inappropriate for the patient with a
the traumatized patient with a full stomach is at danger head injury. Alternatively, the concept of reverse Tren-
for pulmonary aspiration. The incidence of aspiration is delenburg theorizes that the head-up position minimizes
approximately 5% for the patient with a full stomach the incidence of passive regurgitation. However, active
during intubation for emergency surgery.32 vomiting, which can occur in the traumatized patient, is
The risk of complications due to aspiration is directly not prevented and, in the event that the patient vomits,
related to gastric acidity (pH < 2.5), gastric volume, and gravity promotes aspiration. This position is inappropri-
presence of particulate matter. The acidity of the gastric ate for the hypovolemic or hypotensive patient.
contents causes a chemical pneumonitis and the particu- Pharmacologic agents that may decrease the risk of
late matter can produce obstruction of the airway and aspiration are histamine-2 (H2) blocking agents, meto-
inflammatory foreign body reactions. Larger volumes of clopramide and sodium citrate. H2 blocking agents
aspirate can lead to further distribution of the offending inhibit the secretion of gastric acid, resulting in an
material and widespread pulmonary damage. Fasting increase of the pH of the gastric contents. They require
guidelines before inducing anesthesia for elective surgery at least 1 hour to achieve this effect after the drugs have
diminish the risk of aspirating gastric contents. However, been administered IV. Metoclopramide promotes gastric
for the traumatized patient, injury, anxiety, and pain can emptying, reducing gastric volume. It also increases gas-
delay gastric emptying time. Thus, the time interval for troesophageal sphincter tone. It requires at least 20
determining a patient’s state of fasting is measured from minutes, when administered IV, to demonstrate any
the last time a patient ate to the time of injury. If emer- benefit. Its effect may be diminished when opioids have
gent surgery is not indicated, it is most appropriate to been administered. Adverse effects associated with meto-
delay surgery to facilitate gastric emptying. However, the clopramide include hypotension and extrapyramidal
risk of aspiration with induction of anesthesia can persist effects. Sodium citrate is a monoparticulate antacid. It is
despite delaying surgery well beyond the traditional 6- to effective within 15 minutes for raising intragastric pH.
8-hour fast, between the time of last food ingestion and
induction of anesthesia. Intracranial Injury
Several adjunctive techniques and pharmacologic Head trauma is a contributing factor in approximately
agents are available to decrease the risk and severity of 40% of trauma-related deaths.37 It is also a major
aspiration. Insertion of a nasogastric or orogastric tube cause of respiratory depression and long-term disability
provides active evacuation of gastric contents. The gastric in the trauma patient. Morbidity and mortality occur
tube reduces gastric volume and gastric pressure but is as a result of primary brain injury (i.e., the damage
not presumed to empty the stomach completely, espe- produced to the brain by the original mechanical force)
cially of large particulate material. Once placed, the and secondary brain injury, which is usually caused by
gastric tube can remain in place during induction of increased intracranial pressure, ischemia, acidosis, and
anesthesia because it is now thought that its presence hypoxia. Management consists of recognizing primary
neither compromises the integrity of cricoid pressure brain injury and preventing secondary brain injury.
nor acts as a wick for the ascension of gastric contents Prevention can be accomplished by providing oxygen
into the pharynx.33 Placement of a gastric tube stimulates delivery, supporting ventilation, and maintaining cere-
the pharynx and may cause coughing and vomiting in bral blood flow.
the conscious patient. In the patient with a head or globe Emergent airway control is indicated to protect against
injury, this can increase intracranial or intraocular pres- aspiration, correct hypoxia, and support ventilation. In
sure. Other relative contraindications to the placement many communities with advanced medical services, pre-
of a gastric tube include the following: (1) a Le Fort II hospital intubation has been shown to improve the sur-
or III fracture because a nasogastric tube could be placed vival in patients with head injury.38
intracranially; and (2) suspected esophageal perforation. Cerebral blood flow (CBF) may be decreased in the
Cricoid pressure (Sellick maneuver) consists of posterior head trauma patient as a result of an increase in intra-
pressure on the cricoid cartilage, causing temporary cranial pressure secondary to cerebral edema. Local CBF
is regulated by several factors including Paco2. For every an exacerbation of a preexisting neurologic injury. Cervi-
1-mm Hg decrease in Paco2, CBF decreases by 2% to 3%. cal hyperextension, flexion, and traction must be avoided
This is important to understand in the management of when securing the airway. Attention must be given
these patients because a Paco2 of 20 to 25 mm Hg will during all stages of airway management because basic
result in a CBF less than half of normal. Hyperventilation airway maneuvers, such as the head tilt or chin lift, have
is a technique used to reduce intracranial pressure (ICP). been shown to produce disc space expansion.41 Defini-
Hyperventilation reduces ICP by constricting pial and tive airway protection is achieved with orotracheal
cerebral arterioles. Most clinicians attempt to achieve a intubation, blind nasotracheal intubation, fiberoptic
Paco2 around 35 mm Hg, because excessively aggressive intubation, or cricothyrotomy. The literature is equivo-
hyperventilation can further reduce blood flow to injured cal as to which is the most optimal technique for secur-
sites, causing ischemic brain injury with a worse outcome. ing the airway in the patient with a cervical spine
Temporary hyperventilation to a Paco2 of 30 mm Hg or injury.
below is reserved for temporary early control before Blind nasoendotracheal intubation has been advo-
intervention or in obvious signs of herniation.39 The cere- cated as a technique to limit neck movement. However,
brospinal effects of hyperventilation are relatively nasoendotracheal intubation is frequently facilitated by
transient. flexion and extension of the neck.
Barbiturates can be effective in reducing persistent Pressure is also frequently applied to the anterior neck
ICP when other modalities fail. The mechanisms of to position and stabilize the larynx. Pressure applied to
action are related to cerebral vasoconstriction, reduction the anterior neck has been shown to cause posterior
in cerebral metabolism and oxygen requirements, and subluxation at the fracture site.41 Blind nasoendotracheal
reduction in free-radical damage to brain cells. Pentobar- intubation is also associated with a moderate incidence
bital is administered with a loading dose of 5 to 10 mg/ of failure and can cause epistaxis. If an alternative intuba-
kg and continued as a drip of 1.5 mg/kg/hr until the tion technique is required, the bleeding into the airway
ICP is below 15 to 20 mm Hg. Careful monitoring is will decrease visualization and potentially cause laryngo-
necessary (mean arterial pressure [MAP] > 70 mm Hg, spasm or airway contamination.
normovolemic pulmonary artery wedge pressure [PAWP] Because of the potential for neck movement associ-
8 to 12 mm Hg, and temperature > 32° C [90° F]) because ated with blind nasoendotracheal intubation, laryngos-
hypothermia and barbiturate therapy can cause severe copy and oroendotracheal intubation with head and
cardiac arrhythmias. Good results have been reported neck stabilization or fiber optic laryngoscopy are recom-
with lowering ICP; however, questions remain regarding mended for the conscious patient.
improved outcomes and survival. The success of fiberoptic laryngoscopy is dependent
Although intubation is frequently indicated, the route on the skill and experience of the anesthesiologist. Theo-
in accomplishing it may be detrimental, because laryn- retically, there should be no neck movement. To improve
goscopy and intubation can significantly increase ICP. the conditions for a successful intubation, the intensity
Profound anesthesia and muscle relaxation will minimize of the room lights should be decreased. This will allow
the elevation in ICP. Opioids are beneficial in attenuat- the intubating team to determine the position of the
ing the sympathetic response to airway manipulation. endoscope as the fiberoptic light is transilluminated
Succinylcholine-induced fasciculation elevates ICP. Its through the anterior neck. Patient comfort and coopera-
rapid onset and short duration are advantageous for tion can also be improved by anesthetizing the upper
rapid sequence induction but its administration must be airway. Difficulty with this technique in the traumatized
preceded by a defasciculating dose of a nondepolarizing patient can be secondary to distortion of normal anatomy
muscle relaxant.40 Ketamine is contraindicated because and/or hemorrhage. Hemorrhage into the airway fre-
it will increase ICP. quently contributes to intubation difficulty, despite the
Patients sustaining maxillofacial injuries not infre- ability to irrigate and suction with the endoscope. An
quently have a history of loss of consciousness and/or advantage with an awake intubation is that neurologic
amnesia. These patients should not receive any medica- function can be demonstrated after the procedure.
tion that will alter their mental status, such as sedatives, When urgent airway intubation is mandated or an
analgesics, or selected antiemetics. Medications such as awake intubation is contraindicated, the recommended
anticholinergics, which will induce papillary dilation, technique is oroendotracheal intubation with direct
should also be avoided because they will alter the find- laryngoscopy.42 The anterior portion of a rigid cervical
ings during a neurologic examination. In addition to a collar impedes mouth opening and the application of
neurologic examination, these patients should undergo cricoid pressure and therefore is frequently removed.
CT to detect abnormalities before using an anesthetic. Immobilization is accomplished with manual in-line sta-
The concern in patients with a closed head injury is their bilization, which is accomplished by placing the hands
undetected decompensation while under an anesthetic. on both sides of the head, holding down the occiput, and
A patient with a negative head CT scan should be stable preventing rotation and extension. Glottic visualization
and not deteriorate while under anesthetic.40 is frequently decreased compared with intubation without
manual in-line stabilization, but intubation can be accom-
TREATMENT OF SPECIFIC INJURIES plished.43 Due to the likelihood of impaired visualization
Cervical Spine Injury during the laryngoscopy, intubating stylets or semirigid
The goal in the management of the patient with a cervi- bougies can be implemented to facilitate successful
cal spine injury is to prevent a new neurologic injury or passage of the endotracheal tube. If difficulty exists,
there are a number of devices and techniques that can

facilitate intubation.44 One advance in airway manage- Thermal and Inhalation Injury
ment has been the intubating laryngeal mask. However, The maxillofacial surgeon may be involved in the man-
pressure against the cervical vertebrae from the intubat- agement of the burn patient at the time of initial injury
ing laryngeal mask can potentially aggravate a cervical and subsequently several months later for reconstructive
spine injury.45 surgery. The concerns regarding airway management are
Manual in-line stabilization does not limit complete specific to those periods.
cervical movement during airway manipulation. Some Anesthetically, the initial concern is assessment of
studies have shown it to cause distraction of the current airway edema and prediction of subsequent
fracture.46-48 Manual in-line stabilization is also least effec- airway edema as a result of the thermal insult. During
tive in limiting extension of the upper cervical spine, the first 3 to 5 days, changes in vascular integrity occur
which may occur during laryngoscopy and mask ventila- in burn patients. This results in extravasation of fluid,
tion. Patients with injuries to C1 and C2 might be more which also contributes to the edema. Overaggressive
vulnerable to adverse effects arising from intubation. fluid resuscitation during this period further compounds
Airway manipulation, unless the patient is completely the airway edema. Careful and repetitive observation is
obtunded, will require the administration of anesthetic required so that intervention is timely and appropriate.
medications. An induction or sedative agent establishes Because of the potential for periglottic edema, consider-
an anesthetic state that provides sedation and amnesia ation should be given to early airway control and the use
and blunts the hemodynamic response to intubation. The of a smaller than normal endotracheal tube. Added
neuromuscular agent decreases patient movement and attention should be paid to securing the endotracheal
excessive adrenergic stimulation. The presence of a cervi- tube in the patient with a facial burn. Reintubation after
cal spine injury may modify the selection and dosing of an unplanned extubation in the patient with massive
these medications. The patient with a cervical spine injury facial and airway edema may be impossible and ulti-
has a loss of sympathetic stimulation. A vascular vasodila- mately prove fatal. Carbon monoxide toxicity may also
tion with a lack of compensatory tachycardia results in be a complicating factor during initial presentation.
hypotension. Left ventricular dysfunction secondary to Treatment may involve HBO therapy. There are issues
the cervical spine injury may also contribute to the hypo- related to hyperbaric therapy in the burn patient that the
tension.49 This is compounded by the vasodilatory effects trauma team must address. For the patient who is intu-
of the anesthetic medication and the unopposed vagal bated, the endotracheal tube balloon must be filled with
stimulation, which causes a bradycardia secondary to pha- saline. If the patient is wheezing, there is an increased
ryngeal and tracheal stimulation, during laryngoscopy risk of pneumothorax.
and intubation. An anticholinergic agent administered The second phase of airway management involves the
before airway manipulation can blunt the vagal stimula- care that transpires during the several days to weeks after
tion. Decreased dosages and slow administration of seda- the acute inhalation injury. Factors contributing to respi-
tive or induction agent may minimize the vasodilatory ratory insufficiency include diminished alveolar compli-
effects of the anesthetic medications. The patient’s hemo- ance and intrapulmonary shunting. Aggressive and
dynamic status may dictate the complete avoidance of an frequent pulmonary toilet and humidification are
induction agent. A neuromuscular blocking agent may be required to prevent occlusion of the airway secondary to
indicated alone during these situations. sloughing endobronchial debris and secretions. Bron-
There is no ideal neuromuscular blocking agent. For choscopy may be necessary to assist in pulmonary toilet.
rapid sequence intubation in the trauma patient, succi- Pharmacologically, nebulized heparin and acetylcysteine
nylcholine has been the agent of choice. Succinylcholine, may have some benefit.50 Bronchospasm may also be a
however, has been associated with severe hyperkalemia if complication of aerosolized irritants from the inhalation
administered to the spinal cord–injured or burn patient. injury. Management with beta agonists is effective. Chest
The severe hyperkalemia can result in ventricular dys- wall burns may restrict chest wall compliance, resulting
rhythmias and cardiac arrest. This adverse effect associ- in respiratory compromise. Escharotomy of the chest and
ated with succinylcholine develops over the first week; abdomen will be necessary to manage this problem.
therefore, succinylcholine can be used within the first 24 There are a few specific modifications in airway man-
hours of a patient sustaining a cervical spine injury. Alter- agement in regard to the burn patient during this period.
natively, most anesthesiologists would prefer to use a Succinylcholine can cause a massive hyperkalemia, result-
nondepolarizing neuromuscular blocking agent (NMBA). ing in ventricular dysrhythmias and cardiac arrest, and is
Unfortunately, there currently is no ultra–short-acting contraindicated in the patient with a burn exceeding
NMBA available on the U.S. market. Rocuronium is a more than 10% of total body surface. However, this effect
NMBA capable of approximating the rapid onset (≈90 does not occur for a few days and the use of succinylcho-
seconds) similar to that of succinylcholine. However, the line, although preferable to avoid, is not contraindicated
larger dose of rocuronium required to produce rapid in the first 24 hours.51 Succinylcholine should then be
paralysis necessary for a rapid sequence induction lasts avoided for the next 2 years until after the burned skin
far longer than succinylcholine. A rapid sequence dose has healed. A nondepolarizing muscle relaxant should
of rocuronium typically produces a prolonged paralysis be used to facilitate intubation. A transient resistance to
in excess of 30 to 45 minutes, requiring at least partial the nondepolarizing NMBAs may occur between 1 and 6
neuromuscular return before reversal can safely be weeks.52 Pharmacologically, the management of these
instituted. patients will be dictated by the hemodynamic status of
the patient. The burn patient commonly has significant monitored for patients on long-term infusion. Patients
pain and appropriate analgesic therapy should be must also be observed for pancreatitis, which may be
ensured. The burn patient also commonly requires associated with hypertriglyceridemia.60,61
repeated surgical débridements. Ketamine is an excel- Propofol is approved for use in patients older than 3
lent drug in that it maintains spontaneous ventilations, years. Case reports of fatal metabolic acidosis and cardiac
functional residual capacity, and protective laryngeal failure, termed the propofol infusion syndrome, have been
reflexes and provides analgesia into the postoperative reported in children who have had prolonged propofol
period. This facilitates the repeated surgeries with the infusions to assist in optimizing conditions for mechani-
avoidance of repeated intubation. cal ventilation.62-64 A review by the U.S. Food and Drug
Burn patients may need reconstructive surgery several Administration (FDA) has concluded that propofol is not
months after the initial injury. There are two primary directly linked to the metabolic acidosis and pediatric
airway management issues at this time. The patient who deaths.65 Practitioners, however, should be aware of the
has had prolonged intubation or tracheostomy during the risk of this reaction in children and limit the dose and
initial resuscitation may have tracheal or subglottic steno- duration of propofol infusion in these situations.
sis.53,54 The second issue pertains to the physical disfigure-
ment, including microstomia and neck contractures that Benzodiazepines
impede ventilatory and intubation efforts. Fiberoptic Benzodiazepines are commonly prescribed to provide
endoscopic intubation may be the technique of choice. anxiolysis, sedation, and amnesia in intensive care unit
(ICU) patients. Of the benzodiazepines, midazolam or
lorazepam are frequently administered. Midazolam has
POSTOPERATIVE AIRWAY SUPPORT a shorter duration of action. It also has minimal cardio-
vascular depressant effects. It is easily titratable to achieve
POSTOPERATIVE SEDATION AND ANALGESIA IN an appropriate sedative and anxiolytic depth to assist
THE INTENSIVE CARE UNIT with mechanical ventilation. Despite its relatively shorter
Sedative and analgesic medications are frequently pre- duration of action compared with other benzodiazepines,
scribed to the postoperative trauma patient who is midazolam when compared with propofol has been asso-
mechanically ventilated. These medications are pre- ciated with a prolonged weaning time. Midazolam is
scribed to sedate the patient and achieve an optimal level metabolized by hepatic microsomal oxidation. The oxi-
of pain control to ameliorate the detrimental stress dative pathway is susceptible to many factors, including
response. hepatic disease and numerous drug interactions. Loraz-
There are several agents that have been used to sedate epam is often chosen to provide amnesia and sedation
a mechanically ventilated patient. These include propo- for patients requiring mechanical ventilation. It has a
fol, benzodiazepines, etomidate, and dexmedetomidine. prolonged duration of action that reflects a high degree
In selecting an agent, the practitioner seeks to achieve of protein binding and poor water solubility. As such,
sedation, amnesia, and analgesia without producing lorazepam is often dosed twice daily, which can be advan-
physiologic instability. tageous in the ICU setting. Also, it should be noted that
lorazepam has no active metabolites.
Propofol
Propofol is an alkyl phenol. It has sedative, hypnotic, and Etomidate
amnestic properties. Propofol is administered as a rapid Etomidate is an imidazole derivative. The advantage of
bolus for induction, as a weight-based dose ranging from etomidate for induction of anesthesia is that it has
1 to 2.5 mg/kg. It can also be administered as a continu- minimal cardiovascular depressant effects. However,
ous infusion, usually at a rate between 50 to 200 mcg/ etomidate has been associated with suppression of
kg/min.54a It has rapid onset with rapid recovery after adrenal steroid synthesis when administered both as an
discontinuation of the drug.55 Its clearance rate and induction agent and an infusion. This has resulted in
minimal tendency for drug accumulation make it an increased mortality in the ICU patient.
ideal agent for sedating the intubated patient. Assess-
ment of the patient, with the ability of the patient to Dexmedetomidine
respond to verbal commands, usually can be performed Dexmedetomidine is an alpha-2 agonist. It has sedative,
within 10 minutes of discontinuing the propofol infu- anxiolytic, and analgesic properties. Patients sedated
sion. Weaning from mechanical ventilation is most favor- with dexmedetomidine maintain respiratory function.66
able with propofol compared with the benzodiazepines It is a unique drug in that patients sedated with dexme-
because of its rapid recovery, which is relatively indepen- detomidine are readily roused, more cooperative, and
dent of the duration of the infusion.56 interactive when stimulated.67 The drug is also advanta-
Propofol is beneficial in the traumatized patient geous in that it attenuates the response to intubation and
because it decreases cerebral metabolism and has been extubation.68 It is devoid of amnestic properties.
shown to improve outcome in traumatic brain-injured Dexmedetomidine infusion may be associated with
patients.57 It is also beneficial in suppressing seizure adverse effects. Hypertension can occur with rapid IV
activity.58,59 administration, which is short-lasting. Hypotension and
A propofol infusion in the postoperative patient is not bradycardia may subsequently develop and are attribut-
without potential adverse effects. Propofol is formulated able to the inhibition of sympathetic activity in the central
as a lipid emulsion. Triglyceride levels must be nervous system.69
MECHANICAL VENTILATION 11. Woodring JH, Lee C: Limitations of cervical radiography in the
There are a number of traumatized patients who will evaluation of acute cervical trauma. J Trauma 34:32, 1993.
12. Hastings RH, Marks JD: Airway management for trauma
require airway support after surgery. The indications patients with potential cervical spine injuries. Anesth Analg 73:471,
for maintaining control of the airway may be motivated 1991.
by local factors, such as swelling or systemic factors, 13. Mathison DJ, Grillo H: Laryngotracheal trauma. Ann Thorac Surg
including an intracranial injury or cardiopulmonary 43:254, 1987.
14. Ecker RR et al: Injuries of the trachea and bronchi. Ann Thorac
injuries. The intubated patient will often require mechan- Surg 11:289, 1971.
ical ventilation. Mechanical ventilation can provide 15. Kelly JP et al: Management of airway trauma. 1: Tracheobronchial
full ventilatory support (e.g., control mode ventilation), injuries. Ann Thorac Surg 40:551, 1985.
in which the ventilator provides the required minute 16. O’Connor PJ, Russel JD, Moriarty DC: Anesthetic implications of
ventilation or partial ventilatory support (e.g., intermit- laryngeal trauma. Anesth Analg 87:1283, 1998.
17. Herndon DN, et al: Etiology of the pulmonary pathophysiology
tent mandatory ventilation), in which the required associated with inhalation injury. Resuscitation 14:43, 1986.
minute ventilation is partially supported by the ventila- 18. Pruitt BA Jr, Erickson DR, Morris A: Progressive pulmonary insuf-
tor and partially achieved by spontaneous unassisted ficiency and other pulmonary complications of thermal injury.
ventilation. J Trauma 15:369–379, 1975.
19. Sutcliff AJ: Burn patients. In Grande CM, editor: Trauma anesthesia
The decision as to when to extubate the patient may and critical care, St. Louis, 1993, Mosby–Year Book.
prove as challenging as the decision about when to intu- 20. Weiss SM, Lakshminarayan S: Acute inhalation injury. Clin Chest
bate the patient. It will be dictated by local factors (e.g., Med 15:103, 1994.
airway patency) and systemic factors. Systemic factors 21. Barker SJ, Tremper KK: The effect of carbon monoxide inhalation
revolve around the patient’s ability to assume the full on pulse oximetry and transcutaneous Po2. Anesthesiology 66:667,
1987.
work of breathing. These are demonstrated by vital 22. Vegfors M, Lennmarken C: Carboxyhemoglobinaemia and pulse
capacity and negative inspiratory pressure. Adequate oximetry. Br J Anaesth 66:625, 1991.
nutritional support to the patient who has sustained a 23. Capn LM, Miller SM: Trauma and burns. In Barash PG, Cullen BF,
severe injury is important in being able to assist the Stoelting RK, editors: Clinical anesthesia, ed 4, Philadelphia, 2001,
Lippincott Williams & Wilkins.
patient and promote a favorable outcome. 24. MacLennan N, Heimbach DM, Cullen BF: Anesthesia for major
thermal injury. Anesthesiology 89:749, 1998.
SUMMARY 25. Baud FJ, et al: Elevated blood cyanide concentrations in victims of
smoke inhalation. N Engl J Med 325:1761, 1991.
Maxillofacial trauma patients, with their associated inju- 26. Silverman SH, et al: Cyanide toxicity in burned patients. J Trauma
28:171, 1988.
ries, present various challenges to the trauma team 27. Wu CL, et al: Thoracic epidural analgesia versus intravenous
members. This chapter has discussed various anesthetic patient-controlled analgesia for the treatment of rib fracture pain
management techniques demonstrating the importance after motor vehicle crash. J Trauma 47:564, 1999.
of a highly skilled anesthesiologist as a member of the 28. Gabbot DA: The effect of single-handed cricoid pressure on neck
movement after application of manual in line neck stabilization.
trauma team. In rural hospitals, oral and maxillofacial Anaesthesia 52:586, 1997.
surgeons, with their anesthetic and surgical knowledge 29. Barton S, Williams JD: Glossopharyngeal nerve block. Arch Otolar-
of the airway, may function in multiple roles during yngol 93:186, 1971.
resuscitation of the trauma patient. 30. Benumof JL: Management of the difficult adult airway: With special
emphasis on awake tracheal intubation. Anesthesiology 75:1087,
1991.
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42. Norwood SH, Myers MB, Butler J: The safety of emergency neuro- 55. Barr J, et al: Propofol dosing regimens for ICU sedation based
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43. Hastings RH, Wood PR: Head extension and laryngeal view during 56. Kress JP, et al: Sedation of critically ill patients during mechanical
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ology 80:825, 1994. Crit Care Med 153:1012, 1996.
44. Smith CE, et al: Evaluation of tracheal intubation difficulty 57. Kelly DF, et al: Propofol in the treatment of moderate to severe
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(WuScope) versus conventional laryngoscopy. Anesthesiology trial. J Neurosurg 90:1042, 1999.
91:1253, 1999. 58. MacKenzie SJ, Kapadia F, Grant IS: Propofol infusion for control
45. Brimacombe J, Keller C: Cervical spine instability and the intubat- of status epilepticus. Anaesthesia 45:1043, 1990.
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26:708, 1998. propofol: A case series. Crit Care Med 28:1781, 2000.
46. Bivins HG, et al: The effect of axial traction during orotracheal 60. McLeod G, et al: Propofol 2 percent in critically ill patients: Effect
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Ann Emerg Med 17:25, 1988. 61. Possidente C, et al: Elevated pancreatic enzymes after extended
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48. Kaufman HH, et al: Danger of traction during radiography for rhythmia in a child sedated with propofol. Crit Care Med 26:2087,
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49. MacKenzie CF, et al: Assessment of cardiac and respiratory function 63. Parke TJ, et al: Metabolic acidosis and fatal myocardial failure after
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53. Colice GL, Munster AM, Haponik EF: Tracheal stenosis complicat- 67. Coursin D, Maccioli G: Dexmedetomidine. Curr Opin Crit Care
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54. Lund T, et al: Upper airway sequelae in burn patients requiring responses to tracheal intubation and reduces the need for thiopen-
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4, New York, 2006, McGraw Hill, Lange Medical Books. 2000.
CHAPTER
Maxillofacial Ballistic and
27
Missile Injuries
David B. Powers
| Robert I. Delo
OUTLINE
Epidemiology Management of Gunshot Wounds to the Face
Fatal and Nonfatal Firearm Injuries Soft and Hard Tissue Involvement
Risk Factors for Firearm Injuries Bone and Soft Tissue Reconstruction
Characteristics of Maxillofacial Ballistic and Missile Injuries Postoperative Complications
Categorization of Gunshot Injuries
Injury Patterns and Associated Injuries
Acute Care Considerations
Airway Management
Hemorrhage Management
B
allistic injury patterns to the maxillofacial region and taste) only serve further to complicate the potential
present a unique and challenging dilemma for the for catastrophic injury and lifelong deformity that bal-
practicing craniomaxillofacial trauma surgeon. listic injuries cause to the craniomaxillofacial region.
The tissue disruption associated with ballistic injury to Because the face is the component of the body most
the facial region can be daunting, and the identification involved in a patient’s personality and interaction with
of normal anatomic planes, usually embedded within a society, preservation of form, cosmesis, and functional
hemorrhaging mass of pulverized soft and hard tissues, outcome should remain the primary goals in the man-
can try the skills of even the most experienced facial agement of ballistic injury. A logical sequential analysis
trauma specialist. The soft tissue injuries inherent in bal- of the injury patterns to the facial complex is absolutely
listic trauma may exhibit avulsive loss, sequential necrosis necessary for the treatment of craniomaxillofacial bal-
over days to weeks, and compromised vascularity negat- listic injuries. Fortunately, these skill sets should be well
ing potential microvascular or pedicled soft tissue recon- honed by all craniomaxillofacial surgeons through their
struction, in addition to supplying proper nutrients to exposure to generalized trauma, orthognathic, onco-
the underlying hard tissues of the facial skeleton, native logic, and cosmetic surgery patients. Identification of
bone or grafted bone, to promote healing. Due to the injured tissues, understanding the functional limitations
frequent occurrence of comminuted bony fractures, the of these injuries, and preservation of hard and soft
necessity for open reduction of the hard tissue injuries tissues, minimizing the need for tissue replacement, are
further complicates the soft tissue response. A compro- paramount.
mised soft tissue bed can lead to necrosis of free-floating
bone fragments, avascular necrosis of the underlying EPIDEMIOLOGY
facial skeleton, devitalization of stabilized fracture seg-
ments, and development of soft tissue infection or osteo- The epidemiology of ballistic injuries to the maxillofacial
myelitis, resulting in increased tissue loss and scarring of region remains constant in the civilian community due
the facial composite. Hard tissue loss, including bone to the historical and overriding presence of firearms in
and teeth, presents the unique challenges of reconstruc- the United States. Although the presentation of cata-
tion, including reconstitution of the masticatory complex strophic ballistic injuries typically is associated as being
to support the oral intake of nutrition, reestablishment under the purview of the military surgeon during times
of the normal anteroposterior projection and angular of armed conflict, large metropolitan trauma centers,
shape of the facial skeleton, maintenance of lip compe- and many community and rural hospitals in the United
tence, and control of salivation. Beyond the anatomic States, routinely encounter patients injured during crimi-
concerns of reconstruction, the presence of specialized nal acts, attempted suicide, or accidental shootings asso-
vascular and neurosensory components in the maxillofa- ciated with recreational or hunting activities. By better
cial region, including the great vessels of the neck, understanding the causes, craniomaxillofacial surgeons
various branches of the cranial nerves compromising are better prepared to serve as educators and advocates
motor and sensory functions (e.g., sight, smell, hearing in the community for the elimination of these injuries.
696
Maxillofacial Ballistic and Missile Injuries CHAPTER 27 697
120
White male
100
White female
Rate* per 100,000 population
Black male
80
Black female
60
40
20 FIGURE 27-1 Demographics of firearm

homicides for ages 15-54 by race and gender
in the United States, 2002. (Data from
0 National Center for Injury Prevention and
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
Control: WISQARS leading causes of death
Age reports, 1999-2007 [http://webappa.cdc.gov/
* Age-adjusted rate per 100,000 U.S. Standard population based on year 2000 standard sasweb/ncipc/leadcaus10.html]).
FATAL AND NONFATAL FIREARM INJURIES motor vehicle accidents (MVAs). This article highlighted
The most current comprehensive analysis of fatal and the positive efforts by the medical community to effect
nonfatal firearm injuries in the United States was accom- change in treatment protocols and the educational out-
plished by Gotsch et al in 2001.1 In excess of 115,000 reach programs by law enforcement, government, and
firearm-related injuries occur annually in the United the community to reduce the impact of firearms in the
States, with firearms involved in over 58% of homicides United States. There was a reduction in firearm fatalities
and 57% of suicides. Approximately 30,000 of them sus- since 1995 by 29.3% and the number of nonfatal injuries
tained fatal wounds from these incidents, but more than by 46.9%9,10 (see Fig. 27-2D and E).
twice this number survived their injury, many with signifi-
cant injuries and permanent disabilities.2 Coben, in 2003,
reported the average hospital length of stay for a firearm- RISK FACTORS FOR FIREARM INJURIES
related wound was 6 days, with 7% of hospitalized firearm Unintended Firearm Injuries
wound patients expiring from their injuries, and esti- Unintentional firearm injuries and deaths represent a
mated hospital costs to be in excess of $800 million.3 very small proportion of the total number of firearm
Because 29% of these patients were uninsured, and the injuries and have steadily declined since the 1930s.11,12
estimated cost of firearm-related injuries per incident in Ismach et al evaluated unintended shootings in the
the United States is in excess of $17,000 (over $2.3 billion Atlanta area from May 1996 through June 2000 in an
aggregate lifetime medical costs for firearm injury survi- effort to determine the proportion of accidental injuries
vors), the societal impact and payment implications for that might be prevented by safer storage, handling, or
hospitals, local government, and taxpayers are immense.4,5 firearm design.13 Of the 216 unintentional firearm inju-
Black males are disproportionately more likely to suffer ries recorded during this period, most victims were 15 to
firearm-related injuries than any other ethnic group or 34 years of age; 25% of the shootings involved victims
gender1 (Fig. 27-1). According to Logan et al, the homi- younger than 18 years. Handguns were involved in 87%
cide rate for black males aged 10 to 19 years (1999 to of the incidents. Of the 122 cases for which details of
2002) was 17.8/100,000, a rate 10 times that of whites causation could be established, 74% of the incidents
(1.8/100,000), three times that of Native Americans were associated with mishandling of the firearm, 14%
(6.0/100,000), and more than double the rate for His- were associated with child access to the firearm, and
panics (8.0/100,000). 6 The Federal Bureau of Investiga- 32% were associated with perceived deficiencies in
tion (FBI) and Centers for Disease Control and Prevention firearm design. It was concluded the incidence of unin-
(CDC) reported in 2003 that firearms were used in 66.9% tended shootings could be decreased by improving the
of homicides in the United States, so the logical conclu- safety of firearm storage and limiting access, improving
sion would be that the acute management of these condi- available firearm safety mechanisms, and educating
tions in the American health care system would be an owners about the safe handling of firearms, policies con-
expected event7 (Fig. 27-2). In 2007, homicide was the firmed by additional studies conducted by Kochanek
sixth leading cause of death for blacks, regardless of age, et al and the CDC.8,14
while it ranked as the fifteenth leading cause for death
when all races were included.8 A 1999 report indicated Pediatric Firearm Injuries
that over 32,000 deaths resulted from firearm injuries in As noted by Kochanek et al, the pediatric population is
1997, making it the second leading cause of death after at a disproportionately higher risk for firearm-related
United States Firearm Death Profile, 2003

Number Rate*
Total firearm deaths 30,136 10.36
Suicides 16,907 (56.1%) 5.81
Homicides 11,920 (39.6%) 4.10
Unintentional 730 (2.4%) 0.25
Legal intervention 347 (1.2%) 0.12
Undetermined 232 (0.8%) 0.08
*Death rate per 100,000 population
A
Strangulation
1.3% Other
Asphyxiation (including
0.9% drowning)
5.7%
Narcotics and poisoning
0.35%
Fire and explosives
1.1%
Pushed/personal
weapons (hands,fists,
feet, etc) Handguns
6.6% 76.6%
Blunt objects (clubs,
hammers, etc) Firearms
4.5% 66.9%
Knives or cutting
instruments
12.6%
Rifles
5.1%
Shotguns
Other guns or 5.1%
type unknown
13.2%
B Source: FBI Uniform Crime Report
12
10
Rateˆ per 100,000 population
8
Total
6 * Firearm
Non-firearm
4 *
2 *
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
ˆAge-adjusted rates per 100,000 U.S. standard population year 2000 standard.
*Beginning in 1999, mortality data have been coded using ICD-10 codes. Graphs that include data
C from 1999 have a break in the trend line because NCHS has recommended not combining these data.
FIGURE 27-2 A, Firearm death rates in the United States by intent, 2003. B, Homicide weapons in the United States by type, 2003.
C, Firearm and non-firearm homicide trends in the United States,1980-2002. Note the peak in the early 1990s followed by a steady trend
downward. D, Top 10 leading causes of violence-related injury deaths in the United States, 2008. (A, C, Data from National Center for
Injury Prevention and Control: WISQARS leading causes of death reports, 1999-2007 [http://webappa.cdc.gov/sasweb/ncipc/
leadcaus10.html]; B, Data from Federal Bureau of Investigation: Crime in the United States, 2003 [http://www.fbi.gov/about-us/cjis/ ucr/
crime-in-the-u.s/2003/toc03.pdf]; D, Data from National Center for Health Statistics: Top 10 leading causes of violence-related injury
deaths in the United States, 2008, [http://nchspress room.wordpress.com/2009/10/21/10-leading-causes-of-violence-related-injury-deaths-suicide-is-
leading-killer].)

Age Groups
Rank 1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65 Total
Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional
1 suffocation drowning MV traffic MV traffic MV traffic MV traffic poisoning poisoning MV traffic fall MV traffic
1,058 443 385 532 8,647 6,358 7,545 9,496 4,137 19,742 37,985
Homicide Unintentional Unintentional Homicide Homicide Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional
2 unspecified MV traffic drowning firearm firearm poisoning MV traffic MV traffic poisoning MV traffic poisoning
156 346 138 143 4,394 5,946 5,446 5,866 3,547 6,167 31,116
Homicide
Homicide Unintentional Suicide Unintentional Homicide Suicide Suicide Suicide Unintentional Unintentional
other spec.,
3 unspecified fire/burn suffocation poisoning firearm firearm firearm firearm unspecified fall
classifiable
192 111 141 3,188 3,612 2,796 3,789 3,079 4,769 24,013
98
Unintentional Unintentional Homicide Unintentional Suicide Suicide Homicide Suicide Unintentional Suicide Suicide
4 MV traffic fire/burn firearm drowning firearm firearm firearm poisoning fall firearm firearm
98 169 44 123 2,009 2,357 1,966 2,004 1,809 4,143 18,223
Undetermined Unintentional Unintentional Unintentional Suicide Suicide Suicide Suicide Suicide Unintentional Homicide
5 suffocation suffocation suffocation fire/burn suffocation suffocation suffocation suffocation poisoning suffocation firearm
46 145 41 64 1,653 1,752 1,855 1,772 1,164 3,200 12,179
Unintentional Unintentional Unintentional

Unintentional Unintentional Suicide Suicide Unintentional Suicide Adverse Suicide
pedestrian, other land other land
6 drowning drowning poisoning poisoning fall suffocation effects suffocation
other transport transport
41 569 764 1,486 1,300 818 1,677 8,578
111 28 64
Homicide Unintentional
Homicide Suicide Homicide Undetermined Undetermined Homicide Unintentional Unintentional Suicide
other spec., pedestrian,
7 suffocation firearm cut/pierce poisoning poisoning firearm suffocation poisoning poisoning
classifiable other
32 50 504 606 836 1,146 562 1,296 6,442
77 24
Undetermined Homicide Unintentional Unintentional Suicide Homicide Unintentional Undetermined Homicide Unintentional Unintentional
8 unspecified firearm fall suffocation poisoning cut/pierce fall poisoning firearm fire/burn suffocation
28 56 22 50 334 476 540 1,066 489 1,118 6,125
Unintentional Unintentional
Adverse Homicide Unintentional Unintentional Unintentional Unintentional Unintentional Suicide Unintentional
struck by or other land
9 effects unspecified poisoning drowning drowning drowning fire/burn poisoning unspecified
against transport
24 15 37 429 406 510 476 675 5,911
44 302
Unintentional
Unintentional Unintentional Unintentional Undetermined Unintentional Homicide Unintentional Undetermined Suicide Unintentional
struck by or
10 fire/burn fall firearm poisoning fall cut/pierce suffocation poisoning suffocation drowning
against
22 38 29 299 297 393 490 455 580 3,548
D 13
Maxillofacial Ballistic and Missile Injuries CHAPTER 27
699
1.2
Male
1
Female
Rate* per 100,000 population
0.8
0.6
0.4
0.2
0
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85
Age groups
* Age-adjusted rate per 100,000 U.S. Standard population based on year 2000 standard.
FIGURE 27-3 Unintentional firearm mortality by gender and age in the United States, 1999-2002. (Data from National Center for Injury
Prevention and Control: WISQARS leading causes of death reports, 1999-2007 [http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html).)
injuries.14 Paris et al have evaluated risk factors associated traumatically injured patients, regardless of the cause of
with nonfatal firearm injuries among inner city adoles- injury, younger than 21 years, with 42% of them testing
cents in the United States and found that children living positive for alcohol or drugs.18 When the grouping was
with less than two parents, with frequent school absences, narrowed to gunshot wounds in patients younger than
with a previous arrest history, and being black were 18 years, 72% of victims demonstrated evidence of sub-
factors placing them at increased risk for being the victim stance use, with the 14- to 15-year old age group showing
of firearm injury.15 Nance et al have evaluated demo- the highest association. Studies conducted by McLaugh-
graphics and contrasting urban versus rural firearm lin, Shuck, and Johnson et al have demonstrated an asso-
injury trends for Pennsylvania and found that the rate of ciation between drug or alcohol use and the risk of
serious firearm injury in children was 10 times higher in firearm injury.19-21
urban areas than in rural areas.16 Urban firearm injuries
tended to be assaults, whereas rural injuries tended to be Other Risk Factors
nonintentional. Of these injuries, 90.7% were in male Although this is not a complete listing of all factors asso-
adolescents, with an average age of 16.5 years. Unin- ciated with an increased risk of firearm injury, known
tended injuries predominated in children 5 to 9 years of influences include the following19-27:
age (61.4%), with 56.7% of these injuries occurring in 1. Previous or current involvement in the justice system
rural areas. Handguns were the most commonly involved 2. History of incarceration
firearms, regardless of geographic region, age, or injury 3. Depression
circumstances. Nance et al have appropriately that con- 4. Suicidal ideation or active psychiatric disease (Fig. 27-4)
cluded that prevention strategies must be region- and 5. Presence of firearms in the home
situation-specific, taking these demographic variations 6. Ethnic minority status (particularly black)
into account.16 Heninger and Hanzlick have reported 7. Poverty or financial crisis
similar results in 2008, with firearms being used in 88% 8. Presence of alcohol or recreation drugs
of homicides and 61% of suicides in adolescents and
teenagers in the Atlanta metropolitan area17 (Fig. 27-3).
CHARACTERISTICS OF MAXILLOFACIAL
Alcohol and Drug Abuse
BALLISTIC AND MISSILE INJURIES
An intuitive and well-demonstrated risk factor for firearm-
related injury is the use or abuse of alcohol or other The management of ballistic injuries to the craniomaxil-
recreational or prescription drugs. Madan et al have lofacial zone is predicated on a basic understanding of
reported on the blood and urine analyses of 126 the two mechanisms whereby projectiles cause tissue
45
40
Male
Female
Age-adjusted rate per 100,000 population
35
30
25
20
15
10
0
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85
Age group
FIGURE 27-4 Firearm suicide by gender and age in the United States, 2002. (Data from National Center for Injury Prevention and Control:
WISQARS leading causes of death reports, 1999-2007 [http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html).)
damage, crushing and stretching. As the recent conflicts “06” in this term describes the year, 1906, when the car-
in Iraq and Afghanistan have highlighted, missile injuries tridge was introduced to the market. The term grains
to the maxillofacial region may not only be caused by originally was applied to black powder charges and refers
conventional weaponry, with a bullet fired from a cylin- to the weight of the powder in the cartridge, not the
drical chamber, but devastating projectile collisions with number of granules contained in the cartridge case. A
the facial skeleton may be caused by massive bomb blasts .30-30 cartridge has a .308-inch diameter bullet propelled
and shock wave impacts from improvised explosive by 30 grains of smokeless powder. As newer forms of
devices (IEDs).28 Although a comprehensive analysis and gunpowder were developed, this powder charge was no
discussion of the physics of energy transfer and ballistic longer used, but the terminology persists to this day.
theory is beyond the scope of this chapter, a brief review Additional confusion regarding caliber exists because
of the basic concepts of ballistics and kinetic energy is North Atlantic Treaty Organization (NATO) and United
warranted. States military projectiles are described using the metric
system (7.62- or 9-mm rounds), while United States civil-
CATEGORIZATION OF GUNSHOT INJURIES ian firearm munitions are generally referred to in mea-
Gunshot injuries have been categorized in the literature surements relating to inches (.357 or .38). Although the
as penetrating, perforating, or avulsive.10 Penetrating question regarding caliber is commonly asked by medical
wounds are caused by the projectile striking the victim personnel in the management of ballistic injury, the
but not exiting the body. Perforating injuries have reality is that caliber has minimal practical impact on the
entrance and exit wounds, classically described as being care of the patient.30-32
without appreciable tissue loss. Avulsive injuries have The terms high velocity and low velocity as they relate to
entrance and exit wounds, generally presenting with an projectiles can be somewhat misleading. There is no con-
acute loss of tissue associated with passage of the projec- sensus between United States and European research in
tile out of the victim. Rifles, handguns, and submachine the literature, with varying definitions correlating to
guns have rifled barrels—essentially, spiral grooves cut where the study was performed. The U.S. literature des-
into the length of the interior of the bore of the barrel.29 ignates high velocity as being between 2000 and 3000
The grooves are separated by segments of metal, called feet/second (610 to 914 m/second), whereas studies
lands, which project into the middle of the barrel. The from the United Kingdom designate the line between
diameter of the barrel measured between the lands rep- low- and high-velocity projectiles as being 1100 feet/
resents the caliber of the projectile. second (335 m/second), which is the speed of sound in
Caliber specifications based on nomenclature used in air.33 The earliest recognized entry of high-velocity pro-
the United States can be difficult to comprehend. The jectiles having an association with increased wounding
.30-06 and Winchester .308 cartridges are both loaded potential occurred during the Vietnam War. In 1967,
with bullets that have a diameter of .308 inches.29 The Rich et al have reported that bullets fired from the M16
rifle inflict tremendous tissue destruction and injuries on potentially injures tissues such as muscle, vessels, and
enemy combatants.34 The muzzle velocity of the projec- organs. The clinical significance of this cavity is variable,
tile shot from the M16 was 3100 feet/second. When with no real consensus in the literature. The temporary
coupled with erroneous information published by Rybeck cavity caused by the M16 in animal laboratory models is
in 1974, and in the 1975 edition of the Emergency War much smaller than the approximately 18-cm temporary
Surgery manual regarding the size of the temporary cavity cavity seen in ballistic gelatin.30 Dog models have indi-
caused by the missile, this information led to the common cated that acute tissue injury secondary to temporary
misperception that high-velocity projectiles cause more cavity formation sustained with high-velocity projectile
significant injuries.35 strikes were no more than 5 cm and were able to resolve
Part of the confusion regarding the wounding poten- within 72 hours.46,47 The U.S. military has conducted
tial of high-velocity projectiles is becsause of misinterpre- extensive research into the wounding patterns of projec-
tation of ballistic gelatin model studies. Ballistic gelatin tiles (see Fig. 27-5). The unique anatomic differences of
is 10% to 20% gelatin refrigerated to 4° to 10° C (39° to the craniomaxillofacial skeleton, a relatively thin soft
50° F) and is used as the tissue model for ballistic tissue layer overlying a dense foundation of bone, miti-
studies.36,37 The wound profile diagrams included in this gate some of the expected responses of the temporary
chapter represent the findings of these studies. The valid- tissue stretch, because the overall thickness of the soft
ity of the ballistic gelatin model has been confirmed by tissue envelope is generally less than the required total
comparison with human autopsies, although there is distance needing to be traveled prior to exhibiting sec-
confusion in correlating these studies to living patients, ondary cavitation. Although sequential soft tissue necro-
because the human body is more resistant to deforma- sis and small vessel damage can occur, it is much more
tion than gelatin The effects of skin resistance, clothing, likely to be in response to the exaggerated permanent
and opposition to separation of the fascial planes cannot cavity of the projectile, which is greatly enhanced after
be replicated in gelatin.38,39 striking the underlying facial skeleton.31-33,48 The key
Harvey et al evaluated the two types of pressure waves point for understanding the management of ballistic
produced by penetrating objects in 1947, the sonic pres- injuries is the permanent cavity, which involves all the
sure wave and temporary cavity.40 The first wave is the tissues that are pushed aside or destroyed during the
sonic pressure wave, sometimes referred to as the shock flight of the projectile, and is the site of the extent of
wave. This relates the sound of the projectile striking the the initial, or immediate, damage. The size and shape of
target. This wave transmits at the speed of sound (i.e., the permanent cavity are determined by the density and
≈4750 feet/second [1450 m/second]) and is traveling anatomic characteristics of the tissue lying in the projec-
considerably faster than the projectile entering the tile’s path, velocity of the projectile, shape and character-
target. No temporary cavity is formed with the sonic pres- istics of the projectile and, likely most importantly, the
sure wave; in that regard it is analogous to the lithotripsy degree of deformation of the missile as it travels through
devices used for renal calculi destruction, with corre- the tissues.36-39
sponding minimal risks for tissue injury.31 Although The type of firearm used has implications in regard to
American and Swedish researchers have tried to disprove the wounding potential of the projectile. Generalized
Harvey’s conclusions, no definitive evidence suggests discussions of craniomaxillofacial wounding patterns
that his findings are in error, and additional studies by center on handguns, rifles and shotguns. The wounding
French and American researchers have supported the patterns of these weapons are unique and do not fall
original findings.32,41-45 under the classic description of firearm-based injuries.28
The secondary pressure wave, referred to as the tem- The actual projectiles expelled by firearms are limited in
porary cavity, is formed when the penetrating projectile type only by time and the imagination for description,
strikes tissue and the wave radiates away laterally away such as hollow point, round nose, full metal jacket, alloy-
from the permanent cavity of the projectile path. After jacketed, and Teflon-tipped (Fig. 27-6A). The compo-
being struck by the projectile, the ballistic gelatin or nents of a bullet provide a basic understanding of the
tissue displays an obvious temporary cavity, which principles of firearm injury (Fig. 27-6B). The projectile
FIGURE 27-5 A, Ballistic representation of NATO 7.62-mm round fired from an M16 rifle. Observe the relatively consistent permanent
cavity and laterally radiating temporary cavity, which begins to develop at approximately 20 cm into the tissue as the projectile begins to
tumble. This chart represents the projectile not striking any hard structures causing deformation or alteration in trajectory. The anatomic
characteristics of the head and neck do not have over 20 cm of soft tissue present prior to encountering the bony skeleton. This would
have clinical significance in regard to the temporary cavity if the projectile’s trajectory only encounters soft tissue and misses the
underlying facial bones. B, Ballistic representation of a 7.52-mm soft point (SP) round striking muscle and bone. Note that as the
projectile strikes the underlying structures, there is a tremendous increase in the permanent and temporary cavities as the projectile
deforms and fragments due to the soft tip construction. This deformation in the structural characteristic of the projectile, and associated
increase in the permanent and temporary cavities, greatly enhances the wounding potential of this round. C, Ballistic representation of a
22-caliber (5.6-mm) full metal case (FMC) round striking bone and muscle. Note that as the relatively small-caliber projectile strikes the
underlying structures, there is a tremendous increase in the permanent cavity and associated temporary cavity as the projectile deforms
and continues on a new trajectory. This illustrates the wounding potential of a smaller caliber weapon if the projectile actually strikes the
target and engages in energy transfer to the tissues. (Adapted from Szul AC, Davis LB, Walter Reed Army Medical Center Borden
Institute: Emergency war surgery, rev 3, Washington, DC, 2004, U.S. Government Printing Office.)
7.62 mm NATO
Vel - 2830 f/s (862 m/s)
Wt - 150 gr (9.7 gm) FMC
Permanent Cavity
Temporary Cavity
0 cm 5 10 15 20 25 30 35 40 45 50 55 60 64
A
Bullet Fragments
Detached Muscles
Permanent Cavity
7.52 mm SP
Vel - 2923 f/s (891 m/s)
Wt - 150 gr (9.7 gm)
Final wt - 99.7 gr (6.46 gm)
33.4% Fragmentation
1.95 cm
Temporary Cavity
0 cm 5 10 15 20 25 30 35 42
B
22 Cal (5.6 mm) FMC

Wt - 55 gr (3.6 gm)
Vel - 3094 f/s (943 m/s)
Detached Muscles Final wt - 35 gr (2.3 gm)
36% Fragmentation
Permanent Cavity
Temporary Cavity
Bullet Fragments
0 cm 5 10 15 20 25 30 36
C
Projectiles
Case
Wad
Gunpowder
Primer
A
B
FIGURE 27-6 A, Photograph of the tremendous variety of caliber, projectile composition or construction, and variable volumes of
propellant and casings available for the modern firearm. B, Cross-sectional analysis of a bullet and shotgun shell.
is the portion of the bullet that is expelled and strikes bone, which would have a higher exponent (2.5) and
the victim.49 The composition of the projectile (e.g., soft therefore a higher likelihood of permanent injury. The
lead, hollow point, full copper covering) has a direct corrected formula for estimating wounding capacity by
correlation with the wounding potential of the weapon. kinetic energy should be KE = 1 2 mv0.5 to KE = 1 2 mv2.5.
As a projectile deforms after striking the victim, either as Handguns are handheld firearms, with a barrel length
a result of metallurgic composition during manufacture generally 10.5 inches or less, which usually fire projectiles
or as a direct consequence of striking the underlying of a lower velocity and caliber.49 The characteristic low-
bone, the energy transfer to the patient and potential velocity wound has a small rounded, or slightly ragged,
injury to associated tissues is increased. entrance wound, causing fragmentation of teeth and
The case is the container in which the projectile, pro- bony comminution, often exhibiting no exit wound51,52
pellant (gunpowder), and primer are packaged as a (Fig. 27-7). If an exit wound does occur, it is generally
single unit for placement into the firing mechanism of slit-shaped or stellate.
the weapon. Wads are generally plastic frameworks with Handgun injuries generally have a tendency to push
a paper or felt insert that holds the various pellets (pro- away, or stretch, soft tissues, including vessels or nerves
jectiles) together in relation to the propellant to allow as opposed to avulsive loss. Rifles are long guns with
for accurate and safe release of all the projectiles simul- barrel lengths of more than 26 inches.10,49 At a distance,
taneously from the barrel. The propellant, or gunpow- rifle wounds create a low-energy transfer similar to that
der, is the accelerant that actually allows for expulsion of seen with handguns. At close range, the wounding char-
the projectile from the weapon. The more propellant in acteristics are different due to the increased potential
a cartridge, as is seen in Magnum and rifle rounds, the injury associated with velocity and high-energy transfer49
greater velocity the projectile exhibits. The primer is the (Fig. 27-8). The presence of an exit wound is usually
only portion of the bullet with an explosive charge. As found, which may be stellate and larger than the entry
the primer is struck by the firing pin of the weapon, the wound. The presence of avulsive soft or hard tissue
explosive charge is activated, igniting the propellant and wounds and significant bone fragmentation can be char-
sending the projectile on its flight. Although traditional acteristic findings of rifle wounds.
concepts of ballistics teach that impact kinetic energy A shotgun is a long gun that may fire a single pellet,
(KE) is equal to half the mass (m) of the projectile times or numerous pellets, at a relatively low velocity. The gauge
velocity (v) squared (KE = 1 2 mv2), the increased energy of the shotgun is classified as the number of lead balls or
transmitted from a high-velocity projectile does not nec- pellets placed together, equaling the interior diameter of
essarily translate to increased wounding capacity. Cun- the barrel, which would weigh 1 pound. For contact for
ningham et al have suggested that modifications need to close range injuries, the effect of the gas discharged
be used to correct the kinetic energy estimate of wound- under pressure into the wound also needs to be consid-
ing potential for the type of tissue being struck by the ered. This scenario is extremely important in shotgun
projectile.10,33,39,50 They indicated that softer tissues, such and IED blast wounds due to the higher degree of con-
as brain and muscle, should be associated with a lower tamination and presence of propelled gas and shock
exponent of injury (0.5) than harder tissue, such as waves.28 Powder gases are expelled from the muzzle of
A B
C
FIGURE 27-7 A, Characteristic clinical appearance of a low-energy, low-velocity gunshot wound to the anterior mandible. No exit wound
was detected and the patient underwent an emergency tracheostomy secondary to airway concerns. B, Three-dimensional
reconstruction of CT scan indicating the degree of comminution associated with this gunshot wound. The superior aspect of the
projectile can be appreciated at the extreme bottom left of the CT scan. Three-dimensional reconstructions provide superior visualization
and localization of anatomic variants in the management of ballistic injuries to the craniomaxillofacial unit. C, Application of a modern
external fixator for the management of a low-energy, low-velocity gunshot wound to the mandible. Note the conservative treatment of the
gunshot wound, with minimal decontamination and débridement and placement of a wet to dry gauze dressing.
the weapon after combustion of the gunpowder and to the patient, the more dramatic is the hard and soft
follow the projectile out of the barrel. When the muzzle tissue damage. For rifles and handguns, the clinical dif-
of the weapon is in contact with the target, this can be ference in whether the weapon was 10, 100, or 1000 feet
an additional source of tissue displacement, injury, and away from the patient otherwise has no bearing on treat-
thermal burning.38 Shotgun pellet injuries essentially ment. The range of a .22-caliber handgun is approxi-
depend completely on how far the weapon is from the mately 1 mile, whereas the range of a rifle can be as long
target at the time of discharge. Sherman and Parrish have as 3 to 4 miles Although one could argue that at the outer
devised a classification system to describe shotgun wounds limit of a projectile range it is less likely to penetrate a
in relation to the distance from the target. Type I injury target, rarely does a shooting occur outside the effective
occurs from a distance longer than 7 yards, type II injury range of a weapon.49
is sustained when the discharge is within 3 to 7 yards, and As noted earlier, current conflicts in the Middle East
type III injury is within 3 yards.53 Type III injuries usually and Afghanistan have interjected a newer mechanism for
sustain dramatic soft and hard tissue injuries and avulsion the delivery of maxillofacial missile projectiles that cause
of tissue, whereas type I injuries may be minimal (see Fig. gruesome and avulsive craniomaxillofacial injuries, the
27-9A). Because victims often have difficulty in determin- IED28 (Fig. 27-11). Although not a new entity—the
ing how far away the shotgun was at the time of discharge, concept of IEDs has been deployed by guerilla forces
Glezer et al have revised this classification system and since World War II—the description and media interest
directed their attention to the size of the pellet scatter. in the IED warrants a brief discussion of its characteristic
Type I injuries occur when pellet scatter is within an area properties. An IED is a bomb fabricated in an improvised
of 25 cm2, type II injuries are within 10 to 25 cm2, and manner designed to destroy or incapacitate military
type III injuries have pellet scatter less than 10 cm2.54 (Fig. personnel or civilians. The bomb itself may be a conven-
27-10). Although the Glezer classification originally was tional military grade weapon, or an assortment of explo-
developed for abdominal injuries, the information is sive components such as gasoline, or agricultural
transferable to other areas of the body and determina- fertilizer, as seen in the Oklahoma City bombing of 1995.
tions of tissue injury can be correlated directly to the size An IED has five components—a switch (activator), initia-
of the pellet scatter. Intuitively, the closer the shotgun is tor (fuse), container (body), charge (explosive), and
A B
C D
FIGURE 27-8 A, Cannulation of the severed parotid duct with Silastic tubing. All ballistic injuries to the craniomaxillofacial complex should
undergo evaluation under some form of magnification for potential remnants of the salivary ducts and cranial nerves because primary
repair is best accomplished at the time of initial injury. B, High-energy gunshot wound to the anterior mandible. Note the presence of soft
tissue disruption and a second gunshot wound across the anterior neck, glancing off the surface epithelium and providing only superficial
injury to the platysma. C, Initial stabilization of the patient was accomplished with an external fixator secondary to the presence of other
life-threatening gunshot wounds that were sustained at the same time. The patient was subsequently treated with open reduction and
internal fixation with a reconstruction plate and corticocancellous bone graft from the anterior ilium. D, Three-dimensional reconstruction
of CT scan indicating the degree of comminution and avulsive bone loss associated with this gunshot wound. The projectile can easily be
identified at the bottom right of the CT scan.
power source (battery). Antipersonnel IEDs typically It is these sudden and extreme differences in pressures,
contain shrapnel generating components such as nails, and associated dispersal of secondary projectiles, that can
ball bearings, metal fragments, wood, and/or glass. lead to significant neurologic, skeletal, or soft tissue
Direct shrapnel injury is only a single element to be con- injury. While a comprehensive review of IEDs, and their
sidered, because detonation of any powerful explosive increasing use in armed conflict—from the Belarussian
generates a blast wave of high pressure that spreads out Rail War in World War II to the current use by insurgents
from the point of explosion and travels hundreds of in Iraq and Afghanistan—is beyond our intent here, but
yards in all directions. The relative proximity of the its inclusion as a wounding source for modern cranio-
victim to the site of the explosion, the greater the expo- maxillofacial injuries is warranted.
sure to the shock wave energy. The initial shock wave of
very high pressure is followed closely by a so-called sec- INJURY PATTERNS AND ASSOCIATED INJURIES
ondary wind, which is a huge volume of displaced air Hollier et al have retrospectively evaluated 84 patients
flooding back into the area, again under high pressure. with facial gunshot injuries.26 Of these, 67% suffered
A B
C
FIGURE 27-9 A, Characteristic facial appearance of a patient sustaining a shotgun wound from a distance. (Sherman and Parrish, class I;
Glezer, class I). Note the presence of multiple punctate entry wounds, but no significant disruption of the facial features. B, C, Classic
radiographic appearance of a patient sustaining a shotgun wound from a distance (Sherman and Parrish, class I; Glezer, class I). Note
the presence of multiple shotgun pellets on the radiographs.
facial fractures, and 75% of them received surgical treat- involvement in 40%, and midfacial involvement in 38%
ment of these injuries; 21% required emergent tracheos- of patients in their data set. The most common fractures
tomy for airway control (all had injury in the lower third were the maxilla (41%) and mandible (28%). Vascular
of the face); and 14% had great vessel injury diagnosed injury was present in 5 of 54 (9%) as determined by
by angiography, of whom 50% required surgical treat- angiography.
ment (1 in 12 was managed by embolization in the radiol- Lew et al have reported that the incidence of penetrat-
ogy suite). Other associated injuries included eye (31%), ing soft tissue injuries and fractures for U.S. military
brain (18%), and tongue (13%). Facial fracture distribu- personnel in Iraq and Afghanistan was 58% and 27%,
tion included zygoma (35%), mandible (30%), orbit respectively, with 76% of the fractures being open.56 The
(26%), skull (21%), and nasoethmoid (11.9%).26 An location of the facial fractures in descending order of
evaluation of 54 gunshot wound patients by Kihtir et al55 incidence was mandible (36%), maxilla-zygoma (19%),
revealed central nervous system injuries in 22%, orbital nasal (14%), and orbit (11%). The remaining 20% were
R L
A B F
FIGURE 27-10 A, Self-inflicted shotgun wound in a suicide attempt. Note significant hard and soft tissue disruption and avulsion (Sherman
and Parrish, Class III; Glezer, Class III). B, Three-dimensional reconstruction of CT scan showing the degree of hard tissue loss
experienced in a suicide attempt with a high-energy weapon.
soft tissue injuries sustained in Iraq and Afghanistan, and

the ongoing civilian gunshot wound experience in the
United States, Loos recently noted the lack of standard-
ized, controlled clinical studies highlighting the com-
plexity of evaluating the progression of soft tissue injury
for traumatically injured tissues in the zone of injury and
the impact on proposed microvascular and/or pedicled
tissue transfer.57
ACUTE CARE CONSIDERATIONS

As evidenced by the absolute priority highlighted in the
Emergency War Surgery manual and the American College
of Surgeons Advanced Trauma Life Support (ATLS)
course, the primary focus in the immediate post-trauma
period is securing the airway.31,58 The rapid assessment
for signs of airway obstruction in the trauma patient
should focus on evaluation for potential foreign bodies
and facial, mandibular, or laryngotracheal fractures,
which may result in airway obstruction. Ballistic injuries
to the face, head, and neck have direct bearing on ATLS
protocols involving initial assessment and primary man-
FIGURE 27-11 Characteristic facial injuries sustained by an
agement of the airway, because bony instability and sub-
improvised explosive device (IED). Note concomitant burns, tissue
loss, shrapnel injuries, ruptured right globe, and avulsed soft
stantial bleeding from the abundant vasculature of the
tissues. Only a small portion of the left side of the patient’s lateral
facial and great vessels of the neck often accompany
nasal complex was unaffected by this injury. these injuries. The presence of catastrophic wounds to
the craniomaxillofacial complex may also serve as a dis-
traction to emergency medical service personnel, focus-
not otherwise specified, with the primary mechanism of ing their attention away from potentially life-threatening
injury involving missile injuries from IEDs (84%).56 As injuries and wasting valuable time that could be better
noted, Tan et al completed an experimental study in used for treatment of potentially lethal injuries, stabiliza-
dogs in which simulated gunshot injuries were induced tion, and preparation for transport.
and vascular tissue subsequently studied by angiography,
high-speed x-ray photography, and light and electron AIRWAY MANAGEMENT
microscopy following injury; microthrombus formation, As mentioned, Hollier et al found that 21% of facial
vascular endothelial loss, and necrosis as far as 3 cm from gunshot injury patients required emergent tracheostomy
the wound margin were found.48 Despite the extent of for airway control, all of which involved injuries to the
surgical cricothyroidotomy should be considered,

although this should be accomplished by the most expe-
rienced surgeon available, because by definition, an
emergent cricothyroidotomy should be considered as
one of final acts to secure an airway, not the first in the
sequence of airway establishment.
After successful tracheal intubation, the determina-
tion for a surgical tracheostomy to minimize interference
for the reconstruction of the dental occlusion will need
to be made. If prolonged intubation is expected based
on the nature or severity of the craniomaxillofacial inju-
ries, or concomitant intracranial injury, consideration
should be given to early elective tracheostomy.26,28,55 If
multiple staged surgical procedures are anticipated, the
lower third of the face has been injured, or there are
extensive soft tissue injuries of the tongue, floor of
mouth, submandibular triangles, and neck, serious con-
sideration for elective tracheostomy should be given.
Recent literature reports by Mahon et al have advocated
the use of the submental or submandibular intubation
FIGURE 27-12 Anterior mandibular avulsion as a consequence of a technique if it has been determined that the patient will
gunshot wound to the face. The patient is completely alert and not require long-term ventilator support, and the indica-
oriented at the time of presentation and is sitting upright in a tion for tracheostomy is primarily to minimize occlusal
slightly forward positioning to maintain the patency of the airway.
interference.59
Due to the loss of soft tissue attachments to the anterior
mandible, when the patient is positioned supine, the airway is HEMORRHAGE MANAGEMENT
obstructed. Recognition of this fact is an important component of
the initial assessment and during the securement of the airway.
Hemorrhage control, especially in close approximation
to the airway, is a critical step to improve airway patency
and to maintain normal hemodynamic status. Hemosta-
lower third of the face.26 Kihtir et al’s review of 54 civilian sis can be accomplished by a variety of measures, includ-
gunshot wounds found that 33% (18 of 54) required ing the use of pressure to stop acute hemorrhage and
urgent airway control, with the following distribution: suctioning to clear accumulated blood and enhance the
orotracheal intubation (24% [13 of 54] and 72% [13 of surgeon’s ability to identify and ligate, clamp, or cauter-
18] of patients requiring airway management), cricothy- ize bleeding vessels. In case of difficulty in achieving
roidotomy (4% of patients [2 of 54] and 11% of airway primary hemostasis, application of pressure in conjunc-
control patients), tracheostomy (4% of patients [2 of 54] tion with hemostatic dressings such as QuickClot or
and 11% of airway control patients), and nasotracheal Combat-Gauze, kaolin-impregnated gauze dressings used
intubation (2% of patients [1 of 54] and 6% of airway extensively by combat medics in Iraq and Afghanistan
control patients).55 Airway compromise is usually second- (Z-Medica, Wallingford, Conn), can establish a signifi-
ary to edema in close approximation to the airway, but cant reduction or elimination of high-volume vascular
may also be due to loss of structural integrity to the ante- bleeding without the risks of distal emboli previously
rior region of the mandible (Fig. 27-12). On an urgent encountered with other hemostatic agents.60-62 Blind
basis, manually supporting collapsed segments of the clamping is discouraged in the head and neck region due
mandible and base of tongue attachments may quickly to the proximity of motor and sensory nerves or other
resolve posterior airway collapse, as can patient reposi- specialized components, such as salivary ducts, suspen-
tioning. Forward traction on the tongue and/or anterior sory ligaments, and previously uninjured vascular struc-
collapsed mandible can be accomplished by the use of a tures, which may suffer iatrogenic injury. Active
towel clip or large-gauge suture material passed through hemorrhage from the head and neck region may require
the tongue or tissue in the symphysis region. Mask ven- image-guided embolization or surgical access for proxi-
tilation is unlikely to be successful for patients with inju- mal vessel ligation to control bleeding not responsive to
ries to the lower third of the face and may introduce air other more immediately available and less invasive mea-
emphysema into tissue. The use of nasopharyngeal and sures. If major vessel injury is suspected based on entrance
oropharyngeal airways may provide some temporary and/or exit wounds, or on expanding mass effect in
benefit, but endotracheal intubation is still the emer- tissues of the face or neck, then radiographic evaluation
gency airway of choice when partial or complete obstruc- of the vascular components of the neck via angiography
tion is present and the patient displays a diminished level is indicated. Hemodynamic status must be assessed and
of consciousness or obvious evidence of respiratory dis- managed, as necessary, with appropriate fluid resuscita-
tress or impending respiratory failure. The challenges tion and blood component replacement. An important
encountered intubating a patient with a ballistic injury clinical point to remember is that once the patient’s
to the lower third of the face should not be underesti- hypovolemia has been corrected, and mean arterial pres-
mated because edema, bleeding, and macerated soft sure has been stabilized, areas of head and neck hemor-
tissues may completely obscure the airway. The use of rhage previously controlled may begin to bleed actively
again.32 The importance of ongoing evaluation cannot visual acuity and loss of red color perception, which may
be understated; reports of second or multiple gunshot indicate progressive swelling of the optic nerve attribut-
injuries can be as high as 36%, and the patient could able to the initial injury. Based on these findings, surgical
easily be undergoing an exploratory laparotomy or tho- repair of facial fractures is often delayed in an effort to
racic procedure with the head and neck region obscured minimize progression of this optic nerve edema.
from view, allowing the blood loss to continue unabated The concept of débridement is well established in the
and unrecognized.26,28 The presence of a devastating cra- literature and is critical in the management of these bal-
niomaxillofacial ballistic injury may often mesmerize less listic injuries.28,55,65,66 Serial washouts and débridement of
experienced trauma care staff or emergency medical tissue have become mainstays for craniomaxillofacial
personnel, drawing attention from other potential life- trauma surgeons in the treatment of these injuries.
threatening sites of injury. Unfortunately, for many surgeons, the term débridement is
synonymous with the absolute removal of tissue in the
operating room. Although devitalized necrotic tissue
MANAGEMENT OF GUNSHOT WOUNDS TO does require excision, a more accurate definition of the
THE FACE goal of serial washouts should be decontamination. Pres-
ervation of all viable tissues is a critical component in the
Tremendous variation exists in literature reports and in management of gunshot wounds to the maxillofacial
U.S. trauma centers regarding the most appropriate region. Once tissues are lost, the surgeon is faced with
management protocol for the treatment of ballistic two choices—compromise anteroposterior projection to
injuries to the craniomaxillofacial complex. Single-stage allow for primary closure of native tissue, or transfer
versus multiple-stage procedures, or complex, extensive, additional tissue to the region via pedicled or microvas-
early reconstruction versus initial débridement and/or cular grafts. Avoidance of the need for tissue transfer
closed reduction with subsequent later revision surgeries, should be the goal and judicious use of the practice of
are several of the management philosophies supported. decontamination will assist in achieving the desired
Numerous authors have advocated a multidisciplinary results.
approach to the treatment of the more complex of these
injuries.26,28,63-66 Although not specifically mentioned by SOFT AND HARD TISSUE INVOLVEMENT
some, however, it is unlikely that a single surgical spe- Before the initiation of surgical reconstruction of ballis-
cialty can appropriately manage the myriad of surgical tic craniomaxillofacial injuries, an absolute understand-
subspecialty level injuries sustained in complex ballistic ing of the extent of the injuries and any functional and
injuries to the craniomaxillofacial region, except perhaps physiologic deficits is necessary. A critical mistake in the
for the simplest of these cases. Plastic, ophthalmology, management of these disorders is the prevalent desire by
otorhinolaryngology, interventional radiology, neurosur- the surgical team to provide definitive reconstructive
gery, trauma, general and/or maxillofacial prosthetic care to the patient in an expedited manner. Rushing the
dental, and subspecialty microsurgery care is (are) often patient to the operating room without a goal-oriented
indicated for these individuals, as well as other evaluation sequential surgical plan and without having the necessary
and management based on an individual patient’s inju- preoperative treatment planning or required medical-
ries. These would include occupational and physical surgical specialty consultations, will undoubtedly lead to
therapy, nutritional medicine, and behavioral science. a less than desirable surgical result. Evaluation of the soft
Adequate nutritional support is often delayed in the tissues in the maxillofacial region is accomplished by
management of ballistic injuries to the face. Once inter- direct observation and evaluation of the clinical response
ruption of normal oral feeding has been identified for to serial decontamination and débridement. The accu-
any length of time secondary to lower face, floor of racy of this appraisal is compromised by edema, which
mouth, or neck involvement, consideration should also often distorts the remaining tissue, artificially increasing
be given to early gastrostomy tube placement, generally volume assessment and masking the true tissue deficit
in conjunction with a planned anesthetic for débride- present. Cellular soft tissue damage persists and pro-
ment, early reconstructive treatment, or surgical gresses for several weeks, ultimately affecting the quantity
tracheostomy. and quality of soft tissue remaining after completion of
For all facial gunshot injuries, and any complex cra- healing.28,66 Before bony reconstruction occurs, appro-
niomaxillofacial trauma case regardless of cause, consid- priate imaging is necessary to define the magnitude and
eration must be given to a comprehensive ophthalmologic nature of the fractured segments clearly. Computed
evaluation. Hollier et al have found that 31% of patients tomography (CT) with three-dimensional reformatting
experience some form of ocular injury and 54% of them is essential for obtaining this information. Axial and
have ongoing residual visual problems.26 Hollier’s recom- coronal tomography imaging also provide this data, but
mended protocol includes careful evaluation of ophthal- the three-dimensional reconstructions improve concep-
mologic status before any surgical intervention to ensure tualization of the size and location of the fractured seg-
that injury-associated visual disturbance is properly documents and their relationship to one another, which
mented. Cho et al have reported that 32.7% of patients improves the ability to localize and reposition the seg-
with ballistic intracranial injuries sustain concomitant ments intraoperatively. The accuracy and clarity of three-
ocular injuries.67 Both of these studies encouraged dimensional reconstruction have significantly increased
ongoing ophthalmologic evaluation to monitor for trau- during the past decade and should now be part of the
matic optic neuropathy, specifically subtle decreases in standard workup for the treatment of complex ballistic
A B
FIGURE 27-13 A-C, Stereolithography models afford

complete visualization of the hard tissue deficits and
anatomic variations due to ballistic injury. These models are
an invaluable resources for treatment planning, construction
of patient-specific implants, prebending surgical hardware,
and/or determination of hard tissue grafting volume
C
requirements.
craniomaxillofacial trauma. Stereolithographic models, BONE AND SOFT TISSUE RECONSTRUCTION

extremely accurate acrylic resin representations of the The various bony and soft tissue reconstruction options
CT scans, can be used for presurgical planning and pre- for tissue replacement are covered elsewhere in detail in
fabrication of surgical reconstruction plates, increasing this text and are beyond our scope here. Concepts con-
accuracy of the reconstruction while decreasing time in sistent with the principles of bone and soft tissue recon-
the operative theater. The ultimate treatment goal for struction will be addressed, with representative citations
casualties with ballistic facial injuries is the restoration of included for further review.
function and cosmesis. Many patients injured by ballistic Controversy regarding the timing and extent of recon-
projectiles have significant avulsive defects of craniomax- struction exists largely because outcomes for catastrophic
illofacial structures. A vitally important aspect of treating facial ballistic injuries are uniformly disappointing,
these avulsive defects is using appropriate imaging to regardless of the treatment chosen. At a minimum, at the
develop a staged reconstruction plan, with the final end time of initial surgical treatment, the remaining bone
point in mind before any reconstruction begins. segments should be reduced and stabilized with some
Items for consideration when reviewing the soft tissues, form of fixation, as guided by preoperative imaging and
radiographic studies, and stereolithography models are intraoperative evaluation. External fixation with closed
as follows28,66 (Fig. 27-13): reduction obviates the need for elevation of the perios-
• Which structures are missing and which structures teum, which is a necessary component for the applica-
remain tion of rigid internal fixation. The elevation of periosteum,
• Effect of each of these on the reconstruction goals especially in the presence of comminution and multiple
• Which structures require replacement small bone fragments, compromises the vascular supply,
• How those structures will be replaced (nonvascular- which could lead to resorption, volume loss, or
ized versus vascularized tissue) necrosis.48,56
• Identifying stabilization points for replacement Maxillomandibular fixation is necessary when the
structures tooth-bearing portion of the maxilla or mandible is
• Soft tissue considerations involved and should be applied early to ensure that the
• Choice of grafting material occlusion is properly restored. Care should be taken in
• Effect of grafting plan on future implant recon- the application of arch bars in the presence of a com-
struction or dental rehabilitation minuted mandible fracture, as often encountered with
ballistic injuries. Overtightening the wires may lead to injuries with minimal to no tissue loss because, when
lateral displacement of the mandibular angles bilaterally, used for midfacial or complex avulsive injuries, cosmetic
excessively widening the patient’s facial profile and losing and functional results may be suboptimal. Delayed recon-
the angularity normally associated with facial projec- struction of these catastrophically injured patients is
tion.28 The use of dental impressions to fabricate surgical complicated by scarring and wound contracture, which
splints can similarly be complicated by the presence of will undoubtedly occur in the aftermath of a gunshot
complex maxillary and mandibular fractures and loss of injury. Although implied in the literature outlining
normal dental arch anatomy. A widened dental arch complex tissue transfer reconstructions, thorough decon-
form, often produced in the laboratory by plaster models tamination and débridement of foreign material from
lacking definitive bony support and skeletal references, the wound site is indispensable, coupled with proper
may result in inadequate anterior projection of the anatomic reduction and stabilization of the fractured
maxilla and zygomatic arches bilaterally, resulting in a segments with salvage and/or preservation of the remain-
patient profile potentially flattened and wide.66 Avulsion ing native soft and hard tissues. Even the most ambitious
or loss of hard and soft tissue volume should always be reconstructions require these necessary initial steps for
identified before the initiation of reconstructive surgery, optimization of the recipient site on which reconstruc-
because a strategy must be in place for the early or tion is planned.
delayed replacement of this tissue. Possibilities include Others have advocated the use of distraction osteogen-
immediate microvascular or pedicled tissue transfer to esis or other tissue traction for replacement of hard and
the area covering bone, obturation of a defect, or provi- soft tissue lost to facial gunshot injuries.78,79 Shvyrkov et al
sion of a vascular bed for a projected bone graft to the have reported on 33 males with 3- to 8-cm bone and
site. The ideal time for identifying soft tissue, and pos- soft tissue defects of the mandible initially managed by
sibly hard tissue, volume loss is after stabilization of the débridement and collapsing the residual mandibular seg-
bony skeleton. Residual continuity, or volume deficits, ments into the defect, using a transport disc distraction
should be detectable at this stage, affording proper plan- technique to generate bone and soft tissue across the
ning for potential tissue transfer procedures preopera- osseous gap. Of these patients, 28 had distraction com-
tively. Thus, you can obtain proper consent, prep, drape, pleted immediately following injury and 5 had their dis-
and position the patient properly, and have present all traction completed after the initial gunshot injury had
the instrumentation and personnel that will be necessary healed. According to the authors, all 33 patients had
to complete the tissue transfer. acceptable functional and aesthetic outcomes within 3 to
A number of authors have advocated immediate or 4.5 months of reconstruction.78 The advantage to this
early reconstruction, with vascularized free or pedicled procedure is obvious; bone and soft tissue volume are
tissue transfers; they believe that these procedures mini- restored without harvesting tissue from a remote site,
mize scar formation of soft tissue into bony defects, or preventing the morbidity associated with harvest and pre-
the development of wound contracture, which is difficult venting the mismatch of tissue characteristics inherent
to repair subsequently.26,64,66-77 Although clinical and with distant tissue transfer. Although the rationale and
research experience supports the viability of immediate results of this reported technique are exciting, it should
tissue transfer if indicated by the presence of acute tissue be noted that a comprehensive review of the literature
loss, the appropriate use of this technique involves accu- was unable to discover use of this technique for ballistic
rate determination of tissue transfer needs and the viabil- injuries by other authors. Herford and Boyne, however,
ity of the recipient bed. Robertson and Manson have have successfully published on the regeneration of four
reported that high-energy ballistic wounds to the cranio- mandibular body defects secondary to pathologic abla-
maxillofacial region may exhibit progressive necrosis, tions and isolated trauma defects with distraction osteo-
similar to injuries seen in electrical burns, compromising genesis, reporting effective hard and soft tissue generation
the small vessel anastomosis required for microvascular across traumatically compromised and/or irradiated
transfer and the margins of the recipient bed for a ped- tissue beds.80-82 Nonimmediate reconstruction with vascu-
icled flap.65 As noted, Tan et al’s study involved the com- larized pedicled or microvascular tissue transfer has also
pletion of microvascular anastomoses for small vessels been described.83-93
at the ballistic wound site bed.48 The anastomoses were Because gunshot injuries frequently have tissue loss
completed at various times following injury and the secondary to avulsion and/or necrosis, the replacement
short-term success of these anastomoses was evaluated. of tissue is necessary. In areas in which the soft tissue is
Repairs completed 3 days or later following injury main- adequate, free bone grafting may be all that is necessary
tained their patency best, confirming Manson’s belief to restore facial form and function. Inadequate soft tissue
that sequential decontamination and débridement pro- volume can sometimes be expanded, using standard
cedures can effectively result in the recipient tissues soft tissue expansion techniques.94,95 After adequate soft
achieving the desired state of healing to support the tissue expansion, progression to the bone-grafting proce-
transfer of tissues to the site.28 Others have advocated less dure to reconstruct missing osseous elements or the
surgically aggressive approaches to ballistic injuries, placement of custom-fabricated surgical implants can
opting for decontamination and débridement, closed or occur, depending on the location of the defect.96 Pedi-
open reduction of fractures, and secondary reconstruc- cled and free microvascular composite grafts are other
tion of residual defects using autogenous bone grafting, accepted and generally highly successful options for
with or without delayed tissue transfer.27,55,63 This form replacing moderate or large volumes of hard and soft
of treatment is best applied to low-energy injuries or tissue. A summary evaluation of the current literature
indicates that the trend is toward early definitive recon- tion, which may be a component of the elevated compli-
struction of missing hard and soft tissue using vascular- cation rates.
ized tissue transfer techniques as composite grafts or in Sherman and Gotleib have reported a case of carotid-
association with free bone grafts. A key consideration of cavernous sinus fistula developing subsequent to a severe
this method of treatment is to have reestablished the midfacial gunshot injury.100 Although a rare complication
bony projection and angular shape of the facial skeleton of craniomaxillofacial trauma, this trauma-induced
as soon as possible, but definitively within 10 to 14 days, pathologic entity, which matures between the internal
prior to the development of intractable facial scarring carotid artery and cavernous sinus, may result in reti-
and contracture or the formation of soft or hard tissue nopathy, optic atrophy, blindness, or fatal epistaxis. The
infection.28,65 characteristic findings associated with carotid-cavernous
sinus fistula include chemosis, pulsatile exophthalmos,
and supraorbital bruit. If suspected by physical examina-
POSTOPERATIVE COMPLICATIONS tion or clinical response, CT angiography is the accepted
practice for confirmation of the presence of this condi-
As described independently by Manson, Powers, and tion, which is treated in coordination with vascular
others, the most common complication associated with surgery or interventional radiology with ligation of the
ballistic injury management in the craniomaxillofacial internal carotid, embolization or, in some cases, observa-
region is delay in definitive soft or hard tissue reconstruction.100 Tattooing attributable to material incorporated
tion, with the subsequent development of a flattened into the wound at the time of injury can be minimized
wide face as the tremendous forces of facial scarring or eliminated with the use of a Q-switched Nd : YAG
and wound contracture alter the facial composite.28,65,69,77 laser,28 but this should not be used to remove tattooing
Once facial soft tissue scarring and wound contracture attributable to dermal inclusions of gunpowder, which is
have matured, and the underlying bony architecture has shot into the skin at close range. Fusade et al have found
remodeled, the opportunity to re-create any semblance that laser use on these individuals induces bleeding trans-
of normal facial form, contour, and projection is lost. As dermal pits, which subsequently scar in a poxlike fashion,
eloquently stated often by Manson, there is no second with spreading of the pigment into the skin surrounding
opportunity to perform a satisfactory primary reconstruc- the initial areas of the tattoo.101 The theory is that laser
tion.65 Hollier et al have reported the following postop- energy transfers to the gunpowder, causing microexplo-
erative complication rates: cranial nerve palsy (19%), sions and subsequently leading to the observed tissue
blindness (17%), hemiparesis (12%), visual disturbance damage.
(12%), wound dehiscence (4.7%), generalized sepsis Early dermabrasion has been suggested as a mecha-
(2.4%), and epiphora (2.4%).26 Other isolated complica- nism for the prevention of gunpowder tattooing. Pallua
tions reported were cerebral vascular accident, speech has suggested that dermabrasion for the removal of
difficulty, cerebrospinal fluid leak, facial nerve palsy, embedded gunpowder ideally should be completed
seroma, acute renal failure, disseminated intravascular within the first 6 hours following gunshot injury and
coagulation, and ptosis of the upper eyelid. Kassan et al never later than 72 hours postinjury102 (Fig. 27-14). For
have reported a postoperative infection rate, or sepsis, of later gunpowder tattoos or for deeper penetration of
19%, which is higher than that reported by other authors, powder, the recommended treatment is use of a mini-
primarily associated with comminuted low-energy punch excision technique for the removal of these rem-
handgun wounds.27 Kassan also noted similar rates of nants, as described by Kaufmann and Powers et al.28,103
neurologic and ocular complications as described by Although time-consuming, it is technically simple to
Hollier and Cho, in addition to restricted mandibular perform and yields superior aesthetic results, without
range of motion.26,67 Others have described similar rates excessive removal of uninvolved tissue. Many of the tech-
of the same complications listed, especially infection and niques used for immediate, early, and secondary recon-
ophthalmologic compromise.97,98 The higher incidence struction can also be used for secondary reconstruction
of ocular injuries is also seen in the presence of IEDs in or for the management of complications.
modern military action and terrorist attacks; Gataa has
reported a 29% ocular injury rate for civilian craniomax- SUMMARY
illofacial wounds, primarily caused by IED blasts.99 Kihtir
et al reported that 9.3% of ballistic injury patients (5 of Craniomaxillofacial ballistic injuries pose incredible
54) experienced coincident palatal injuries acutely and challenges to the facial trauma surgeon, offering the
were treated by only limited early surgical management opportunity for a tremendously rewarding—or emotion-
at a large metropolitan hospital in New York.55 Oronasal ally draining—personal and operative experience. Tech-
fistulas developed in two of these patients at the comple- nologic advances in surgical hardware manufacture,
tion of healing, for a complication rate of 13%. Of the radiologic imaging capabilities, and improved operative
54 patients, 8 received closed reduction of their mandi- techniques have afforded the facial trauma surgeon the
ble fractures with one resulting in nonunion. One man- tools necessary to accomplish the primary goal of surgical
dibular fracture patient was treated with open reduction treatment: returning these injured patients to a reason-
and internal fixation, subsequently developing osteomy- able level of aesthetics, form and function, and allowing
elitis, although the reported algorithm from this study them to integrate back into society. Although the cata-
encouraged delayed treatment and management of all strophic nature of these injuries places obvious limits on
maxillary, orbital, and zygomatic fractures without reduc- what can be realistically achieved, continuously striving
A B
FIGURE 27-14 A, Blast injury patient with embedded gunpowder, shrapnel, and other debris. B, The same patient immediately
postoperatively after conservative decontamination and débridement, foreign body removal, and superficial dermabrasion.
for surgical excellence should remain the focus of all 11. Frattaroli S, Webster DW, Teret SP: Unintentional gun injuries,
firearm design, and prevention: What we know, what we need to
surgical interventions. This is best accomplished by a know and what can be done. J Urban Health 79:49–59, 2002.
comprehensive presurgical evaluation, identification of 12. Baker SP, O’Neill B, Ginsburg M, Li G: The injury fact book, New
injured and noninjured tissues, understanding of the func- York, 1992, Oxford University Press.
tional and anatomic limitations imposed by the wounds, 13. Ismach RB, Reza A, Ary R, et al: Unintended shootings in a large
and clarity of purpose and rationale for the proposed metropolitan area: An incident-based analysis. Ann Emerg Med
41:10–17, 2003.
reconstructive procedures. The application of the prin- 14. Kochanek KD, Murphy SL, Anderson RN, Scott C: Deaths: Final
ciples outlined in this chapter, coupled with the primary data for 2002. Natl Vital Stat Rep 53:1–115, 2004.
tenet of the Hippocratic Oath, Primum non nocere (“First, 15. Paris CA, Edgerton EA, Sifuentes M, et al: Risk factors associated
do no harm”), will serve the facial trauma surgeon well. with non-fatal adolescent firearm injuries. Inj Prev 8:147–150,
2002.
16. Nance ML, Denysenko L, Durbin DR, et al: The rural-urban con-
tinuum: Variability in statewide serious firearm injuries in chil-
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CHAPTER
Head and Neck Burn Injury
28
Hossein Mortazavi
| Arash Khojasteh
| Husain Ali Khan
|
Shahrokh C. Bagheri
OUTLINE
Epidemiology Management
Mechanisms of Burn Injury Initial Assessment
Thermal Injury Criteria for Hospital Admission
Chemical Burns Prehospital care
Electrical Burns Hospital care
Radiation Burns Primary Burn Wound Management
Pathophysiology of Burns Secondary Burn Wound Management
Skin Anatomy
Body Responses to Burns
Severity Index
Classifications of Burn Depth
Burn Assessment
T
he acute and chronic management of facial burns management, and despite our advances in reconstructive
is one of the most challenging injuries affecting modalities, however, the best treatment of facial burns
the oral and maxillofacial region. Such injuries remains the emphasis on prevention.
require the combined expertise in trauma management,
complex soft and hard tissue reconstructive techniques EPIDEMIOLOGY
such as composite vascularized free tissue transfer, skin
grafts, facial re-animation, scar revisions, dental implants, A burn is defined as a traumatic injury to the skin or
and regenerative medicine. Traditional treatment of other organic tissue primarily caused by thermal or other
facial burns relied on the inherent healing capabilities acute exposure. Burn injury to tissues is caused by the
of the patient with minimal reconstructive efforts. contact with heat, flame, chemicals, electricity, or radia-
Modern management of facial burns integrates complex tion. Timely and adequate management of burn injuries
local and distant soft and hard tissue grafting. The is paramount. Such injuries are painful and can result in
re-creation of facial animation and underlying muscula- mutilating and scarring, amputation or necrosis of
ture to restore facial expression continues to elude treat- affected tissue or, in extreme cases, death. Peripheral
ing surgeons. Injury to the muscles of facial expression nervous system, vasculature, skeletal muscles, and bones
and associated facial nerve are extremely difficult to could be affected at a distant site to the burn.1 Burns are
reconstruct. Frequently, the patients remain seemingly one of the most distressing injuries and contribute to
expressionless, with a masklike facial stigmata, com- major global morbidity and mortality.2,3 Each year,
pounded by mismatched graft colors and anatomic dis- approximately 450,000 people in the United States seek
crepancies. Injuries to the eye and periorbita are medical care for burns.4,5 The mortality rate for the hos-
debilitating with possible loss of vision with associated pitalized patients reaches 3.9%. An estimated 3,000
reconstructive challenges, such as orbital enucleation deaths result from residential fires and 500 from other
and prosthetic eye rehabilitation. Despite the many tech- sources, including motor vehicle accidents (MVAs) and
nologic and scientific advances since the treatment of aircraft crashes and contact with electricity, chemicals, or
facial burns by Simon Hullihen in the nineteenth century, hot liquids and substances. About 75% of these deaths
there remains extensive room for scientific and technical occur at the scene or during initial transport. Fire and
improvements in this field. The recent advances in facial burn deaths are combined because deaths from burns in
transplantation are exciting; however, their application fires cannot always be distinguished from deaths from
to facial burns remains unclear, yet promising. The future smoke poisoning. Most burn injuries, approximately
will bring advanced grafting and practical transplanta- 66%, occur in the home setting. The 2011 National Burn
tion technology. More importantly, enhanced tissue engi- Repository has reported that burns due to fire and flame
neering, growth factors, and application of gene therapy predominate in the 5-year and older age group. Scalds
modalities to reconstruct and rehabilitate the burn victim were most frequent in children younger than 1 to 5 years.
will be developed. Given the existing challenges in burn In Middle East countries, burning from oil explosion are
717
among the most common types of the burn in oil well

workers.6 Self-burning suicide also is prevalent in these
countries. Patients with a total burn size of 40% burn
surface or more accounted for only 4.2 % of cases. Fatal-
ity clearly increases with burn size. The burn size associ-
ated with a 50% case fatality appears to be approximately
70% total burn surface (TBSA). Complications such as
pneumonia, cellulitis, and urinary tract infections are the
most prevalent complications noted in burn center
patients. Many burn injuries are minor and do not
require hospital admission.7,8 The mean length of hospi-
tal stay was approximately 9 days in 2010.
MECHANISMS OF BURN INJURY

Burns may be caused by several different mechanisms
with associated complications:
THERMAL INJURY
The depth of the burn injury is related to contact tem-
perature, duration of contact of the external heat source,
and thickness of the skin. Thermal injury is generally
classified as scald or flame injury.5 As the temperature
rises, increasing molecular collisions occur, resulting in
altered molecular conformation and the disruption of
intermolecular bonds. This process leads to cell mem-
brane dysfunction as ion channels are disrupted, result-
ing in sodium and water intake. As the temperature rises FIGURE 28-1 Classic example of an electrical oral commissure
burn, which is a full-thickness injury with a well-demarcated
further, protein denaturation occurs, oxygen radicals are
eschar. (From Ward Booth P, Eppley B, Schmelzeisen R:
liberated, and eventually cells die with the formation of
Maxillofacial trauma and esthetic facial reconstruction, ed 2, St.
the burn scar.9
Louis, 2012, Saunders.)
Scalds
These types of burns result when skin comes into contact
with hot liquids. About 70% of burns in children are tissues (Fig. 28-1). The amount of heat generated, and
caused by scalds.10 hence the level of tissue damage, is equal to 0.24 multi-
plied by (voltage)2 times resistance. Domestic electricity
Flame Injury is low voltage and tends to cause small deep contact
Flame burns comprise 50% of adult burns. They are burns at the exit and entry sites. Electricity greater than
often associated with inhalational injury and other con- 1000 V may cause muscle damage, rhabdomyolysis, and
comitant trauma. Flame burns tend to be deep dermal renal failure.10
or full-thickness burns. Flame injuries and scalds are the
most common causes of burns in children and adults RADIATION BURNS
worldwide.5 Radiofrequency energy or ionizing radiation can cause
damage to skin and tissues. The most common type of
Cold Exposure (Frostbite) radiation burn is sunburn.10
Damage occurs to the skin and underlying tissues when
ice crystals puncture the cells or when they create a
hypertonic tissue environment. Blood flow can be inter- PATHOPHYSIOLOGY OF BURNS
rupted, causing hemoconcentration and intravascular
thrombosis, with tissue hypoxia.11 SKIN ANATOMY
The skin is the largest organ of the body. It functions as
CHEMICAL BURNS a neurosensory organ and protects against the invasion
These burns result from contact of the skin with chemi- of foreign bodies and organisms. It has specific immune
cals or by ingestion of chemicals. Most chemicals that and metabolic functions and is important in regulating
cause chemical burns are strong acids or bases. Contact body temperature and fluid, protein, and electrolyte
with acid produces tissue coagulation, whereas alkaline homeostasis. Loss of the functional skin barrier after
burns generate colliquation necrosis.11 thermal injury remits increases the susceptibility to infec-
tion, which is the major cause of morbidity and mortality
ELECTRICAL BURNS postburn.12 Skin thickness varies with age and body loca-
Electrical energy is transformed into thermal injury as tion, but averages only 1 to 2 mm (0.04 to 0.08 inch)
the current passes through poorly conducting body thick. The skin is composed of several layers, with the two
Head and Neck Burn Injury CHAPTER 28 719
FIGURE 28-2 Anatomic layer of the skin and burn depth classification according to the anatomic layer of the skin. (From Shiland B:
Mastering health care terminology, ed 2, St. Louis, 2006, Mosby.)
primary layers being the epidermis and underlying of high blood flow. This heat dissipation may decrease
dermis (Fig. 28-2). The thickness of skin affects suscepti- the depth of burn in such areas.15 Major burns have three
bility to burning. The skin on the palms of the hands and distinct zones of injury (Jackson’s thermal wound theory),
on the soles of the feet, for example, is thick and more which usually appear in a bull’s-eye pattern.16
resistant to burning than that of the forearms or eyelids. Zone of Coagulation. The zone of coagulation com-
Skin consists of three different layers of varying thickness prises the dead tissues that form the burn eschar, located
throughout the body. The epidermis is the outermost at the center of the wound nearest to the heat source.
layer of the skin with self-renewal properties and protects Zone of Stasis. The tissue just adjacent to the necrotic
the skin from the exogenous environment. The average area is called the zone of stasis, which is still viable.
thickness of the epidermis is 0.1 mm.13 The dermis has However, decreasing perfusion can lead to necrosis.
an average thickness of 2 mm and is a fibrous network of Increasing tissue perfusion in the initial wound manage-
tissue that gives resiliency to the skin. Major proteins ment stage has paramount importance in the inhibition
found in the dermis are collagen and elastin produced of irreversible injuries. Prolonged edema, infection,
by fibroblasts. The vasculature in the dermis helps with unnecessary surgical intervention, and hypotension can
thermoregulation and provides nutrients for the epider- convert this zone to the zone of coagulation.
mis. The superior part of the dermis is called the papil- Zone of Hyperemia. In this outermost zone, tissue
lary dermis, which abuts the epidermis. It consists of perfusion is increased. The tissue here will invariably
loose connective tissue with a lower amount of collagen recover unless there is severe sepsis or prolonged
and elastic fibers. The inferior part of the dermis, the hypoperfusion.17
reticular dermis, with lower cell density, contains higher
amounts of collagen and elastin fibers. An areolar subcu- Systemic Responses
taneous tissue lies below the dermis and is the third Where the area of the burn wound exceeds 20% TBSA,
anatomic layer of the skin. there is a risk that the protective inflammatory response
becomes overwhelmed, with proinflammatory mediators
BODY RESPONSES TO BURNS and subsequent significant systemic manifestations. The
Local Responses early phase of burn edema, lasting from minutes to 1
Fairly high temperatures can be sustained by the skin hour, is attributed to mediators such as histamine, prod-
because of its substantial water content. As long as the ucts of platelet activation, eicosanoids, and proteolytic
water content is not totally eliminated by the heat in products of the coagulation, fibrinolytic, and kinin cas-
thermal injury, the temperature of the skin will not cades. Vasoactive amines may also act by increasing
exceed 82° C (179.6° F).14 Areas of increased vascularity microvascular blood flow or vascular pressures, accentu-
allow heat to be transferred from the burn site because ating the burn edema.18
Cardiovascular Changes. Capillary permeability is

increased, leading to loss of intravascular proteins and
fluids into the interstitial compartment. Histamine is
probably responsible for the early phase of increased
vascular permeability after burn injury because it is
released in large quantities from mast cells in burned
skin immediately after injury.19 Peripheral and splanch-
nic vasoconstriction occur. The cardiomyocyte shock
state is a result of impaired calcium homeostasis and
subsequent intracellular signaling dysregulation.20
Respiratory Changes. Inflammatory mediators cause
bronchoconstriction; in severe burns, adult respiratory
distress syndrome can occur.
Metabolic Changes. The basal metabolic rate increases
up to three times its original rate.17 Glucose metabolism
is elevated in almost all critically ill patients, including FIGURE 28-3 Superficial scalp burn from house fire, which will heal
those with burn injuries. Gluconeogenesis and glycoge- on its own. (From Ward Booth P, Eppley B, Schmelzeisen R:
nolysis are increased in burn patients. In addition, plasma Maxillofacial trauma and esthetic facial reconstruction, ed 2, St.
insulin levels typically are elevated in burn patients. The Louis, 2012, Saunders.)
basal rate of glucose production is elevated despite this
hyperinsulinemic state, which can be defined as hepatic • Superficial or epidermal (first-degree burn; Fig. 28-3)
insulin resistance.21 Exogenous insulin administration to • Partial-thickness (second-degree burn; Fig. 28-4)
achieve euglycemia has been shown to decrease donor • Full-thickness (third-degree burn; Fig. 28-5).
site healing time and decrease length of stay while ame-
liorating skeletal muscle catabolism.22 Lipolysis occurs at Burns extending beneath the subcutaneous tissues and
a rate in excess of the requirements for fatty acids as an involving fascia, muscle, and/or bone are considered
energy source due to alterations in substrate cycling. Pro- fourth-degree burns (see Fig. 28-2 and Table 28-1).5,11,24
teolysis is increased in burn patients. Following utiliza-
tion, protein is excreted primarily in the urine as urea. Superficial Burn (First-Degree)
This results in an increased efflux of amino acids from These burns affect the outer layer of skin, causing pain,
the skeletal muscle pool, including gluconeogenic amino redness and swelling (see Fig. 28-3). Superficial burns
acids. Protein intake greater than 1 g/kg/day has been equal to first-degree burns involve minimal tissue damage
recommended for all thermally injured patients and, for and involve the epidermis (skin surface). Sunburn is a
burn patients with normal renal function, the recom- good example of this type of burn.
mended protein intake is 2 g/kg/day.
Immunologic Changes. All injuries, including burns, Partial-Thickness Burns (Second-Degree)
are immunosuppressive. Nonspecific downregulation of Partial-thickness burns involve the epidermis and por-
the immune response occurs, affecting cell-mediated tions of the dermis and can be clinically categorized as
and humoral pathways. superficial partial-thickness or deep partial-thickness
burns (see Fig. 28-4). Superficial partial-thickness burns
characteristically form blisters between the epidermis
SEVERITY INDEX and dermis. Because blistering may not occur for some
hours after injury, burns that initially appear to be only
Assessing the severity of a burn injury requires accurate epidermal in depth (first degree) may be determined to
clinical staging, which permits appropriate therapy to be be partial-thickness burns 12 to 24 hours later. Most
initiated in the proper medical facility. It is important to superficial partial-thickness burns heal spontaneously in
determine the source and circumstances of the injury, less than 3 weeks, and do so typically without functional
probable depth of cutaneous destruction, and extent of impairment or hypertrophic scarring. Deep partial-
the body surface involved.14 thickness burns extend into the lower layers of the
dermis. They possess characteristics that are distinctly
CLASSIFICATIONS OF BURN DEPTH different from superficial or mid-dermal partial-thickness
A precise classification of burn injury may be difficult. burns. If infection is prevented and spontaneous healing
The depth of a burn can be assessed clinically by its is allowed to progress, these burns will heal in 3 to 9
appearance. Punch biopsy of burned tissue with subse- weeks. However, they invariably cause considerable scar
quent histologic assessment has been regarded by some formation. These burns are best treated by excision and
as the criterion standard of depth diagnosis, serving as grafting. For the patient, a partial-thickness burn that
the basis for comparison of other diagnostic modalities.23 fails to heal within 3 weeks is functionally and cosmeti-
Burn lesions are originally classified based on the clinical cally equivalent to a full-thickness injury.
signs and symptoms, from first- to fourth-degree burns.
The American Burn Association in 2009 released a newer Full-Thickness Burns (Third-Degree)
classification based on anatomic depth involvement of Full-thickness burns extend down into the hypodermis
the skin: or subcutaneous tissue (see Fig. 28-5). These burns in
A B
C
FIGURE 28-4 Partial-thickness facial burns. A, Flash burn from gas grill. B, Flash burn from throwing gasoline on burning wood.
C, Deeper partial-thickness burn from flames from house fire. (From Ward Booth P, Eppley B, Schmelzeisen R: Maxillofacial trauma and
esthetic facial reconstruction, ed 2, St. Louis, 2012, Saunders.)
FIGURE 28-5 Full-thickness facial burn from house fire involving the
forehead, cheek, and ear. (From Ward Booth P, Eppley B,
Schmelzeisen R: Maxillofacial trauma and esthetic facial
reconstruction, ed 2, St. Louis, 2012, Saunders.)
TABLE 28-1 Burn Depth Classification
Depth Cause Appearance Sensation Healing Time (days)

Superficial Ultraviolet exposure Dry, red Painful 3-6
Very short flash Blanches with pressure
Superficial partial Scald (spill or splash) Blisters Painful to 7-20
thickness Short flash Moist, red, weeping temperature and
Blanches with pressure air
Deep partial Scald (spill) Blisters (easily unroofed) Perceptive of >21
thickness Flame Wet or waxy dry pressure only
Oil Variable color (patchy to
Grease cheesy white to red)
Does not blanch with pressure
Full thickness Scald (immersion) Waxy white to leathery gray to Deep pressure only Never (if >2% TBSA)
Flame charred and black
Steam Dry and inelastic
Oil No blanching with pressure
Grease
Chemical
Electrical
Mertens DM, Jenkins ME, Warden GD: Med Clin North Am 1997: 32:343, Peate WF, Am Fam Physician, 1992:45:1321; Clayton MC, Solem LD: Postgrad
Med 1995:97:151.
TABLE 28-2 American Burn Association: Burn Injury Severity Grading System
SEVERITY
Burn Type Minor Moderate Major
Criteria <10% TBSA burn in adults 10%-20% TBSA burn in adults >20% TBSA burn in adults
<5% TBSA burn in younger 5%-10% TBSA burn in younger >10% TBSA burn in younger or
or older patients or older patients older patients
<2% full-thickness burn 2%-5% full-thickness burn >5% full-thickness burn
High-voltage injury High-voltage burn
Suspected inhalation injury Known inhalation injury
Circumferential burn Any significant burn to face,
eyes, ears, genitalia, or joints
Medical problem predisposing Significant associated injuries
to infection (e.g., diabetes (fracture or other major
mellitus, sickle cell disease) trauma)
Outcome Outpatient Admit to hospital Refer to burn center
Reproduced with permission from Hartford CE, Kealy CP: Care of outpatient burns. In Herndon DN (ed): Total Burn Care, ed 3, Philadelphia, 2007,
Elsevier.
themselves are generally not painful; however, there may crucial treatment decisions, such as the extent of exci-
be surrounding areas of partial-thickness burns that are sion and grafting required. Laser Doppler imaging (LDI)
painful. Skin appearance can vary from waxy white to has been shown to provide a more objective measure-
leathery gray to charred and black. The skin is dry and ment on which to base the decision to operate.25
inelastic and does not blanch with pressure. Hairs can
easily be pulled from hair follicles. Vesicles and blisters
do not develop. BURN ASSESSMENT
To determine the need for referral to a specialized burn
Fourth-Degree Burns unit, an assessment tool is needed to aid in the decision
Fourth-degree burns are deep and potentially life- making process.5,11 Under this system, burns can be clas-
threatening injuries that extend through the skin into sified as major, moderate, and minor. This is assessed
underlying tissues such as fascia, muscle, and/or bone.11 based on a number of factors, including TBSA burnt,
However, the clinical methods outlined may not provide involvement of specific anatomic zones, age, and associ-
sufficient accuracy of evaluation of burn depth to support ated injuries (Table 28-2).
FIGURE 28-6 Burn assessment—the rule of

nines. (From Veenema TG: Handbook for
disaster nursing and emergency
preparedness, ed 2, St. Louis, 2009,
Mosby.)
Burn Size
The Rule of Nines. To approximate the percentage of TABLE 28-3 Lund-Browder Chart
burned surface area, the body has been divided into
eleven sections: head, right arm, left arm, chest, abdomen, AGE (YR)
upper back, lower back, right thigh, left thigh, right leg Area 0-1 1-4 5-9 10-15 Adult
(below the knee), left leg (below the knee). Each of these Head 19 17 13 10 7
sections takes about 9% of the body’s skin to cover it. Neck 2 2 2 2 2
Added all together, these sections account for 99%. The
Ant. trunk 13 17 13 13 13
genitals make up the last 1% (Fig. 28-6). This rule is rela-
tively accurate in adults, but inaccurate in children. In Post. trunk 13 13 13 13 13
children, the Lund-Browder chart is the recommended R. buttock 2 12 2 12 2 12 2 12 2 12
method because it takes into account the relative per- L. buttock 2 12 2 12 2 12 2 12 2 12
centage of body surface area affected by growth (Table Genitalia 1 1 1 1 1
28-3).11 In small burn injuries, the extent of injury can R.upper arm 4 4 4 4 4
be quickly estimated because the palm of a patient’s L. upper arm 4 4 4 4 4
hand represents approximately 1% of the TBSA.
R. lower arm 3 3 3 3 3
L. lower arm 3 3 3 3 3
MANAGEMENT R. hand 2 12 2 12 2 12 2 12 2 12
L. hand 2 12 2 12 2 12 2 12 2 12
INITIAL ASSESSMENT R. thigh 5 12 6 12 8 12 8 12 9 12
The initial evaluation includes assessing for evidence of L. thigh 5 12 6 12 8 12 8 12 9 12
respiratory distress and smoke inhalation injury, evaluat-
R. leg 5 5 5 12 6 7
ing cardiovascular status, looking for other injuries, and
determining the depth and extent of burns. Initial assess- L. leg 5 5 5 12 6 7
ment for the burn occurs concomitantly with the burn R. foot 3 12 3 12 3 12 3 12 3 12
resuscitation. L. foot 3 12 3 12 3 12 3 12 3 12
Adapted from MacAfee KA II, Zeitler DL, Mayo Kathleen: Burns of the
CRITERIA FOR HOSPITAL ADMISSION head and neck. In Fonseca RJ, Walker RV (eds): Oral and maxillofacial
The initial problem in the management of a patient with trauma, Philadelphia, 2007, Saunders, pp 949–966.
thermal injury is to determine whether it is advantageous
to admit the patient to the hospital or whether he or she
can be safely treated as an outpatient. Table 28-1 shows

the indications for referral to a burn center when meeting
the criteria for a major burn. The following burn patients
are usually considered for admission:
1. Partial-thickness and full-thickness burns totaling
>10% TBSA in patients younger than 10 or older
than 50 years
2. Partial-thickness and full-thickness burns totaling
>20% TBSA in other age groups
3. Partial-thickness and full-thickness burns involving
the face, hands, feet, genitalia, perineum, or major
joints
4. Full-thickness burns >5% TBSA in any age group
5. Electrical burns, including lightning injury
6. Chemical burns FIGURE 28-7 Patient with high suspicion of inhalation injury with
7. Inhalation injury perinasal and perioral burns from a house fire. Bronchoscopy is
8. Burn injury in patients with preexisting medical dis- mandatory. (From Ward Booth P, Eppley B, Schmelzeisen R:
orders that could complicate management, prolong Maxillofacial trauma and esthetic facial reconstruction, ed 2,
the recovery period, or affect mortality St. Louis, 2012, Saunders.)
9. Any burn with concomitant trauma (e.g., fractures)
in which the burn injury poses the greatest risk of
morbidity or mortality. If the trauma poses the Fluid Replacement
greater immediate risk, the patient may be treated Emergency medical personnel should place an IV line
initially in a trauma center until stable before being and begin fluid administration with lactated Ringer’s
transferred to a burn center. The physician’s deci- (LR) solution at a rate of approximately 1 liter/hr in the
sion should be made with the regional medical case of a severe burn; otherwise, a maintenance rate is
control plan and triage protocols in mind. appropriate assuming there is no concomitant nonther-
10. Burn injury in children admitted to a hospital without mal trauma.21
qualified personnel or equipment for pediatric care
11. Burn injury in patients requiring special social, HOSPITAL CARE
emotional, and/or long-term rehabilitative support, Inhalation Injury
including cases involving suspected child abuse21 Inhalation injury is the most common cause of death in
the burn patient30 (Fig. 28-7 ). Burn lesions larger than
PREHOSPITAL CARE 70% of TBSA increase the risk of inhalation injury.31
Eliminating the Heat Source Upper airway edema can rapidly occur and distort the
Eliminating the heat source is the single most important normal anatomy of the airway tracts. In the absence of
action to be taken at the scene of the injury. The involved hypoxia, there is no definitive tool to assess whether
clothing should be removed, as well as rings, watches, inhalation injury has occurred.32 Given the progressive
and other jewelry. Cooling and/or neutralization with nature of burn injury in the first 48 hours, it is preferable
water or water gel dressing may also be appropriate to to secure an airway early. Any patient with deep facial or
stop the initial burning process; however, once the heat intraoral burns, facial or upper airway edema, or sus-
source has been removed, cooling is no longer of benefit pected inhalation injury should be considered for early
and may result in significant hypothermia and peripheral oral or nasotracheal intubation before edema causes
vasoconstriction that can extend thermal damage. airway compromise. There is some evidence for using
Cooling cannot halt the process of burning through the aerosolized heparin and N-acetylcysteine to remove bron-
physical skin barrier, but there is some evidence that chopulmonary casts and reduce edema.33
decreasing the amount of the prostoglandins and lessen- Carbon Monoxide Toxicity. Carbon monoxide (CO) is a
ing the inflammatory process around the damaged zone tasteless, odorless, and colorless gas present in the smoke
is helpful.26,27 Chemical burns should be copiously irri- of the combustion of organic materials, such as wood,
gated with water; however, dry chemicals should be gently coal, and gasoline. Because CO has a 200 to 300 times
brushed off the skin before irrigation is begun. greater affinity to stay bound to hemoglobin than oxygen,
the oxygen-carrying capacity of hemoglobin is reduced.
Airway Management and Oxygen Administration The clinical findings of CO toxicity are highly variable
Patients with upper airway burns should be intubated and largely nonspecific. Symptoms and signs may include
early, before airway anatomy becomes distorted by edema. headache, nausea, malaise, altered cognition, dyspnea,
Soot in the mouth, facial burns, and body burns may be angina, seizures, cardiac dysrhythmias, heart failure,
more useful predictors of inhalation injury than symp- and/or coma. The presence of bright, cherry red lips is
toms of stridor, hoarseness, drooling, and dysphagia.28 an insensitive indicator of CO poisoning.34 Pulse oxime-
Any patient rescued from a burning building or exposed try is an unreliable tool in measurement of the oxygen
to a smoky fire should be placed on 100% oxygen via a saturation in CO toxicity. Monitoring of the end-tidal
non–rebreathing mask if there is any suspicion of smoke CO2 using capnography and assessing arterial blood gas
inhalation in awake patients.29 levels can help determine the efficacy of the primary
resuscitation care.35,36 An electrocardiogram (ECG) is Therefore, a nasogastric tube should be placed in patients
also obtained to assess for cardiac dysfunction. with burns more than 20% TBSA.35,49,50
Fluid Resuscitation. A burn is a dynamic wound. Cyto-
kines enter the circulation when the burn reaches 20% PRIMARY BURN WOUND MANAGEMENT
of TBSA and results in a systemic inflammatory response.37 Traditional management of the burn wound involves
Prostaglandins and leukotriene cause leaking of the fluid careful débridement of loose necrotic tissue, gentle
and protein to the interstitial tissue, so cardiac output cleansing of the wound with a bland soap, and applica-
decreases and burn shock occurs. Peripheral vasocon- tion of dressings.51 Burn wounds should initially be
striction happens due to the sympathetic response cleaned with mild soap and water. Disinfectants are typi-
leading to conversion of the zone of stasis to the zone of cally avoided because they may inhibit normal wound
necrosis. Children younger than 2 years with more than healing. Clothing and debris that are embedded in the
5% and any patient with more than 15% body surface wounds should be removed. Débridement of devitalized
area (BSA) burns will require IV fluid therapy.5 In patients tissue (including ruptured blisters) decreases the risk of
with major burns, an IV line should be placed through infections.35 Needle aspiration of blisters should be
nonburned skin. Overadministration of fluids and elec- avoided, because this increases the risk of infection.49,52-54
trolytes can lead to pulmonary edema, peripheral edema, A variety of proteolytic enzymes, such as collagenase, has
and compartment syndrome.35 The Parkland (also known also been used for débridement of burn wounds.55,56
as Baxter) formula is the most widely used guide to
administer fluid in burn patients.38,39 According to this Wound Dressing
formula, the fluid requirement during the initial 24 Superficial burns, especially minor burns in the face, do
hours of treatment is 4 mL/kg of body weight for each not require dressings and treatment consists of gentle
percent of TBSA burned, given IV.40 Superficial burns are cleansing with a mild soap followed by the application of
excluded from this calculation. Half of the calculated a topical agent.49 For patients who are being rapidly
fluid needed is given in the first 8 hours and the remain- transferred to a burn unit, burns should be covered with
ing half is given over the subsequent 16 hours.41 dry sterile dressings.35
Another formula for resuscitation of burn patients is Topical Antibiotics. The goal of therapy is not to steril-
the modified Brooke formula, which recommends ize the wound but to control bacterial density and
administering 2 mL/kg of body weight for each percent decrease the likelihood of burn wound infection. Early
of TBSA.35,42,43 The modified Brook formula lessens administration of systemic antibiotics to prevent burn
edema formation and decreases the incidence of pulmo- wound infection is of little or no benefit and therefore
nary complications in those with preexisting cardiopul- is not recommended. This practice is ineffective in reduc-
monary disease. To avoid overhydration, resuscitate ing morbidity and mortality and is likely to promote the
patients with a urinary output in the range of 1 to 2 mL/ rapid emergence of resistant microorganisms.57 There is
kg/hr for children less than 30 kg and 0.5 to 1 mL/kg/ no consensus on which topical antimicrobial agent or
hr for those weighing 30 kg or more.44,45 Peripheral dressing is best suited for burn wound coverage to
pulses should be checked regularly, especially in limbs prevent or control infection.58 They are generally divided
with a circumferential burn, to determine whether there into potent agents used to prevent burn wound invasion
is distal perfusion. Pulse rates are not very useful as a (e.g., silver sulfadiazine, mafenide acetate, silver nitrate)
guide to resuscitation because tachycardia with a rate of and milder agents (e.g., bacitracin, Neosporin, Polyspo-
100 to 120 beats/min is common in even adequately rin, mupirocin) used to treat small or superficial wounds.
resuscitated patients. Capillary refill may also be useful The more potent agents may delay epithelialization and
in assessing adequate distal limb perfusion.46 should be reserved for use in managing more extensive
and deeper burns. The milder agents, when used in com-
Tetanus Consideration bination with nonadherent gauze, provide a comfortable
Tetanus immunization should be administered to chil- protective environment that promotes epithelialization
dren with burns deeper than superficial-thickness burns of the wound.
who have not received booster immunizations in more Silver-Containing Dressings. Silver-containing dress-
than 5 years.35 ings slowly release silver into the wound. Activated silver
has broad spectrum antimicrobial activity and may also
Pain Control have an anti-inflammatory benefit.59 Silver nitrate solu-
Although thermal injuries are usually extremely painful, tion (0.5%) is an effective agent but has decreased in
burn patients frequently do not receive analgesia in the popularity over the past 2 decades. It is painless on appli-
emergency department.47 In small burn injuries, empiri- cation, has a wide spectrum of antimicrobial activity, and
cal analgesic therapy is with nonsteroidal anti- has no known bacterial resistance. Its use is limited due
inflammatory drugs (NSAIDs) and, in larger burn to its staining, requirement for greater nursing care, and
injuries, a combination of an opioid and NSAID can be the leeching of electrolytes from the wound. Paraffin
useful.48 gauze over a silver-based dressing was shown to be effec-
tive in superficial burns.60
Gastrointestinal Interventions Silver Sulfadiazine. Silver sulfadiazine cream (SSD) is
Shock from thermal burn injuries results in mesenteric the most commonly used topical agent for dressing.58 It
vasoconstriction predisposing to gastric distension, is bacteriostatic but poorly diffusible and limited in its
ulceration (so-called Curling’s ulcer), and aspiration. penetration of the burn wound. It is painless on
application and has a soothing effect. The antimicrobial coverage with a biologic dressing. The wound is reevalu-
spectrum of SSD includes Staphyloccus aureus, Escherichia ated and grafted 24 to 72 hours later.67 Critical areas must
coli, Enterobacter, and Candida albicans.46 Transient leuko- be grafted first to achieve optimal functional and cos-
penia has been reported in up to 5% of patients; this metic results. Blood loss is a major consideration in exci-
usually resolves spontaneously, even with continued use sional therapy. In adults, approximately 200 mL of blood
of the drug.61 SSD should not be used in women who are is lost per percentage of TBSA excised and grafted.68 In
pregnant or breastfeeding, or in infants younger than 2 children, blood loss is approximately 3% to 4% of the
months.56,62 circulating blood volume per percentage of TBSA excised
Chlorhexidine. Chlorhexidine gluconate, a long- and grafted.69 Following burn wound excision, skin grafts
lasting antimicrobial skin cleanser, is often used with a are applied to the viable tissue bed. Split-thickness skin
gauze dressing for burn wound coverage in superficial grafts are harvested with a dermatome at a depth of 0.008
partial-thickness burns. Chlorhexidine dressings do not to 0.016 inch (0.2 to 0.4 mm). For small burns, full-
interfere with wound reepithelialization, in contrast to thickness skin grafts (with primary closure of the donor
silver sulfadiazine.56 site) should be used because they result in minimal
Mafenide Acetate. Mafenide acetate (MA) cream is donor site morbidity and excellent long-term functional
bacteriostatic, freely soluble, and readily diffuses through and cosmetic results. For larger burn defects, meshed or
burn eschar to the viable tissue interface. This agent also nonmeshed split-thickness skin grafts can be used. Allo-
has the broadest spectrum against Pseudomonas spp. and genic cadaveric skin from a human tissue bank also
gram-negative organisms. MA inhibits protein synthesis would be an option for a total-body burn patient for
in P. aeruginosa. Up to 90% of the dose enters the wound whom additional donor site for grafting is not available.
within 5 hours and it reaches peak concentration within TransCyte is a cultured epidermal autograft produced by
1 to 2 hours. Its concentration decreases to subinhibitory culturing dermal fibroblasts onto a synthetic scaffold,
levels within 10 hours; therefore, it must be applied at which consists of a mostly nylon mesh. Skin fragility and
least twice daily.46 The principal limitations of this agent susceptibility to infection are the disadvantages.56
are the pain produced when applied to partial-thickness
wounds and the inhibition of carbonic anhydrase that Facial Burns
predisposes to the development of metabolic acidosis. The head and neck area is the anatomic site most fre-
Use of this agent is generally limited to wounds with or quently involved in burn injuries. Facial burn injuries can
at high risk for invasive infection.56,63 produce devastating cosmetic and social alterations,
Biosynthetic Dressings. Tissue engineering has pro- which can affect self-image and societal perception.
gressed in the last decade and can now be applied for Marked edema can develop with partial-thickness burns
the replacement of injured tissue. Bioengineered skin in the face due to the looseness of the tissue and rich
dressing, also called semibiologic skin substitute, is used blood supply. Inhalational injuries should be suspected
to increase the healing potential of the recipient bed and in any facial burn. The basic principles of grafting pro-
decrease the number of dressing changes.56,64 Biobrane cedures performed on the head and neck must include
and Integra have been recognized by the U.S. Food and the importance of aesthetic facial units. When grafting is
Drug Administration (FDA) as wound dressing materials. undertaken, replacing an entire aesthetic unit is indi-
Both substitute as a matrix-like structure for harvesting cated, rather than applying grafts in patches.70 Skin grafts
fibroblasts and forming collagen. Following the activity to the face are thicker than those used elsewhere in the
of the fibroblast cells, the endothelial cells can also body to provide less contracture; they are not meshed to
promote vasculogenesis, which can help with manage- enhance aesthetics.71 Grafting of the face is done by aes-
ment of the partial-thickness burn. thetic region and every effort should be made to recon-
struct the dermatologically defined facial units, including
Escharotomy the forehead, eyebrows, upper eyelid, lower eyelid,
Mechanical obstruction of the airway, as well as distal cheek, upper lip, lower lip, and chin. Immobilization of
tissue compartment syndrome, can occur due to the the graft by pressure dressings, nasogastric feedings, and
eschar formation in the neck and chest area. Releasing avoidance of speaking are essential.46 Donor sites of good
incisions during primary wound management can help quality for the face are the scalp, neck, supraclavicular
provide distal tissue pressure that does not exceed 30 mm region, and inner thigh or arm.67 Flame or contact burns
Hg.35,65 in the head and neck may occur concomitantly with
facial trauma in MVAs (Fig. 28-8).
SECONDARY BURN WOUND MANAGEMENT
Full-thickness or partial-thickness burns that fail to heal Eye Burn Injury
within 3 weeks should be excised and treated with graft- Chemical burns of the eye constitute ocular emergen-
ing. An early appropriate decision for the burn excision cies. Acid burns of the eye are much better tolerated than
and grafting can lead to shorter hospitalization and fewer alkali burns, which may result in injury ranging from
complications.66 If early excision and grafting is the treat- mild corneal erosions to severe and generalized eye
ment of choice, it may be a one- or two-stage technique. burns that manifest as blurring of the pupil and blanch-
With the one-stage technique, the operation consists of ing of the conjunctiva and sclera.14,71,72 The initial treat-
excision of the burn to viable tissue and the placement ment is copious irrigation with normal saline. Staining of
of a graft. In the two-stage technique, the first operation the eyes with fluorescein is performed to detect corneal
is for the excision of the burn to viable tissue and injury. If corneal abrasion is present, a topical antibiotic
A B
FIGURE 28-8 Facial burn associated with maxillofacial trauma. C D

FIGURE 28-9 In severe full-thickness eyelid burns, the globe can
is prescribed. The main complications of chemical burns be protected by the raising and closing of upper and lower
of the eye are symblepharon and corneal ulceration. conjunctival flaps, which are then covered by a skin graft.
A, Outline of conjunctival flaps. B, Sharp elevation of conjunctival
Eyelid Burn flaps. C, Suturing upper and lower conjunctival flaps together for
corneal coverage. D, Vascularized conjunctival bed for skin graft
The eyelid as a protector of the globe may be involved
placement. (From Ward Booth P, Eppley B, Schmelzeisen R:
in most burn injuries of the face (Fig. 28-9). The eyelid
Maxillofacial trauma and esthetic facial reconstruction, ed 2,
has the thinnest skin on the face, which makes it suscep-
St. Louis, 2012, Saunders.)
tible to early contracture and exposure of the cornea. An
ophthalmologist should be consulted because corneal
abrasion and exposure keratitis are the most common
associated sequelae. An early grafting with tarsorrhaphies ear cartilage by burn and/or secondary infection can
should be considered in management of the eye burn. lead to chondritis. The organisms most commonly
In severe full-thickness eyelid burns, the globe can be responsible are S. aureus and P. aeruginosa.76 Ear injuries
protected by the raising and closure of the upper and may need local débridement or resection, but a regimen
lower conjunctival flaps, which are then covered by a skin with minimum débridement and use of a topical antibi-
graft. Split-thickness grafts for the upper lid and full- otic may be useful. Avoiding pressure on the ear is
thickness grafts for the lower lid are generally indicated.73 another important aspect of primary management. If
With superior lid débridement, one should be aware of chondritis occurs, it can be managed by removal of the
the levator musculature and possible lid ptosis. The most affected cartilage. Attempts to salvage viable cartilage
common complication of eyelid burns is contracture and may be made by burying cartilage in soft tissue pockets
the development of ectropion. and later performing secondary graft reconstruction.
Some patients may require local regional temporalis
Brow Burn fascia flaps for coverage. Denuded cartilage can be
A number of reconstructive techniques are available for covered by skin grafts or local cutaneous advancement
full-thickness brow burns, including punch grafts, single- flaps from the retroauricular region. Flaps are elevated
hair transplants, temporal vessel-based scalp flaps, and in the supraperichondrial plane. Small segments of non-
composite hair- bearing scalp grafts. The composite scalp viable cartilage can be removed without altering aesthet-
graft should be no wider than 3 mm in a vascularly com- ics. Larger defects may need to be reconstructed with a
promised bed. Multiple strips can be grafted and the composite graft.46,77 For total ear reconstruction, the use
intervening skin excised after healing. The procedure of osseointegrated implants and prosthesis is probably
can be performed under local anesthesia, with good the best treatment.78
success.74,75
Nasal Burn Injuries
Ear Burn Injury The nose has a prominent feature in the face and burn
Lack of subcutaneous tissue, thinning of the skin, and injuries are common. The thick skin on the lower portion
lateral prominence of the ear can aggravate the severity of the nose can provide some protection to this area, but
of the burn in this area (Fig. 28-10). Direct injury to the the skin across the lateral aspect and bridge of the nose
D E
FIGURE 28-10 Partial-thickness ear burns. A, Superficial partial-thickness ear burn 3 days after injury. B, 3 months postinjury with
spontaneous healing. C, Deeper part-thickness ear burn on admission. D, Complete healing by 1 month after injury. E, Combination
partial and full-thickness ear burn 3 days after admission. (From Ward Booth P, Eppley B, Schmelzeisen R: Maxillofacial trauma and
esthetic facial reconstruction, ed 2, St. Louis, 2012, Saunders.)
is thin.72 Generally, the nose is allowed to heal by spon- used in reconstruction of the lower third of nose struc-
taneous epithelialization. A deep partial-thickness burn tures.79 Providing a vascular bed in scar recipient sites can
defect of the nose requires a full-thickness skin graft. increase the viability of the composite graft (Fig. 28-11).
Maintaining skeletal cartilage support is an essential
factor for the optimum aesthetic result. Auricular carti- Scalp Burn Injuries
lage provides a contoured graft material and costochon- Scalp burns are often partial-thickness burns due to the
dral rib grafts also may be sculpted.46 Nasal injuries can thickness of the skin in this anatomic area and deep
be devastating and hard to reconstruct. Flattening of the placement of the hair follicles. Split-thickness skin grafts
alar region is often encountered secondary to contrac- can be used in partial-thickness injuries. Rotational flaps
ture. Intraoral flaps, because of their proximity, can be or tissue expansion can be part of the treatment plan in
A B
C D
FIGURE 28-11 A, Depressed lower left alar rim due to a previous burn. B, Pedicle rotational intraoral flap for reconstruction of the
avascular bed. C, Suturing of the helical composite graft over the mucosal flap. D, 12-month follow-up of the patient. (Courtesy
Dr. F. Pourdanesh, Shahid Beheshti University of Medical Sciences, Tehran, Iran.)
a highly aesthetic area. Perforation of the cortical bone commissure burn deserves special mention because it is
for the appropriate vascularization can help in better not uncommon and is easily treated. Typically, the burn
survival of the flap. In severe burns, removal of the outer area is sharply demarcated and the eschar is separated
table of the cortical bone is an alternative option. Tech- slowly. Conservative treatment with an orthodontic
netium bone scans can be used to show a lack of perfu- appliance to avoid microstomia is the first step. The
sion in areas of nonviable bone and increased uptake in second step would be correction of the scar, especially
areas of bone sequestration and regeneration.71,80 in the vermilion border. Upper and lower lip grafts
can be placed to reconstruct the vermilion. Mucosal
Mouth Burn Injuries advancement flaps can also be used. Later, secondary
Burns that involve one or both lips can lead to severe reconstruction may be necessary, including scar-releasing
microstomia. Hypertrophic scars in this area lead to dif- procedures.
ficulty in eating or intubation of the burning patient. See Figures 28-13 to 28-18 for illustrations of repair of
Oral splinting devices should be fabricated and inserted various facial burn injuries.
as soon after the burn as possible. In a child, the appli-
ance conforms to the teeth and stabilizes the commissure SUMMARY
by an attached horizontal bar. Adults are generally more
cooperative and will wear a mouth splint, such as the one Complex burn reconstruction requires all the skills of
depicted in Figure 28-12.81 The most frequently encoun- the facial reconstructive surgeon. In the acute phase,
tered burn injury in children is an electrical burn injury. patients frequently have concomitant medical and meta-
Electrical burns of the mouth predominate in 1- to 2-year- bolic abnormalities requiring a team approach for com-
old children and generally result from putting the socket prehensive treatment. Burn patients are ideally treated
terminal of an extension cord into the mouth or sucking in centers dedicated to burn care. Oral and maxillofacial
on the wall socket.82 The tongue, lower and upper lips, surgeons are an essential part of the burn team for facial
and commissures all may be affected.14,83 The oral and oral reconstruction.
FIGURE 28-12 Custom-made device for the inhibition of the microstomia

following burn.
FIGURE 28-13 A, Patient not happy with lower

face skin graft and would like to have a
B
beard. B, Bilateral rotational scalp skin graft.
FIGURE 28-13, cont’d C, Final postoperative

result after a few months. D, Preoperative
and postoperative views of vertex.
D
(Courtesy Dr. Hossein Haghshenas.)
FIGURE 28-14 Almost total facial burn, including neck, midface, lower face, and right ear. (Courtesy Dr. Hossein Haghshenas.)
FIGURE 28-15 Multiple facial reconstruction
with skin graft and forehead flap for nasal
reconstruction. (Courtesy Dr. Hossein
Haghshenas.)
FIGURE 28-16 A, Application of tissue

expander at left neck for reconstruction of
lower face burn. B, Postoperative
photograph. (Courtesy Dr. Hossein
B
Haghshenas.)
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CHAPTER
Management of Pediatric Facial
29 Fractures
Shahid R. Aziz
| Vincent B. Ziccardi
OUTLINE
Anatomic Considerations Alveolar Fractures
Epidemiology of Facial Fractures Midfacial Fractures
Diagnosis Frontal Sinus Fractures and Nasal-Orbital-Ethmoid
Clinical Examination Fractures
Radiologic Examination Fractures of the Zygomatic Complex
Types of Fractures Mandibular Fractures
Dental Trauma
ANATOMIC CONSIDERATIONS cancellous than cortical) is less conducive to the use of

screw or wire fixation to fixate fractures internally. For
The primary differences in craniomaxillofacial trauma in these reasons, closed reduction is a viable option for
the pediatric or growing patient compared with the adult most facial fractures in the growing patient. The osteo-
patient are based on developmental anatomy. At birth, genic and bone remodeling potential of a child exceed
the cranium-to- face ratio is 8 : 1. This decreases to 4 : 1 that of an adult. Fractures of the maxilla and mandible
by age 5 and 2.5 : 1 as an adult.1 As such, in infants, a large that are not reduced within several days of injury often
cranium protects the face, although infants are more cannot be adequately reduced because of the rapid bone
susceptible to cranial trauma. As the child grows older, healing that occurs.
the cranium-to-face-ratio decreases, making the child The contour heights of the crowns of deciduous teeth
more susceptible to facial fractures, in particular midface are below the gingival level, which does not lend itself
fractures.2 The orbits reach skeletal maturity early in life well to circumdental wiring when arch bars are necessary
(5 to 7 years of age); therefore, the lower third of the to stabilize fractures during childhood. In addition,
face is relatively protected during childhood. During the resorption of roots and attrition of deciduous teeth make
mixed dentition years, the mandibular growth catches up these teeth less stable in keeping arch bars in place. It is
with the rest of the facial skeleton in an anterior and often necessary to supplement circumdental wiring with
downward pattern. Skeletal maturity of the facial skele- skeletal wiring (e.g., piriform aperture, circumzygomatic,
ton occurs at approximately 14 to 16 years of age in or circummandibular) to maintain adequate fixation of
females and 16 to 18 years of age in males.3 Palatal, arch bars or splints when relying on the deciduous or
midaxillary, and premaxillary suture growth are com- mixed dentitions.7 When placing these skeletal wires,
pleted by age 12 years.4 care must be taken not to pull them through the child’s
Unique to the jaw of growing patients is the consider- soft bone and the position of the developing canine must
ation of dental development and the potential complica- be considered in the piriform region. In addition to
tions and morbidity that arise from surgical manipulation skeletal fixation, the clinician can use Risdon wires in the
in the region of developing teeth. By the age of 2 years, pediatric patient with complete primary dentition or in
chin prominence develops and the primary dentition the case of mixed dentition.
begins to erupt. Transverse maxillary growth is complete
with palatal, premaxillary, and midline maxillary suture EPIDEMIOLOGY OF FACIAL FRACTURES
growth complete and obliterated by ages 8 to 12 years.5
The deciduous dentition starts with the replacement of Approximately 8.5 million children are evaluated annu-
the permanent dentition by 6 years, representing a ally in emergency rooms in the United States.8 An esti-
period of mixed dentition. As the mandible continues to mated 11.3% of pediatric emergency room visits overall
grow, it lengthens and widens to accommodate develop- are a result of craniofacial injuries.9 Facial fractures are
ing teeth. Growth of the mandible continues by deposi- less common in the growing patient than in adults. In an
tion posterior and resorption anterior to the ramus.6 analysis of 1500 facial fractures by Rowe,10 5% of all facial
The pediatric maxillofacial complex is also malleable, injuries occurred in children younger than 12 years and
because there is a greater cancellous-to-cortical ratio. As less than 1% of these fractures occurred in children
such, greenstick fractures of the facial skeleton occur younger than 6 years. Midface fractures in children
more frequently in children compared with adults. The accounted for less than 1%, with 4% of these fractures
consistency of the growing patient’s bone (more being variations of Le Fort type I, in part attributed to
735
follicular crypts and developing dentition in the maxilla 13,853 children between the ages of 2 and 5 years involved
for children younger than 6 years.11 The lower incidence in MVAs, those inappropriately restrained in seat belts
of fractures in children compared with adults is also sec- rather than child safety seats, suffered a fourfold
ondary to the underdeveloped facial skeleton in children increased chance of having significant head trauma.19
as well as increased support form unerupted dentition. A
2008 survey from the National Trauma Data Bank (2001
to 2005) identified 277,008 pediatric trauma patient DIAGNOSIS
admissions, including 12,739 (4.6%) who sustained facial
fractures. Of the 12,739 patients, 32.7% sustained man- CLINICAL EXAMINATION
dibular fractures, 30.2% nasal bone fractures, and 28.6% As with all trauma patients, primary survey of the pediat-
maxillary-zygomatic fractures. Nasal and maxillary frac- ric patient is indicated, specifically ensuring that the
tures were the most common in patients younger than 1 airway is patent, the patient is breathing, and vital signs
year; mandibular fractures were the most common are stable. Airway assessment in the child is of particular
among teenagers. Of those with mandible fractures, sym- importance because the smaller airway of the child
physeal, angle, and body were most common areas of increases the relative airway resistance and ease of
fracture; 25% of all these patients required operative obstruction, and the threshold for intubating a child with
intervention. Finally, 68% of pediatric fracture patients injury or obstruction of the airway should be low. Once
were male; motor vehicle accidents (MVAs) accounted the child’s airway and cardiopulmonary status have been
for 55% of pediatric facial fractures, followed by assault stabilized, secondary assessment is completed to identify
(14.5%), and falls (8.6%).12 Literature on the incidence all areas of injury. In particular, with facial trauma, it is
of pediatric facial trauma has indicated that 1.5% to 8% important to rule out neurologic injury.
of all facial fractures occur in children younger than 12 Prior to examination, a comprehensive history should
years and 1% or less of such trauma occurs in children be obtained. Specific questions focus on the cause of
younger than 5 years.13 A 2008 Swiss survey of 291 pediat- injury, time frame from injury to evaluation, and any
ric maxillofacial trauma patients found that 64% were history of loss of consciousness. In addition, if dental
secondary to falls, 22% were secondary to MVAs, and 9% trauma is suspected, questions regarding loss of dentition
were sports-related accidents.14 are indicated. If teeth were avulsed from the injury, it is
Dental trauma in the growing patient, as isolated inju- important to determine factors such as the location of the
ries or associated with facial fractures, has been studied teeth, transport medium of the teeth, and whether the
extensively. Andreasen, examining a European popula- teeth were rinsed or swallowed or aspirated. Finally,
tion, estimated that one in every other child suffered obtaining a basic past medical history, if feasible, is war-
dental injury by the age of 14 years.15 In the American ranted. The battered child complex must be considered
population, age-specific, population-based incidence of a possibility when the historian’s account does not corre-
dental trauma to the incisor teeth between the ages of 6 late with the extent of the patient’s injury. This suspicion
and 50 years has been estimated to be 24.9%.16 must be addressed if unexplained bruises, burn marks, or
A 2011 study of 772 patients from the University of repeated traumatic incidents appear in the child’s medical
Pittsburgh found that the 69% of pediatric facial trauma history or are discovered on physical examination.
patients were male, with an average age of 10.7 years. In Initial examination is focused extraorally by first
children younger than 5 years, 56.4% sustained orbital observing for edema, ecchymosis, or lacerations. Chin
fractures. Falls were the most common mechanism of lacerations, in particular, are often associated with con-
injury. In children between the ages of 6 to 11 years, dylar or symphyseal fractures. Facial edema, periorbital
orbital fractures were the most common fracture type, ecchymosis, subconjunctival hemorrhage, subcutaneous
with MVAs as the most common mechanism of injury. emphysema, and nasal bleeding are all indicators of pos-
The 12- to 18-year-old age group comprised almost half sible facial fracture. Assessment of the trigeminal nerve
of patients in this study. Orbital fractures were again the function can also provide clues about possible injury due
most common injury, primarily attributed to interper- to fragments impinging on the peripheral trigeminal
sonal violence. Of the 772 patients, 55% had associated nerve branches. Examination should be followed by pal-
injuries, particularly cervical spine and neurologic pation of the facial skeleton, noting any steps or crepitus.
trauma (primarily concussions). The incidence of associ- The presence of postauricular ecchymosis (Battle’s sign)
ated neurologic injury decreased as the age of the patient or hemotympanum is suggestive of a basal skull fracture.
increased. This study also demonstrated the importance A basic ophthalmologic examination should be com-
of seat belt and helmet use; 45% of pediatric patients pleted, if possible, including assessment of pupillary reac-
injured in this study from MVAs were unrestrained and tivity, visual screening, and extraocular movements. If
67% of patients involved in bicycle and all-terrain vehicle orbital trauma in suspected, an ophthalmologic consulta-
(ATV) accidents were not wearing helmets.17 In addition, tion is indicated. Identification of intraoral ecchymosis,
young children using seat belts too soon, rather than especially within the mucobuccal folds or sublingual
other more appropriate means of car restraints, sustained area, should alert the examiner to the probability of
facial fractures 1.6 times more than those appropriately facial fractures. Furthermore, palpation for steps intra-
restrained for their age. Of pediatric facial fractures orally, assessment of occlusion, presence of ecchymosis
observed in MVAs, 51.4% were nasal fractures, 15.5% in the floor of the mouth, and mobility of dental seg-
were mandibular fractures, 11.6% were orbital fractures, ments are all part of a comprehensive clinical examina-
and 8.7% were fractures in the zygoma and maxillary tion. Assessing mandibular range of motion and any
bones.18 In addition, Winston et al have found that of deviations may indicate facial fractures—in particular,
Management of Pediatric Facial Fractures CHAPTER 29 737
fractures involving the mandibular condyles. Another have a mixed dentition of primary and adult teeth. Teen-
often forgotten part of the intraoral examination is agers and older patients will have adult dentition. Usually,
assessing the dentition, most importantly counting all the anterior central incisors are prone to injury due to
teeth and accounting for any missing dentition. If missing their position. Trauma to the dentition in the pediatric
dentition is unaccounted for, a chest radiograph is indi- patient can be divided into primary dentition and second-
cated to rule out aspiration of dental hard tissue. A neu- ary dentition. In general, trauma to primary dentition is
rosurgical consultation is mandatory if there is loss of treated via extraction, although restoration of primary
consciousness, altered mental status, postauricular ecchy- dentition may be warranted if the dental trauma is mild
mosis, cerebrospinal fluid (CSF) rhinorrhea, facial nerve or if there is a concern about space maintenance. If a
changes, or hemotympanum. Children are prone to the primary tooth is avulsed, it is not recommended for
development of epidural hematomas; it is critical to replantation, unlike permanent dentition. When perma-
observe their behavior and level of consciousness follow- nent dentition is injured, treatment is based on the degree
ing significant facial trauma. of injury. Traumatized adult (secondary) teeth can be
classified via the Ellis classification of dental injury:
RADIOLOGIC EXAMINATION • Ellis type 1—fractures of the crown that only affect the
A combination of the clinical examination coupled with enamel
a radiographic evaluation allows the clinician to diagnose • Ellis type 2—fractures of the crown that affect the enamel
facial fractures. Radiographs should not be used solely to and dentin
diagnose facial trauma. In the pediatric population, • Ellis type 3—fractures of the crown that affect the
greenstick fractures are often not visualized by conven- enamel, dentin, and pulp chamber
tional radiographs and developing tooth buds may also • Dental subluxation—displacement or mobility of teeth
obscure fractures on plain films. The simplest radiograph secondary to damage to the periodontal ligament
to diagnose mandibular, alveolar, or dental trauma is the • Dental avulsion —tooth is extracted or lost from the
panoramic radiograph. This film allows for clear assess- oral cavity
ment of all aspects of the mandible, assessing dentition Ellis types 1 and 2 injuries are typically treated via
and tooth buds, and providing a global view of the maxilla dental restorations. Ellis type 3 requires root canal
and mandible. Limitations of the panoramic film include therapy followed by dental restoration. Dental sublux-
its two-dimensional nature, distortion of the anterior ation often will require splinting of the subluxed tooth
maxilla and mandible, and inability to differentiate green- to adjacent teeth for 3 to 4 weeks to stabilize the tooth.
stick fractures from bicortical fractures. When dental The treatment of avulsed teeth is based on the time from
trauma or alveolar trauma is suspected, dental radio- injury to treatment. The ideal treatment is to reimplant
graphs including occlusal films and/or periapical radio- an avulsed tooth immediately after avulsion. It is impor-
graphs are helpful. tant not to wash the tooth to ensure that the periodontal
Panoramic and dental radiographs may not be readily ligament is not washed away. If reimplantation is not
available in the emergency department. If this is the case, immediately feasible, the tooth should be transported
another choice is plain radiographs or skull films. A com- ideally in saliva. However, keeping the tooth in the vesti-
plete facial series of radiographs should include left and bule of the mouth during transport is not advisable in a
right lateral oblique views of the mandible to observe the pediatric patient secondary to risk of aspiration; thus,
mandibular body and ramus, a Towne projection to iden- transporting the tooth in a cup of the patient’s saliva is
tify condylar injuries, a posteroanterior view to examine preferred. If less than 2 hours has passed since avulsion,
the mandible and midface, a Waters view for midfacial the tooth may be replanted directly into the site. If more
and nasal fracture detection, and a submental vertex view than 2 hours has passed, the tooth should be rinsed off
for visualization of the zygomatic arches. As technology (at >2 hours out of the mouth, the periodontal ligament
has evolved, 3-mm axial, coronal, and sagittal computed has most likely necrosed), pulp chamber obturated, and
tomography (CT) for imaging in pediatric facial trauma then replanted. In all cases, once replanted, the tooth
patients has become routine and is now the standard of needs to be splinted for stability and placed out of direct
care, replacing plain films in many institutions. Sagittal occlusion. It is important to note that once a tooth has
images are particularly useful for evaluating orbital floor been repositioned and splinted, the patient’s occlusion
trauma. Finally, three-dimensional CT is now readily avail- should be checked to ensure that the injured tooth has
able and should be performed for all complex facial been repositioned into its pretrauma position.20
fractures to assess facial fractures globally from multiple
angles and assist with surgical planning. Three-dimensional ALVEOLAR FRACTURES
CT imaging is also preferred to assess postoperative out- Alveolar fractures involve the supporting bone of the
comes of reduction and internal fixation, particularly dentition. These are considered the most common type
injuries in those areas not well visualized by plain films, of pediatric facial fractures4 and may be often associated
such as midface trauma and orbital floor injuries. with dental trauma or tooth avulsion. Classically, an alve-
olar fracture may have a segment of teeth that are mobile
as a group, with associated soft tissue injury and maloc-
TYPES OF FRACTURES clusion. Primary treatment is conservative, consisting of
immobilizing the arch segment using an arch bar, wire
DENTAL TRAUMA ligation, or a composite supported orthodontic wire
Children younger than 6 years have only primary denti- extended to stable teeth in the injured arch. Significant
tion. Children 6 to 12 years of age (or slightly older) will alveolar injury may result in alveolar bone loss and loss of
primary or permanent dentition. If there is bone loss and characteristics of the child’s maxilla include quantity of
loss of primary dentition, consideration must be given to cancellous bone, unerupted teeth, and underdeveloped
whether the underlying adult dentition will erupt into maxillary sinuses. The piriform aperture and zygomati-
adequate bone. If the alveolus and permanent dentition comaxillary buttress are much thicker structures and the
are lost, consideration must be given to replacing the soft tissue contains more adipose tissue in the child than
alveolar bone and dentition. Ideally, tooth replacement in the adult. As such, considerable force is necessary to
via dental implants should be considered; however, the disrupt the midfacial skeleton of the growing patient.
placement of dental implants should be delayed until Pediatric Le Fort fractures often occur in combination
alveolar growth is complete. Patients can be managed with other trauma and these concomitant injuries may
with a removable prosthesis of fixed bridgework until often be fatal.
they are old enough to be candidates for dental implant Physical examination often reveals the classic signs of
placement. Patients with significant alveolar bone loss a LeFort fracture—maxillary vestibular ecchymosis, facial
can have the alveolar bone reconstructed via autogenous edema, malocclusion, and gross mobility of the maxilla.
bone grafting and standard dental reconstruction.21 For higher level Le Fort fractures (type 2 or 3) there may
be periorbital edema, traumatic telecanthus, and perior-
bital ecchymosis. CT scans help provide a definitive diag-
MIDFACIAL FRACTURES nosis (Fig. 29-1A). Closed reduction is the treatment of
Nasal Fractures choice; however, in the primary and mixed dentition
Nasal fractures are the second most common type of phases, this presents a challenge because arch bars are
pediatric facial fractures.4 A complete history and clinical
findings such as epistaxis, nasal-periorbital ecchymosis,
nasal edema, nasal septal ecchymosis, or associated lac-
erations may indicate the presence of a nasal fracture.
Provided the child permits a physical evaluation, palpa-
tion of the nasal bones for bony irregularities is then
completed. Additionally, intranasal speculum examina-
tion is important to rule out a possible septal hematoma,
which (if present) requires emergent evacuation to avoid
septal cartilage necrosis or resorption, resulting in a
saddle nose deformity.22 Fractures of the nasal structures
that occur before growth is completed should be
managed like those in the adult. Epistaxis is common
with nasal trauma and can be controlled by local means
by pinching the nostrils for 5 to 10 minutes, with the
head slightly elevated. Although rare, local means of
control may fail and the surgeon must surgically cauter-
ize the region with silver nitrate or minimal electrical
cauterization or by placement of a balloon inflation cath-
eter, angiographic embolization, or ligation of vessels.
CT will allow the clinician to visualize the direction and A
degree of displacement of the nasal bones.
Treatment consists usually of closed reduction if the
injury is less than 1 week old. Older children with mini-
mally displaced nasal bone fractures may be compliant
enough to allow closed reduction to be performed under
conscious sedation in the emergency department or
office setting. However, in younger children or with sig-
nificantly displaced nasal bone fractures, general anes-
thesia is indicated to ensure proper reduction of the
fracture. Nasal elevators allow for reduction of the nasal
bones from an intranasal approach. Nasal packing and
splinting are required after satisfactory reduction of the
fracture for stabilization. If the injury is more than 1 week
old or there is an existing laceration providing access to
the nasal facture, open reduction could be considered.
Secondary rhinoplasty procedures can be considered
B
after facial growth has been completed, generally after
age 16 years. FIGURE 29-1 A, Three-dimensional CT scan of 4-year-old boy,
status post–MVA, sustaining a bilateral Le Fort 2 fracture and a
Maxillary Fractures fracture extending from the right superior orbit to the frontal bone.
Isolated Le Fort fractures are rare in the pediatric B, Le Fort II fracture in relationship to developing tooth buds.
population (>10% of all facial fractures).4,11 Unique (Courtesy Dr. Edward Kozlovsky.)
often not feasible. Additionally, the presence of unerupted Type 2: Craniofacial Fractures
adult dentition or tooth buds will make internal fixation 2a—growing skull fractures
that much more difficult (see Fig. 29-1B). An alternative Type 3: Orbital Fractures Associated With Common
to arch bars is the application of orthodontic brackets to Fracture Patterns
the facial surface of the dentition, which will allow for 3a—fractures of floor in inferior orbital rim
closed reduction with heavy elastics or thin (26- or 3b—zygomatic maxillary complex fractures
28-gauge) wire; heavier wire will dislodge the brackets 3c—naso-orbital-ethmoid (NOE) fractures
from the teeth. Another advantage of this technique is 3d—other fracture pattern
that application of orthodontic brackets is not invasive Findings on physical examination include periorbital
and can be accomplished in the office setting, provided edema and ecchymosis, subconjunctival hemorrhage,
there is patient compliance. Alternatively, screw fixation enophthalmos, diplopia, and infraorbital nerve paresthe-
of the piriform and zygomatic buttresses bilaterally, as well sia. A forced duction test should be used to evaluate for
as placing similar screws in the symphyseal region of the inferior rectus muscle entrapment. In children, this may
mandible, can be used for intermaxillary fixation and require sedation to ensure cooperation. An ophthalmol-
immobilization. Limitations of this technique include the ogy consultation is indicated to rule out global injury
necessity for this to be done under general anesthesia and because up to 24% of cases of pediatric orbital trauma
the risk of damaging underlying tooth buds. However, have associated injury to the globe.4,5
placing the screws superior to the maxillary fracture and Treatment of pediatric orbital trauma is primarily by
at the inferior border of the mandible minimize this risk. conservative management. The most common type of
Also, secondary anesthesia for removal of the screws may pediatric orbital fracture is the type 1 fracture (pure
be required. If these techniques are ineffective, impres- orbital). Recommendations include conservative man-
sions may be taken and models poured and sectioned to agement. Surgical intervention is warranted only when
facilitate splint construction for closed reduction. Surgi- there is evidence of entrapment, enophthalmos, or verti-
cal intervention into the tooth-bearing areas of the maxilla cal orbital dystopia.23 Type 2 fractures (orbital fractures
for placement of stabilization wires or plates increases the occurring in conjunction with the craniofacial skeleton)
incidence of disruption of developing tooth buds and should also be treated conservatively. Finally, type 3 frac-
should be reserved for the most unusual circumstances. tures that occur in conjunction with other facial fractures
Closed reduction is typically performed for 2 to 3 weeks should be treated surgically as part of the concomitant
with 26-gauge wire followed by 3 weeks of progressively fracture. Approaches to the orbit are similar to those for
lighter elastics. Minor occlusal discrepancies may be the adult and have similar complications, including the
noted; these can be addressed orthodontically or with subciliary incision and/or transconjunctival incisions. It
occlusal equilibration once healing is completed. is recommended that orbital fractures in children with
evidence of muscle entrapment be treated sooner to
Orbital Fractures avoid necrosis of the extraocular musculature and associ-
Orbital fractures are not uncommon injuries in the pedi- ated oculorotary dysfunction.
atric population, as noted; they can be isolated to the
orbit or extend to adjacent facial bones. Before the age FRONTAL SINUS FRACTURES AND NASO-ORBITAL-
of 7 years, most fractures of the orbit in the pediatric ETHMOID FRACTURES
patient occur in the orbital roof, with extension to the Frontal sinus fractures in children are rare. Of the para-
frontal sinus. This is due to the underdevelopment of the nasal sinuses, the frontal sinuses are the last to develop
sinuses. After the age of 7 years, injury to the orbital roof, and do not fully pneumatize until adolescence. Associ-
medial and lateral walls, floor, and frontal sinus are more ated intracranial injuries are more common in pediatric
frequent. Because most growth of the orbits is complete patients with frontal sinus fractures compared with
after the age of 7, fractures of the orbit in children 7 adults.24 A 2005 study of 120 pediatric maxillofacial frac-
years or older should be managed like those in the adult, tures found 11 with frontal sinus fractures. Of these 11,
without concern for growth disturbances.5 Prior to any all suffered concomitant orbital fractures, usually the
type of surgical intervention, a complete ophthalmologic orbital roof, 7 sustained significant intracranial injury,
examination should precede orbital exploration. CT and 4 had CSF leaks.25 Management involves identifying
scanning is again the imaging modality of choice, with and treating any concomitant intracranial injury in the
coronal, axial, sagittal, and three-dimensional recon- acute setting and preventing long-term complications
structions. There remains debate about the timing of such as CSF fistula, meningitis, frontal sinusitis, muco-
open reduction; some advocate immediate surgery, cele, and cosmetic deformities. Conservative manage-
whereas others advocate waiting until periorbital edema ment is indicated for pediatric frontal sinus fractures
has resolved. A classification system has been developed with nondisplaced anterior or posterior table fractures,
based on a 2008 study of 74 pediatric patients with orbital provided there is no CSF leak. Displaced pediatric frontal
bone fractures23: sinus fractures involving the anterior table require open
Type 1: Pure Orbital Fractures reduction and internal fixation (ORIF); fixation can use
1a—floor fractures resorbable plates or titanium plates, which may require
1b—medial wall fractures removal in the future. Posterior table involvement may
1c—roof fractures require cranialization of the frontal sinus. The role of
1d—lateral wall fractures frontal sinus obliteration in the pediatric population is
1e—combined floor and medial wall fractures not well described.
CASE 29-1
14-year-old male s/p struck in face with a baseball bat (Fig. 29-2A). By report, there was no loss of
consciousness. On exam, the patient had significant frontal and periorbital edema. CT scan revealed a left frontal
sinus fracture extending to the superior orbital rim as well as a left naso-orbital fracture (see Fig. 29-2B). ORIF
was performed. Of note, the patient and his mother elected not to have a bicoronal flap performed to access the
fracture; rather, they elected to have a hemi–open sky type incision to access the fractures using existing
lacerations, which were extended (see Fig. 29-2C-E).
NOE fractures are also rare in the pediatric patient. Growth of the middle face is dependent on growth of the
anterior cranial fossa (sphenoid), orbit, and nasal septum. When open reduction of the NOE region is undertaken,
the periosteum is removed from the nasal and orbital bones, and this alone has the potential to inhibit subsequent
growth. Therefore, stripping of the periosteum should be performed with extreme care to prevent growth
retardation. Growth in this region is imperative for the formation of the midface and is dictated by the expansion of
the cranium to compensate for the brain at the frontoethmoid, frontolacrimal, frontomaxillary, ethmoidal maxillary,
and nasomaxillary sutures.5 Open reduction of the NOE complex should be carried out within 4 days of injury and
with minimal disturbance to the nasal septum.
The region can be approached through an existing laceration by extending the inferior lid incision superiorly on
the lateral nasal bone, through incisions made over the nasal dorsum or through a coronal incision. Precise
reduction of the medial orbital rim, frontal process of the maxilla, and medial canthus is necessary to ensure
restoration of aesthetics and lacrimal function. If the nasolacrimal duct is torn, it should be cannulated and
splinted for several months. If traumatic telecanthus is present, the medial canthal ligament alone or with the
associated fragment of bone from the orbital rim may have detached. The ligament must be reduced and held in
place in a superior and posterior position, similar to surgical procedures performed for adults. Children do not
tolerate internal or external splinting well; therefore, it is important to reduce and fixate the nasal bridge and
medial canthus without the use of splints, if possible.26
A B
C D E
FIGURE 29-2 A, 14-year-old boy with a left frontal sinus fracture extending to the left superior orbital rim and left naso-orbital region.
B, Preoperative three-dimensional Hollender CT scan. C, Hemi–open sky approach. D, Postoperative three-dimensional CT scan.
E, 2 weeks postoperatively.
CASE 29-2
An 8-year-old female was impaled with a fence pole during a motor vehicle accident, resulting in avulsion of her
left globe and a complex NOE fracture. The patient was taken urgently to the operating room with ocuplastic
surgery carried out, in which NOE was plated via the lacerations and globe enucleated. A prosthetic globe spacer
was placed at time of surgery. Postoperative picture demonstrates early healing with preliminary prosthetic globe.
Patient subsequently required further nasal revision surgery (Fig. 29-3).
A B
C D
FIGURE 29-3 A, 8-year-old girl impaled by a fence pole, resulting in a complex NOE fracture and avulsion of the left globe. B,
Coronal CT scan view of comminuted NOE fracture. C, 6 weeks postsurgery with prosthetic globe in place. D, Postoperative
CT scan.
FRACTURES OF THE ZYGOMATIC COMPLEX Fractures of the Mandibular Condyle

Zygomatic complex fractures include fractures of the Pediatric mandibular fractures represent less than 10%
zygoma, zygomatic maxillary complex, zygomatic orbital of all mandibular fractures, but up to 50% occur in the
complex, and zygomatic arch. These are common frac- condylar region. 27In younger children (<6 years) these
tures that represent up to 41% of all pediatric midface fractures appear in the intracapsular region of the
fractures.10 As the patient ages, the zygoma becomes condyle; in older children, they occur in the condylar
more prominent and fractures to this area increase in neck region.28 The treatment of these fractures is an area
incidence. Diagnosis is based on clinical examination of debate in oral and maxillofacial surgery. Treatment
coupled with CT evaluation. Physical findings include options range from observation and soft diet to maxil-
periorbital edema, possible trismus if the arch is frac- lomandibular fixation (MMF) to ORIF. The two issues
tured and displaced, infraorbital nerve hypoesthesia, flat- unique to pediatric condylar fractures are the risk of
tening of the malar process, and palpable bony steps. temporomandibular joint (TMJ) ankylosis and potential
Because there often may be an associated orbital frac- progressive growth disturbances of the face. The intact
ture, a thorough ophthalmologic examination is war- condylar unit is essential to the integrity of the TMJ
ranted. Reduction of the fractured arch of the zygoma is apparatus. In addition, the condyle acts as the growth
often the only treatment necessary and, just as in the center for the developing lower facial third.29 Based on
adult, is performed only if a cosmetic deformity exists or the functional matrix theory of Moss—essentially, that
if notable trismus is present. Greenstick or minimally form (structure) follows function and condylar cartilage
displaced arch fractures in the pediatric patient are is responsible for the maintenance of a correct condylar
treated conservatively by observation, but ORIF may be head–glenoid fossa relationship during facial and man-
necessary for significantly displaced or comminuted frac- dibular growth, which in turn supports normal mandibu-
tures. Intraoral and extraoral approaches are often indi- lar function and normal mandibular anteroposterior
cated to stabilize a true zygomaticomaxillary fracture. growth. The lack of a condyle interferes with the func-
Like the adult patient, three-point stabilization is ideal, tional matrix, which leads to an arrest of growth.30 Dis-
Our experience has indiacted that often the zygomatico- ruption of this growth center can result in significant
frontal process, infraorbital rim, and zygomatic buttress facial asymmetry as an adult, specifically an open bite on
are reduced and rigidly fixated. Of note, facial edema the contralateral side resulting from decreased ipsilateral
often is associated with these fractures, which may require vertical dimension, deviation of the mandible toward the
a delay in treatment to allow for the edema to resolve. fracture site in opening and closing movements, changes
Additionally, care should be taken when placing the rigid and remodeling of the contralateral joint, ankylosis, and
fixation in the zygomatic buttress region to avoid damag- TMJ dysfunction.
ing any underlying tooth buds. Isolated zygomatic arch Commonly, in children, a fall with a point of impact
fractures can be treated via an extraoral (Gilles) or intra- in the symphyseal region of the anterior mandible can
oral (Keane) approach. In both cases, rigid fixation is force the growing condyle into the glenoid fossa, result-
not required. The reduced arch must be protected post- ing in an intracapuslar condylar fracture. As such, the
operatively from any trauma or pressure during the clinician should rule out condylar fractures in children
initial postoperative period to ensure that the reduced with chin lacerations. On physical examination, there
arch does not displace. Growth disturbances rarely occur may be some degree of trismus and the mandible devi-
with these types of fractures.5 ates to the affected side if dislocation of the proximal
segment occurs. Preauricular swelling may be present on
MANDIBULAR FRACTURES the affected side. Malocclusion may also be present; in a
The treatment goals of treating a fractured mandible unilateral condylar or condylar-ramus fracture, an open
include restoring occlusion and facial form to preinjury bite malocclusion on the unaffected side is often present,
function and appearance. Specific to the pediatric patient a result of shortening of the condylar-ramus complex and
is the presence of underlying tooth buds, which may premature occlusal contacts on the injured side. Bilateral
complicate reduction and fixation of mandibular frac- condylar fractures result in an anterior open bite second-
tures. Similar to pediatric midface trauma, conservative ary to bilateral shortening to the condylar-ramus unit.
therapy is preferred, with ORIF reserved for select
situations.
CASE 29-3
6-year-old male 5 years s/p motor vehicle accident, presents with severe trismus—maximal incisal opening is
5 mm. He also has a significant anterior open bite. Three-dimensional CT scanning demonstrates bilateral TMJ
ankylosis. The patient subsequently underwent bilateral gap arthroplasties and bilateral coronoidectomies, followed
by aggressive physical therapy (Fig. 29-4).
FIGURE 29-4 A, 6-year-old boy 4 to 5 years after a MVA, resulting in bilateral condylar fractures. Currently, the patient presents with
severe trismus and an anterior open bite. B, Preoperative three-dimensional CT scans demonstrating TMJ ankylosis. C, Intraoperative
view of gap arthroplasty.
In the literature, there is a documented remodeling relationship between the long axis of the ramus and
of the condyle postinjury, especially in the pediatric pop- condylar process. The authors termed this restitutional
ulation. Remodeling, in this case, can be defined as an remodeling, unique to children. Teenagers and adults did
uprighting of the condylar process and restoration of not share this ability to heal postcondylar fractures.
TMJ joint function. It appears that there are two active Lindahl went on to state that there exists a genetic guid-
mechanisms involved in remodeling—resorption of the ance for increased cellular activity to rebuild the condy-
fractured, displaced condylar segment plus apposition of lar process in children sustaining condylar fractures. In
bone to create a new condyle.31 In a series of articles by teenagers and adults, once skeletal maturity has been
Lindahl and Hollender, it was noted that young patients reached, there is a decreased proliferation of cells in the
(<12 years) have an exceptional ability to remodel postcondylar process—hence, a much-decreased ability to
condylar fracture.32 In this study, patients from 3 to 11 regenerate and remodel.
years demonstrated a complete straightening to a normal
CASE 29-4
A 27-month-old male was referred from the pediatrician’s office
for evaluation of the lower jaw 2 days after a fall. Physical exam
was significant for a 1-cm contusion of the right symphysis as
well as a slight occlusal prematurity on the left. There was a
decreased range of motion of the mandible as well as significant
tenderness to palpation over the left TMJ joint region. A facial
series performed on the day of injury was consistent with a high
left condylar fracture, demonstrating head of the condyle
displaced anteromedially (Fig. 29-5A). Treatment at this point
was conservative, limited to a soft nonchewing diet as well as
close follow-up and assessment: 1 week follow-up revealed
reestablished centric occlusion, improved range of mandibular
motion, and decreased tenderness on examination; 1 month
follow-up revealed full range of mandibular motion as well as
toleration of a regular diet; at 2-year follow-up, the patient was
without complaint, demonstrating full range of mandibular motion
and a maintained stable class I occlusion. His face was noted to
be well formed and symmetrical in all planes. At 2.5 years
postinjury, MRI studies were performed, revealing normal-
appearing TMJ apparatus and condyles bilaterally (see Fig. A
29-5B).
A P
B
FIGURE 29-5 A, 27-month-old child after a fall, hitting the chin.
This Towne’s view demonstrates a left condylar fracture, with the
condylar head displaced medially. B, Magnetic resonance imaging
(MRI) scan obtained 30 months after injury, demonstrating a new
condyle. (Courtesy Dr. Barry Wolinsky.)
Although plain films or panoramic radiographs are treated conservatively via closed reduction, because these
good diagnostic tools, CT is necessary to evaluate condy- fractures are usually easily reduced. In addition, the
lar fractures properly. Studies have shown that CT scans osteogenic potential in children to heal bone is signifi-
have 90% accuracy in diagnosing pediatric condylar frac- cantly enhanced compared with the adult. As such,
tures, but panoramic radiographs have only 73% only 2 to 3 weeks of MMF is required. As noted, a simple
accuracy.33 technique of MMF in the pediatric patient is bonding
orthodontic appliances. When MMF is not feasible,
Treatment of Condylar Fractures an alternate technique is to fabricate a lingual splint
In pediatric patients with minimally displaced condylar from dental models. This requires alginate impres-
fractures, conservative management is the treatment of sions of the fractured mandible and upper arch; in the
choice. If the occlusion is reproducible, a soft diet for 2 uncooperative patient, this may require conscious
to 3 weeks is indicated. In condylar fractures that are not sedation or general anesthesia. From these models,
easily reproducible or mandibular asymmetry accompa- model surgery is performed to reduce the fracture on
nies a condylar fracture, MMF may be indicated for 2 the stone cast. From the reduced mandibular cast, a
weeks followed by physical therapy. Placement of Erich lingual acrylic splint is fabricated with holes interden-
arch bars, used for MMF in adults, is often not feasible tally to hold the splint in place. Once the splint is com-
in the primary or mixed dentition stages because of pleted, the patient’s mandible is manually reduced
primary teeth risk avulsion after application of the arch and the splint is wired into place and held there for 2 to
bar. As such, we have found that using an orthodontic 3 weeks. Generally, MMF is not required in addition to
appliance, applied to the facial surface of the primary lingual splint application for treating pediatric mandibu-
dentition, is an ideal method to provide for MMF. Longer lar symphyseal fractures.
fixation may result in potential TMJ ankylosis. Open reduction of the angle, symphysis, or body of
Absolute indications for open reduction of pediatric the mandible in the pediatric patient is rarely indicated.
condylar fractures are similar to those for adults and In patients with associated condylar fractures, however,
include: displacement of the condyle into the middle internal fixation of the symphysis fracture limits the need
cranial fossa, inability to obtain adequate occlusion by for MMF and permits early function of the condyles.
closed reduction, lateral extra capsular condylar dis- Typically, open reduction is limited to patients in whom
placement, and the presence of a foreign body. Relative there is a severely displaced fracture, closed reduction is
indications for open reduction of pediatric condylar frac- not feasible, or there is an associated condylar fracture.
tures include: severe seizure disorder, mental retarda- In these cases, we have used midface (1.5-mm profile)
tion, severe upper airway obstruction, and psychologically plates to reduce the fracture. It is important to note that
unable to tolerate MMF.34 the plates should be placed as inferiorly as possible to
A critical aspect of managing pediatric patients with avoid tooth buds; in addition, these plates will require
condylar fractures is monitoring mandibular and facial removal 4 to 6 months after reduction to ensure that
growth. One recommended monitoring protocol is clini- there is no restriction in mandibular growth. The intra-
cal examination at 1 and 4 weeks postinjury, followed by oral approach for the placement of intraosseous wires or
clinical and radiographic examination at 2, 6, and 12 plates is the method of choice because it eliminates
months post injury. The child should then be followed visible scars and possible injury to the facial nerve. Con-
annually until cessation of growth and stabilization of the sideration could be given to the use of resorbable plates;
permanent dentition occur.35 Examination should however, some are large caliber and not suited for
include obtaining panoramic films, as well as assessing younger patients due to size limitations.
occlusion and TMJ function. If there is any crepitus,
decreased range of motion, malocclusion, or facial asym-
metry noted, further imaging is indicated as well as func- ACKNOWLEDGMENT
tional appliances and orthodontics.
The authors want to thank the previous contributions to
Mandibular Angle, Body, and Symphysis Fractures this chapter by Dr. Timothy A. Turvey, Dr. Ramon L. Ruiz,
Isolated fractures of the mandibular angle, body, and Dr. George H. Blakey III, Dr. Roland T. Biron, and
symphysis region in the growing patient are typically Dr. Lawrence M. Levin.
CASE 29-5
10-year-old male s/p struck by a car. Sustained a left parasymphyseal fracture and a displaced right angle
fracture. Because of his mixed dentition phase and displacement of the right angle fracture, closed reduction was
not feasible. As such, the patient underwent ORIF of the fractures, with removal of plates planned 4 months after
open reduction (Fig. 29-6).
B C
FIGURE 29-6 A, Preoperative CT scan demonstrating bilateral mandibular fractures in a 10-year-old child after being struck by a car.
B, Intraoperative view of ORIF. C, Postoperative three-dimensional CT scan.
CASE 29-6
A 12-year-old male, s/p assault sustaining bilateral mandibular body fractures. Because the occlusion was easily
reproducible, a decision was made to place the patient into MMF using orthodontic brackets. Fixation was
maintained for 2 weeks followed by 2 weeks of elastics and soft diet, with good outcome (Fig. 29-7).
A L
B C
FIGURE 29-7 A, Preoperative panoramic radiograph demonstrating minimally displaced mandibular body fractures on a 12-year-old boy.
B, Application of orthodontic brackets. C, Use of orthodontic brackets for MMF.
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CHAPTER
Oral and Maxillofacial Trauma in the
30
Geriatric Patient
Brian M. Smith
| Dmitry Peysakhov
OUTLINE
The Biology of Aging Soft Tissue Trauma and Wound Healing
System Changes Facial Fracture Management in the Geriatric Patient
Cardiovascular System Maxillary Fractures
Respiratory System Midface Fractures
Renal System Mandibular Fractures
Nutrition Atrophic Mandibular Fractures
Psychosocial Issues Geriatric Trauma: Outcome and Survivability
T
he older population in the United States is on the and older patients sustaining major trauma are known to
rise. A number of factors have contributed to this have higher complication and mortality rates than their
trend, including early detection and prevention of younger counterparts.4 The purpose of this chapter is to
life-threatening diseases and a more widespread engage- review the biologic effects of the aging process on major
ment in exercise and fitness activities among the older. organ systems and its effects on the psychological status
As a result, more than half of the current U.S. population of older adults, and discuss management of traumatic
can anticipate living to age 80, with a contemporary life injuries to the maxillofacial region.
expectancy at age 75 of 11 years and at age 85 of 6 years.1
From 1990 to 1994, the older population, defined as 65 THE BIOLOGY OF AGING
years and older, increased 11-fold and the segment of the
population younger than 65 years only increased three- Aging is a biologic process that results in a progressive
fold. Based on several variables, including fertility rate, deterioration of structure and function over time that
mortality rate, immigration activity, and the aging of the cannot be stopped or reversed. It is a process that is
baby boomer generation, the U.S. older population is genetically programmed but modified by environmental
projected to increase by 18% over the next 10 years and influences. Kohn5 has described the aging population as
by more than 50% within 50 years.2 It is estimated that having multiple coexisting diseases that are progressive
by 2050, more than 20% of the population will be 65 within a physiologic framework that has a diminished
years of age or older. The impact of these population ability to react to stress. This results in increased mortal-
trends on the national health care system is significant ity from injuries and other various insults. Although
considering the adjustments that must take place in the aging should not be considered a disease, these age-
delivery of health care and reallocation of resources. related changes will eventually result in disease and
The geriatric population has been an increasing focus death. Human aging is associated with molecular, cellu-
of health care providers and therefore is one of the lar, and physiologic changes characterized by a deterio-
largest consumers of health care in regard to resources rating homeostatic balance associated with the increasing
and funding. Although older adults make up only 14% prevalence of neoplasia and other diseases. At the molec-
of our population, they receive more than 30% of all ular level, aging has been associated with an increase
prescribed medications.3 Trauma is the seventh leading in DNA point mutations, telomere attrition, and
cause of death in older adults, making up 25% of all alterations in patterns of methylation.6-9 Each of these
trauma admissions. The most common mechanisms of can disrupt the normal expression and/or function of
injury among older adults are falls and motor vehicle proteins involved in cellular growth, maintenance of
accidents (MVAs). Most deaths occur in the first 24 genomic integrity, responses to cellular stress, and
hours, usually due to head injury. Late mortality is related inflammation.7,8
to severity of organ failure and existence of a premorbid On the cellular level, multiple age-related changes
condition. Approximately one third of long-term survi- have been observed, including the increase in the
vors require nursing home care. The oral and maxillofa- number of nucleoli as a result of invagination of nuclear
cial surgeon, as a specialist involved in the care of trauma membrane around the clumped nuclear chromatin.
patients, will see an increasing number of older patients Decreased levels of protein production have been attrib-
requiring treatment for trauma-related injuries. Increas- uted to reduction in rough and smooth endoplasmic
ing age puts a trauma patient into a higher risk category reticulum. Changes in mitochondrial size and function
749
have been linked to reduced efficiency of fatty acid usage

in the aged cell.10,11 In 1968, Harman proposed that mito- TABLE 30-1 Common Age-Related Cardiovascular
chondria determine life span due to its damage by free Changes and Associated Diseases
radicals.12 As the cell ages, there is a progressive loss of Age-Related Changes Associated Cardiovascular Disease
water from the cytoplasm, causing an increase in the Decreased heart rate Sinus pauses
viscosity of the cytoplasm, which reduces the exposure of response
biologically active cell surfaces.13 Cell membrane perme- Longer P-R intervals Second- and third-degree AV
ability also increases and the sodium-potassium pump block
becomes less efficient. There is a shift of water out of
Right bundle branch block Left bundle branch block
cells, increasing the extracellular space. The total level
of intracellular potassium is also reduced.14 These altera- Increased atrial ectopy Atrial fibrillation
tions in membrane function have to be considered when Increased ventricular ectopy Sustained ventricular
managing fluid administration and resuscitation in the tachycardia
older patient. All these changes affect the cell’s ability to Altered diastolic function Decreased systolic function
produce energy and maintain vital biochemical func- (ejection fraction)
tions. In its entirety, these age-related cellular changes Aortic sclerosis Aortic stenosis, aortic
are directly responsible for the physiologic aberrations regurgitation
that characterize the older patient. Annular mitral calcification Mitral regurgitation, stenosis
The age-old question of why we age still has to be systolic hypertension diastolic
answered. Throughout the years, many theories have hypertension
been proposed to answer this question. The popular pro-
grammed theory of aging proposes that aging is similar
to other biologic processes controlled by the expression predispose a person to these diseases and, in many cases,
of a specific gene.15 This theory is supported by observa- worsen the prognosis, such as a patient with a myocardial
tions that every organism has a physiologic life span that infarction (MI). Preexisting age-associated changes in
is highly characteristic for its species. In this model, vascular and ventricular properties alter the substrate on
so-called senescence genes, when expressed, are respon- which the infarction occurs and probably play a crucial
sible for modulating various cellular functions that begin role in the poor prognosis of older patients with acute
the aging process. The somatic mutation theory focuses MI.19
on mitotic errors as an important factor in the aging It is difficult to measure the direct age-related effect
process. It is thought that the gradual accumulation of on the cardiovascular system because most studies have
genetic errors, which has been observed in older cells, eliminated asymptomatic individuals with a clinically sig-
results in chromosomal losses that have a negative impact nificant CAD (coronary artery disease). Wenger20 has
on cellular metabolism. Others have hypothesized that found that about 20% of patients older than 80 years of
the aging process is directly related to alterations in age have clinically manifest CAD, but most older people
immune system function characterized by an increase in with significant obstructive CAD are asymptomatic.
the levels of circulating autoantibodies.16 Some have When planning appropriate treatment for a trauma
linked aging to the release of a specific hormone that patient, it is important to understand the patient’s car-
reduces the response of peripheral tissue to the effects diovascular status, based not only on the past medical
of thyroid hormone.17 Harmon12 has proposed that free history but also on age-related changes. Older patients
radicals from the diet, environment, or metabolic cellu- with hypertension are two to three times more likely to
lar processes can accumulate in cells and interfere with have a cardiovascular event than younger patients with
cellular oxidation. Older cells, therefore, will have a similar hypertension.
greater exposure to these agents and are more likely to As the heart and blood vessels age, there is a gradual
experience these negative effects. decline in the elasticity of these structures as a result of
a decrease in the content of elastic tissue and increase in
the amounts of collagen, calcium, and smooth muscle.
SYSTEM CHANGES The degree of collagen cross-linking increases with age
and results in a stiffer, less compliant ventricle. The
CARDIOVASCULAR SYSTEM reduced elastic recoil of the large- and medium-sized
As a person ages, cardiac function is altered in an age- vessels, coupled with atherosclerotic changes, culminates
related manner and a risk of cardiovascular disease in an increase in total peripheral vascular resistance.
increases directly proportional to age. These age-related Fibrosis and calcification of the aortic valve, which
physiologic changes (Table 30-1) do not include common adversely affect left ventricular function, are present in
cardiovascular diseases such as coronary artery and cere- 20% of patients older than 65. The combination of these
brovascular diseases, which increase in frequency with effects increases the preload and afterload of the heart
aging. Clinical manifestations and prognosis of these car- and results in a decrease in cardiac output (1%/year)
diovascular diseases likely become altered in older and stroke volume (0.7%/year) and an increase in sys-
persons of advanced age because interactions occur tolic and diastolic pressures. The impact of cardiovascu-
between age-associated cardiovascular changes in health lar disease on the surgical mortality in older patients is
and specific pathophysiologic mechanisms that underlie significant. In a large controlled study, the average mor-
a disease.18 As a result, these significant changes tality of 2.4% increased to 6.6% with the presence of
Oral and Maxillofacial Trauma in the Geriatric Patient CHAPTER 30 751
cardiovascular disease.21,22 The mortality rate increased Alternatively, age-related renal changes are accelerated
to 7.2% in patients older than 60 years and 14% in by comorbid conditions such as hypertension, athero-
patients older than 70 years. sclerosis, and heart failure.30 Bax et al have assessed the
data of 1056 patients to study the effect of atherosclerosis
RESPIRATORY SYSTEM on renal size and function and concluded that athero-
The respiratory system undergoes anatomic, physiologic, sclerosis accelerates the decrease of renal size and
and immunologic changes with age. Due to variability in increase of serum creatinine levels with age.31
physiologic respiratory measurements among healthy The extensive pharmacologic treatment commonly
adults, it is sometimes difficult to differentiate between a seen in older adults, in combination with a decrease in
diseased state and normal state. Although the overall renal clearance, leads to significant pharmacokinetic
number of alveoli does not change appreciably with age, changes, which ultimately result in reduced receptor sites
structural changes do occur, which affects gas exchange. for drug binding, an increase in volume of distribution
Alveolar ducts enlarge and septa collapse because of a of lipid-soluble drugs, and subsequent prolongation of
loss of elastic tissue, resulting in reduced total alveolar elimination half-life.32,33 This should be an important
surface area.22 The reduction in elastic lung tissue and consideration when administering anesthetic medica-
increased calcifications at rib articulations results in a tions to the geriatric patient or assessing the patient
stiff, less compliant lung. The effort to expand the lung who is on a cardiovascular drug regimen.34 Failure to
decreases 30% from 20 to 60 years of age.23 Diaphrag- excrete anesthetics and analgesics normally by the
matic breathing assumes a greater role in ventilation but kidneys can lead to toxic levels of these agents and may
is less efficient as it flattens with age, decreasing the lead to complications such as oversedation and apnea.
muscle length and strength. These changes function to There is often a narrow therapeutic index for opioid
reduce the elastic recoil of the lungs and lead to prema- analgesics related to hepatic and renal insufficiency and
ture airway closure, air trapping, and increased dead an increased sensitivity to central nervous system (CNS)
space. The functional residual capacity increases approx- drugs, and so adverse effects must be carefully moni-
imately 10% by age 60.24 This will create ventilation and/ tored.35 For example, in older patients, a longer duration
or perfusion mismatches and shunting, resulting in a of action has been observed following morphine admin-
lower Pao2. These changes will decrease an older patient’s istration due to a prolonged elimination of the drug
ability to deliver oxygen to the tissues that are actively from the plasma.36 When assessing geriatric patients,
involved in respiration. The operative mortality risk asso- dose adjustment should be considered for all medica-
ciated with symptomatic pulmonary disease is related to tions that are eliminated renally, such as allopurinol,
the severity of the dysfunction. This can be determined amantadine, most antibiotics, atenolol, carteolol, digoxin,
by preoperative quantitative pulmonary function testing. lithium, gabapentin, H2 blockers, procainamide, quini-
Respiratory system reserve is limited with age and dimin- dine, and sotalol.37
ished ventilatory response to hypoxia and hypercapnia From a surgical standpoint, older patients with active
makes it more vulnerable to ventilatory failure during renal disease, especially dialysis patients, require optimal
high-demand states (e.g., heart failure, pneumonia) and perioperative management. The perioperative concerns
possible poor outcomes.25 There is no evidence that the include a high incidence of CAD and myocardial dys-
changes in the respiratory system with aging affect day to function and difficulty adjusting fluid and electrolytes in
day function of older adults, but they may become evident the perioperative period in patients with diminished
under circumstances when physiologic demand reaches renal function.38 Hyperkalemia is the most common
the limits of supply.26 complication and may require immediate postoperative
dialysis.39 Other surgical complications include increased
RENAL SYSTEM perioperative bleeding complications and poor blood
Age-related renal changes are mainly characterized by pressure control, including hypertension and hypoten-
decrease in renal mass, renal blood flow, glomerular fil- sion. In addition, surgery may need to be deferred
tration rate (GFR), tubular secretion and absorption, to nondialysis days due to heparin coadministration
and creatinine clearance.27 The decrease in GFR can during hemodialysis and the possibility of intraoperative
occur with a normal serum creatinine level and may hemorrhage.
increase the risk of renal failure and mortality from estab-
lished renal failure. Older patients with end-stage renal NUTRITION
disease (ESRD) undergoing dialysis have a substantial
and sustained decline in functional status, and are more Adequate nutrition is essential for maintaining homeo-
likely to die in an acute hospital setting. Along with stasis in the normal state and trauma patient, in whom
decreased renal function, a number of significant cellu- so many physiologic systems can be stressed. This is par-
lar changes occur as a result of aging, including an ticularly significant in older patients for whom protein
increase in some renal membrane transporters and renal energy and micronutrient deficiencies are common.
membrane protein metabolism; also, Na,K-ATPase Energy intake below 30% of estimated needs and a low
protein abundance and activity and renal adaptation to serum albumin level have been associated with longer
a number of challenges are often diminished.28 The age- hospital stays, higher readmission rates, higher in-hospital
related kidney disease is characterized by phenotypic mortality rates, and increased mortality at 90 days and
changes in mesangial cell progenitors and is an entity 1 year.40,41 These concerns are compounded by the fact
distinct from all other causes of renal disease.29 that certain older maxillofacial surgery patients with
to range from 43% to 50%47,48 and was higher for patients

TABLE 30-2 Caloric Requirements for the Geriatric in extended-care facilities.
Patient Given the prevalence of malnutrition in the older
Degree of Stress Caloric Requirement (kcal/kg/day) population, a complete preoperative nutritional assess-
Nonstressful activity 25 ment by a clinical nutritionist is often indicated. Deficits
Mild stress (mild URI, grade I 30
and requirements are established based on an evaluation
or II pressure ulcer) of anthropometric, biochemical, clinical, and dietary
data. Anthropometric measurements are important for
Moderate stress (pneumonia, 35
determining the weight status of patients. The body mass
UTI, grade III pressure ulcer)
index (BMI) is a relative measure of weight to height and
Severe stress (major trauma, 40 is used to distinguish patients who are underweight (BMI
sepsis, grade IV pressure
< 22) from those who are overweight (BMI > 27). Several
ulcer)
biochemical markers can be used to assess nutritional
URI, Upper respiratory tract infection; UTI, urinary tract infection. status. Levels of albumin, thyroxine-binding albumin,
Adapted from Abbasi A: Nutrition. In Duthie EH, Katz PR, editors: Practice transferrin, insulin growth factor-1, and micronutrients
of geriatrics, Philadelphia, 1998, WB Saunders.
such as vitamin B12, iron, folate, and zinc are evaluated.
Deficiencies of any of these elements that are considered
compromised oral function secondary to postoperative clinically significant are indicative of malnutrition and
swelling or maxillomandibular fixation (MMF) will not should be corrected. Clinical signs and symptoms of mal-
be able to maintain normal oral nutrition. In addition, nutrition are assessed by a thorough review of systems.
the stress of trauma and surgery will elicit a series of Evidence of muscle wasting, poor skin turgor, altered
physiologic and metabolic responses that will markedly mobility, and altered gastrointestinal (GI) function is
alter the nutritional requirements of the trauma patient. suggestive of malnutrition. The dietary component of
The presence of comorbid conditions, such as diabetes, the nutritional assessment involves an evaluation of
renal disease, and heart failure, will serve to compound typical dietary habits and type of food intake. For the
this effect. Identifying and correcting nutritional defi- older patient, this will often provide an insight into the
ciencies preoperatively will have a significant impact on preoperative nutritional status.
the healing and recovery of the patient. Following a When the nutritional assessment is complete and the
meta-analysis of clinical studies involving hospital patients specific requirements are calculated, nutritional replace-
with malnutrition, Potter et al have reported that patients ment can commence. Older patients who have sustained
who began nutritional supplementation on hospital day facial trauma or have their jaws immobilized for fracture
3 or sooner have an average length of stay 3 days shorter treatment may not be able to sustain their nutritional
than those who started later.42 requirements through a transoral route. In that situation,
The caloric requirement of older adults declines by other routes of nutritional replacement must be consid-
22% from the age of 30 to the age of 80 years.43 This ered. Enteral feeding with a feeding tube is the most
decline is reflective of a decrease in lean body mass and effective physiologic approach. Nasoenteric feeding
metabolic rate secondary to reduced physical activity. tubes are easily placed at the bedside and can be used in
However, in the older trauma patient, caloric needs will patients who require enteral support for less than 30
be altered according to the clinical setting. An assess- days. Enteral feeding through a nasogastric suction tube
ment of the caloric requirement must be established should be avoided because these tubes are not well toler-
before initiating nutritional support (Table 30-2). ated by patients and can cause mucosal irritation and
Although the caloric requirements of older patients are ulceration. Gastrostomy tubes are indicated for patients
lower than those of younger patients, their protein who require prolonged enteral nutritional support. The
requirements are the same and may be elevated. The tubes are inserted percutaneously through the anterior
current recommendation for protein intake in older stomach wall under endoscopic guidance. Regardless of
adults is 0.8 g/kg/day. During episodes of physiologic the type of feeding tube used, the proper position of the
stress (e.g., trauma, surgery) the protein requirement tube in the GI tract must be confirmed radiographically
may be as high as 1.0 to 1.5 g/kg body weight.43 Follow- before initiating tube feedings. Nutritionists determine
ing the stress of surgery or trauma, glycogen stores are the content, character, concentration, and rate of deliv-
depleted within 36 hours. When glycogen stores are ery of the nutritional supplement. Nutritional support
depleted, energy demands are met through the process should also be part of the discharge planning process in
of gluconeogenesis, in which protein from skeletal older patients with compromised maxillomandibular
muscle is converted to glucose. This increases the demand function.
for protein intake. Surgical patients with a low protein
intake have a fourfold increase in medical complications PSYCHOSOCIAL ISSUES
and a sixfold increase in mortality, and are more likely
to have an extended hospital stay.44,45 In older adults, The older patient will often exhibit cognitive, emotional,
inadequate intake of protein has been reported in 10% and behavioral changes that may significantly alter the
of men and 20% of women.46 Protein-energy malnutri- surgical outcome and recovery. These changes are usually
tion (PEM), defined as a deficit in energy (in kilocalories secondary to the normal aging process. Dementia caused
[kcal]) and protein, is also common in older patients. In by Alzheimer’s disease is the leading cause of disability
older surgical patients, the incidence of PEM was reported in the older population49 and represents the most
common reason for institutionalization.50 Such patients function, poor functional status, and abnormal serum
demonstrate a compromised ability to recall, compre- electrolyte levels were found to be independent corre-
hend, and conceptualize issues of daily life. These limita- lates for postoperative delirium.51 Operative blood losses
tions are magnified in the older trauma patient who has requiring a transfusion and a postoperative hematocrit
additional physiologic reasons to be confused and disori- less than 30% have also been associated with a higher
ented. The most common cognitive difficulties displayed likelihood of developing postoperative delirium.53
by older patients are reduced attention span, poor short- Completing an objective assessment of the patient’s
term memory, and difficulty processing complex infor- cognitive abilities via direct interaction with the patient
mation.51 This will result in poor compliance with or family members will enable the clinician to identify
preoperative and postoperative management strategies, psychosocial issues that might compromise surgical care
including compliance with prescribed medications and and modify treatment accordingly. In patients with severe
obtaining an informed consent for treatment. In addi- cognitive impairments, proper discharge planning with
tion, age-related cognitive and behavioral changes the assistance of a social worker and caretakers is essen-
increase the incidence of depression and anxiety and tial for ensuring that appropriate postoperative care will
may directly contribute to the cause of the traumatic occur.
injury.
Postoperative mental status changes have been associ-
ated with a significant negative effect on outcome. Mar- SOFT TISSUE TRAUMA AND
cantonio et al51 have reported a sevenfold increase in WOUND HEALING
mortality, a sevenfold increase in major complications,
and a notable increase in the length of hospital stay. Data Soft tissue injuries in the geriatric population present a
on surgical outcome from a multicenter Veterans Admin- unique treatment challenge due to multiple intrinsic
istration hospital study52 have demonstrated an associa- structural changes in the skin and underlying tissues and
tion between postoperative delirium and complications age-associated comorbidities that affect healing. As the
such as postoperative pneumonia, unplanned intuba- aging population grows, it is not uncommon for them to
tion, and failure to wean from the ventilator. More sig- be more physically active and successfully employed well
nificantly, the death rate in this study was eight times into their 60s, 70s and even 80s. This in turn reflects in
higher in patients with postoperative delirium. Identify- increase in the number of traumatic injuries (Fig. 30-1).
ing older patients who are at increased risk of having In 2009, there were an estimated 210,830 nonfatal
postoperative changes in cognitive function is therefore work injuries and illnesses among workers 55 years and
important. Various preoperative, intraoperative, and older, with 94% being the result of trauma. Regardless of
postoperative factors have been studied in an effort to the patient’s age, the importance of proper tissue
identify variables related to postoperative delirium. Pre- management with careful attention to detail cannot be
existing cognitive impairment, poor functional status, overemphasized because the face is considered the
and polypharmacy are factors commonly associated with most conspicuous and significant portion of a person’s
postoperative mental status changes. In a large prospec- identity.54
tive study of noncardiac surgery patients, age older than Wound healing is a complex and dynamic process of
70 years, alcohol abuse, poor preoperative cognitive restoring cellular structures and tissue layers. Wounds
A B C
FIGURE 30-1 This 71-year-old man suffered multiple facial lacerations as a result of electric grinder injury at work (A), immediately
following repair (B), and 5 weeks after injury (C).
heal significantly more slowly in older adults compared fit and relining of dentures, taking impressions, and ver-
with younger adults regardless of gender and indepen- tical dimension may be necessary to use some reduction
dent of demographic factors such as ethnicity, alcohol or techniques successfully.
nicotine use, or BMI.55 In addition, older adults are more Bony changes in the geriatric population also affect
prone to injury and have a decreased healing ability due treatment choices. The bone in the maxilla is often thin
to multiple changes that occur in the skin and underly- and comminution at the fracture areas is more common.
ing tissues. Aging affects all stages of wound healing. A Suspension techniques that depend on stable bone in
decreased rate of cell proliferation is a result of reduc- the fracture area may not be as useful in older adults.
tion in collagen synthesis and slower epithelization, Alveolar bone atrophy is common in areas of tooth loss.
mainly due to a decline in the number of mast cells and In severe cases, there is atrophy of the basal bone as
compromised macrophage function, which leads to a well. Among the most challenging fractures to manage
decreased inflammatory response and a limited mito- are bilateral body fractures in the severely atrophic
genic response of keratinocytes and fibroblasts.54-60 These mandible.
cellular changes decrease wound tensile strength, colla- Historically, many maxillary and mandibular fractures
gen deposition, and wound contraction.61 have been managed with closed reduction techniques.
In addition to these alterations, concomitant medical These techniques often did not fully reduce fractures
illness, pharmaceutical intake, and dietary changes and the immobilization of the fracture was not complete.
further decrease the rate of wound healing and increase The past decade has seen a shift to open reduction, with
rates of wound dehiscence, ecchymosis, tape strip inju- good reduction of the fractures and rigid fixation of the
ries, infection, and persistent contact dermatitis.62,63 The fractures in the general population and in older adults.
pH of the skin surface increases with age, increasing its Often, however, weighing the risks and benefits in the
susceptibility to infection. Neurosensory perception of geriatric patient is more complex.
superficial pain is diminished in intensity and speed of
perception, thus increasing the risk of thermal injury; MAXILLARY FRACTURES
deep tissue pain, however, may be enhanced. A decline Although the treatment techniques are not unique to the
in lipid content as the skin ages inhibits the permeability geriatric population, patients with partial or full dentures
of nonlipophilic compounds, reducing the efficacy of are more common in this population. The patient with
some topical medications. Allergic and irritant reactions an edentulous maxilla and maxillary alveolar atrophy
are blunted, as is the inflammatory response, compromis- often has treatment compromised by thin bone and
ing the ability of aged skin to affect wound repair. These diminished bony volume in areas that might normally be
functional impairments, although a predictable conse- used to secure a denture or splint. The most common
quence of intrinsic structural changes, have the potential maxillary fracture involves the junction of the horizontal
to cause significant morbidity in the older patient and plate of the palatine bone and posterior part of the
may also be greatly exacerbated by extrinsic factors, such maxilla.64 The nature of the fractures also presents the
as photodamage. risk of collapse of vertical or anteroposterior positioning
as suspension wires are tightened. Poor bone quality and
the high likelihood of fracture comminution also increase
FACIAL FRACTURE MANAGEMENT IN THE the complexity of using rigid fixation in this patient
GERIATRIC PATIENT population.
For patients with existing suitable dentures, the
In the geriatric patient, treatment planning decisions for patient’s denture is altered to be useful in positioning
facial fractures are frequently influenced by risks of pro- and immobilizing the maxilla.65-69 Holes are drilled in the
longed or invasive surgery, the impact on function from easily repaired pink acrylic area of the denture to aid in
intermaxillary fixation or recuperation from open securing arch bars to the denture, making stabilization
surgery, and even the psychological implications. Preex- to the underlying bone easier. If the denture is not avail-
isting medical conditions are frequently encountered, able or not usable, a Gunning’s splint can be fabricated70-72
along with diminished cardiac, pulmonary, and wound- (Fig. 30-2). Impressions of the maxillary and mandibular
healing abilities that occur with aging. Techniques such arches are taken to make study models. These models
as closed reduction with intermaxillary fixation may chal- may have to be cut and repositioned to simulate the
lenge the patient’s respiratory function or the ability to planned fracture reduction. They are then mounted on
obtain adequate nutrition. Fractures that are not opti- an articulator to ensure the correct jaw relationship. Cap-
mally reduced and would normally heal uneventfully in turing the correct jaw relationship or creating the correct
a younger patient run a greater risk of fibrous union, jaw relationship on the articulator can be a challenge
nonunion, or prolonged healing time in the older when the fracture(s) or injuries make testing the splint
patient. Open reductions with greater surgical insult impossible preoperatively.
and longer time in anesthesia are a greater challenge to The denture or Gunning’s splint can be secured to the
the patient’s cardiac, pulmonary, and wound-healing maxilla in several ways. The amount of alveolar atrophy,
abilities. location of the fractures, and thickness of the bone influ-
Management of fractures can also be more challeng- ence the decision about which method to choose.
ing because of partial or complete edentulism. The Transalveolar wiring, transalveolar pin placement or sus-
patient’s use of partial or full dentures and their fit and pension wires from the malar buttress, piriform rims,
condition affect treatment options. Knowledge about the nasal spine, or zygomas are all commonly used and are
B
FIGURE 30-2 A, A Gunning splint is used to treat this edentulous patient with a mandible fracture. Impressions of the patient’s maxillary
and mandibular ridges were taken. A bite registration was used to mount the study models on an articulator before fabrication of the
splint components. B, The Gunning splint is secured to the maxilla via suspension wires in the buttress and piriform areas. It is secured
to the mandible with circummandibular wires. In this case, arch bars have been directly luted into the acrylic during the splint fabrication.
The arch bars are used to secure the maxillary and mandibular splints together.
suitable methods. Circummandibular wires are the alone.76 The principal complication was palatal tipping,
method used for securing a mandibular prosthesis or full presumably from unequal tightening of the suspension
mandibular dentures. Partial dentures may be secured by wires in unstable fracture areas.
ligation to the remaining teeth with the aid of an arch
bar that is also secured to the partial dentures. MIDFACE FRACTURES
Circumpalatal wiring has also been used to secure the The comprehensive treatment of midface fractures is
prosthesis to the nonfractured maxilla.73-75 These wires covered in the earlier chapters in this text. As with any
are passed from the anterior maxilla through the nose surgical treatment concerning the aging patient, an
to the junction of the hard and soft palate. They are assessment has to be made regarding the surgical and
brought into the mouth again at the junction of the hard anesthetic risk factors versus the necessity and benefits
and soft palates by perforating the tissue in this region of open or closed treatment. Midface fractures in the
with the wire-passing awl. They are then brought anteri- geriatric population that do not involve occlusion are
orly under the prosthesis and secured to the free ends in managed similarly to those in the general population.
the anterior vestibule. However, due to age-related soft and hard tissue changes,
The use of craniomaxillary suspension in maxillary some surgical approaches are more suited for a geriatric
fractures should be used with some caution in the geri- patient. The aging face has more rhytids, which can be
atric patient. Complications have been reported with an advantage for some approaches. The infraorbital
craniomaxillary suspension when compared with MMF approach provides direct and easy access to the
A B C
FIGURE 30-3 A, 83-year-old woman with a left orbital blowout fracture after a fall. B, Transconjuctival incision with lateral canthotomy
allows good visualization of the defect. C, Reconstruction of the orbital floor using a Silastic-impregnated titanium plate.
infraorbital rim and orbital floor. This approach is less Another method of obtaining immobilization of the
popular in younger people because it is unaesthetic, but jaw is with intermaxillary fixation screws.86,87 These are
is usually satisfactory aesthetically in the geriatric popula- self-tapping bicortical screws that are placed in the alveo-
tion. In contrast, aging causes laxity and downward shift lus. The screw is placed between the roots of the teeth,
of eyelid tissues and atrophy of the orbital fat. These if teeth are present. Placing the screw deep in the vesti-
changes contribute to the cause of several eyelid disor- bule and below the tooth roots will often result in local
ders such as ectropion, entropion, dermatochalasis, and mucosal ulceration that may be difficult for the patient
ptosis. The higher eyelid skin crease and ptosis may be to tolerate. One screw is placed in each quadrant. The
due to age-related disinsertion of the levator muscle apo- intermaxillary fixation wire is passed through holes in
neurosis and involutional atrophy of the orbital fat. The the end of the screw or wrapped around the screw end.
horizontal eyelid fissure shortens by about 10% with This method has the advantage of being a rapid method
aging.77 Thus, supraorbital approaches including midlid for the application of intermaxillary fixation. Placement
crease and subciliary incisions should be used with can be performed with local anesthetic. It is also effective
caution due to their inherently higher risk of ectro- when crown and bridgework make the application of
pion.78,79 A transconjuctival approach, with and without traditional arch bars difficult. These screws must be posi-
lateral canthal extension, may be successfully used for tioned properly because damage to tooth roots and the
reconstruction of both zygomaticomaxillary complex mental nerve has been reported.88
and isolated orbital fractures (Fig. 30-3). It results in Mandibular fractures have also been managed with
minimal postoperative complications, is cosmetically a closed technique that uses external fixation89-91 (Fig.
acceptable, and has a minimal incidence of ectropion 30-4). The early instrumentation in the Joe Hall Morris
compared with cutaneous approaches.80-82 and biphasic reduction kits used special screws that were
placed into the mandible, usually two on either side of
MANDIBULAR FRACTURES the fracture through stab incisions and holes drilled in
As in the maxilla, the treatment techniques for mandibu- the mandible. Steinmann pins or Kirschner wires can
lar fractures are not unique to the geriatric population. also be used as external pins and do not have to have a
Weighing the risks and benefits of closed versus open hole drilled before insertion. Once external pins are in
reduction has traditionally resulted in a preference for position, the fracture segments are manipulated to
closed reduction in this population. However, like the achieve reduction and then the pins are locked in this
general trends in fracture management, open reductions position by application of an acrylic mix placed over the
have become more common over the last decade.83-85 ends of the pins that are protruding out of the skin. The
Closed reductions are most frequently accomplished acrylic is allowed to harden while the mandible is held
with intermaxillary fixation using the teeth. Missing teeth in the reduced position. The biphasic kit has armamen-
or the presence of crown and bridgework may compli- tarium that allows three-dimensional adjustment of the
cate this standard technique. Partial or full dentures or segments as an intermediate step before application of
extensive fixed bridgework are more common in this the acrylic bar. For difficult or unstable fractures, obtain-
population. For patients with dentures, the dentures may ing or maintaining an excellent reduction with this tech-
be altered to aid in immobilization of the fracture. The nique can be challenging. This technique can be used in
mandibular full denture is stabilized to the mandible combination with an open technique, with or without
with circummandibular wires. These wires are placed internal fixation, to aid in obtaining a good alignment
using an awl or Keith needle. Care is taken to avoid the of the fracture segments.92
mental nerve and facial artery and vein on the inferior Open reduction techniques have a prominent role
and lateral surface. Placement close to the lingual surface in geriatric mandible fracture management. The advan-
avoids the submandibular duct and lingual nerve. Partial tages of direct visualization and achieving excellent
dentures may also be secured in this manner with arch reduction and immobilization can be significant. This
bars attached to the remaining teeth and secured to the can be particularly important with unstable fractures or
partial denture. fractures in areas with diminished healing capacity.
B
C
D
FIGURE 30-4 Demonstration of the application of a biphasic external pin appliance in the management of fractures of edentulous
mandibles. A, At least two pins are placed on either side of the fracture site. Note that the pins are not parallel but diverge slightly
from one another. B, Following reduction, first-phase stabilization is obtained with the application of a connecting bar and universal
connectors. C, Second-phase stabilization proceeds with cold-cured acrylic applied while the connector bar is in place. Once the acrylic
has cured, the universal connectors and bar are removed, as seen here. D, Clinical application.
Fractures of the atrophic edentulous mandibular body in atrophic mandible. Although the earliest description of
older adults represent one of the more challenging inju- MMF was by Hippocrates in 460 bc, it was not until 1894
ries to manage successfully. that Gunning splints were first introduced, and are still
used today (see Fig. 30-2).87-99 Open reduction and inter-
ATROPHIC MANDIBULAR FRACTURES nal fixation (ORIF) with a silver wire was first performed
The incidence of atrophic edentulous mandibular frac- in 1869, but was largely abandoned for almost a century
tures, although rare in the past, is continuing to rise due in favor of other procedures, such as external pin fixa-
to the improved quality of life for many older adults, tion and biphasic pin placement, which came into use in
correlating with more physical mobility and engagement the late 1930s and 1940s. Although both techniques have
in more leisure activities.93 Although atrophic mandibles been successfully used, they were occasionally plagued by
present a surgical as well as a restorative challenge, man- poor fracture reduction due to relatively small surface
dibles that have 5 mm or less of bone height at their most area at the fracture site. To achieve better reduction,
resorbed point (Cawood type VI) are at high risk for a open techniques have been used in conjunction with
spontaneous fracture. As a person ages, with progressive external pin fixation and biphasic pin placement. Place-
loss of teeth, atrophy of the alveolar bony apparatus ment of transosseous wires and eventually the use of
ensues, resulting in contributing to this fracture poten- small bone plates have enhanced the stability of the
tial.94 This change in bony volume results in a decreased reduction. As the use of plating systems advanced, the
vascular supply from periosteum and endosteum and a reliance on the use of open reductions with the applica-
decreased potential for osteogenesis, which can compro- tion of rigid internal plate fixation increased. By the early
mise bony healing in this patient population. The inher- 1970s, Bradley demonstrated that the body region of the
ent instability of edentulous, atrophic, mandibular body edentulous atrophic mandible was primarily dependent
fractures makes maintaining an adequate reduction and on a periosteal vascular supply.95 This led to a cautious
immobilization without direction stabilization unpredict- approach, which resulted in minimizing periosteal strip-
able. The challenge is made greater by the position of ping in the management of these fractures.
the inferior alveolar nerve, which can make internal fixa- The current treatment of edentulous atrophic man-
tion very difficult. dibles is generally divided into closed reduction and sta-
Throughout history, various treatment modalities bilization with gunning splints, closed reduction with
have been used to treat the fractures of edentulous and external fixation, and ORIF (Fig. 30-5). The treatment
A
B
C
FIGURE 30-5 A, Bilateral fracture in an atrophic edentulous mandible. B, Wide access is obtained in preparation for placing large plates.
C, 2.4-mm plates are used to provide prolonged stability from the plating system.
of atrophic mandible fractures should be based on the

degree of atrophy. The edentulous mandible with an GERIATRIC TRAUMA: OUTCOME
adequate ridge is usually amenable to closed reduction AND SURVIVABILITY
with Gunning splints. More rigid fixation may be neces-
sary in mandibles with less than 15 mm in bone height.96 Advanced age has long been considered a risk factor for
To minimize subperiosteal stripping, many surgeons poor outcomes following major trauma. Compared with
prefer to treat these fractures with closed reduction tech- younger patients, older trauma patients have higher mor-
niques or open techniques that involve less periosteal tality and morbidity rates. This has been attributed to
elevation, such as wiring or miniplate fixation.95-97 Sugiura various factors (see earlier), which include the presence
et al99 have reported no noticeable differences in com- of preexisting diseases and a poor level of physiologic
pressive stress levels in the bone around screws in the reserve. Identifying older trauma patients who will
single- or double-miniplate models with bone contact. benefit from expensive and aggressive resuscitative tech-
On the other end of the spectrum, some surgeons niques is important in addressing the ethical question of
have advocated bone grafting at the time of fracture who should and should not receive care. In an effort to
management as a means of increasing the likelihood of establish an evidence-based guideline in the decision
bony union. Although these techniques have often been algorithm of trauma care for older patients, Jacobs et al
successful, poor reductions, fibrous unions, and non- reviewed the existing literature for an answer to various
unions were not uncommon with this method. care-related problems.110 There were several limitations
Techniques directed at attaining excellent reduction to this approach, including the paucity of prospective
and providing longer periods of fracture stability through randomized studies, lack of consensus regarding how to
a more rigid internal plating system have gained in popu- define the geriatric trauma patient, and the fact that
larity, in spite of the need for significantly more perios- most of the studies reviewed were at least 10 years old
teal stripping.100-105 The use of larger plates, 2.4-mm and did not reflect current trends and improvement in
mandibular fracture or reconstruction plates, and bicor- trauma care. Despite these limitations, certain recom-
tical screws applied to an atrophic mandibular body frac- mendations about the triage and resuscitation of older
ture has gained acceptance as a technique that can best trauma patients developed from this review, including
prevent the common problem of nonunion and fibrous the following:
union.106 Ellis and Price107 have evaluated 32 patients with 1. Advanced age should lower the threshold for triage
unilateral or bilateral atrophic mandibular fractures who directly to a trauma center.
were treated through an extraoral approach with rigid 2. Age alone is not a predictor of poor outcome and
internal fixation. They reported complete healing in all should not be the determining factor in limiting care.
patients with no incidence of any complications, and 3. The presence of preexisting medical conditions
concluded that the use of a seemingly more aggressive adversely affects the outcome in older trauma
approach for managing fractures through the atrophic patients.
mandible, in the end, may be more conservative than a 4. Older trauma patients (≥65 years) with a Glasgow
less aggressive approach. Coma Scale score less than 8 have a very poor prog-
In addition to spontaneous fracture potential, severely nosis. If improvement is not possible within 72 hours,
atrophic mandibles, in which the maximum bone height limitation of continued aggressive therapy should be
is 5 mm or less, may be associated with neurosensory considered.
loss and fistula formation. In addition, poor retention 5. Low survival rates and longer lengths of stay are
of the dental prosthesis may seriously compromise the associated with postinjury complications.
nutritional status of an already medically compromised 6. Given that 85% of older trauma patients will return
individual. Various attempts have been described for to independent function, resuscitation should be
reconstruction of severely atrophic mandibles. A highly pursued aggressively on patients who are not mori-
successful technique to augment a severely atrophic bund on arrival.
mandible involves the use of a freeze-dried cadaveric 7. Older patients with an admission base deficit less
mandible packed with autogenous cancellous iliac bone than −6 have a high mortality rate (66%) and may
(Fig. 30-6). Recently, there has been success in recon- benefit from inpatient acute care nursing.
struction with implants and simultaneous bone graft 8. Patients 65 years of age or older with a trauma
placement. Lopes et al108 have reported successful treat- score less than 7 or a respiratory rate less than 10
ment of a severely atrophic mandible with four short have a 100% mortality rate; in these patients, limita-
dental implants at the symphysis with an immediate tion of continued aggressive therapy should be
bone graft and a 2.0-mm large-profile bone plate for considered.
reinforcement. Marx et al109 have presented a long-term 9. Despite meeting the criteria for triage to a trauma
follow-up of 64 patients with initial mandible height center, trauma patients who are 55 years and older
ranging from 3 to 6 mm who were treated with dental are much more likely to be improperly triaged.
implants as tent poles to consolidate and maintain the 10. Invasive hemodynamic monitoring is indicated for
volume of simultaneously placed bone graft. At 3-year geriatric trauma patients with uncertain cardiovascu-
follow-up, they reported a mean bone height gain of lar or renal disease.
10.2 mm, no permanent neurosensory disturbance, and 11. Effort should made to optimize the cardiac index
successful osseointegration of 354 of 356 dental implants (>4 liter/min/m2) and oxygen consumption index
placed (99.5%). (170 mL/min/m2).
A B
C D
E F
FIGURE 30-6 Reconstruction of severely atrophic mandible (6 mm) using freeze-dried cadaveric mandible packed with autogenous
cancellous iliac bone. A, Intraoral view demonstrating a severely resorbed alveolar ridge. B, Panoramic view of generalized severe
mandibular atrophy. C, Outline of incision using an existing skin crease. D, Hollowed-out, freeze-dried cadaver mandible filled with
cancellous autograft from anterior iliac crest. E, Exposed view of the inferior border. F, Cadaver mandible is fitted to the inferior border of
the patient’s mandible and secured with circummandibular wires.
Because these recommendations are based on retro- 2. U.S. Census Bureau: Current population reports, series P-25, No. 952:
Projections of the population of the United States by age, sex and race 1988
spective data collection, they should be applied cau- to 2080, Washington DC, 1989, U.S. Department of Commerce.
tiously in individual patients. Prospective, randomized 3. Johnson JF: Considerations in prescribing for the older patient.
controlled trials are necessary so that valid evidence- Scottsdale, Ariz, 1998, PCS Health Systems, pp 1–98.
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5. Kohn RR: Principles of mammalian aging, Upper Saddle River, NJ,
1971, Prentice-Hall.
6. Davidovic M: Genetic stability: The key to longevity? Med Hypotheses
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CHAPTER
Reconstruction of Avulsive Defects of
31
the Maxillofacial Complex
David B. Powers
| Eduardo D. Rodriguez
OUTLINE
Causes of Avulsive Injuries of the Maxillofacial Complex Reconstruction of Avulsive Hard Tissue Injuries
Firearm Injuries Mandibular Reconstruction
Occupational and Farm Injuries Simple Alveolar Defects
Tearing Injuries Small Mandibular Defects Requiring No Cutaneous or
Abrasion Injuries Mucosal Grafting
Incidence Mandibular Condyle Defects
Assessment and Initial Medical Management Large Mandibular Defects and/or Those Requiring Soft
Classification Tissue Coverage
Avulsive Soft Tissue Maxillofacial Injuries Midfacial and Upper Facial Third Reconstruction
Avulsive Hard Tissue Maxillofacial Injuries Special Concerns
Initial Surgical Management of Avulsive Maxillofacial Injuries Combined Mandibular and Midfacial and Upper Facial Hard
Reconstruction of Avulsive Soft Tissue Injuries Tissue Reconstruction
Ear Avulsions Osseointegrated Implants
Scalp and Nasal Avulsions Custom-Fabricated, Patient-Specific Implants and
Anterolateral Thigh Flap Endocultivation
Adjunctive Therapy for Complete and Partial Soft Tissue Computerized Surgical Stents
Avulsions of the Maxillofacial Region Composite Tissue Allograft Transplant
Hyperbaric Oxygen Therapy
Medicinal Leech Therapy
A man’s face as a rule says more, and more interesting things, amputation of the extremities; integration back into
than his mouth, for it is a compendium of everything his society is slightly easier if you have never known life
mouth will ever say, in that it is the monogram of all this without your congenital defect, or your lower extremity
man’s thoughts and aspirations. amputation has been replaced by a state of the art pros-
Arthur Schopenhauer, German philosopher thetic limb. The comprehensive management of avulsive
facial injuries rarely has been the focus of any epidemio-
Trauma, including unintentional and violent injury, logic, demographic, or other therapeutic studies. A com-
remains the leading cause of death and disability in the plete review of the potential treatment modalities, soft
United States for individuals from the age of 1 year to and hard tissue reconstruction options, and manage-
the mid-40s (Fig. 31-1).1 Arguably, no other physical ment principles of avulsive hard and soft tissue wounds
deformity is as psychologically devastating as a traumatic to the craniomaxillofacial unit is beyond the scope of this
defect to the face, exceeded only by those defects involv- chapter, and would take volumes of data and literature
ing avulsive loss of hard and soft tissue.2 Although the art to address the topic adequately. Instead, the focus here
and science of prosthetic limb replacement has advanced is to provide the practicing facial trauma surgeon with
tremendously during the past 2 decades, with current an overview of the causes, incidence, diagnosis, classifica-
research investigating true brain-machine integration, tion, and surgical management of these devastating
no satisfactory component has been developed to serve injuries.
as a replacement for the facial unit.3,4 Imagine an indi-
vidual living a normal life, such as eating in a restaurant,
shopping, or sitting at the local coffee house while using CAUSES OF AVULSIVE INJURIES OF THE
their laptop computer to browse the Internet. And, in MAXILLOFACIAL COMPLEX
one cruel twist of fate, the focal point of their self-image,
and the source of their engagement with society, is per- The description of injury can be summarized simply as
manently mutilated. Avulsed hard and soft facial tissues the effects of energy overcoming inertia. Our study of
leave enormous psychological, interpersonal, functional, physics, and the work of Sir Isaac Newton, has shown that
and physical disabilities, well beyond those encountered the velocity of a body remains constant unless the body
by those with congenital deformities or traumatic is acted on by an external force. To quote Haug, “In the
763
764
10 Leading Causes of Death, United States

2007, All Races, Both Sexes
Age Groups
Rank 1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65 All ages
Congenital Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Malignant Malignant Heart Heart
1 anomalies injury injury injury injury injury injury injury neoplasms neoplasms disease disease
5,785 1,588 965 965 6,493 9,404 14,977 16,931 50,167 103,171 496,095 616,067
Short Congenital Malignant Malignant Malignant Heart Heart Malignant Malignant

Homicide Homicide Suicide
2 gestation anomalies neoplasms neoplasms neoplasms disease disease neoplasms neoplasms
2,224 3,327 5,278
4,857 546 480 479 13,288 37,434 65,527 389,730 562,872
Chronic low.
Congenital Heart Unintentional Cerebro- Cerebro-
SIDS Homicide Homicide Suicide Suicide Homicide Respiratory
3 anomalies disease injury vascular vascular
2,453 398 213 1,481 2,659 4,758 disease
196 11,839 20,315 115,961 135,952
12,777
Maternal Chronic low. Chronic low.
Malignant Malignant Malignant Malignant Liver Unintentional
pregnancy Homicide Suicide Suicide Respiratory Respiratory
4 neoplasms neoplasms neoplasms neoplasms disease injury
comp. 133 180 6,722 disease disease
364 673 980 3,463 8,212 12,193
1,769 109,562 127,924
Unintentional Heart Heart Congenital Heart Heart Heart Diabetes Alzheimer’s Unintentional
HIV Suicide
5 injury disease disease anomalies disease disease disease mellitus disease injury
3,572 7,778
1,285 173 110 178 346 738 3,223 11,304 73,797 123,706
Chronic low.
Placenta cord Influenza and Heart Congenital Congenital Cerebro- Cerebro- Diabetes Alzheimer’s
PART IV Special Considerations in the Management of Traumatic Injuries
Respiratory HIV Homicide

6 membranes pneumonia disease anomalies anomalies vascular vascular mellitus disease
disease 1,091 3,052
1,135 109 131 191 211 6,385 10,500 51,528 74,632
54
Chronic low.
Bacterial Influenza and Cerebro- Diabetes Liver Diabetes Liver Influenza and Diabetes
Septicemia Respiratory HIV
7 sepsis pneumonia vascular mellitus disease mellitus disease pneumonia mellitus
78 disease 127
820 48 71 610 2,570 5,753 8,004 45,941 71,382
64
Chronic low.
Respiratory Perinatal Benign Influenza and Cerebro- Cerebro- Cerebro- Influenza and
Respiratory HIV Suicide Nephritis
8 distress period neoplasms pneumonia vascular vascular vascular pneumonia
disease 4,156 5,069 38,484
789 70 41 55 124 505 2,133 52,717
71
Circulatory Chronic low.

Benign Cerebro- Cerebro- Diabetes Complicated Congenital Diabetes Unintentional
system Respiratory Nephritis Nephritis
9 neoplasms vascular vascular mellitus pregnancy anomalies mellitus injury
disease disease 4,440 46,448
59 38 45 55 116 417 1,984 38,292
624 4,153
Chronic low.
Neonatal Benign Diabetes Liver Viral
Respiratory Septicemia Septicemia Septicemia Septicemia Septicemia Septicemia
10 hemorrhage neoplasms mellitus disease herpatitis
disease 36 53 910 4,231 26,362 34,828
597 43 113 384 2,815
57
FIGURE 31-1 Statistics for leading causes of death in the United States, 2007. (From National Center for Injury Prevention and Control: WISQARS leading causes of death reports,
1999-2007, 2010 [http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html].)
Reconstruction of Avulsive Defects of the Maxillofacial Complex CHAPTER 31 765
case of maxillofacial trauma, the object is the specific

maxillofacial body part, and kinetic energy is provided
by the wounding agent, either bullet, bludgeon, or motor
vehicle.5 When considering avulsive defects of the maxil-
lofacial complex, a sufficient quantity of energy must be
delivered to the body part to remove it from its native
bed. Kinetic energy (KE) is related as 1 2  mv2 (where m
= mass and v = velocity), but Cunningham has hypothe-
sized that softer tissues, such as brain and muscle, are
associated with a lower exponent of injury (0.5) than
harder tissues, such as bone, which would have a higher
exponent (2.5) and therefore a higher likelihood of per-
manent injury. Thus, the corrected formula for estimat-
ing wounding capacity by kinetic energy would be as
follows:
1 0 .5 1
KE = mv to KE = mv 2.5 FIGURE 31-2 Victim of a mauling by a jaguar (Panthera onca).
2 2
Note the bite wounds to the scalp as the jaguar was attempting
depending on the location of the trauma. 6 to crush the patient’s skull.
FIREARM INJURIES
Firearm injuries have been described in detail in another
chapter of this text and are acknowledged as possibly the
most common source of avulsive tissue loss of the cranio-
maxillofacial components currently seen by facial trauma
specialists. Whether sustained as a the result of self-
inflicted wound, accidental hunting or recreational inci-
dent, criminal activity, or of military or professional
service to the community, high-energy avulsive ballistic
wounds present a vexing treatment dilemma to restore
form, function, and cosmesis adequately to the facial
unit.6-8
OCCUPATIONAL AND FARM INJURIES

Industrial or agricultural accidents possess the potential FIGURE 31-3 MVA victim who suffered severe abrasion and total
to create severe crush or avulsive wounds of the soft and avulsion of the external ear and upper eyelid. The victim’s
hard tissues of the maxillofacial complex. Whether low automobile flipped on the driver’s side door, breaking the window.
or high velocity, the sheer mass of the injury platform The victim was restrained by his seatbelt and was held against
associated with industrial machinery create tissue injury the roadway as the vehicle continued to slide along the pavement.
patterns characteristics of a high-energy impact.9-11 As
seen in firearm and ballistic injuries, if the injury pattern
is consistent with a high-energy impact, the degree of injury can be contaminated by a wide range of microor-
tissue disruption occurring in the hard and/or soft ganisms, including viruses, bacteria, and mycobacteria.
tissues may result in separation from the native tissue bed Significant areas of soft tissue overlying the facial skele-
and avulsion. If the wounding mechanism is a crush ton may be avulsed, crushed, or bruised, compromising
injury, the soft tissue overlying the bone can sustain cata- vascular supply and delaying initiation of the body’s host
strophic compromise to the vascular pedicle, resulting in defense mechanism. Gross contaminants on machinery
soft and/or hard tissue necrosis. This necrosis, resulting parts, including industrial residue and/or microbial
in partial loss of tissue or the physical structure or com- sources from many sites of origin, serve as infectious
plete loss of the anatomic component, has the same reservoirs, further complicating the normal healing
physical outcome as avulsion. cascade.
TEARING INJURIES ABRASION INJURIES

Shearing or cutting injuries created by blades or saws, Abrasion injuries are another source of avulsive tissue
tearing wounds caused by industrial machinery, and bites loss in the craniomaxillofacial region, which have the
inflicted by animals are capable of creating avulsive potential to create horrific defects. Although relatively
defects and contaminated crush injuries of the cranio- unusual for a victim to be actively dragged by a moving
maxillofacial unit.12-16 Whereas large domestic animals object, when it does occur, as seen in a motor vehicle
can bite with forces as great as 450 lb/inch, animals in accident (MVA) or a motorcyclist sliding along the road,
the wild, such as bears or jaguars, can have bite forces in the overlying soft tissues will bear the brunt of the
excess of 1700 lb/inch2,17 (Fig. 31-2). This form of crush injury18-20 (Fig. 31-3). Protruding anatomic structures,
skin, muscles, and neurovascular components will be lost

before the bone is potentially injured or avulsed. The
result is an injury that is grossly contaminated and devoid
of any healthy soft tissue for local flap reconstruction,
and that will require adjacent tissue recruitment or
remote transfer for adequate rehabilitation.21
INCIDENCE
Historically underreported in the craniomaxillofacial
trauma literature, or noted primarily in case reports from
periods of military conflict, avulsive defects to the maxil-
lofacial region have been recognized to occur infre-
quently and are perceived to have a poor prognosis in
regard to an acceptable cosmetic and functional
repair.5,20,21-30 In the civilian literature, the decade-long
experiences of Clark et al at one of the busiest and
premier level I trauma centers in the United States, have
identified approximately 1.5 cases/year of avulsive tissue
loss to the craniomaxillofacial region.24 Considering the
reported volume of over 6700 unique trauma patient
identifiers at the shock trauma center annually, the rela-
tive infrequency of this occurrence becomes apparent.31 FIGURE 31-4 Avulsive injuries to the face are potentially lethal.
Clark et al noted that approximately 46.6% of these inju- Strict attention should be paid to establishing an airway,
ries involve the mandible, maxilla, and orbit; 26.6% ventilating the patient, and then controlling hemorrhage while
involve the mandible and maxilla; and 26.6% involve the protecting the cervical spine.
mandible alone. Haug et al have reported a 1% occur-
rence of avulsive maxillofacial injuries (5 of 475patients)
during a review of experiences at a civilian trauma center
in Cleveland, with most cases involving self-inflicted mandible fractures being the second and fourth most
gunshot wounds with shotguns in a suicide attempt.27 In commonly reported surgical procedures.29 The place-
a survey of over 9400 patients treated during the Vietnam ment of IEDs, usually well below the level of the head
conflict, Osbon had previously noted that 9.4% exhibit and neck, would obviously place the anterior-inferior
an avulsion of a notable portion of their mandible.25 aspect of the mandible at increased risk as the explosive
Because Vietnam represented the first armed modern force and associated shrapnel would proceed in a supe-
conflict against nonconventional military forces, the rior vector, striking the lower face. Modern body armor
avulsive loss of mandibular anatomy was not previously plays a significant role in the overall survivability of
experienced to the degree as seen in this conflict.29 wounded military personnel, but Dobson et al’s observa-
Dobson outlined classic forms of warfare to include: tions offer a unique perspective and potential additional
minor conventional warfare, major conventional warfare, cause for the increased craniomaxillofacial injuries seen
rural attack, and terrorist attack.32 in OIF-OEF.
Rural attacks, minor conventional warfare, and major
conventional warfare displayed remarkably similar his-
torical incidences of head and neck injury, with 16%, ASSESSMENT AND INITIAL
16%, and 15% for British, Commonwealth, and military MEDICAL MANAGEMENT
personnel, respectively, since 1914. Terrorist attacks,
however, displayed a statistically higher incidence of Obviously, avulsive injuries to the craniomaxillofacial
21%. In the only known paper published during Opera- complex are potentially life-threatening (Fig. 31-4).
tion Iraqi Freedom–Operation Enduring Freedom (OIF- Compromise of the airway through anatomic collapse,
OEF) with reported battlefield conditions consistent with hemorrhage, foreign body obstruction, or aspiration are
classic military combat, Montgomery et al noted the inci- acknowledged as known risks, requiring immediate inter-
dence of head and neck casualties as 25% for U.S. mili- vention to provide for continued oxygenation of the
tary personnel, which is consistent with the previously patient. As prescribed in the current Advanced Trauma
reported historic norms for U.S. conflicts.33 Dobson Life Support (ATLS) protocols, securing the airway
et al32 have described terrorist attacks as highlighted by definitively should be accomplished by conventional oral
the unconventional use of improvised explosive devices or nasal endotracheal intubation, intubation of a visible
(IEDs), which correlates with the injury pattern of the component of a traumatically exposed trachea, or crico-
IED as used by insurgents in OIF-OEF. Most hard tissue thyroidotomy or surgical tracheostomy.21 After the airway
facial injuries were sustained in the mandible due to its has been established, attention should be directed to a
prominence from the facial skeleton. This was also noted thorough analysis of the patient for potentially lethal
in Lew et al’s study of maxillomandibular fixation (MMF) injuries and appropriate interventions initiated. Control
and open reduction and internal fixation (ORIF) of of hemorrhage should be established with simple
A B
FIGURE 31-5 A, Note the devastating avulsive injury to the anterior mandible in this two-dimensional CT scan, indicating significant loss of
bone and soft tissue. B, Note the clarity and identification of anatomic injuries and the presence of an avulsive loss of the anterior cranial
vault floor in this three-dimensional reconstruction of a CT scan of a patient involved in a motorcycle accident.
pressure to the site by compression dressings or manual CLASSIFICATION

palpation, ligation of visible sources of active bleeding,
or use of hemostatic dressings impregnated with compo- AVULSIVE SOFT TISSUE MAXILLOFACIAL INJURIES
nents such as chitosan or similar compounds.33 Injuries Avulsive injuries of the soft tissue of the craniomaxillofa-
to the deep vessels of the head or neck, or those not cial region should be classified as either complete avul-
visible from routine surgical access, may require inter- sion or partial avulsion. Complete avulsion should be
ventional approaches to gain control of the hemor- defined as an injury in which there is complete loss or
rhage.34 During the course of fluid resuscitation, detachment of a portion of the craniomaxillofacial struc-
particular attention should be paid to the head and neck tures, without the ability to regenerate the missing ana-
region because seemingly benign scalp lacerations, or tomic entity (Fig. 31-7). The ability to regenerate the
those not recognized due to lack of hemorrhage second- missing component is directly related to the magnitude
ary to hypovolemia, have been associated with exsangui- of the avulsion and the vascular status of the remaining
nating hemorrhage as the patient’s mean arterial pressure soft tissue bed. A partial avulsion is defined as one in
is increased.35 If the head and neck region is covered which the segment is still attached to the remaining
under surgical drapes due to ongoing therapy in other native tissue bed, but presents with obvious concerns for
areas of the body, this unrecognized source of bleeding viability (Fig. 31-8). The same classification holds true for
can confound anesthesia providers and surgeons, or scalp injuries. Complete avulsion would be one in which
potentially be lethal. a portion of the scalp is lost and the magnitude of the
After all life-threatening injuries have been recog- loss is significant enough to prevent complete regenera-
nized and successfully managed, identification of the tion from the surrounding soft tissue bed (Fig. 31-9). A
avulsive facial defects can be accomplished. Computed partial avulsion would be one in which loss of the scalp
tomography (CT) scans with three-dimensional recon- has occurred, with resultant vascular compromise, with
struction are the minimum baseline studies required for or without the necessity for tissue replacement.
the treatment planning of avulsive craniomaxillofacial
defects (Fig. 31-5). Most avulsive soft tissue injuries, and AVULSIVE HARD TISSUE MAXILLOFACIAL INJURIES
all avulsive hard tissue injuries, will be definitively treated Currently, no universal classification system exists for
in an operating room environment. After stabilization, avulsive defects of the craniomaxillofacial complex. The
medical management should commence with appropri- injuries are usually described in anatomic terms, such as
ate early nutritional and psychiatric support for the mandibular, midfacial and/or upper facial third, or full
patient, with antibiotic therapy directed toward cutane- thickness or partial thickness for skin, or by the wounding
ous, oral, pharyngeal, nasal, and sinus contaminants.33,36 mechanism (e.g., low energy, thermal, high energy).27,28
Because these wounds are typically contaminated, and With the advent of composite facial allografts, and the
may exhibit vascular compromise, consideration should various descriptions used by the transplant community to
be given to the administration of the appropriate tetanus describe these surgeries, a uniform system for the descrip-
prophylaxis (Table 31-1) and, in the case of animal bites, tion of avulsive loss of craniomaxillofacial components
rabies prophylaxis (Fig. 31-6). will likely be forthcoming in the near future.37-40
TABLE 31-1 Rabies Postexposure Prophylaxis (PEP) Schedule
Vaccination Status Intervention Regimen*

Not previously Wound cleansing PEP should begin with immediate thorough cleansing of all wounds with soap and
vaccinated water. If available, a virucidal agent (e.g., providine-iodine solution) should be used to
irrigate the wounds.
Human rabies Administer 20 IU/kg body weight. If anatomically feasible, the full dose should be
immune globulin infiltrated around and into the wound(s), and any remaining volume should be
(HRIG) administered at an anatomic site (IM) distant from vaccination administration. Also, HRIG
should not be administered in the same syringe as vaccine. Because HRIG might
partially suppress active production of rabies virus antibody, no more than the
recommended dose should be administered.
Vaccine Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)
1.9 mL, IM (deltoid area†), one each on days 0,‡ 3, 7, and 14§
Previously Wound cleansing PEP should begin with immediate thorough cleansing of all wounds with soap and
vaccinated¶ water. If available, a virucidal agent (e.g., providine-iodine solution) should be used to
irrigate the wounds.
HRIG HRIG should not be administered.
Vaccine HDCV or PCECV, 1.0 mL (deltoid area†), one each on days 0‡ and 3.
*
These regimens are applicable for persons in all age groups, including children.
†
The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be
used. Vaccine should never be administered in the gluteal area.
‡
Day 0 is the day that dose 1 of vaccine is administered.
§
For persons with immunosuppression, rabies PEP should be administered, using all five doses of vaccine on days 0, 3, 7, 14, and 28.
¶
Any person with a history of preexposure vaccination with HDCV, PCECV, or rabies vaccine absorbed (RVA); prior to PEP with HDCV, PCECV or RVA;
or previous vaccination with any other types of rabies vaccine and a documented history of antibody response to the prior vaccination.
Adapted from (Centers for Disease Control and Prevention: ACIP recommendations: Use of a reduced (4-dose) vaccine schedule for postexposure
prophylaxis to prevent human rabies, 2011[http://www.cdc.gov/rabies/resources/acip_recommendations.html]).
INITIAL SURGICAL MANAGEMENT OF should be performed with identification and definitive

AVULSIVE MAXILLOFACIAL INJURIES control established through ligation or cautery. Efforts
should be directed to preservation of all hard and soft
After initial stabilization and resuscitation, the patient tissues, including those with questionable vitality, because
may be transported to the operating room for their first they may be able to be preserved or surgically reattached
surgical procedure. The goals of the initial operation are through conventional or microsurgical techniques. Soft
as follows: tissue is generally repaired from inside-out, with stable
1. Secure a definitive airway. reapproximation of the deep tissues. Identification of
2. Control hemorrhage. clinically significant soft tissue injuries, including transec-
3. Explore and identify remaining native tissue and doc- tion of the facial nerve or salivary ducts, should be per-
umentation of avulsed components. formed under magnification with surgical loupes or
4. Identify, document, and primarily repair, if possible, microscope, and primary repair attempted, if feasible.
the presence of significant soft tissue injuries: The recognition of facial nerve injury is a critical finding
a. Neurovascular structures for the rehabilitation of the patient because the determi-
b. Facial nerve nation for facial reanimation surgery and the timing for
c. Salivary structures repair options have a finite period for intervention.41,42
d. Muscle disinsertion, detachment Hard tissue repair can be accomplished by beginning
e. Globe injury with the mandible and reestablishment of the occlusion,
5. Salvage and maintain remaining hard and soft tissues. followed by the midface and upper facial third. The
6. Establish anatomic landmarks and an osseous founda- frame of the midface and upper face should be estab-
tion for definitive reconstruction. lished from the supraorbital bar, lateral orbital rims,
7. Prevent infection and subsequent exacerbation of soft malar buttresses, and arch projection first, followed by
tissue contracture. the central midface of the naso-orbital-ethmoid (NOE)
Because of the likely multitude of surgical interven- region, with final corrections of the dentoalveolar unit at
tions and concurrent soft tissue edema that the patient the Le Fort I level accomplished last. Although the
will experience, not only due to the primary injury but mandible-first protocol generally is applied most often,
as a tissue response to initial and subsequent fluid resus- if the midface or upper facial third is minimally injured,
citations, strong consideration should be given to per- and a more accurate reconstruction for the surgical foun-
forming an elective surgical tracheostomy if not done dation can be accomplished in those areas, reconstruc-
previously. Wound exploration for transected vessels tion should commence in those regions.
Summary guide to tetanus prophylaxis

in routine wound management
Assess wound
A clean, minor wound All other wounds (contaminated with dirt, feces, saliva,
soil; puncture wounds; avulsions; wounds resulting from
flying or crushing objects, animal bites, burns, frostbite)
Has patient completed a primary Has patient completed a primary

tetanus diphtheria series?1, 7 tetanus diphtheria series?1, 7
No/unknown Yes No/unknown Yes
Administer vaccine today.2, 3, 4 Was the most recent Administer vaccine and Was the most recent
Instruct patient to complete dose within the past tetanus immune gobulin dose within the past
series per age-appropriate 10 years? (TIG) now.2, 4, 5, 6, 7 10 years?
vaccine schedule.
No Yes
Administer vaccine today.2, 4 Vaccine not needed today.

Patient should receive next Patient should receive next
dose per age-appropriate dose at 10-year interval after
schedule. last dose.
1 4
A primary series consists of a minimum of 3 doses of tetanus- and Tdap is preferred for persons age 10 through 64 who have never
diphtheria-containing vaccine (DTaP/DTP/Tdap/DT/Td). received Tdap. Td is preferred to tetanus toxoid (TT) for persons
2 Age-appropriate vaccine: 7 through 9 years, or 65 years, or those who have received a
• DTaP for infants and children 6 weeks up to 7 years of age (or Tdap previously. If TT is administered, an adsorbed TT product is
DT pediatric if pertussis vaccine is contraindicated); preferred to fluid TT. (All DTaP/DTP/Tdap/DT/Td products contain
• Tetanus-diphtheria (Td) toxoid for persons 7 through 9 years of adsorbed tetanus toxoid.)
age; and 65 years of age; 5 Give TIG 250 U IM for all ages. It can and should be given
• Tdap for persons 10 through 64 years, unless the person has simultaneously with the tetanus-containing vaccine.
received a prior dose of Tdap.* 6 For infants 6 weeks of age, TIG (without vaccine) is recom-
3 No vaccine or TIG is recommended for infants 6 weeks of age mended for “dirty” wounds (wounds other than clean, minor).
with clean, minor wounds. (And no vaccine is licensed for infants 7 Persons who are HIV positive should receive TIG regardless
6 weeks of age.) of tetanus immunization history.
FIGURE 31-6 Summary guide to tetanus prophylaxis in routine wound management. (Centers for Disease Control and Prevention: ACIP
recommendations: Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies, 2011[http://
www.cdc. gov/rabies/resources/acip_recommendations.html]).
The initial surgical procedure should not be consid- identifying as accurately as possible the avulsed or injured
ered as a definitive reconstruction, but as an examination soft and hard tissue components.
under anesthesia, with the primary focus being to iden- After this primary surgery, the patient should undergo
tify which structures have been lost and which remain, a complete CT imaging survey to evaluate anatomic reduc-
and to prevent further progressive or iatrogenic loss of tion or fixation, better identify tissue loss, and assist with
additional hard and/or soft tissue. The existing identifi- treatment planning for an early reconstruction. As
able bone should be located, identified, and rigidly fixed described by Powers and Robertson and others, the patient
in an anatomic position with surgical reconstruction will likely require frequent returns to the operating room
plates, with the reestablishment of a functional occlusion at 2- to 3-day intervals to control infection, decontaminate
being the ultimate goal. The remaining soft tissue wound and/or débride necrotic tissue, and reassess vitality in the
edges are arranged in as close an anatomic approxima- remaining tissues.33,43 Good mucosal coverage with ade-
tion as possible, even if tension at points of closure or quate vascularity of the osseous structures internally, and
blanching of the tissue occurs, and a comprehensive similar cutaneous coverage externally, will help prevent
evaluation under anesthesia should commence, infection and mitigate hard tissue necrosis.
FIGURE 31-7 Complete avulsion of external ear as a consequence

of being an ejected passenger from an MVA and sliding across
the pavement of the highway.
FIGURE 31-9 Complete avulsion of the scalp as a consequence of

an industrial accident. The patient had long hair, which was
maintained in a tight pony tail, and a portion of the hair became
entrapped in a machine driven fan belt.
when compared with surrounding soft tissue. Pulse oxim-

etry may provide another measure for determining the
adequacy of vascularity to a reconstructed segment.
Although no specific guidelines are found in the litera-
ture, the Sao2 of a repaired component of soft tissue
should probably be at least 80% for predictable surviv-
ability. Capillary refill is a useful clinical tool to assess
venous congestion versus arterial compromise of partial
avulsions of facial soft tissue. Capillary refill of facial soft
FIGURE 31-8 Partial avulsion of the ear. Note that only a small tissue should be about 2 to 3 seconds. Prolonged capil-
pedicle is maintaining vascularity to the entire ear. This patient lary refills longer than 3 seconds suggest arterial insuffi-
underwent immediate closure of the partial ear avulsion and had ciency and rapid capillary refills shorter than 1 to 2
an uneventful postoperative course. seconds indicate venous congestion. Appropriate identi-
fication of the need for adjunctive procedures to assist
with maintenance of vascularity can be achieved by fol-
RECONSTRUCTION OF AVULSIVE SOFT lowing these recommendations.
TISSUE INJURIES EAR AVULSIONS
Initial determinations of reconstructive options for avul- Débridement of the wound begins the process of repair
sive soft tissue injuries are aligned under the decision to in treating complete and partial avulsions of the ear. The
proceed with prosthetic reconstruction, or native soft concept of débridement is well established in the litera-
tissue utilization. As previously described by Haug and ture and is a critical component in the management of
Carlson, the necessity for adjunctive therapy of native avulsive injuries to the craniomaxillofacial complex.33,43
soft tissue rehabilitation is determined by the following Serial washouts and débridement of tissue have become
parameters: temperature, color, oximetry, and capillary mainstays for craniomaxillofacial trauma surgeons in the
refill.5 treatment of these injuries. Unfortunately for many sur-
Unimpeded vascular supply provides nutrients and geons, the term débridement is synonymous with the abso-
warmth to a body part, so comparing the temperature of lute removal of tissue in the operating room. Although
the reapproximated avulsed segment with its surround- devitalized necrotic tissue does require excision, a more
ing tissue allows for a qualitative assessment of adequate accurate definition of the goal of serial washouts should
arterial circulation. Color is an acceptable evaluator of be the term decontamination. Preservation of all viable
blood flow—venous congestion will appear blue or tissues is a critical component in the management of
purple and arterial insufficiency will appear pale or white gunshot wounds to the maxillofacial region. Once tissues
with microvascular anastomosis, if possible.44 When

microvascular anastomosis of an avulsed segment is not
possible, the surgeon may elect to proceed with primary
Descending Ascending branch reattachment of the ear and adjunctive use of hyperbaric
branch of of lateral femoral oxygen or leech therapy to address the resultant venous
lateral femoral cutaneous vessels
cutaneous
congestion and vascular concerns.45 If the ear has not
vessels been stored or transported in a cool environment, exces-
Superior perforator sive contamination exists, or perceived excessive isch-
emia time with obvious tissue necrosis is present, the
wound may be primarily closed and future reconstruc-
Septal perforator
tion planned. Partial ear avulsions are those in which the
traumatized segment of the ear is still attached but
there is questionable vascularity to the partially avulsed
Musculocutaneous segment. Partial ear avulsions should be treated with
perforator primary closure of the partially avulsed segment as soon
as possible to prevent tissue necrosis and loss.
SCALP AND NASAL AVULSIONS

Partial scalp avulsions are those in which significant lac-
erations have occurred in the otherwise intact and pre-
served scalp, thereby compromising its blood supply and
impairing healing. Although most surgeons are inclined
to provide primary closure of such wounds, it is advisable
also to consider adjunctive therapy. The completely
avulsed scalp injury requires local flap surgery for recon-
A struction of the avulsed segment or, in the case of larger
magnitude avulsions, reconstruction with skin grafts or
possibly microvascular flaps. As with ear avulsions, it is
always advisable to attempt to locate vessels in the com-
pletely avulsed scalp for microvascular reconstruction in
the event that it is brought to the hospital with the
patient. If not possible, it may be appropriate simply to
reattach the avulsed segment and resort to adjunctive
therapy to salvage the avulsion. Complete and partial
avulsions of the nasal complex require a management
approach identical to that of the ear and scalp.
ANTEROLATERAL THIGH FLAP

Avulsive loss of soft tissue exclusively is seen in the injury
patterns described, such as tearing, shearing, abrasion,
and some forms of ballistic damage. Although rotational
B soft tissue techniques, including pedicled myocutaneous
flaps, present a viable treatment option in some scenar-
FIGURE 31-10 A, Anatomy for anterolateral thigh flap. B, ios, the transfer of tissue is limited by the attachments of
Anterolateral thigh flap ready to be delivered from the donor bed. the vascular base or available size of tissue to be trans-
ported. When a large volume of soft tissue only is required
at a remote site, the anterolateral thigh (ALT) flap is a
are lost, the surgeon is faced with two choices— proven choice, easily delivering skin pedicles 8 to 10 cm
compromise the anterior-posterior projection to allow in width and 25 cm in length, still allowing for a cosmetic
for primary closure of native tissue or transfer additional primary closure of the donor site46,47 (Fig. 31-10). Larger
tissue to the region via pedicled or microvascular grafts. skin paddles may be taken, but may require other forms
Avoidance of the need for tissue transfer should be the of closure, such as skin grafting. The ALT flap requires
goal, and judicious use of the practice of decontamina- a microvascular craniomaxillofacial surgeon for its appli-
tion will assist in achieving the desired results. cation in clinical scenarios. Microvascular reconstruction
Pulsatile jet irrigation with normal saline may be indi- has the advantage of providing greater quantities of
cated for the débridement of avulsive soft tissue wounds. tissue of varying types for replacement of the defect, with
It is important, however, to prevent iatrogenic trauma large volumes of bone and associated soft tissue trans-
with overexuberant use of jet irrigation. In the case of ported to the recipient site, depending on the donor
complete avulsion of an ear segment, in which the source chosen. Microvascular transfer allows for the
segment has been salvaged and accompanies the patient immediate restoration of contour with a reliable vascular
to the hospital, the component should be cleansed with supply ensuring osseous incorporation and healing, and
antiseptic solution and a salvage procedure attempted also permitting the transfer of soft tissue to replace lost
or damaged skin or mucosa. Microvascular reconstruc-

tion requires additional training and expertise in addi-
tion to the added expense of specialized surgical
equipment necessary for clinical use. Due to the length
of added surgical time associated with this treatment
modality, two surgical teams are typically used, with one
team working at the recipient site and the other team
harvesting the surgical graft.
The ALT flap is marked with the patient supine on the
operating table. Readily palpable bony landmarks, the
anterior superior iliac spine and superolateral patella, are
identified and a line connecting the two is drawn.46,47 A
Doppler signal identifies the cutaneous perforator vessels
from the lateral circumflex femoral artery and the skin
paddle is designed to the dimensions required. The initial
exploratory incision is performed along the medial aspect
of the proposed flap. The ALT flap may be raised in a
suprafascial or subfascial plane, depending on the desired FIGURE 31-11 The medicinal leech, Hirudo medicinalis.
thickness. Once adequate perforators have been identi-
fied, the flap is elevated by retrograde dissection of the
selected perforators to the source vessels in the intermus- viability of those severely compromised wound areas con-
cular septum. Meticulous intramuscular dissection, with sidered to be questionable or hopeless, thereby prevent-
strict adherence to hemostasis and maintenance of perfo- ing clinically significant tissue loss.
rator integrity, is of paramount importance and continues
proximally until the desired length of the pedicle is MEDICINAL LEECH THERAPY
obtained. The vascular pedicle is transected and layered In complete or partial avulsions of facial structures, sig-
closure of the harvest site is accomplished, generally nificant venous congestion may be encountered in the
without the need for drains. The advantages to the ALT postoperative period. If left untreated, the reconstructed
flap include its versatility as a cutaneous or fasciocutane- tissue may undergo necrosis secondary to vascular com-
ous flap for tissue resurfacing or as a musculocutaneous promise and be lost, necessitating free tissue transfer or
flap for oromandibular or complex maxillary defects. rotational coverage with adjacent native tissue. Incision
Coupled with the large volume of soft tissue obtained with and drainage of the venous congestion may not be suc-
essentially minimal donor site morbidity, the ALT flap has cessful in releasing the pressure. Although hyperbaric
become a versatile first choice for soft tissue reconstruc- oxygen may assist with delivery of oxygen to injured
tion of avulsive craniomaxillofacial defects. tissues, it will not be effective in relieving the congestion
from venous stasis. In clinical situations such as this,
ADJUNCTIVE THERAPY FOR COMPLETE AND medicinal leeches may be considered.52-54 The medicinal
leech, Hirudo medicinalis, acts by removing excess blood
PARTIAL SOFT TISSUE AVULSIONS OF THE and secreting hirudin, a long-acting anticoagulant that
MAXILLOFACIAL REGION promotes prolonged venous drainage from the puncture
site, into the tissues, resulting in a lowering of venous
HYPERBARIC OXYGEN THERAPY pressure until the injured tissues can reestablish normal
Although not indicated for routine management of soft blood flow (Fig. 31-11). During active use of medicinal
or hard tissue injuries, in the setting of vascular com leech therapy, consideration for protection of the body
promise to the craniomaxillofacial subunit, hyperbaric cavities, such as the external auditory canal, nasal aper-
oxygen therapy may have an important role in maintain- ture, or oral cavity, should be performed with oblitera-
ing the viability of an injured anatomic region. Normal tion of dead space with gauze dressings, packings, or
atmospheric sea level pressure is referred to as 1 atmo- surgical drapes to prevent migration and loss of the
sphere absolute (1 ATA). An increase in atmospheric leech. While therapy is ongoing, antibiotic prophylaxis
pressure to 2 to 3 ATA results in an increase in the oxygen- should be directed against Aeromonas spp.5 The leeches
carrying capacity of the blood by hemoglobin saturation spontaneously fall off when engorged and therapy may
and dissolving oxygen in plasma to meet all the require- need to be repeated several times to achieve the desired
ments for normal maintenance and physiologic activity, result.
even if there is insufficient hemoglobin to bind and trans-
port oxygen. This may occur in an avulsive tissue loss or RECONSTRUCTION OF AVULSIVE HARD
compromised vascular pedicle.5,48-51 As hyperbaric oxygen
saturation increases the oxygen supply to all body tissues, TISSUE INJURIES
including those that have sustained partial or complete
avulsion, hyperoxygenation can minimize or eliminate MANDIBULAR RECONSTRUCTION
hypoxic and ischemic conditions and can be used for After the patient has been medically stabilized, the fol-
temporization of such injuries. This adjunctive therapy, lowing steps are needed prior to scheduling the primary
especially in the acute traumatic injury, can maintain the reconstruction:
TABLE 31-2 Advantages and Disadvantages of Various Osseous Graft Types for Craniofacial Reconstruction
Available Soft Tissue Simultaneous

Type of Graft Bone Pedicle Harvest Advantages Disadvantages
Fibula free flap 25 cm 24 × 9 cm Yes Mandibular reconstruction, May require skin graft for
Any length, versatile, closure, edema, ankle
supports implants, blood instability, questionably reliable
supply permits contouring skin paddle
in osteotomies
Scapula free flap 14 cm 12 × 20 cm No Wide latitude in placement, Shoulder debilitation, widened
relative to skin or muscle, scar if oriented transversely
versatile orbit, base of skull, and closed primarily, thin bone
maxilla, zygoma, palate, often inadequate for implants
mandibular defect with
massive intraoral/extraoral
soft tissue defect
Iliac crest free flap 15 cm 10 × 20 cm Yes Reconstruction of large Technically difficult, especially
mandibular defects, curve in obese patients, abdominal
parallels mandible, mass weakness and hernia,
permits contouring hemorrhage, thigh pain,
osteotomies, supports +/− sensory deficits, gait
implants disturbance, cutaneous portion
of flap bulky
Radial forearm 12 cm Any portion Yes Intermediate mandibular Radius fracture, poor cosmesis,
free flap of forearm defect requiring bone and sensory deficit, bone often
skin soft tissue coverage inadequate for implants,
unicortical bone intolerant of
osteotomies
Ilium cancellous or 30-50 mL None Yes (anterior) Mandibular defects, orbital Hernia, hemorrhage, seroma,
corticocancellous (anterior) No (posterior) reconstruction, thigh pain +/− sensory deficits,
graft 80-100 mL augmentation of small gait disturbance, intraperitoneal
(posterior) midfacial defects communication (ileus,
perforated viscus)
Split calvarium Extensive None No Orbital reconstruction, nasal Palpable or cosmetic defect if
dorsum, zygoma, maxilla, outer table used dural tear
mandible
Rib 12-18 cm None Yes Mandibular condyle, ramus, Pneumothorax
anterior mandible, midface
(split), contourable
From Haug RH, Bradrick JP, Billy ML: Avulsive hard tissue facial injuries. In Fonseca RJ, editor: Oral and maxillofacial surgery, Philadelphia, 2000, WB
Saunders.
1. Appropriate clinical examination with identification The patient’s needs are then assessed and matched
of hard and soft tissue deficits with the appropriate osseous and soft tissue donor sites,
• Quantity of hard and soft tissue replacement considering the advantages and disadvantages of each
• Potential nerve grafting: Reanimation surgery modality (Table 31-2).
• Prosthetic rehabilitation plans: Auricular, ocular,
nasal; dental SIMPLE ALVEOLAR DEFECTS
2. Adequate radiologic studies Minor alveolar defects of the maxilla or the mandible
• Three-dimensional reconstruction may be reconstructed by using soft tissue local flaps or
• Fabrication of stereolithography models tissue expansion, followed by cancellous bone augmenta-
3. Soft tissue decontamination and débridement tion from the lateral anterior iliac crest or tibial bone
accomplished harvest. This harvest can be performed with a minimally
• Vitality of remaining soft and hard tissues invasive trephine or the traditional open approach. For
established the anterior iliac crest harvest, the determination for
• Sites free of potential infection: White blood cell local anesthesia, conscious sedation, or general anesthe-
count sia will be the choice of the surgeon. In a minimally
4. Viability of native vascular or recipient bed invasive trephine approach, the anterior ilium should
confirmed be palpated, determining the position of the crest and
anterior superior iliac spine.55-59 After placement of sub- MMF by whatever fashion is preferred. The various
cutaneous or subperiosteal local anesthesia, the crest of methods for surgical access to the mandible are covered
the ilium is secured, the overlying skin tensed, and a stab elsewhere in this text in greater detail, and will be
incision with a sterile scalpel blade is accomplished that deferred to the prerogative of the individual operative
is slightly larger than the diameter of the trephine. surgeon. Regardless of the method for chosen access,
After incision, the subcutaneous fat is divided and residual fibrous tissue must be removed, along with avas-
Scarpa’s fascia is identified. The fascia is incised down cular bone, from the defect, to provide adequate recipi-
through the periosteum with the scalpel blade and is ent site viability. If cancellous bone is the reconstruction
laterally displaced from the bone. The trephine is intro- choice, a titanium reconstruction plate may be placed to
duced and cancellous bone is removed with each pass maintain proper positioning of the recipient hard tissue
until a sufficient amount has been harvested to overfill sites and serve as a foundation for bone graft support. If
the defect. a corticocancellous graft is used, the reconstruction plate
In the tibial harvest technique, Gerdy’s tubercle is should be coupled with a mitered recipient site and mod-
located and identified on the anterior surface of the ified with a reciprocating or sagittal saw in a stepped
lateral proximal tibia where the iliotibial tract attaches.60 fashion to create butt joints.5
Palpation of the tubercle is essential to avoid violation of As the recipient site is being prepared, the graft
the articular surface of the tibial plateau and head of the harvest team should identify the iliac crest and anterior
fibula. A stab incision is accomplished through the skin superior iliac spine and then manually reposition the
to the layer of the fascia of the iliotibial tract and perios- overlying skin in a medial direction. This alteration of
teum, which is laterally displaced, allowing direct access tissue planes in a medial vector will prevent the incision
to the surface of Gerdy’s tubercle and underlying cancel- from lying immediately over the anterior iliac spine,
lous bone. A layer of subcutaneous fat may be readily increasing cosmesis and preventing trauma from wearing
encountered during the dissection, based on the body of pants or a belt postoperatively. A 5- to 6-cm long inci-
habitus of the patient. Care should be taken to verify sion should be created through skin, which when not
correct angulation and depth of the trephine to prevent tensed will lay 3 cm lateral to the crest. The sensory
potential iatrogenic violation of the joint space of the nerves that are most commonly encountered in this
knee. Direct pressure, electrocautery, or microfibrillar field are the lateral cutaneous branches of the subcostal
collagen is useful in controlling hemorrhage. The graft and iliohypogastric nerves. Approximately one third of
may be stored in normal saline-soaked gauze until place- patients will experience transient sensory deficits of the
ment and then a layered closure is performed. The skin over the gluteus medius and gluteus minimus sub-
defect in the alveolus is repaired by first creating an inci- sequent to this approach.5 The dissection is carried out
sion through the mucosa along the crest of the remain- as described earlier for the cancellous-only retrieval
ing ridge adjacent to the defect, much like that created technique.
for repair of secondary cleft alveolus deformities. After For adolescents and growing children treated before
incision and subperiosteal dissection, the defect is exam- ossification of the iliac crest, a lateral cortical window is
ined, curetted free of fibrous tissue, and the harvested opened with saws or chisels below the crest to eliminate
bone placed. Consideration for the use of platelet-rich the risk of growth disturbances by damaging the cartilagi-
plasma or collagen-based barrier membranes to prevent nous cap, or the cap can be carefully split in a clamshell
fibrous ingrowth into the bone graft is at the discretion manner during the dissection to prevent an iatrogenic
of the surgeon. avulsion. The cancellous marrow or corticocancellous
blocks are then harvested. A medial osteotomy is made
SMALL MANDIBULAR DEFECTS REQUIRING NO with saws or chisels, and then the iliac crest is fractured
medially while still attached to the abdominal muscles.
CUTANEOUS OR MUCOSAL GRAFTING Cancellous bone may then be curetted from the donor
Anterior Ilium site.55-59
Mandibular defects of the body, angle, ramus, or symphy- To obtain a corticocancellous block graft, a more
sis that are 5 cm or smaller and require no soft tissue extensive dissection will be required medially under the
augmentation may be reconstructed with cancellous or iliacus muscle. Saws and chisels may be used to separate
corticocancellous bone grafts from the anterior ilium55-59 the medial table and corticocancellous block from the
This technique has the advantage of having the patient ilium, taking care during the outfracture of the medial
remain in the supine position, facilitating the option for wall to guard against excessive lateral forces being applied
a simultaneous two-team approach. The disadvantages to the body of the remaining ilium and subsequent
are that simultaneous soft tissue grafting is impossible iatrogenic fracture. Hemorrhage is best controlled
with the free tissue transfer method and only relatively with electrocautery and/or microfibrillar collagen. The
small osseous defects may be repaired. For this recon- wound is closed in layers and a pressure dressing may be
structive procedure, the patient is maintained in a supine used to eliminate potential dead space. Postoperative
position under general anesthesia and a hip roll is placed infusion pumps, elastomeric or mechanical, and admin-
under the patient’s hip to be harvested to make the ilium istering controlled doses of local anesthesia have proven
more prominent. If two teams are used for the recon- beneficial in controlling the patient’s pain, reducing the
struction, the first approaches the mandibular defect and need for postoperative narcotics and expediting postsur-
the second harvests the bone from the ilium. If this is a gical ambulation.61-64 Postoperative antibiotics can be
dentate procedure, the patient should be placed into administered based on the surgeon’s preference.
their lifetime, as well as the potential for a foreign body

Posterior Ilium response by the patient’s immune system.
For bone defects larger than 5 cm, without the need for Detailed surgical approaches to the TMJ region and
simultaneous soft tissue coverage, the posterior ilium is mandibular condyle are covered in other chapters of this
the preferred donor site choice. The primary disadvan- text and will not be reviewed here. To harvest a costo-
tage of this technique is the need to have the patient in chondral graft, the skin adjacent to the fourth, fifth, or
the prone position for harvest, and then turned intraop- sixth rib is identified and an incision is made through
eratively back to the supine position for reconstruction the skin and subcutaneous tissue directly over the rib to
and stabilization of the graft. After stabilizing the patient be harvested for males; for females, the incision is created
in the prone jackknife position, the sacroiliac articula- in the inframammary crease for aesthetic concerns. The
tion, dorsal lumbar spines, and posterior iliac crest pectoralis major and then the intercostal muscles are
should be identified by palpation and marked with a identified, along with the rib and junction to the sternum.
surgical marking pen.56,57,64 A 6- to 7-cm semilunar inci- The incision is created along the rib, through perios-
sion is created over the posterior iliac crest through the teum from the midaxillary to midclavicular line.5,70,71
skin and subcutaneous fat from the posterosuperior iliac Periosteum is carefully dissected free, with care taken not
spine in a vector superiorly and laterally. The middle and to perforate the pleura, and a rib cutter is used to section
superior cluneal nerves can be avoided by placing the the rib once an appropriate length has been determined
incision along the posterior iliac crest between the sac- (Fig. 31-12A). A scalpel blade may be used to carve the
roiliac junction and the region superior and lateral to cartilaginous component of the rib from the costosternal
the posterior gluteal ridge. Identification of the lum- junction so as not to dislodge the cartilaginous cap. The
bodorsal fascia ensures the location of a proper depth of pleura is evaluated for perforation and the determina-
dissection. The periosteum should be incised in the tion for potential thoracostomy tube placement is made.
intermuscular plane over the posterior iliac crest. Sub- The wound is closed in layers.
periosteal dissection of the gluteus maximus and gluteus Once harvested, the cartilaginous component of the
medius at the posterior gluteal line will expose the lateral rib may be carved with a blade to resemble the contours
cortex. Injury to the sciatic nerve and superior gluteal of the head of a condyle (see Fig. 31-12B). Care must be
vessels within the greater sciatic notch may be prevented taken not to fracture off the costochondral junction
by carefully restricting exposure cephalad to an imagi- during modification and placement into the joint space.
nary line drawn perpendicular to the operating table The rib is inserted through the inferior incision and its
from the posterosuperior iliac spine. Caution should be position within the glenoid fossa verified (see Fig.
exercised when harvesting cancellous marrow because 31-12C). The rib can then be secured to the mandible
the medial cortical table is thin and friable and is easily with titanium screws using a lag screw technique or by
perforated into the sacroiliac articulation. Microfibrillar using a small locking plate, which aids in retention while
collagen, gelatin foam, or other hemostatic agents may preventing an inadvertent split of the rib. If concerns
be applied to the donor site before closure, decreasing remain regarding potential ankylosis development, a bio-
postoperative hemorrhage. Postoperative local anesthe- logic spacer can be introduced through the use of a
sia infusion pumps may be considered as an adjunct in temporalis muscle or temporoparietal fascia flap.72,73
controlling the patient’s pain, reducing the need for For prosthetic joint reconstruction, surgical access to
postoperative narcotics or inpatient physical therapy con- the glenoid fossa and inferior border of the mandible is
sults, and expediting postsurgical ambulation.61-63 achieved in a similar manner to the costochondral graft.
Current prosthetic reconstructive options fall under two
MANDIBULAR CONDYLE DEFECTS broad categories, temporary-transitional and definitive.
Avulsive loss of the mandibular condylar apparatus pres- Temporary-transitional TMJ reconstruction consists of
ents a unique challenge to the craniomaxillofacial trauma condylar attachments applied to existing titanium recon-
surgeon, primarily due to the limited availability of struction plates, used as an interim management proto-
reconstructive options. Although exotic choices can be col for TMJ rehabilitation (Fig. 31-13). Documentation
found in the literature, two basic choices predominate in of the temporary nature of this form of reconstruction,
current treatment philosophy: prosthetic joint recon- patient understanding, and definitive reconstruction
struction and costochondral rib graft.65-71 The costochon- plans must be present. Definitive reconstruction uses a
dral graft can be readily harvested in a two-team approach TMJ prosthesis that is anticipated to provide the final
and fashioned morphologically to re-create a condyle. reconstructive option for TMJ replacement surgery,
The cartilaginous cap is an appropriate reconstructive although by nature this appliance is also temporary in
choice for communication with the glenoid fossa or tem- that the functional life of the appliance generally is less
poromandibular joint (TMJ) disc, minimizing the risk than the lifespan of the patient. Definitive TMJ replace-
for bony or fibrous ankylosis and restricted mandibular ment can use a stock condylar prosthesis and variable
function. Surgical risks and drawbacks include second types of glenoid fossa prostheses, allowing treatment to
surgical site morbidity, potential for iatrogenic pneumo- be altered intraoperatively because of the selection and
thorax, and postoperative pain with inspiration, leading diversity of implants, or computer-aided diagnosis and
to atelectasis or decreased pulmonary function. Pros- computer-aided manufacture (CAD-CAM) prosthesis
thetic joint reconstruction alleviates the need for an addi- manufactured from a chromium cobalt alloy is also avail-
tional surgical site with its associated morbidity, but the able, providing a custom-fit prosthesis68,69 (Fig. 31-14).
patient runs the risk of eventual replacement during The advantages and disadvantages of each design are
A B
C
FIGURE 31-12 A, Delivery of a rib prior to sectioning with a rib cutter. Note the placement of the incision in the inframammary crease on
this female patient. B, The rib is contoured with a scalpel blade maintaining several millimeters of cartilaginous cap on the distal extent of
the graft, contacting the glenoid fossa to prevent ankylosis. C, Verifying positioning of the costochondral graft in the temporomandibular
joint. Note the presence of a temporoparietal fascia flap in the superior aspect of the surgical exposure.
determined by patient needs, with the size and variability result, with identification of the volume of hard and soft
of the reconstructive options dependent on the system tissue requirements and the available stock achievable
chosen. The stock set will have greater intraoperative from the chosen donor site. The choice of recipient
flexibility but limited reconstruction size, whereas the vessels for anastomosis will be determined by the degree
custom-designed appliance allows for a more detailed of injury at the site and resultant tissue injury, diameter
and extensive reconstruction of the TMJ, but without the and viability of the native vessels, and length of the vas-
ability to alter the original treatment plan. cular pedicle for the graft.
Free Fibula Flap
LARGE MANDIBULAR DEFECTS AND/OR THOSE The free fibula flap has many advantages for use in man-
REQUIRING SOFT TISSUE COVERAGE dibular reconstruction, including the ability to be easily
Osseous defects larger than 5 cm, and those requiring contoured to re-create mandibular shape, simultaneous
concurrent replacement of soft tissue, necessitate micro- transfer of an impressive stock of soft tissue to assist with
vascular surgical repair. The choice of the reconstructive mucosal reconstruction, and adequate bone stock to be
option is dependent on patient needs and clinical ben- reconstructed with dental implants (Fig. 31-15). The
efits of each modality (see Table 31-2). Comprehensive chief drawback to its use is the inability to re-create the
presurgical planning is critical to achieve the desired normal height and width of the anterior mandible
A B
FIGURE 31-13 A, Temporary condylar head prosthesis attached to a prebent titanium reconstruction bar. B, Temporary condylar
prosthesis in position after stabilization of the reconstruction plate. Proper documentation, and patient concurrence, should be present in
the medical records regarding the long-term plans for replacement of this temporary reconstruction.
A B
C D
FIGURE 31-14 A. Wax-up of the planned definitive reconstruction of the TMJ with a custom-manufactured chromium cobalt alloy
manufactured from a CAD-CAM stereolithographic model. B, The manufactured custom fossa implant and condylar apparatus after
casting. C, Intraoperative view indicating proper positioning of the fossa implant and condylar head. This patient suffered a ballistic injury
to the left TMJ during military service in Iraq, resulting in complete destruction of the normal joint anatomy. D, Postoperative CT scan
verifying correct positioning of the appliances.
Flexor
hallucis
longus
muscle
Soleus Posterior
muscle intermuscular
septum
Posterior
tibial artery Posterior tibial
and vein Peroneal artery artery and vein
and vein
Posterior
tibial Fibula Peroneal
muscle artery and
vein
Peroneus longus
Interosseous and brevis
membrane muscles
Tibia Extensor hallucis
longus muscle
Nutrient
Anterior tibial Extensor digitorum vessels
artery and vein longus muscle from the
A
peroneal
artery
Fibula
Tibia
B
FIGURE 31-15 A, B, Anatomy of the fibula for free grafting.
anatomically.74,75 The fibula ipsilateral to the site of the vascular pedicle of the fibula graft is connected to the
recipient neck vessels is generally chosen, depending on appropriate recipient vessels, providing necessary blood
prior history of lower extremity trauma and vascular flow and oxygen transport to maintain vitality (Fig.
supply concerns. The proposed skin paddle is outlined 31-17). The skin paddle is secured to the appropriate
over the fibula to ensure adequate al blood supply.5After location, providing immediate soft tissue reconstruction.
elevation of the leg and application of an operative tour- The donor site is closed primarily in layers. Customary
niquet, the skin is incised anteriorly through the deep monitoring of graft viability is accomplished in an inten-
muscle fascia and the lateral compartment muscles are sive care, monitored setting, with scheduled Doppler
removed from the graft, with only a thin cuff of muscle and clinical evaluations, with particular attention
left attached to the bone. The septum between the lateral directed in the immediate postsurgical period for poten-
and anterior compartments is then incised. tial occlusion and/or compromise of the vascular anas-
The posterior skin is transected and a cleft between tomosis. Gait disturbances are the feared consequence
the soleus and flexor hallucis muscles is developed, of fibula grafts, but fortunately the incidence of true
allowing the soleus to be separated. Proximal and distal ambulatory disability is low, with most patients exhibit-
osteotomies are created and the peroneal vessels and ing no long-term functional consequence to surgery.76-78
flexor hallucis muscle are identified, exposed, and Concerns regarding inadequacy of appropriate height
divided. Traction will expose the tibialis posterior for mandibular reconstruction with free fibula transfers
muscle, which is also divided, and the posterior tibial have been addressed by use of the double-barrel tech-
vessels, which are identified and divided. After delivery nique.79 Simply by placing two lengths of the fibula on
from the donor site, the graft can be removed and pre- top of each other, and securing the sites with titanium
sented to the recipient site surgical team for modifica- plates and/or osseointegrated dental implants, a signifi-
tion, shaping, and inset to the mandible in standard cant increase in form and volume of bony reconstruc-
fashion with titanium plates and screws (Fig. 31-16). The tion can be obtained.
A B
Osteotomy sites
FIGURE 31-16 A, The anticipated fibula recipient site replacing the

right body of the mandible. B, Fibula graft with a vascular pedicle
and small monitor skin panel C, Fibula graft inset and secured to
titanium reconstruction bar. D, Graphic representation of the classic
Reconstruction handheld osteotomy of the fibula prior to inset into the craniofacial
D plate defect.
circumflex iliac artery and vein are then identified, dis-

Iliac Crest Free Flap sected free, isolated, and traced to their origin. The
The iliac crest free flap is an excellent choice for man- external oblique aponeurosis is dissected free, and the
dibular reconstruction because it can simulate the man- ascending branch of the deep iliac circumflex artery is
dible in shape, height, and width, providing an impressive identified, which is then traced downward, making dis-
bone stock and a generous soft tissue paddle.80-82 Due to section of the vascular pedicle easier and safer.
its width and height, the iliac crest flap is an ideal recipi- The dimensions of the skin, bone, and muscle for
ent for osseointegrated implants. The anatomic position harvest are planned and diagrammed on the skin. An
in the anterior aspect of the pelvis allows for a simultane- elliptical skin paddle may be dissected with subcutaneous
ous two-team surgical approach (Fig. 31-18). Significant tissue and fascia capturing the perforating vessels. This
morbidity, including hernia, ileus, hemorrhage, and gait flap is included with a cuff of external oblique and deep
disturbances, are reported consequences of surgical abdominal muscles. The iliac crest is identified, perios-
intervention.5An incision is made along the upper border teum divided, and medial and lateral osteotomies
of the inguinal ligament and iliac crest, roughly the created with a reciprocating or sagittal saw to begin to
length of the anticipated bone graft. The deep free up the graft. The iliac muscle is divided and anterior-
posterior osteotomies are performed. The composite
graft is mobilized and the vascular pedicle dissected free,
exposed, and ligated (Fig. 31-19). After delivery of the
graft to the recipient site surgical team, meticulous
layered closure is performed, with consideration given to
placement of a suction device to prevent hematoma for-
mation. Contouring, inset, stabilization, and reestablish-
ment of vascular supply to the graft is accomplished, as
described earlier.
Free Radial Forearm Flap
As with several other reconstructive options, the radial
forearm flap has the advantage of providing bone and
soft tissue for reconstruction and can be harvested by a
second team without turning the patient.83-85 The disad-
vantages are deficient bone stock in regard to morphol-
ogy and size, which generally is unsuitable for dental
implant rehabilitation, and a smaller soft tissue paddle
than other microvascular sources.5 Although some con-
troversy exists, an Allen’s test should be performed to
ensure adequate circulation to the hand. In the rare case
of an exclusive radial artery vascular supply to the hand,
a radial forearm flap would have catastrophic conse-
FIGURE 31-17 The graft is inset and secured with titanium quences. After application of a tourniquet, an incision is
miniplates. Subsequently, the arterial supply and venous drainage created through the skin, parallel to the radius, and con-
are anastomosed to the external carotid artery (or facial or tinued distally to the wrist, curving medially. The radial
superior thyroid arteries) and jugular vein. artery and cephalic veins are then identified, dissected
Transverse
abdominis muscle
Internal oblique
muscle
External oblique External
muscle iliac artery
Ascending branch of Inferior epigastric

the deep circumflex artery and vein
iliac artery
Deep circumflex
Iliac muscle iliac artery
Deep circumflex External
iliac artery iliac vein
External iliac artery
Inferior epigastric
artery and vein
Sartorius muscle
External iliac vein
Lateral femoral
cutaneous nerve
Inguinal ligament
FIGURE 31-18 Anatomy of the ilium for microvascular grafting.
A B
FIGURE 31-19 A, Iliac crest free flap. Note that the vascular pedicle, bone, muscle and skin all contained as a composite graft for inset
into an avulsive maxillary defect secondary to a self-inflicted gunshot wound. B, Iliac crest free flap donor site. Note full-thickness removal
of iliac bone incorporated into the flap.
free, and isolated (Fig. 31-20A). The radial nerve should should also be maintained as the dissection is continued
be identified, protected, and maintained. An attempt deep to the medial and lateral border of the scapula. The
should be made to avoid the lateral and medial ante- circumflex scapular artery and veins are identified, dis-
brachial cutaneous nerves of the forearm. The flexor sected free, and isolated. Finally, the osseous flap is
carpi radialis and brachioradialis muscles are then identi- designed and osteotomies created so that scapular and
fied and separated. The radius is identified and care parascapular bone harvest may be performed. The patient
taken to preserve the perforator vessels from the radialis is repositioned allowing access to the recipient site, and
artery through the intramuscular fascia to the bone. contouring, inset, stabilization, and re-establishment of
Oblique, proximal, and distal osteotomies are first per- vascular supply to the graft is accomplished as previously
formed in the appropriate length for harvest, and then described (see Fig. 31-21B and C). The harvest site is
the bone is sectioned. Swanson et al have recommended closed in layers and standard postoperative microvascular
a harvest of only 33% or less of the diameter of the radius graft evaluation protocols will apply.
because greater amounts will compromise the integrity
of the wrist and may render the wrist susceptible to frac-
ture during rotation; any level of bone harvest from the MIDFACIAL AND UPPER FACIAL
radius reduces the breaking strength by 76%86 (see Fig. THIRD RECONSTRUCTION
31-20B and C). A split-thickness skin graft may be used
to cover the cutaneous defect caused by the harvest. The Undoubtedly, middle and upper facial third reconstruc-
wound is closed in layers while the graft is inset, stabi- tion is of critical importance in regard to the manage-
lized, and anastomosed. Physical therapy of the wrist may ment of avulsive craniomaxillofacial injuries. Serving as
be necessary and some suggest postoperative casting to the focal point of facial anatomy and characteristics,
prevent fracture. Standard postoperative microvascular accurate reconstruction of this region of the craniomaxil-
graft evaluation protocols apply. lofacial unit is necessary to allow the patient to reinte-
grate into society as seamlessly as possible. Slight deviation
Free Scapula Flap from anatomic norms can result in the patient having an
The free scapula graft may provide significant amounts unacceptable clinical result and potential long-term psy-
of bone and skin of multiple shapes, but is difficult to chological disorders.91-93 Reconstruction of maxillofacial
contour and generally does not permit placement of avulsive defects for the midfacial and upper facial thirds
osseointegrated implants because of inadequate osseous can be categorized into injuries that require simultane-
thickness (Fig. 31-21A). Harvesting the graft will require ous skin or mucosal replacement and those that do not.
the patient to be positioned in a lateral decubitus posi-
tion, or essentially prone, preventing simultaneous two- Defects Not Requiring Soft Tissue Replacement
team surgical site preparation.5,87-90 The head and torso Extensive access to the upper and middle third of the
must be protected with padding to minimize the possibil- craniomaxillofacial complex can be obtained with rela-
ity of the development of decubitus ulcers. The flap tively minor surgical incisions. While it is beyond the
design is then planned and an incision is created from scope of this chapter to detail the intricacies behind each
the posterior border of the deltoid muscle lateral and of these techniques, the approaches are covered else-
parallel to the lateral border of the scapula. The cutane- where in this text, or within other excellent photographic
ous flap is created by incision and careful dissection, and graphic sources.94 The incisions that are most versa-
maintaining the subcutaneous vascular plexus of the tile in providing access to defects of the midfacial and
scapular and parascapular skin. The thoracodorsal fascia upper face are as follows:4
Flexor carpi
radialis muscle Medial antebrachial
cutaneous nerve
Lateral antebrachial
cutaneous nerve
Brachioradialis
muscle
Cephalic vein
Radial veins
Radial nerve
Radial artery
Flexor pollicis
longus muscle
Radius
Intermuscular
fascia
A Ulna
C
FIGURE 31-20 A. Anatomy of the radius for microvascular reconstruction. B, Model representation of stabilization of the radius with
titanium reconstruction bar at the completion of graft harvest. C, Radius osteocutaneous flap procedure with sagittal saw performing
osteotomy. (From Schmelzeisen R, Neukam RW, Hausamen JE: Atlas der mikrochirurgie im kopf-halsbereich, Munich, Germany, 1996,
Carl Hanser Verlag.)
1. Coronal: Extended inferiorly to the zygomatic arch for soft tissue transfer, cranial bone is an excellent
2. Transconjunctival: Transcaruncular extension choice for reconstructive surgical procedures to the
3. Circumvestibular: Nasal extension, intercartilaginous midface and upper facial third.95-97 Identification of the
incisions coronal and sagittal sutures and then the temporal line
• Complete transfixion incision: Midfacial degloving are critical first steps in the harvest; these landmarks
approach—will require columellar sutures; nasal are necessary references to avoid potentially lethal
strut graft at closure necessary to support the nasal complications with obtaining the graft. A large volume
tip of bone can safely be harvested from the entire parietal
4. Extension of existing facial lacerations area, at least 1.0 to 1.5 cm lateral to the sagittal suture,
Properly locating and performing these incisions will mitigating exposure of the sagittal sinus and possible
provide dramatic access to the facial skeleton, accom- exsanguination, and superior to the temporal line,
plished with minimal to no visible scarring. With the avoiding the thin squamous region and potential intra-
calvarium visualized via the coronal incision and the cranial violation. A sagittal saw or fissure burr is used to
avulsive defect exposed, in the absence of a requirement outline the particular shape of the graft desired. An
Scapular spine
Infraspinatus muscle
Parascapular
Subscapular artery free graft
Teres minor muscle

Descending
Circumflex scapular cutaneous branch
artery
Lateral scapular
Transverse
margin
cutaneous branch
Lateral scapular
margin Scapular free
graft
Descending
cutaneous branch
Descending
Descending branch branch
Teres major muscle Latissimus dorsi

free graft
Triceps muscle
Thoracodorsalis artery Inferior scapular angle
C
FIGURE 31-21 A, Anatomy of the scapula for microvascular reconstruction. B, Scapula inset into anterior mandibular soft or hard tissue
defect C, Completed free scapula flap reconstructing the soft or hard tissue deficits of the anterior mandible. Note the presence of the
skin paddle reconstructing the floor of the mouth.
osteotomy is created through the outer table only into lever the cortical graft from the cranium, generally yields
the diploe, which is easily identified by the presence of a structurally intact graft without microfractures. Electro-
bleeding. cautery, bone wax, and microfibrillar collagen may be
A pear-shaped acrylic burr is then used to create a helpful in controlling hemorrhage from the donor site.
bevel for assistance with continuing the osteotomy and Use of the outer table as the graft can create irregularities
elevation of the graft adjacent to the osteotomy site. A in surface contours of the donor site that are especially
pronounced bevel will allow access by an osteotome or visible with male pattern baldness. If additional volume
oscillating saw at a 90-degree angle to the graft, decreas- of bone is required, or concerns with donor site surface
ing the likelihood of directing the osteotome or saw irregularities persist, coordination with the neurosur-
intracranially. Undermining the graft with the sagittal geon to perform a full-thickness calvarial harvest or a
saw on all four sides, followed by use of the osteotome to split calvarium technique is indicated (Fig. 31-22A).
A B
FIGURE 31-22 A, For avulsive defects of the maxillofacial region, cranial grafts are useful. This was a full-thickness graft taken by the
neurosurgeon to allow for a split calvarial technique in a ballistic trauma case. Note the presence of the titanium mesh reconstructing a
portion of the posterior skull and the presence of the burr holes used by the neurosurgeon for access. B, PEEK custom calvarial implant.
Note that the contours of the implant perfectly reconstruct the defect of the skull.
After the full-thickness calvarial graft is harvested, the contouring and reconstruction of the various osseous
inner table is sectioned free for use as the donor graft components of the midface.103 If obliteration of the
and the outer table is replaced, maintaining normal defect, and not osseous reconstruction is the goal, an
cephalic projection. Contourable titanium mesh may be ALT flap would be the preferred microvascular surgical
used as an alloplastic bone substitute. This mesh can be approach. Depending on the size and location of the
adapted to a broad range of contours and form, is bio- defect, a rotational pectoralis myocutaneous or tempora-
compatible, and can be used as bone replacement for lis flap could be considered.
the midface and upper face. Continued technologic
advances in biomaterials have provided a number of
bone substitutes projected to replace autogenous SPECIAL CONCERNS
grafting—ceramic-based (calcium phosphate), poly-
etheretherketone (PEEK), polymer-based, and allograft- COMBINED MANDIBULAR AND MIDFACIAL AND
based substitutes98-102 (see Fig. 31-22B). When addressing UPPER FACIAL HARD TISSUE RECONSTRUCTION
small residual defects or voids in the facial skeleton that Considerable amounts of hard and soft tissues may be
are not in intimate contact with the dura, paranasal required if multiple facial units are lost, especially if the
sinuses, or mucosa, acceptable cosmetic results may be adjacent or overlying soft tissue is compromised in quan-
achieved with some of these materials, such as calcium tity or quality.104 In this situation, multiple segmental free
phosphate or polymer-based pastes. Foreign body reac- osteocutaneous flaps or sequentially linked free flaps have
tions and infections have been reported when calcium a role.5,105,106 When planning treatment and executing the
phosphate pastes have been placed with direct commu- surgical procedure, it is important to keep in focus the
nication to sinus tissue. individual form for the functional units of the mandible,
maxilla, orbit, nose, and cranium.
Defects Requiring Soft Tissue Replacement
A significant challenge in the reconstruction of avulsed OSSEOINTEGRATED IMPLANTS
midfacial and upper facial hard tissue defects is the Osseointegrated implants are an integral component in
subset of patients who have additionally lost soft tissue. facial reconstruction, including patients with avulsive
It is imperative that the neurocranium be isolated from defects of the craniomaxillofacial complex. In addition
the nasopharyngeal and oronasal compartments, with to the routine dentoalveolar applications, prosthetic
the obvious microbiologic flora and environmental con- noses, auricles, and orbits can be secured through trans-
taminants present. It is also desirable for the nose and cutaneous osseointegrated implants and can comple-
oropharynx to be physically separated. The free fibula, ment the reconstruction of the total patient.107-109
free scapula, and in some cases free radius forearm grafts Osteocutaneous flaps, especially free fibula and free
are acceptable choices for midfacial injury. Each provides ilium, have been found to offer enough bony substance
soft tissue to substitute for oral and nasal mucosal lining in quality, width, and height to ensure osseointegra-
and orbital osseous support. Each can be cabled to tion.5,110 Implant fixtures may be placed at the time of
provide a palatal, zygomatic, and/or nasal or cranial the delayed primary reconstruction or during subse-
segment, although the fibula graft has more flexibility in quent operations (Fig. 31-23).
A B
C
FIGURE 31-23 A, Complete avulsion of external ear as a consequence of being ejected passenger from an MVA and sliding across the
pavement of the highway. B, Placement of auricular implants. C, Final appearance of patient after completion of prosthetic ear
replacement.
highly accurate surgical guides can be brought to the

CUSTOM-FABRICATED, PATIENT-SPECIFIC operating room with the desired surgical angles for oste-
IMPLANTS AND ENDOCULTIVATION otomies programmed into their manufacture. The result
With technologic advances, the ability to create CAD-CAM is a faster, more accurate shaping and inset of the micro-
customized, patient-specific implants, which perfectly vascular transfer, decreasing ischemia time and poten-
re-create the missing or avulsed hard tissues, will become tially improving patient outcomes (Fig. 31-24).
more prevalent. Depending on the location, extent, and
features of the injury, custom-fabricated implants are COMPOSITE TISSUE ALLOGRAFT TRANSPLANT
now a reality (see Fig. 31-22B). Ongoing efforts in the Patients with devastating burn wounds or massive disfig-
realm of regenerative medicine have succeeded with the urement to the craniomaxillofacial complex due to avul-
endocultivation of hard tissue components from biologic sive trauma, will unfortunately experience suboptimal
frameworks in Japan and Europe, and will likely see functional, cosmetic, and physiologic outcomes with con-
development of patient-specific, soft tissue regenerative ventional surgical reconstruction. The likely result will be
processes in the future, as indicated by the recent com- a multitude of psychological and emotional issues, only
pletion of the first total mandible replacement with a complicating the already arduous recovery from injury.2,91-93
patient-specific custom titanium implant.111-113 For this unique subset of patients, consideration should
be given to their suitability for composite tissue facial
COMPUTERIZED SURGICAL STENTS transplantation.37-40 A comprehensive physical and psy-
Preoperative planning with computer-based technology chological evaluation will be a necessary component in
allows for the fabrication of acrylic resin surgical stents the presurgical period at the transplantation center and
for complex reconstructive craniomaxillofacial microvas- the patient will need to be fully cognizant of the risks
cular surgical cases. Via CT analysis of native donor and associated with this intervention. Although this patient
recipient sites, virtual surgery can take place with pool is extremely limited, composite facial transplant
extremely accurate placement of the osseous compo- surgery for a select few may provide the only avenue for
nents in the correct anatomic position. By transferring attaining a quality of life previously thought to be lost
these data to a CAD-CAM–generated acrylic resin stent, forever (Fig. 31-25).
A B
C
FIGURE 31-24 A, Virtual surgery performed on a patient with avulsive loss of her anterior maxilla. She is anticipated for a free fibula graft
replacing the missing soft and hard tissue. An exact osseous reconstruction, with ideal osteotomy angles, can be created on the
computer program, and subsequently the native fibula can be aligned perfectly with the mandible, assisting with eventual dental
rehabilitation and incorporating osseointegrated implants. B, Based on the previous information gathered, a surgical guide stent is
created in a CAD-CAM format and is positioned on the fibula with precise angle cuts already determined to obtain the planned surgical
outcome. C, The stent is positioned passively on the fibula. Due to the high degree of accuracy in manufacture, the stent will align on
specific anatomic variables of the fibula, ensuring proper positioning. Once the positioning is verified, the stent is stabilized with titanium
screws. D, Sagittal saw blades are placed through the guide slots and the osteotomies are performed expeditiously.
A B
C
FIGURE 31-25 A, Cadaveric specimen with catastrophic middle and lower facial injuries, displaying significant avulsive loss of hard and
soft tissue in all regions of the face. Conventional reconstructive techniques would offer this patient a compromised final product in
regard to function and aesthetics. B, Composite tissue allograft harvested from a donor cadaver, replacing lost bony architecture and
soft tissue envelope. C, Inset of the facial transplant. Note reconstruction of hard and soft tissues, with adaptation of the graft to the
underlying facial skeleton providing superior soft tissue projection and facial aesthetics.
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wall of the iliac crest on the deep circumflex iliac artery for man- 101. Afifi AM, Gordon CR, Pryor LS, et al: Calcium phosphate cements
dibular reconstruction. In Strauch B, Vasconez LO, Hall-Findley in skull reconstruction: A meta-analysis. Plast Reconstr Surg
EJ, Lee BT, editors: Grabb’s encyclopedia of flaps: Head and neck, ed 126:1300, 2010.
3, Philadelphia, 2009, Lippincott Williams & Wilkins. 102. Gilardino MS, Cabling DS, Bartlett SP: Long-term follow-up expe-
83. Boyd JB: Radial forearm free osteocutaneous flaps for intraoral rience with carbonated calcium phosphate cement (Norian) for
reconstruction. In Strauch B, Vasconez LO, Hall-Findley EJ, Lee cranioplasty in children and adults. Plast Reconstr Surg 123:983,
BT, editors: Grabb’s encyclopedia of flaps: Head and neck, ed 3, Phila- 2009.
delphia, 2009, Lippincott Williams & Wilkins. 103. Sun GH, Patil Y, Harmych BM, Horn DB: Inpatients with gunshot
84. Jaquet Y, Enepekides DJ, Torgerson C, Higgins KM: Radial forearm wounds to the face. J Craniofac Surg 23:e62, 2012.
free flap donor site morbidity: Ulnar-based transposition flap vs. 104. Sadove RC, Powell LA: Simultaneous maxillary mandibular recon-
split-thickness skin graft. Arch Otolaryngol Head Neck Surg 138:38, struction with one free osteocutaneous flap. Plast Reconstr Surg
2012. 121:293, 1995.
85. Wolff KD, Holzle F, Eufinger H: The radial forearm graft for the 105. Demas PN, Sotereanos GC: Transmaxillary transfer for recon-
osteocutaneous fibula graft in mandibular reconstruction. Int J struction of a large palatal defect: report of a case. J Oral Maxillofac
Oral Maxillofacial Surg 32:614, 2003. Surg 47:197, 1989.
86. Swanson E, Boyd JB, Mulholland RS: The radial forearm flap: A 106. Wells MD, Luce EA, Edwards AC: Sequentially linked free
biomechanical study of the osteotomized radius. Plast Reconstr Surg flaps in head and neck reconstruction. Plast Reconstr Surg 21:593,
85:267, 1990. 1990.
87. Robb GL: Free scapular flap reconstruction of the head and neck. 107. Dilber E, Koc O, Ozturk AN, Karamese M: A craniofacial implant
Clin Plast Surg 21:45, 1994. retained auricular prosthesis: a case report. J Oral Implantol 2011
88. Urken ML, Bridger AG, Zur KB, Genden EM: The scapular osteo- [Epub ahead of print].
fasciocutaneous flap: A 12-year experience. Arch Otolaryngol Head 108. Dings JP, Maal TJ, Muradin MS, et al: Extra-oral implants: Inser-
Neck Surg 127:862, 2001. tion pre- or post-ablation? Oral Oncol 47:1074, 2011.
89. Vinzenz KG, Holle J, Würinger E, et al: Prefabrication of com- 109. Karakoca-Nemil S, Aydin C, Yilmaz H, Bal BT: A method for fab-
bined scapula flaps for microsurgical reconstruction in oro- ricating an implant-retained orbital prosthesis using the existing
maxillofacial defects: A new method. J Craniomaxillofac Surg prosthesis. J Prosthodont 20:583, 2011.
24:214, 1996. 110. Moscoso J, Keller J, Genden E et al: A comparative anatomic study
90. Swartz WM: Scapular osteocutaneous flap. In Strauch B, Vasconez of bone stock from various donor sites to assess suitability for
LO, Hall-Findley EJ, Lee BT, editors: Grabb’s encyclopedia of flaps: endosseous dental implants. Arch Otol Head Neck Surg 120:136,
Head and neck, ed 3, Philadelphia, 2009, Lippincott Williams & 1994.
Wilkins. 111. Warnke PH: Endocultivation: Computer-aided tissue regeneration
91. Islam S, Cole JL, Walton GM, et al: Does attribution of blame of customized, vascularized bone grafts for mandibular recon-
influence psychological outcomes in facial trauma victims. J Oral struction. In Strauch B, Vasconez LO, Hall-Findley. EJ, Lee BT,
Maxillofac Surg 70:593, 2012. editors: Grabb’s encyclopedia of flaps: Head and neck, ed 3, Philadel-
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cross-sectional study between UK and Australia. J Craniomaxillofac ing of bone repair and replacement materials: impact on cranio-
Surg 40:82, 2012. facial surgery. J Craniofac Surg 23:304, 2012.
93. Islam S, Ahmed M, Walton GM, et al: The association between 113. 2009 (http://www.layerwise.com/LayerWise_worlds_first_AM_
depression and anxiety disorders following facial trauma—a com- lower_jaw/PR_LayerWise_EN_Worlds_first_AM_lower_jaw.pdf).
parative study. Injury 41:92, 2010.
CHAPTER
Infection in the Patient with
32
Maxillofacial Trauma
Stuart E. Lieblich
OUTLINE
Causes of Infection Facial Bone Fractures
Local Factors Antibiotic Therapy
Systemic Factors Management of Teeth Associated With Mandibular Fracture
Anergy Infections Associated With Fractures
Management of Wounds Midfacial Fractures
Preparation of the Patient for Surgery Nosocomial Infections
Prophylactic Antibiotics Tetanus
Early Detection of Infection Treating the Patient With Viral Infection
Treatment of Wound Infection
Infections Caused by Oral and Maxillofacial Trauma
Soft Tissue Lacerations
Animal Bites
Human Bites
I
nfection following a traumatic injury continues to be the body’s initial and perhaps most important defenses
a major problem, despite many advances in the man- against bacterial invasion. Intact skin and mucous mem-
agement of the trauma patient. Local infections branes provide a mechanical barrier to bacterial inva-
occurring at the site of injury, such as osteomyelitis sion. Once bacteria have penetrated this barrier through
from a jaw fracture, may result in the loss of teeth and areas of abrasion, laceration, or avulsion of tissue, non-
bone structure. The individual may survive the initial specific and specific host defense mechanisms are neces-
injury but may be left with significant residual problems, sary to control the invasion. If colonization and growth
such as a facial deformity or malocclusion and joint of invading organisms are checked, infection will not
dysfunction. develop. This is the usual course of events after an injury
Systemic infections are likely to occur in the trauma- involving a break in surface integrity.
tized patient through two avenues. First, bacteria may It is known that a sufficiently large number of bacteria
gain direct entry to the host’s systemic circulation through are necessary to produce an infection. Studies have
the site of injury, IV line, or urinary catheter. Second, shown that an initial inoculum must contain at least 105
invasive manipulations, such as endotracheal intubation, bacteria/g of tissue for a clinical infection to occur.2,3 In
may bypass previously competent host defense mecha- a traumatic injury, however, far fewer microorganisms
nisms, causing pneumonia. Thus, although the mainte- may cause infection owing to the presence of devitalized
nance of life is addressed during the initial treatment, tissue and foreign bodies in the wound.
early interventions are necessary to prevent potentially Normally, surface flora are kept to a minimum by skin
disastrous infections. In fact, sepsis is the most frequent appendages that secrete various antimicrobial substances.
cause of death following trauma.1 Sweat gland production of lactic acid, amino acids, uric
This chapter deals with the causes of infection from acids, and ammonia is bacteriostatic.4 Secretory immuno-
traumatic injuries, suggests early interceptive methods globulin A (IgA) in the oral mucosa is also an important
that are effective at reducing the potential for infection, component of the host defense mechanism for control-
and describes the treatment of established infections ling bacterial colonization or overgrowth on the mucosal
associated with trauma to the maxillofacial structures. surfaces. Thus, a break in the skin or mucosal surface
will not in itself always provide a large enough inoculum
to produce an infection.
CAUSES OF INFECTION Vascularity is also an important local factor in the
control of invading organisms. If a wound is compro-
LOCAL FACTORS mised by vessel trauma, contusion, or edema, the trans-
After sustaining a traumatic injury, the patient has a vastly port of immunologic host defense products to the site of
increased risk of infection. At the local level, the injury injury is impaired. The decrease in circulation to the
may disrupt the skin and mucous membranes, which are tissue provides a more anaerobic environment, which
790
Infection in the Patient with Maxillofacial Trauma CHAPTER 32 791
may permit the growth of certain pathogenic organisms

that are inhibited by normal tissue oxygen tension. Local
compromise in vascularity is sometimes caused iatro
genically by the injection of epinephrine-containing
solutions. For example, a subinfective inoculum of Staph-
ylococcus aureus will occasionally produce an infection if
placed into tissues that have been injected with
epinephrine-containing solutions.5
Foreign bodies within a wound also permit infection
to occur with much lower numbers of organisms.
Infection-potentiating factors have been identified in
soil. These factors are highly charged anionic particles
that interfere with leukocyte functions and inactivate
antibiotics.6 Inoculation with only 100 bacteria/g of A
tissue may cause an infection in the presence of soil. Even
the placement of a suture will reduce the number of bac-
teria necessary to cause infection by a factor of 10,000.7
Thus, vigorous débridement and irrigation are necessary
components of wound management, along with the use
of the fewest number of sutures acceptable.
Certain mechanisms of injury are more associated
with the presence of foreign bodies within a wound. With
a gunshot wound, the missile itself is sterilized on explo-
sion and therefore can be left if imbedded in deeper
structures. Tooth or bone fragments may be carried into
deeper tissue by the primary or secondary missile and
do require removal. Other mechanisms, such as motor
vehicle accidents (MVAs), should lead the surgeon to
search for broken glass embedded in the wound. Small,
puncture-type wounds in these cases may harbor substan-
tial foreign bodies that should be removed during
primary wound treatment. These are not often apparent
on routine radiographs but may show up on computed
tomography (CT) scans (Fig. 32-1).
Nonvital tissue within a wound provides a reservoir B
and culture medium for invading organisms, allowing FIGURE 32-1 A, Significant laceration of frontonasal region
proliferation to the extent that a clinical infection will following an MVA. No fractures could be palpated in the wound.
result. Dead space in a closed wound is filled with serous B, CT scan shows a foreign body fragment, medial surface, near
exudate and cellular debris. This area is isolated from the right globe. The benefit of CT is that it can depict a foreign
the systemic circulation, depriving it of host defense body that may lead to secondary infection if not removed.
products that enter to phagocytose the bacteria.
Local wound management is therefore critical in the
prevention of infection. The goal of initial wound therapy forcing bacteria into the injured tissue are not well
is to reduce the number of bacteria to levels that can be founded. Experimental studies have shown that even
readily managed by the host. Débridement of foreign with high-pressure irrigation, bacteria and foreign bodies
bodies and devitalized tissue should be accomplished as will not be forced more deeply into traumatically injured
early as possible. Local anesthetic solutions containing tissue.9 However, a reduction in particulate material and
epinephrine should not be used because they may further bacteria within open bone wounds is not improved with
compromise the local blood supply, significantly increas- the use of high-pressure lavage versus conventional bulb
ing the potential for infection. syringes.10
Irrigation under pressure is recommended to remove The type of solution used for irrigation is also critical.
foreign bodies and reduce the local concentration of Further devitalization and tissue damage may occur if
bacteria. Gross et al8 have shown that wounds contami- toxic solutions are used to irrigate wounds. Studies by
nated with bacteria and sterilized soil were more likely to Brånemark et al11 have shown that normal saline solution
be rendered sterile if irrigation was accomplished with is the least toxic and best tolerated of the commonly used
jet lavage instead of a bulb syringe. The use of large solutions. Solutions such as hydrogen peroxide, chlorhex-
volumes of irrigation will not be effective unless the pres- idine, povidone-iodine, and hexachlorophene cause
sure equals or exceeds 8 psi. Mechanical irrigation direct tissue damage. These agents kill fibroblasts and
devices are available, but the amount of pressure neces- will further devitalize tissue and predispose the wound to
sary can also be achieved using a 50-mL syringe and a infection. “Don’t put in a wound what you wouldn’t put
19-gauge needle. Concerns that the use of a high-pressure in your eye” is a good approach to irrigating solutions
irrigation in a wound will further inoculate the site by for injuries.12
INJURY OR INFECTION
Vascular Response Inflammatory Cell Exudation Release of Mediators

(Leakage From:)
Vasoactive Inflammatory
Mediators Phagocytes Lymphocytes cell-derived Plasma Cell-Derived
mediators Systems Mediators
Endothelial Injury Granulocytes Monocytes T-Cells B-Cells
Intercellular Gaps Adherence Lymphokines Antibodies Complement Histamine
Transcellular Canals Locomotion and Killer Other Kinin Serotonin
Chemotaxis Cells Functions
Pinocytotic Vesicle Fibrinolytic Eicosanoids
Transport Phagocytosis Other
Circulation and Functions Inflammatory Coagulation Lysosomal
extravascular Microbial cell-active Components
distribution Killing mediators
of cells Prostaglandins
and factors
Lymphokines
INFLAMMATION
FIGURE 32-2 Interactions among the vascular response, inflammatory cell exudate, and release of mediators following an injury. (From
Maderazo EG: Infections and the host. In Topazian RG, Goldberg MH, editors: Oral and maxillofacial infections. Philadelphia, 1987, WB
Saunders.)
SYSTEMIC FACTORS tissue. Margination can be disrupted (e.g., by injection

Through appropriate wound management, local factors of epinephrine or by a traumatic injury), which causes a
can be controlled and modified by the surgeon to reduce transitory leukocytosis as the neutrophils are displaced
the bacterial load in a wound site. However, it is impos- from the endothelial cells back into the circulation.
sible to sterilize a traumatic wound, and some bacteria Once the neutrophils have adhered to the endothelial
will be present in the tissue. The immunocompetence of cells, they can be mobilized to the source of infection by
the host is the factor that usually determines whether a following the chemical gradient of chemotactic factors.
clinical infection will occur. Some of the known chemotactic factors include various
Once an organism has invaded the host through a bacterial toxins, the degenerative products of inflamed
break in the mechanical barrier, the next line of defense tissue, and certain reaction products of the complement
is the blood-transported phagocytic cells (i.e., neutro- system and blood clotting systems from the site of injury.
phils and monocytes). The disruption of the physical The interactions among inflammatory cell exudates, the
barrier provided by the skin and mucosa allows the direct vascular response to injury, and the release of immuno-
entrance of surface organisms into the deeper tissue. logic mediators are shown in Figure 32-2.
Phagocytosis is necessary to remove the organisms from Once the neutrophils are mobilized to the site of the
the tissue. infection, additional reactions are necessary for bacterial
Phagocytosis requires a coordinated set of actions for killing. First, phagocytosis of the organisms must occur.
the microorganisms to be removed. Initially, the circulat- This phagocytosis is enhanced by the local presence of
ing polymorphonuclear neutrophils (PMNs) must be opsonins, which coat the organism, allowing it to be
brought to the site of the bacterial invasion through the more readily phagocytosed. Opsonins include the C3b
bloodstream. When released from the bone marrow, the and C5b fragments of the complement system. The
granulocytes normally have a life span of 4 to 8 hours in phagocytosis of opsonized particles is facilitated in the
the bloodstream and another 4 to 5 days in the tissue. presence of tuftsin. Tuftsin-releasing enzyme is produced
However, in infected tissue, this span is considerably in the spleen and therefore is deficient in splenectomy
reduced, because as the granulocytes phagocytose and patients, which increases their risk of infection.13
kill the bacteria, they are also destroyed. Phagocytosis is also augmented by the presence of the
Monocytes circulate for a comparable length of time antibody specific to the offending organism. When the
and also function by phagocytosing invading organisms. antibody fragment attaches to the cell wall of the bacte-
When they leave the circulation, however, they become ria, it will activate the complement cascade. As noted, this
established as tissue macrophages and may persist for will improve the host response by the elaboration of
years in a latent state until recruited by lymphokines chemotactic factors to attract more PMNs and macro-
secreted by T lymphocytes to phagocytose an organism. phages to the site. Monocytes and neutrophils also have
A specific sequence of events is necessary to bring receptors for the Fc fragment of the antibody, which
neutrophils out of circulation to an extravascular site significantly facilitates engulfment of the organism.
where organisms are invading. Initially, neutrophils As bacterial lysis occurs, released degradation prod-
adhere to the capillary endothelial cells through a ucts attract more leukocytes and monocytes to the site of
process known as margination. This process gives the infection. Thus, the host response is augmented and will
neutrophils a foothold on entering the extravascular continue to increase until the infection is cleared.
A B
FIGURE 32-3 A, This patient sustained multiple traumatic injuries, including a laceration of his lower lip, which was primarily closed.
B, Breakdown of the wound occurred on the fifth day after injury. The blood glucose level at that time was 380 mg/dL owing to the
systemic response to severe trauma.
Once phagocytosed, the bacteria are killed through immunocompromised patients. Defects of opsonization
two mechanisms in the neutrophil, the oxygen-dependent can be caused iatrogenically in patients receiving
and oxygen-independent systems. In the oxygen- exogenous corticosteroids. The steroid binds to the
dependent system, interactions with reduced nicotinamide- receptor site on the neutrophil for the antibody frag-
adenine dinucleotide phosphate (NADPH) and oxygen ment of the immunoglobulin, preventing antibody-
create highly reactive and toxic free radicals. This process assisted phagocytosis.
is also known as the respiratory burst.
The oxygen-independent system involves a lowering ANERGY
of the pH inside a phagocytic vacuole. In the neutrophil, After major trauma, a substantial reduction in immuno-
additional bactericidal and bacteriostatic agents are pro- competence may occur. Anergy can often be demon-
duced, including lysosomes, which digest the bacterial strated, which shows that a significant loss of the delayed
cell wall, lactoferrin, which binds iron, and cationic response to infection occurs. Severe trauma also causes
proteins, which interfere with the metabolism of the overactivation of the T cell suppressor population.14 In
organism. addition to these findings, it is known that the stress of
The patient’s state of health before the trauma and trauma increases the output of endogenous epinephrine
microbial invasion plays a significant role in determining and corticosteroids. Epinephrine blocks the secretion of
the host defense responses. Certain disease states are insulin, stimulates the release of glucagon and, along
known to compromise the four functions of neutrophils with the steroid, increases gluconeogenesis. This combi-
discussed earlier—adherence, locomotion and chemo- nation of events will lead to an abnormal rise in plasma
taxis, phagocytosis, and microbial killing. For example, a glucose levels and to a notable increase in the susceptibil-
patient with poorly controlled diabetes has defects in all ity to infection. The blood glucose level of the patient
the four functions of neutrophils, despite normal anti- seen in Figure 32-3 was notably elevated following injury
body formation and complement activity. The defects in and the persistent hyperglycemia may have led to immu-
PMN activity can be reversed if adequate amounts of nocompromise, wound breakdown, and subsequent
insulin are present and a hyperosmolar state is avoided. infection.
Defects in chemotaxis will be present in patients with
inherent deficiencies in complement and in disease MANAGEMENT OF WOUNDS
states that consume complement, such as systemic lupus
erythematosus. In addition, an inhibitor to chemotaxis After the immediate needs for life support are addressed
(chemotactic factor inhibitor [CFI]) is found to be following an injury, the patient’s wounds should be
present in larger quantities than normal in patients with treated. Lacerations should be covered with sterile moist
cirrhosis of the liver, sarcoidosis, or chronic renal disease, sponges after hemostasis is achieved. Although the emer-
thereby increasing their risk of infection after injury. gency room is not always the appropriate place for defini-
Patients with certain systemic diseases or deficiencies tive wound care because aseptic conditions may be
in the production of the preceding factors are, as difficult to maintain, the treatment initiated here may
expected, more susceptible to infection. As noted, prevent infection and may preserve the maximum
patients who have had a splenectomy are lacking in amount of tissue.
tuftsin, rendering them especially susceptible to infec- On the basis of the history of the injury and direct
tion by encapsulated organisms, such as pneumococci, examination, the surgeon should first evaluate the mech-
which resist phagocytosis by PMNs. anism of injury to distinguish between blunt and sharp
Disorders of phagocytosis and bacterial killing will injuries. Significantly more force is necessary to cause
also increase the chance for infection in these soft tissue injury from blunt trauma than from shear
forces, such as glass shards or a knife.15 The additional and draws out serous and any other exudate from the
energy absorbed from blunt trauma causes a broader wound. Changing the dressing at least twice daily accom-
area of tissue contusion, ischemia, and necrosis. Thus, plishes two goals:
the stellate forehead laceration caused by striking a wind- 1. It permits observation of the wound bed to deter-
shield is far more susceptible to infection than a lacera- mine whether an infection is developing.
tion from a sharp object. The surgeon should consider 2. The removal of the pack results in débridement of
more aggressive use of débridement and antibiotic pro- dead cells and exudate that have adhered to the
phylaxis in injuries resulting from blunt trauma. gauze surface.
In general, the risk of an infection depends on the The wound is repacked at least twice daily and observed
following three factors: for 3 to 5 days. If no signs of infection are present, the
• The amount and type of microbial contamination of wound margins are sharply incised and primarily closed.
the wound Wounds treated by delayed primary closure will heal as
• The condition of the wound at the end of the treat- fast as those closed primarily, because the reparative pro-
ment (e.g., the presence of residual necrotic tissue, cesses have already been initiated. It has been shown that
foreign bodies, and bacterial numbers) as long as a clean wound is closed within 4 days following
• Host susceptibility16 an incision, the wound strength is equivalent to 7 days,
Initial wound management is then directed toward regardless of whether primary closure or delayed primary
reducing the number of organisms present in the wound. closure was used.19
This reduction is carried out by vigorous cleansing, Before the closure of questionably contaminated
careful débridement of grossly nonvital tissue, and wounds, a technique can be used to provide a rapid esti-
copious irrigation under pressure with normal saline mate of the number of bacteria present in the wound.20
only. Primary wound management must be performed This method may then guide the surgeon in determining
with anesthetic for thoroughness. Local anesthetics, if whether primary or delayed closure will be used. To
used, should be administered by a field block to prevent perform this test, the wound surface is cleansed with
deep wound inoculation of bacteria, which may occur if isopropyl alcohol to remove surface organisms and a
the anesthetic is injected directly into the wound. Solu- biopsy specimen is taken from the wound. The specimen
tions without epinephrine should be used to prevent is homogenized and diluted 1 : 10 with thioglycolate.
local tissue ischemia. With a micropipette, 0.02 mL of the suspension is placed
A decision should be reached early about whether on a glass slide and is confined to an area 15 mm in
primary or delayed closure will be performed. In general, diameter. The slide is oven-dried for 15 minutes at 75° C
only wounds that are treated early and can be adequately (167° F) and then Gram-stained.
decontaminated should be closed primarily. Because of Under high power (97×), the entire slide is examined
their rich vascular supply, facial wounds may be closed for the presence of organisms. If any are noted, the
primarily after a greater delay than would be acceptable wound is considered to contain more than 105 microbes/g
in other areas of the body. The risk of infection in facial of tissue. As noted, wounds with fewer than this critical
wounds is reduced because the preinjury quantity of bac- number are unlikely to become infected and may be
teria in the facial region is usually much less than in closed primarily. This technique was validated by com-
other areas, such as the foot, in which the numbers and paring it with the more time-consuming method of serial
types of bacteria result in a much higher infection rate. dilutions and plating of colonies. The rapid slide tech-
Therefore, many authors believe that up to 24 hours fol- nique results correlated with those of the serial method
lowing injury is an acceptable period in which to attempt and are available within 1 hour, instead of the 24 to 48
primary closure of facial injuries.17 hours necessary for the serial dilution technique.
Wounds of the face are usually closed primarily. Punc- The method of wound closure will also affect the
ture wounds are preferably left open to heal by second- chance of infection. As discussed, each additional suture
ary intention to reduce the potential for infection allows an infection to occur with a lesser number of bac-
caused by the trapping of bacteria within the wound. teria. However, to prevent the formation of a residual
Secondary healing of puncture wounds may also lead to hematoma, sutures must be placed in sufficient numbers
an aesthetically satisfactory scar, especially on a concave to close all the dead space. Studies have shown that
surface, such as the medial canthus and nasolabial approximately one third of all wound infections are due
fold.18 If adequate débridement, irrigation, and princi- to residual hematoma.21
ples of closure are followed, this primary closure of Hemostasis should be meticulously achieved but not
facial wounds that are deeper or more extensive pro- at the expense of creating areas of nonvital tissue in the
vides the most aesthetically satisfying result. More wound. Careful ligation of vessels and appropriate use of
detailed coverage of this topic can be found in Chapter electrocautery should be used . If a hematoma can be
25. In severely contaminated wounds or those in which predicted because of the exposure of large areas of med-
a significant delay in treatment has occurred, a delayed ullary bone or the raising of a large flap, drainage of the
primary closure technique should be used. In this tech- wound should be established.22 A closed system, suction-
nique, the wound is thoroughly débrided, irrigated, and type drain (e.g., Jackson-Pratt) exiting from a separate
packed open with frequent dressing changes. A wet to stab incision is least likely to serve as a conduit for bacte-
dry dressing is applied, which involves moistening sterile rial ingress into the wound. Drains should be removed
gauze in contact with the wound bed and overlaying this as soon as possible, usually within 48 hours or earlier if
with layers of dry gauze. This dressing has a wick effect drainage has ceased.
Topical hemostatic agents are occasionally necessary The physical preparation of the surgical patient is also
to arrest bleeding from the cut edges of cancellous bone important in controlling the possibility of infection.
or injured organs and when the precise source of a con- Although antibacterial agents are most often used in
tinuous ooze cannot be localized. Many formulations surgical preparation, studies have not shown a decrease
are available, including gelatin foam (Gelfoam, Upjohn, in the rate of infection when compared with the rate of
Kalamazoo, Mich), microfibrillary collagen (Avitene, infection seen when a simple soap and water scrub is
MedChem, Humacao, Puerto Rico), and oxidized regen- used. This finding is consistent with the fact that it is the
erated cellulose (Surgicel, Johnson & Johnson, Arling- mechanical aspect of the surgical scrub that reduces the
ton, Tex). The use of these agents must be tempered by local factors of infection (e.g., number of bacteria, pres-
the knowledge that most have been shown to act like ence of dirt), and that this mechanical factor is of more
foreign bodies, predisposing the patient to infection value than the antibacterial agent. In an open wound,
when a normally subinfective inoculum of bacteria is iodophors and chlorhexidine solutions are contraindi-
present. Oxidized regenerated cellulose is the only cated because they may cause tissue devitalization. A
hemostatic agent shown to be bactericidal and thus is the nonionic surfactant (e.g., decylpolyglucose [Sea-Clens,
preferred agent.23 Sween, North Mankato, Minn]) is recommended for
For superficial skin closure, reinforced tape (Steri- cleansing open wounds. This agent will not devitalize
Strips) has been shown to be superior to a cutaneous tissue and has been shown to be nontoxic, even when
suture in terms of preventing infection.24 If skin sutures injected intravenously. Using the surfactant on a sterile
are placed, they should be removed in 3 to 5 days to sponge, the wound can be thoroughly scrubbed to
preclude tissue reaction, the formation of stitch abscesses, remove debris and reduce the amount of bacterial flora.
and permanent scarring. Edlich et al have recommended using this agent exclu-
The surgeon must avoid crushing and damaging the sively on traumatic wounds.15
tissue. Devitalized tissue will result from grasping the Oxygen delivery is critical to the tissue to reduce the
wound margins with tissue forceps. Instead, atraumatic potential for infection. The role of oxygen in improving
skin hooks should be used and placed from within the wound healing is being critically reviewed in the litera-
wound to elevate the margins for suturing. ture. Studies have shown that the prediction of infection
of a surgical site can be correlated to the local oxygen
PREPARATION OF THE PATIENT tension of the wound.27 The administration of supple-
FOR SURGERY mental oxygen is therefore postulated to reduce the risk
of infection. Studies by Grief28 have demonstrated a
Factors influencing infection in the trauma patient who reduction in wound infections by the administration of
is scheduled for surgery are as follows: 80% oxygen for the period of surgery and via face mask
• Length of the preoperative period of hospitalization 2 hours following the completion of the procedure. This
• Use of razors to shave the operative site easy method of oxygen delivery would indicate a substan-
• Nature of preparation of the operative site tial benefit for the patient and consideration for earlier
• Maintaining normothermia administration to the trauma patient should be consid-
• Oxygen therapy ered, particularly if surgery is being deferred.
• Associated resuscitative procedures (allogeneic blood Because the goal is to deliver this increased oxygen to
transfusions) the tissue, it is the increase in the subcutaneous oxygen
Keeping the preoperative stay short is a factor known tension (Pso2) that is critical to improve bacterial killing
to reduce the likelihood of infection by diminishing the by white blood cells. To deliver more oxygen locally, the
period during which colonization with resistant hospital- local tissue perfusion must be optimized. Factors affect-
acquired bacteria may occur. In the traumatized patient, ing local tissue perfusion include maintenance of nor-
this is accomplished by early operative intervention mothermia. Because many trauma patients may have
rather than admitting the patient for a few days before prolonged exposure to the elements at the scene of the
surgery. For example, if there will be a delay in schedul- injury, the surgeon should expect a notable decrease in
ing the operation for an open reduction, the patient core temperature on arrival in the emergency depart-
could be considered for discharge and then readmitted ment. Peripheral vasoconstriction will reduce local tissue
on the day of surgery. Traumatically injured patients are blood flow, reducing the oxygen supply to the injured
unlikely to have an infection within 48 to 72 hours of site. The trauma patient’s core temperature needs to be
hospitalization, but the rate increases for longer stays.25 monitored and consideration for warming blanket place-
Having surgery within 24 hours of admission was shown ment is usually indicated. Exposure of the patient during
to reduce the chance of infection when compared with the primary, secondary, and tertiary surveys for injuries
longer time intervals.26 further reduces the core temperature. Mild hypothermia
The presence of hair in or around the operative site triples the risk of infection created by the reduction
must be considered by the surgeon. It is well documented in oxygen supply.29 Finally, even mild hypothermia will
that preoperative shaving will notably increase the rate increase intraoperative blood loss and the possible neces-
of infection owing to damage to the epidermal barrier sity for blood transfusions (see later), which are also
and introduction of skin flora into the planned operative associated with an increased infection risk.30
site. The preferred method of hair removal is by clipping Further reducing blood flow to injured tissue is the
or depilatory cream. If shaving is necessary, it should be presence of hypovolemia. Tissue hypoxia is directly
performed only at the start of the case. related to hypovolemia, so fluid deficits should be
corrected. Although not studied in trauma patients, the

use of supplemental crystalloids (an increase of 1.1 liters BOX 32-1 Indications for Administration of Prophylactic
on the first day versus the control group) increased the Antibiotics to Trauma Patients
Pso2 in surgical patients.31 Optimizing tissue perfusion • When the wound enters a joint space or when it is associ-
and oxygen delivery involves the administration of ated with an open fracture
greater amounts of crystalloid than what normally would • When there is heavy contamination
be indicated by observing blood pressure and urine • When adequate débridement is not appropriate
output alone. Fluid supplementation of an initial bolus • When débridement is delayed
of 10 mL/kg followed by 16 to 18 mL/kg/hr (continu- • In burns
ing for 1 hour postoperatively) notably increases Pso2 in • In injuries prone to clostridial infections
surgical patients.32
One seeming paradoxical issue in the improvement of (From Altheimer WA et al: Manual on control of infections in the surgi-
cal patient, Philadelphia, 1984, JB Lippincott.)
tissue oxygen supply for reducing infection is that the
transfusion of allogeneic blood actually increases the risk
of infection. The increase in infection is proportional to
the number of units transfused and is postulated to be risk of contamination because saliva contains 108 to 109
related to immunosuppression.33 This, in conjunction bacteria/mL.37 These wounds also warrant antibiotic
with hemorrhage, creates an additive immunodepressive administration.
effect.34 Of note is that this immunosuppression can be The surgeon must determine the appropriateness of
shown to be present for several years with reduced lym- thoroughly débriding and decontaminating the wound.
phocyte function, natural killer cell cytotoxicity scores, If the injury involves essential structures—such as nerves,
and helper and/or suppressor cell ratios.35 glands, or major amounts of facial tissue—the surgeon
may be reluctant to débride the area extensively. If nonvi-
PROPHYLACTIC ANTIBIOTICS able tissue, foreign bodies, and dead space are left
behind, the risk of infection is vastly increased despite
The administration of prophylactic antibiotics is often the use of antibiotics. A delay in débridement and decon-
indicated in the injured patient. Using the most common tamination also permits the wound to fill with serous
classifications of wounds—clean, clean-contaminated, exudate and cellular debris and an invasive infection may
contaminated, and dirty or infected—traumatic wounds be initiated.
fall into the last two categories. Because of this, the risk Other factors that affect the decision regarding
of infection is much higher in these two types of wounds whether to use antibiotics may be present. Correlations
than in clean operative incisions and antibiotics prove exist between the length of surgery and risk of infection.
valuable when administered prophylactically. Traumatic As a general guideline, if the surgery is expected to take
wounds are already inoculated by bacteria, so many more than 4 hours, prophylactic antibiotics should be
authors consider the administration of antibiotics adjunc- administered. As noted earlier, certain preexisting
tive in this situation as opposed to a true prophylactic or medical conditions that potentiate the risk of infection
therapeutic indication. may be present. Local wound healing and host defenses
To obtain the maximal protective benefit and reduce are often compromised in morbidly obese or malnour-
the rate of infection, prophylactic antibiotics must be ished patients and antibiotics are often given in these
administered within 3 hours after the inoculation of situations.38
bacteria.36 When the administration of the antibiotic is In trauma patients, prophylactic antibiotics should be
delayed beyond 3 hours, the bacteria are able to invade administered by the IV route. Obtaining high serum
and multiply in the wound. The products of hemostasis levels of the antibiotic is mandatory and additional delays
(e.g., fibrin) further isolate the bacteria from the host because of absorption from the oral route must be
defenses, allowing enough bacterial growth to cause an avoided. The IV route is also the most predictable method
invasive infection. of achieving and maintaining blood levels.
Thus, the decision whether to administer prophylactic The amount of antibiotic administered must be altered
antibiotics to the trauma patient must be made as soon from standard dosing based on the amount of fluid resus-
as the patient comes to the emergency department. The citation the patient has undergone. Units of blood, crys-
American College of Surgeons recommends the admin- talloid, and other fluids can greatly increase the volume
istration of antibiotics to the traumatized patient in the of distribution (Vd) available for the antibiotic to be
situations listed in Box 32-1. diluted, thus potentially causing a subtherapeutic serum
The seriousness of the consequences of an infection level.39 The amount of cephalosporin necessary to prevent
must be considered when determining if an antibiotic infection in an experimental animal model with vascular
should be administered. If the consequence is trivial, shock was found to be increased seven times.40
such as the occurrence of a dry socket, no antibiotics are The frequency of dosing is related to the antibiotic’s
necessary. However, infection of a joint or bone from an half-life (t 12 ). Repeat doses should be given at an interval
open fracture may lead to permanent disability and, in of twice the t 12 of the drug.41 A drug such as penicillin
these situations, antibiotics are indicated. They are also has a t 12 of 0.5 hour and would be repeated at 60- to 90-
indicated with jaw fractures because teeth and bone may minute intervals for prophylaxis.
be lost if infection occurs. Maxillofacial wounds commu- Once the operative procedure is completed, with the
nicating with the oral cavity are associated with a higher wounds débrided and closed, there is little indication for
the continuation of antibiotic therapy. However, when

there is the potential for continued salivary leakage into BOX 32-2 Guidelines for Administration of Antibiotics to
the wound, antibiotics are given for a period of 3 days to Trauma Patients
allow a seal to form between the wound and oral cavity. • Administer immediately on arrival at the emergency room
An example of such a situation would be an open reduc- • Administer the antibiotics IV
tion of a mandibular fracture with a tooth in the line of • Dose at twice the t 12 of the antibiotic
the fracture. Because of the seriousness of the potential • Discontinue the antibiotic at the end of surgery unless per-
infection (osteomyelitis), antibiotics are continued until sistent contamination is anticipated (e.g., salivary leakage)
there is soft tissue coverage of any exposed bone. There • Choose an antibiotic on the basis of the potential infectious
is a tendency to administer antibiotics for an excessive organisms (e.g., penicillin for intraoral trauma versus a
length of time in the severely injured patient. One study42 cephalosporin for contaminated external wounds)
found that IV antibiotics were administered for an
average of 15 days to noninfected patients. Besides the
cost factor, the surgeon must consider possible toxicity adequate débridement is not possible, a 7- to 10-day
and other side effects from prolonged administration. course would be indicated.
The choice of antibiotic will be based on the potential Once the need for antibiotics has been established,
type of infection that can occur from the injury. Facial administration should follow the guidelines in Box 32-2.
soft tissue wounds are subject to staphylococcal infection,
but prospective studies of wounds have not shown a EARLY DETECTION OF INFECTION
benefit from prophylactic antibiotic administration.36
Instead, proper wound care principles (débridement, After a traumatic injury, careful and continuous monitor-
irrigation, hemostasis, and careful closure) will prevent ing of the patient is necessary to determine whether
most infections in this region. infection may be developing. The cardinal signs of rubor,
The compromised host is an exception to this guide- dolor, calor, and tumor may be present. However, early
line. Patients known to have a higher incidence of infec- detection of an infection will permit treatment to be
tions, such as those with poorly controlled diabetes or more effective than if delayed until a full-blown infection
asplenic patients, may require antibiotic coverage. Facial is present.
lacerations should be treated with vigorous wound care Local wound changes that indicate a developing infec-
and a decision should be made regarding the necessity tion include redness, increased heat, and localized
for prophylactic antibiotics. The use of a cephalosporin, edema. The differentiation between cellulitis, which is an
such as cefazolin, should be considered for facial lacera- early sign of bacterial invasion, and inflammation, which
tions. Penicillin should be used only if there is concern is part of the usual process of wound healing, may be
for intraoral bacterial contamination. If an antibiotic is difficult.
used, it must be administered immediately on presenta- If the condition is due to the traumatic insult, it will
tion because delays reduce its potential effectiveness. be noted in the first 24 hours following an injury. If bac-
Another group of patients who should have antibiotic teria are responsible for the local tissue damage, the
coverage are those with prosthetic heart valves and any inflammatory response will persist and progress beyond
of the other risk factors for the development of bacterial the first 24 hours. Local vasodilation of capillaries
endocarditis (valvular disease). Cases of prosthetic valve will cause the area to become erythematous and warm.
endocarditis (PVE) have been reported following facial Chemical mediators of inflammation (e.g., histamine,
wound infections.43 There are additional complications bradykinin, serotonin, prostaglandins, products of the
in the management of these wounds because most of immune system) will collect in the area. Swelling intensi-
these patients are receiving anticoagulant therapy. fies, nd the wound may become indurated as the extra-
Recommendations for wound management in patients vascular fluid clots owing to the presence of fibrinogen
with prosthetic valves include immediate administration and other plasma proteins, which in turn block lym-
of IV antibiotics on entering the emergency department. phatic drainage of the injured area. This reaction is
The regimen used for facial lacerations is cefazolin plus the host’s attempt to contain or wall off the invading
gentamicin.43 This combination is synergistic against the bacteria.
resistant forms of staphylococci, which are responsible The systemic response to infection and injury will
for most cases of PVE. If the patient is allergic to the include immediate leukocytosis caused by the release of
penicillins, vancomycin is used. Wound management granulocyte-releasing factor from the breakdown of the
should be carried out in the operating room instead of inflamed tissue. Leukocytes are recruited from the bone
the emergency department, even if general anesthetic is marrow and spleen and marginated intravascular leuko-
not indicated. This practice provides a more aseptic envi- cytes are mobilized in response to injury. The stress of
ronment and reduces the risk of hospital-acquired the traumatic injury is also known to cause a transient
infection. leukocytosis through increased secretion of endogenous
The length of time necessary for administration of the corticosteroids and epinephrine.
antibiotic is determined by the nature of the wound. Inflammation will also cause the release of a colony-
Because the wound occurred in the community, it is stimulating factor that increases the rate of production
initially considered contaminated but can be rendered of leukocytes from the bone marrow. This activity will
clean by appropriate wound care. In this case, antibiotics cause an increase in immature forms (band cells) to be
would be continued for a maximum of 2 days. If noted in a peripheral blood smear and is more diagnostic
FIGURE 32-4 Steps in evaluating the cause of infection in a trauma patient. (From Majeski JA, Alexander JW: Complications of wound
infections. In Greenfield LJ, editor: Complications in surgery and trauma, Philadelphia, 1984, JB Lippincott.)
of an infectious process than of a simple increase in the release pyrogen as a result of phagocytosis. This induc-
number of neutrophils. tion is confirmed by the presence of a lag time between
The formation of pus at the suspected site of infection phagocytosis and a rise in temperature.45 Thus, the neu-
is the result of a continuing host response to the invading trophils do not contain pyrogen but are stimulated to
organisms. As tissue macrophages and neutrophils conform it after contact with exogenous pyrogens.
tinue to phagocytose bacteria, they die and lyse. The The differential diagnosis of fever in the trauma
local blockage of tissue lymphatics causes a cavity to form patient is often complicated by multisystem injury. An
in the region; this cavity contains a combination of dead algorithm for guiding the workup of an infection in the
white blood cells and necrotic tissue, which is clinically trauma patient is presented in Figure 32-4. Clinical
noted as pus. The formation of pus is an irrefutable local inspection of the wound is the most important diagnostic
sign that infection has occurred. In the severely anergic tool in determining if the fever is due to wound infection.
patient (anergy may occur even in previously healthy Local signs, such as increasing inflammation, induration,
individuals following major trauma), pus may form local pain, and edema, often precede frank drainage and
without the preceding signs of inflammation.44 pus formation.
Monitoring the patient’s temperature may also Any drainage from a wound site should always be care-
confirm the presence of an infection. Body core tem- fully collected for Gram staining and cultures. If local
perature is regulated by the hypothalamus and normally signs warrant, sutures should be removed and the wound
fluctuates around a range of 1° F (−17° C), with the peak opened to permit further evaluation and allow drainage.
temperature occurring at approximately 6 pm daily. The To obtain fluid for cultures, the ideal collection tech-
diurnal increase in endogenous corticosteroids in the nique is to prepare the skin surface with an antiseptic,
morning usually blunts a fever, so measurements should allow it to dry, and aspirate the fluid into a sterile syringe.
be obtained in the late afternoon or early evening when Any air in the syringe is expressed and the syringe is
the corticosteroid levels are lowest. Rectal temperature capped and immediately transported to the laboratory
recordings should be made because they reflect body for aerobic and anaerobic cultures. The laboratory
core temperature more accurately. should be alerted that anaerobic cultures are being sub-
Fever, a body temperature higher than normal, is mitted. Gram staining is also performed at this time to
usually caused by exogenous substances (primarily bac- provide immediate evidence of bacterial invasion and
teria and endotoxin) and released endogenous proteins some preliminary indication of the type of bacteria
known collectively as pyrogens. These pyrogens act on present, because the cultures will take at least 24 hours
the thermostatic control in the hypothalamus to reset to yield positive results.
the homeostatic temperature at a higher level, resulting Other causes for a rise in the patient’s temperature
in fever. Endogenous pyrogen is produced from white must also be considered. The cause of the fever may be
blood cells, with the major source being neutrophils, differentiated by the time at which it occurs. For example,
monocytes, and eosinophils. Neutrophils are induced to after an operation, a fever that develops in the initial
24-hour period is often a result of atelectasis, which is not many of the invading organisms, usually beta-hemolytic
an established infection, but the collapse of the small streptococci.
airways that entrap bacteria in the lungs. The alveolar Cellulitis is managed with antibiotics and warm soaks.
macrophages and recruitment of neutrophils initiate the Penicillin is the antibiotic of choice for non–hospital-
inflammatory response; pyrogens are produced and acquired cellulitis.50 Early therapy for cellulitis increases
fever ensues. If left untreated, pneumonia can develop the chance that the host response can remove the invad-
as the bacteria proliferate and invade the collapsed lung ing organisms. Incision and drainage are indicated only
segment. Patients with traumatic injuries have a sixfold to relieve pressure and only if ischemia is developing.
higher rate of acquiring pneumonia in the intensive care Once a local abscess or collection of pus develops,
unit than nontrauma surgical patients.46 The risk is surgical management of the wound is indicated. The
increased if there is chest trauma and frequent sputum abscess cavity may be surrounded by a cellulitic area, but
cultures are indicated. Early pneumonia is often due to incision and drainage of the wound are part of the
Haemophilus influenzae. Individuals with chronic alcohol- initial management. Surgical drainage provides many
ism also have a twofold increased likelihood of having important functions in the management of the infec-
pneumonia.47 tion. By establishing drainage, the number of bacteria
Urinary tract infection should be considered in any present in the tissue is notably decreased. In addition,
patient who has had a Foley catheter placed at some time. the local collection of bacterial products, such as endo-
Urosepsis in these patients is usually from a hospital- toxins, is reduced. The fluids that collect in a wound
acquired organism, necessitating culture and sensitivity become less active in supporting host phagocytosis and
testing before treatment. neutrophil killing. Opsonization is also reduced and
The development of so-called third-day fever should drainage of a wound will improve these vital neutrophil
alert the surgeon to the possibility of an infection caused functions.
by an IV catheter. Catheters are responsible for 40% of Finally, drainage of an infection also provides speci-
fevers that develop on the second or third day of hospital mens for Gram staining and for culture and sensitivity
admission.1 As a rule, IV sites should be changed every testing. Appropriate antibiotic therapy may be instituted
48 hours. In addition, many hospitals routinely change while waiting for the culture results. However, antibiotic
all lines inserted in the field or in the emergency room administration is not a substitute for surgical manage-
on admission to the floor. These acutely placed lines are ment of an infected wound, which should not be delayed.
associated with a higher rate of infection.
Patients with closed head injuries are also at risk for INFECTIONS CAUSED BY ORAL AND
maxillary sinusitis, which may lead to persistent bactere-
mia48 and unexplained fever. These patients have often MAXILLOFACIAL TRAUMA
received corticosteroids along with prolonged nasogas-
tric or nasotracheal intubation. Facial films obtained at SOFT TISSUE LACERATIONS
the bedside can show opacification; early treatment with The large quantities of endogenous organisms contami-
lavage will resolve the infection rapidly. nating an intraoral tissue injury would apparently predis-
Finally, the surgeon must be aware of noninfectious pose many patients to infection. The bacterial count in
causes of fever. The most common is a drug fever, which saliva is high (108 to 109 bacteria/mL), with anaerobes
represents a hypersensitivity reaction. Eosinophils, which outnumbering aerobes by about 5 : 1. In reality, the rate
are involved in allergic reactions, are stimulated to of infection from an intraoral laceration is low. The well-
produce endogenous pyrogens and are often found in vascularized tissue may confer an advantage on the host’s
increased numbers during a drug fever. Eosinophilia will ability to prevent an infection in the presence of a large
be noted in the differential white blood cell count in number of bacteria. Complete débridement of devital-
cases of drug fever. Cessation of the offending drug ized intraoral tissue can be accomplished with less
(usually an antibiotic) is indicated; the temperature will concern for the aesthetic result than would be necessary
return to normal in 48 to 72 hours.49 for extraoral lacerations.
Patients with maxillofacial trauma often have sus- The routine use of antibiotics for the uncomplicated
tained blunt head injury, which may cause contusion of intraoral wound is unnecessary. Instead, thorough
the hypothalamus. Typically, the loss of temperature reg- débridement, removal of any foreign bodies, irrigation,
ulation in these patients will be noted by periods of and careful closure are indicated. If an antibiotic is indi-
hyperthermia and hypothermia.45 cated, penicillin is the drug of choice because of its effec-
tiveness against oral anaerobes.
TREATMENT OF WOUND INFECTION Soft tissue lacerations of the face and scalp have also
been shown to be relatively resistant to the development
Once a wound infection is diagnosed, local treatment is of a wound infection. In studies of infection following
indicated and a decision regarding systemic therapy must soft tissue lacerations, the rate of infection of facial lac-
be made. Cellulitis is the most common infection in sur- erations was only 1.3% compared with 12.5% of lacera-
gical practice. True cellulitis is an invasive nonsuppura- tions of the feet.51 This difference in infection rate is
tive infection. The signs of redness, warmth, and pain most likely caused by the lower number of endogenous
are due to the inflammatory response elicited by the bacteria found on the face when compared with the feet.
invading bacteria. Walling off the inflammation is not It has been shown that all tissues have the same resistance
seen because of the fibrinolytic agents elaborated by to infection (tongue, fat, muscle, skin), but an infection
administration of antibiotics for facial wounds caused by

animal bites.54 Instead, of all the variables controlled for,
the lack of débridement was found to cause the highest
rate of infection.
The microbiologic features of infections caused by
animal bites will differ from those usually noted in trau-
matic injuries, owing to the different flora of the animal’s
mouth. A gram-negative rod, Pasteurella multocida, is
responsible for 30% of infections from dog bites. Its
pattern of infection is such that rapid development of
local erythema, pain, and swelling occur within 24 hours
of injury, enabling the diagnosis to be made on the basis
of clinical course. If the infection occurs after 24 hours,
it is usually caused by S. aureus or Streptococcus viridans,
and occasionally by Bacteroides spp. and fusobacteria, all
FIGURE 32-5 A patient with significant road abrasions and avulsed of which are common intraoral organisms in a healthy
tissue incurred after being dragged by a motor vehicle. These animal.55
road burn injuries can become infected by Bacillus spp., which Asplenic patients and other immunologically compro-
are usually rare pathogens. mised individuals are also susceptible to infection by a
group of aerobic, gram-negative bacilli found in animals.
uniformly developed in those tissues once a level of more These organisms are identified by the Centers for Disease
than 106 bacteria/g of tissue was reached.36 Control and Prevention (CDC) by alphanumeric names—
Again the decision regarding whether to use prophy- IIj, EF-4, and DF-2. Infection with these organisms is
lactic antibiotics for lacerations of the face is not clear- usually manifested by cellulitis, bacteremia, purulent
cut. No study has shown a decrease in the rate of infection meningitis, and endocarditis. Thus, because of the
if an antibiotic is given. Instead, the clinician must be serious sequelae of this infection, penicillin prophylaxis
guided by some of the factors known to increase the risk is indicated after a dog bite in all asplenic and alcoholic
of wound infection, as discussed earlier. patients (including bites from one’s own pet).56 Penicil-
Certain mechanisms of injury will direct the clinician lin is also the drug of choice for the prevention and
toward a specific treatment. For example, road burn inju- treatment of P. multocida infections; tetracycline and
ries (Fig. 32-5) are frequently contaminated with Bacillus erythromycin may be used in patients with a known
spp. other than Bacillus anthracis. Bacillus spp. are sapro- history of an allergic reaction to penicillin.
phytes existing in soil and dust, which previously were An additional consideration in the treatment of animal
thought to be nonpathogenic.52 They are typically resis- bites is the determination of the necessity for prophylaxis
tant to β-lactam antibiotics. Thus, in heavily contami- against rabies. The rabies virus causes an acute encepha-
nated wounds or in those that cannot be completely lomyelitis in infected individuals, with almost 100% mor-
débrided, antibiotics are indicated. An interesting factor tality. Typically, rabies is transmitted through a bite by an
may be the length of the wound. Some studies have infected dog, but cats, horses, cows, skunks, bats, rac-
noted an increase in infection rate based on the number coons, and foxes are also associated with its transmission.
of sutures necessary to close the wound. Stellate lacera- It is unusual to find rabid rodents, lagomorphs (rabbits),
tions with abrasion of the wound edges also have an birds, or reptiles.
increased rate of infection compared with simple linear The infection is transmitted from the saliva of an
lacerations. infected animal to the nervous system of the bitten
It must be emphasized that if antibiotics are to be person by spread from the peripheral nerves to the spinal
given, they should be administered by a parenteral route ganglia and into the central nervous system. This migra-
immediately on entry to the emergency room. There is tion of the virus occurs rapidly, with viral particles found
no benefit to closing a laceration and handing the patient in the brain within 72 hours.
a prescription to be filled at some later time if there is a Bites from animals that may be infected with rabies
concern about potential wound sepsis. No prophylactic must be treated aggressively. Postexposure prophylaxis is
effect is demonstrated by antibiotics administered 3 given in cases of unprovoked attacks by domestic animals
hours or more after injury.53 (unless the animal is known to be immunized) and in
cases of wild animal bites. Initial wound care is impor-
ANIMAL BITES tant, consisting of thorough irrigation with quaternary
Lacerations from animal bites are considered heavily ammonium compounds with 70% alcohol, which have
contaminated wounds. Immediate treatment of the been shown to be rabicidal.57 Rabies immune globulin
wound is indicated, with measures directed at reducing and active immunization are also given, along with pro-
the number of organisms present. High-pressure saline phylaxis against tetanus (see later).
irrigation and thorough débridement are the mainstays
of treatment. HUMAN BITES
Dog bites of the face and scalp are much less likely to Many authors believe that human bites are more serious
become infected than those at other sites. Again, studies than animal bites and should be treated differently.
have failed to demonstrate a significant benefit to the However, contemporary management that includes
A B
C
FIGURE 32-6 A, Human bite wound causing avulsion of a portion of the lower lip. The wound was packed open for 4 days and observed,
with daily dressing changes. At the time of closure, there were no signs of infection. B, Primary closure of the wound. C, Its appearance
3 weeks following closure. Excellent cosmetic results were obtained with delayed primary closure. (Courtesy Dr. David Forman.)
débridement, prophylactic antibiotics, and copious irri- is a delay in treatment or in the arrival of the patient in
gation has reduced the infection rate of human bites to the emergency room.
the face to about 2.5%.55 As with animal bites, the ana- Antibiotics, if indicated, must be administered imme-
tomic location of the injury plays an important role, with diately on arrival of the patient. Again, no clinical trial
facial injuries having a much lower incidence of infection clearly shows an advantage to antibiotic administration
than extremity wounds. for bites to the face. In fact, in low-risk human bite
The aesthetic results of treating a human bite are wounds, which penetrate only the epidermis and are
improved if primary closure can be performed. A delay treated within 24 hours, no decrease in infection was
in treatment or a failure of adequate surgical débride- seen with the administration of antibiotics.58 The oral
ment of the wound, however, may lead to wound break- cavity preponderantly contains anaerobes sensitive to
down and a compromised aesthetic result. Thus, in the penicillin and this is the drug of choice. Antitetanus
attempt to attain primary closure, extensive surgery may therapy is unnecessary, because Clostridium tetani has
be necessary and should probably be undertaken in the never been shown to be present in the mouth59 (for an
operating room. in-depth discussion of bite injuries, see Chapter 27).
The high bacterial count in saliva results in an exten-
sive inoculum in the wounded person. Often, the surgeon
may elect to treat these wounds by delayed primary FACIAL BONE FRACTURES
closure. In these cases, the wound is packed with moist
gauze, which is changed twice daily. The dressing changes Because the morbidity of osteomyelitis is so notable, the
remove the fibrinous exudate that collects in the wound appropriate management of facial bone fractures is
and could support bacterial growth. In addition, the important. Early management is necessary to prevent
twice-daily dressing changes provide a chance for fre- infection resulting from the frequency of oral contamina-
quent observation and monitoring for the development tion of the fracture site. It is a rare mandibular fracture
of infection. After a 4-day waiting period, primary closure that is not considered contaminated at the time of pre-
can be carried out, with little risk of infection (Fig. 32-6). sentation. Exceptions would be closed fractures of the
This technique of closure is particularly indicated if there subcondylar region. These, along with closed fractures of
TABLE 32-1 Antibiotic Recommendations for Maxillofacial Trauma Patients
Injury Antibiotic Pencillin-Allergic Duration

FACIAL SOFT TISSUE
<12 hr from injury; cleaned, no None NA NA
foreign bodies remain
>12 hr, contaminated; foreign Cefazolin, 1 g q8h (add Clindamycin, 900 mg IV q8h 48 hr postclosure, change to
bodies remain; delayed metronidazole, 500 mg IV (add metronidazole, 500 mg PO
closure q6h, to above if grossly IV q6h, to above if grossly
contaminated) contaminated)
>12 hr, contaminated, with Aq Pen G, 2.0 mU IV q4h Clindamycin, 900 mg IV q8h 48 hr postclosure, change to
intraoral communication (add metronidazole to (add metronidazole to PO
above if grossly above if grossly
contaminated) contaminated)
MANDIBULAR FRACTURES
Condyle, closed None NA NA
Open fracture (intraoral wound) Aq Pen G, 2.0 mU IV q4h Clindamycin, 900 mg IV q8h IV until fracture trx, then 48 hr
postop
Open fracture + gross Ampicillin-sulbactam, 1.5 gr Clindamycin, 900 mg IV q8h 72 hr post-treatment
contamination IV q6h plus
± delayed trx Metronidazole, 500 mg IV q6h
ZYGOMATIC, MAXILLARY None NA NA
FRACTURE
FRONTAL SINUS FRACTURE Ampicillin-sulbactam, 1.5 g IV Clindamycin, 900 mg IV q8h 72 hr postoperatively
q6H
PANFACIAL FRACTURE Ampicillin-sulbactam, 1.5 g IV Clindamycin, 900 mg IV q8h 72 hr postoperatively
(CONTAMINATED) q6h plus
or Levofloxacin, 750 mg IV or
Piperacillin-tazobactam, PO qd
3.375 g IV q6h
NA, Not applicable.
Adapted from U.S. Army Institute of Surgical Research: Joint theater trauma system clinical practice guideline: Guidelines to prevent infection in combat-
related injuries, 2012 (http://www.usaisr.amedd. army.mil/assets/cpgs/Infection_Control_2_Apr_12.pdf).
the zygoma and other facial bones, would not be indi- and isolated from the systemic circulation and to multi-
cated for antibiotic treatment60. ply into the critical number necessary to cause an infec-
If definitive treatment of mandibular fractures is to be tion of the fracture site.
delayed, temporary intermaxillary fixation is indicated to The surgeon’s choice of antibiotic will be guided by
prevent mechanical pumping of saliva and bacteria into many factors, including the following:
the fracture site. This can be readily achieved with inter- • Identification of the causative agent or the usual
maxillary fixation screws or the placement of bridle-type organism that may cause an infection if prophylaxis is
wire for fractures within dentate segments. Movement of indicated
the fracture also causes rebleeding at the fracture site, • Use of the least toxic antibiotic
which increases the local hematoma and causes a more • The patient’s drug history—to avoid known drugs to
anaerobic environment. The temporary intermaxillary which the patient has previously reacted adversely
fixation will also make the patient more comfortable. • Use of a bactericidal as opposed to a bacteriostatic
drug, because the bactericidal drug relies less on the
ANTIBIOTIC THERAPY host’s resistance, kills the bacteria directly, and works
All jaw fractures involving tooth sockets must be consid- faster
ered compound fractures requiring antibiotic treatment. • Cost of the antibiotic regimen41
More recent studies have looked at the risk of infection A guideline for consideration of antibiotic administra-
of facial fractures and noted that mandibular fractures tion is presented in Table 32-1.
are the most common types associated with infection.
Rarely are infections noted with other facial fractures. MANAGEMENT OF TEETH ASSOCIATED WITH
Because this decision can be made early, with an exami- MANDIBULAR FRACTURE
nation of the patient, parenteral administration should A significant controversy centers on the management of
not be delayed, even if definitive treatment of the frac- teeth in the line of fracture and their relationship to
ture is deferred. As noted, delays in the administration infection. Studies of complications of mandibular frac-
of an antibiotic may allow bacteria to become established tures have shown a higher incidence of infections when
FIGURE 32-7 Osteomyelitis developed after the open reduction of this mandibular fracture. The placement of multiple wires in an area of
comminution requires stripping of the periosteum from the small bone fragments and a subsequent devascularization.
teeth are involved in the line of fracture. This finding has

led some clinicians to recommend extracting all teeth in BOX 32-3 Risk Factors for Osteomyelitis
the line of fracture. In 1965, Bradley suggested removal
of all teeth associated with a fracture.61 More recently, • Ineffective fixation, reduction, and immobilization
a retrospective review of 327 mandibular fractures • Delay in treatment (old fracture)
appeared to recommend leaving in place healthy non- • Delay in administration of antibiotic therapy or inadequate
mobile teeth in the line of fracture.62 Contemporary frac- antibiotic therapy
ture management supports removing teeth in the line of • More than 50% of a tooth root exposed in a fracture
fracture only if the following conditions exist: • Premature removal of fixation devices
• The tooth is loose. • Devitalized segments of bone in the fracture site because
• The tooth is grossly carious or periodontally involved. of excessive stripping of periosteum, overzealous use of
• More than 50% of the root is exposed in the fracture transosseous wiring, or overheating of the bone by burs
line. • Decreased host resistance or increased susceptibility to
• Adequate reduction is mechanically blocked by its infection (e.g., patient is alcoholic, diabetic)
retention.
Retention of healthy firm teeth may help in the reduc-
tion of a fracture and preserve the dentition.
Zallen and Curry have shown that with the administra- infection. Bacterial contamination of the fracture site
tion of antibiotics, the incidence of infections is signifi- should be reduced on fixation of the fracture and some
cantly reduced if teeth are involved with the fracture.63 method of temporary fixation should be applied as soon
Although their study was not controlled, the incidence as possible. Open reduction allows débridement of any
of infection was 50% without antibiotics and 6% if they nonvital tissue and evacuation of hematoma and permits
were given. When mandibular fractures are compounded close alignment of the fracture, thus reducing the dead
into the oral cavity (i.e., through the dentoalveolar struc- space. However, open reduction may also result in further
tures), therapeutic antibiotics should be administered devascularization of tissue, especially when small bone
immediately. These fractures are contaminated or even fragments in a comminuted fracture have been stripped
infected at the time of presentation. The antibiotic of of the periosteal attachment. Considering these factors,
choice is penicillin. If the fracture is compounded onto the surgeon should exercise good judgment in perform-
the skin, a penicillinase-resistant penicillin should be ing an open reduction when notable communition of the
added or a semisynthetic penicillin with a β-lactamase fracture has occurred (Fig. 32-7).
inhibitor should be used. Clindamycin is used in patients
allergic to the penicillins. Alternatively, a cephalosporin, INFECTIONS ASSOCIATED WITH FRACTURES
such as cefazolin, can be used, which has been shown to Owing to the compound nature of most fractures of the
reach high levels in bone. Antibiotic therapy is continued mandible, the risk of osteomyelitis is notable. Factors
for 3 days in these patients. associated with an increased incidence of infection devel-
Continued mobility of a fracture causes rebleeding oping after mandibular fractures are noted in Box 32-3.
and decreased levels of oxygen tension at the fracture Infection of the mandible following a fracture is
site. These local changes can increase the risk of known as post-traumatic osteomyelitis. After injury and
subsequent reduction of the fractures, certain signs and important. Continuous irrigation and drainage systems
symptoms indicate that an osteomyelitis is developing. can be placed through a closed wound following
The early signs of an acute suppurative osteomyelitis appropriate débridement if the infection is extensive or
include the following: refractory to conventional drainage and irrigation.
• Deep intense pain Antibiotic-containing solutions may be of benefit for irri-
• High intermittent fever gation but have not been comprehensively studied in
• Paresthesia or anesthesia of the mental nerve regard to their efficacy. Recent studies of systems that
(arising after the trauma and reduction of the deliver a high concentration of antibiotic locally to a site
fracture) of osteomyelitis have shown promise. These systems use
• A clearly defined cause64 materials that are impregnated with an antibiotic, usually
At this phase, the infection is spreading through the gentamicin, which is then implanted in the infected
intramedullary portion of the bone, with little cortical wound. The benefits of such a system are that high and
destruction; therefore, radiographs will not show any sig- sustained concentrations of antibiotics are delivered
nificant findings. Parenteral antibiotics should be admin- locally, with low systemic levels, thereby reducing the
istered at this time. toxic side effects of some agents.
As the osteomyelitis becomes established, a firm cel- In addition, a means of fixation must be used to
lulitis will develop over the involved portion of the man- prevent further movement of the fracture segments. This
dible and lead to intraoral or cutaneous sites of drainage, often requires the use of external pins to span the gap
or both. The cellulitis is often firm or brawny hard created by the removal of the involved bone. Reconstruc-
on palpation. Systemic signs are variable but may tion of the bony defect usually is not attempted until all
include a mild leukocytosis with a shift to more immature signs of infection are gone, generally after at least 2
(band) forms of PMNs, a rise in temperature, and occa- months. The absence of infection is determined on the
sionally an increase in the erythrocyte sedimentation rate basis of a lack of local signs of infection, such as drainage
(ESR). or cellulitis. A bone scan using the technetium and
Although radiographic signs of osteomyelitis are not gallium subtraction technique can be carried out (see
evident until late in the process or until 50% demineral- earlier) to corroborate the clinical impression that the
ization has occurred, they may precede the development infective process has cleared. The secondary reconstruc-
of frank drainage. Classic radiographic findings of osteo- tion of continuity defects resulting from an osteomyelitis
myelitis include a moth-eaten appearance of the bone is discussed in Chapter 36.
and the development of sequestra, which are islands of This discussion of osteomyelitis centers on its treat-
devitalized bone. The sequestrum is surrounded by an ment in the mandible as opposed to the maxilla and
involucrum (a sheath of new bone), separated from it by other bones of the facial skeleton. The endochondral
a radiolucent zone. bone of the mandible is structurally similar to the long
The extent of the osteomyelitis will be greater than bones of the body, which are more susceptible to osteo-
that noted on routine radiographic examination. To plan myelitis. The intramembranous bone of the maxilla has
the appropriate surgery and ensure adequate treatment, less medullary tissue and thinner cortical plates, which
scintigraphy is often a useful adjunctive study. Typically, allow the infection to pass through quickly and into the
technetium 99m–labeled phosphate compounds are surrounding tissue; hence, it does not have the opportu-
administered IV and become concentrated in areas of nity to become established as readily as it does in the
increased bone activity. Because this test cannot differen- mandible. The blood supply to the maxilla is more exten-
tiate between areas of increased formation and areas of sive and therefore less susceptible to disturbance from
resorption of bone, more information regarding the infection.
osteomyelitis can be obtained using a subtraction study. The use of hyperbaric oxygen for osteomyelitis of the
The test is carried out by performing a second scan with mandible has been reported.65 Its clear benefit over sur-
gallium, which is known to collect in white blood cells. gical and medical treatment has not been demonstrated,
An area that shows both technetium and gallium uptake but it may be of use in cases that are refractory to more
probably represents acute or suppurative osteomyelitis. conventional means of therapy.
If the site shows an uptake of technetium but not of Often, a 6-week course of antibiotics is referred to in
gallium, it probably represents an area of bone repair. the treatment of osteomyelitis. This is based on previous
Scintigraphy is also useful for monitoring the course of studies that reviewed the management of childhood
the disease and efficacy of treatment and may also indi- hematogenous osteomyelitis in contrast to osteomyelitis
cate when treatment can be safely stopped. secondary to a contiguous focus of infection or chronic
Once established, osteomyelitis associated with frac- osteomyelitis. These latter two types depend on com-
ture is treated using a combined surgical and medical bined surgical and antibiotic management, and resolu-
approach. Nonvital tissue, foreign bodies, and associated tion is expected more quickly. Surgery is necessary
teeth must be removed. At the surgical procedure, speci- because antibiotics will not penetrate necrotic bone.
mens of bone should be obtained using meticulous tech- Certain antibiotics attain a much greater serum con-
nique and submitted quickly for culture and sensitivity centration in bone than others. In experimental osteo-
testing, without secondary contamination. This practice myelitis infections caused by S. aureus, clindamycin was
must be strictly observed to preserve fastidious anaerobes found to have a 98% serum concentration in the infected
that may be the causative organism of the osteomyelitis. bone. Cefazolin concentrations reached only 6%, whereas
Débriding infected areas and establishing drainage are cephalothin showed a 3.5% concentration.66
MIDFACIAL FRACTURES disease has a fatality rate of about 45% in the United
Facial bone fractures involving sites other than the man- States,70 but active immunization is successful at prevent-
dible are usually involved with one or more of the sinuses. ing the disease.
The microbiologic characteristics of an infected sinus Because viable spores are present in soil, in house
differ from those of an infected oral cavity, specifically dust, and on clothing, even minor injuries may cause the
because of the presence of Streptococcus pneumoniae and disease in unimmunized individuals. The organism is not
H. influenzae. However, the healthy sinus has been shown invasive but gains entry through puncture wounds and
to be a relatively sterile environment,67 and the choice of lacerations; the most frequent sites are the hands, feet,
prophylactic antibiotics should be based on the most and legs.
likely source of the potentially infective bacteria. When evaluating a wound that may be likely to cause
Le Fort II and III fractures may communicate with the tetanus, an immunization history should be obtained. If
cranial cavity, as evidenced by a cerebrospinal fluid (CSF) a full set of three vaccines has been given and a booster
leak from the nose or external ear canals (CSF otorhinor- received within the previous 10 years, no further therapy
rhea). Antibiotic prophylaxis to prevent the possibility of is necessary. When passive immunization is to be given,
a meningeal infection is controversial because studies a single dose of human tetanus immune globulin (TIG)
have not shown a reduction in the incidence of menin- is administered. Subsequently, the patient should com-
gitis in patients who have received prophylaxis. In fact, plete an active immunization series.
after 5 days of systemic antibiotics, the nasopharynx Certain wounds are classified as more tetanus-prone
usually becomes colonized with more resistant organ- than others. Linear wounds, less than 6 hours old with a
isms,68 generally acquired in the hospital—making treat- sharp mechanism of injury (e.g., by a knife or glass), are
ment of meningitis more complicated. Therefore, early considered nontetanus- prone and TIG is never indi-
reduction of the fractures is indicated, which will nor- cated.71 If a previously immunized patient has a tetanus-
mally stop the CSF leak. This reduction is indicated as prone wound and has not been immunized within the
soon as the patient is neurologically stable. past 5 years, a booster dose of tetanus and diphtheria
toxoids is administered.
NOSOCOMIAL INFECTIONS The diagnosis of tetanus is made by clinical signs,
The hospitalized, traumatically injured patient is at risk because organisms are recovered in only about 30% of
for having an infection during the period of admission. cases. The incubation period is 2 to 56 days, with earlier
Nosocomial infections affect a notable number of patients onset associated with a poorer prognosis. The classic
each year, causing delays in discharge and notable mor- signs of trismus (lockjaw), rigidity of the facial muscula-
bidity and increased cost of care. ture (risus sardonicus), and reflex spasms are pathogno-
Traumatized patients are at increased risk for nosoco- monic for the disease. The patient is managed with
mial infection because they are compromised hosts. The antiserum (TIG), muscle relaxants, tracheostomy, and
mechanical barrier of the skin and mucous membranes antibiotics (penicillin).
is violated by injury or interventions, such as surgery and
insertion of IV lines. Host defenses are also reduced TREATING THE PATIENT WITH
owing to some of the systemic effects of the trauma. Of VIRAL INFECTION
additional concern is the fact that hospital-acquired
infections often involve organisms with unusual viru- Maxillofacial trauma includes a high incidence of inter-
lence or resistance to antibiotic therapy. personal violence, much of which may be related to
The diagnosis of a nosocomial infection is similar to obtaining or selling illegal drugs. Because these individu-
that of any type of infection. The source of the fever in als are often IV drug abusers themselves, the incidence
the hospitalized patient may require a full systemic work- of human immunodeficiency virus (HIV) infection is
up, including evaluation of the lungs, wounds, IV sites, much higher than in the general population. The acute
urine, and blood. Cases of septicemia have been reported nature of trauma also does not typically permit a fully
to occur because of contaminated IV fluids.69 Thus, the detailed review of risk factors for each patient, especially
source of infection may require consideration of many during resuscitative and other emergent treatment.
factors. In a study of urban trauma patients, the incidence of
Owing to the variable resistance patterns of the respon- HIV infection (HIV Ab+ or Ag+) is found to be 4.3%,
sible organisms, antibiotic therapy is withheld until spe- with an incidence of surface antigen of the hepatitis B
cific culture and sensitivity test results are available, if virus (HBsAg) of 3.1%.72 Predictors of a preexisting viral
possible. Other therapeutic interventions are important, infection included patient aged 20 to 49 years, IV drug
such as pulmonary physical therapy for suspected atelec- abuse, prior HIV testing, shock, and death (all p < .05).
tasis or pneumonia. Review of the patient’s hospital IV drug abuse was the single most significant predictor.
course, including any IV sites or catheterizations, may Patients who required resuscitation or eventually died of
further assist in the investigation. In addition, the bedrid- the trauma had a 12% to 21% infection rate with HIV,
den traumatized patient is susceptible to thromboembo- hepatitis B virus (HBV), or both.72
lism and fat embolism, which may cause fever. This important proportion of virally infected patients
requires heightened awareness and training to prevent
TETANUS disease transmission. One factor associated with violating
Tetanus is caused by the production of an exotoxin from barriers to the oral and maxillofacial surgeon is the
C. tetani, an obligate anaerobic, gram-positive rod. The placement of arch bars. Single gloving of the surgeon is
BOX 32-4 Strategies for Preventing Transmission of

SUMMARY
Infection to the Operative Team from the Patient The acutely injured patient often attracts a great deal of
• Use protective gloving initial attention in the emergency room because of the
• Use double gloving for all surgeries immediate need for resuscitation. Once the patient’s
• Consider triple gloving or double gloving with an internal condition is stabilized, the risk of infection should be
glove liner for insertion of arch bars evaluated and appropriate therapy started. The trauma-
• Change gloves after completion of arch bar insertion and tized patient is severely compromised in the ability to
rescrub resist even a normal bacterial insult. The progression of
• Change gloves after every 2 hr of surgical time infection may result in loss of structures, limb, and even
• Only one surgeon is to pass wires at a time life if sepsis occurs. It is therefore incumbent on the
• Never use fingers as retractors treating physician to be aggressive in wound débride-
• Never do anything like bending needles or recapping ment, bacterial load reduction, and appropriate antibi-
syringes otic and antitoxin administration, and in assuming the
• Use impermeable gowns management of the injuries to maximize the functional
• Use face shield–splash guard or eyeglasses with side and aesthetic result. Surgeons also have a responsibility
shields to themselves, residents in training, and other staff to
• Obtain appropriate hepatitis B vaccination and boosters
maintain a high standard in regard to prevention of
• Consider use of composite resin bonded arch bars
disease transmission from a potentially virally infected
patient to a member of the surgical team.
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CHAPTER
Principles of Fixation for
33
Maxillofacial Trauma
Ashish A. Patel
| Vasiliki Karlis
OUTLINE
History of Fracture Treatment and Development Of Miniplates
Modern Osteosynthesis Reconstruction Plates
Biology of Bone And Bone Healing Lag Screws
Biophysics of the Facial Skeleton Midface and Upper Face Fixation
Methods of Fixation Bioabsorbable Plate Fixation
Rigid Versus Functionally Stable Fixation Complications of Internal Fixation
Compression Plate Osteosynthesis Surgical Site Infection
Noncompression Osteosynthesis Dental Injury
Mandibular Fixation Nerve Injury
Locking Plates Malocclusion
plating of the mandible using Arbeitsgemeinschaft für

HISTORY OF FRACTURE TREATMENT Osteosynthesefragen-Association for the Study of Inter-
AND DEVELOPMENT OF nal Fixation (AO-ASIF) techniques.
MODERN OSTEOSYNTHESIS From Luhr and Spiessl’s work, eccentric dynamic com-
pression plating was developed and adapted for cranio-
Bone fractures have been treated with various conserva- maxillofacial trauma use, but lost popularity due to its
tive techniques for centuries and it was not until the highly technique-sensitive nature and no proven benefits
eighteenth century that internal fixation was first docu- over other modern fixation methods.
mented. Icart, a French surgeon in Castres, performed
ligature fixation with brass wire on a young man with a BIOLOGY OF BONE AND BONE HEALING
humeral fracture. Since then, many surgeons developed
several methods for internal fixation, but one of the Bone is a complex and ever-evolving connective tissue
greatest leaps in bone trauma surgery was in 1886, when and serves multiple purposes. Besides being the main
Hansmann of Hamburg published a technique using constituent of the human skeletal system, bone is highly
retrievable metal bone plates with transcutaneous screws. metabolically active and essential for the regulation of
Soon after, a Belgian surgeon, Albin Lambotte, improved serum electrolytes—namely, calcium and phosphate.
these techniques and coined the term internal fixation. Marrow cavities are filled with hematopoietic elements
Lambotte developed and manufactured a variety of bone necessary to manufacture and maintain blood compo-
plates and screws and much of his armamentarium nents and regulate the immune system. Bone is com-
remained in use until the 1950s.1 prised of calcified bone matrix and three major cell
In the twentieth century, Sherman improved on Lam- types, osteocytes, osteoblasts, and osteoclasts.
botte’s designs and created parallel, threaded, fine- Bone’s organized structure is illustrated in cross
pitched, self-tapping screws. This hardware was made of section revealing the haversian system, or osteon. Each
corrosion-resistant vanadium steel, which was a strength osteon contains concentric layers of compact bone sur-
improvement over silver and ivory fixation materials. rounding a central haversian canal, which harbors the
Although sturdy, these early alloys were inflammatory neurovascular bundle supplying the unit. Cells sus-
and were eventually replaced entirely by titanium in the pended in this highly calcified, highly vascular structure
1970s. In the 1930s, Eggers rediscovered an older design are perfused via small capillary-containing cylindrical
for sliding slot plates, which eventually led to the devel- cavities called canaliculi.2
opment of a compression plate by Danis in 1947. Luhr Bone healing can be broadly categorized in two ways,
helped advance the principles of compression and primary and secondary. Primary, or direct bone healing,
dynamic compression, but it wasn’t until 1977 that he requires rigid fixation and immobility of fracture seg-
developed these techniques to the maxillofacial skeleton. ments with a minimal gap between them (less than 100
Spiessl later popularized dynamic compression bone µm). Osteoclasts migrate to the fracture site and widen
808
Principles of Fixation for Maxillofacial Trauma CHAPTER 33 809
A B C
FIGURE 33-1 A, Fracture hematoma. B, Soft callus. C, Hard
callus.
adjacent haversian systems, allowing osteoblasts to deposit

bone matrix, or osteoid, eventually to calcify into orga-
nized mature lamellar bone.3
Secondary, or indirect bone healing, is more complex
and occurs when a significant gap or interfragmentary
motion is present. Secondary bone healing involves the FIGURE 33-2 In many fractures, it may be difficult to achieve and
formation of a fibrocartilaginous intermediary bone assess complete bone contact through the entire width of the
fracture. In this case, healing by primary intention may still occur,
callous (Fig. 33-1) There are four distinct stages of indi-
but as contact healing where there is good apposition and gap
rect bone healing but the end product is the same as
healing where there is a space. In gap healing, bone is deposited
mature bone formed in primary healing. The initial
parallel to the fracture and eventually remodels and becomes
insult propagates the inflammatory stage. A hematoma parallel to the long axis of the native bone.
between and around the fracture develops and stabilizes,
drawing inflammatory cells to the site. Necrotic and non-
viable bone near the fracture is cellularly débrided and Applied force Resistance
repair is initiated by angiogenesis and the activation of (muscles) (bite force)
osteoprogenitor cells and fibroblasts. The second, or soft
callus, stage is characterized by conversion of the hema-
toma to a fibrocartilaginous mass to bridge the fracture.
Fibroblasts and mesenchymal elements are highly active Fulcrum
(condyle)
in laying down new collagen to create the substrate into
which the third phase, or hard callus stage, develops.
During this period, osteoid is calcified and periosteal and
endosteal bone ingrowth starts to replace the soft callus
as a result of endochondral bone formation. Finally, in
the remodeling stage, the woven bone of the hard callus FIGURE 33-3 The mandible as a class III lever.
matures and organizes to a trabecular structure to
re-create the native preinjury structure.4
Although distinct, both types of bone healing may The muscles of mastication and suprahyoid muscles,
occur simultaneously in the same fracture. As three- however, produce significant forces on the jaws and sur-
dimensional structures, bones may have varying levels of rounding osseous structures. Bite force is generated by
contact and fracture reduction in the same general site, contracture of the masseters, temporalis, and medial
resulting in endochondral and lamellar elements in dif- pterygoids; the sum of these vectors allows for occlusion
ferent areas at the same point in time (Fig. 33-2). of the teeth via movement of the mandible.
It is imperative to understand the physics and forces
BIOPHYSICS OF THE FACIAL SKELETON applied to facial bones to fixate fractures properly and
use biomechanics to our advantage. Due to its dynamic
Although complex, the facial skeleton does not consist nature, the mandible bears most of the forces applied by
of many moving parts. The major axis of bony motion in facial musculature to the skeleton. Beam mechanics dic-
the face is around the mandibular condyles, or temporo- tates that the mandible is a class III lever, with the condyle
mandibular joints (TMJs). The muscles of facial expres- being the fulcrum, the muscles of mastication acting as
sion originate on various bones of the craniomaxillofacial the applied force, and bite load acting as the resistance
skeleton, are invested in the superficial musculoaponeu- (Fig. 33-3). This rationale applies to one side of the man-
rotic system, and insert on each other and the facial skin. dible at a time, but as a horseshoe-shaped bone, the
These have little effect on forces exerted on facial bones. mandible is more than a simple class III lever. Vectors
the moment of the bite force applied, but generally cor-

relates to the plane in which the inferior alveolar neuro-
vasculature lies, and therefore not acceptable to place
hardware. The inferior mandibular border is a biologi-
cally sound location for hardware placement. Bicortical
screw fixation here is extremely stable, there is adequate
vascular soft tissue to prevent dehiscence or hardware
palpability, and dental structures usually do not extend
to this area. To compensate for lack of stability at the
zone of tension, a tension band can be applied. This
could be a monocortical low profile miniplate, lag screw,
or arch bar, all of which resist tensile forces without vio-
lating biologic principles of surgery.
In vivo, the mandible is more complicated than the
model just described. Because of the three- dimensional
nature of the mandible, multiple muscular insertion
A sites, and bilateral nature of the muscles, zones of com-
pression and tension are not always static around a frac-
ture. For example, in the mandibular corpus or
parasymphysis, forces may be inverted if bite force is
applied posterior to the fracture line secondary to forces
applied from the contralateral musculature.8 This creates
compression at the alveolus and tension at the inferior
border. Torsional forces also act on segments due to the
bilateral nature of the forces applied. This is easily dem-
onstrated by rotation of segments around the neutral
zone when only one point of fixation is implemented or
widening of the mandible at the condyles due to alveolar
process torquing.9
METHODS OF FIXATION
Traumatic injuries of the facial skeleton can be properly
managed and treated in numerous ways. AO-ASIF guide-
B lines of rigid fixation follow four basic principles to
FIGURE 33-4 A, The effects of the masticatory apparatus (thin ensure adequate treatment of fractures: bony segment
arrows) and occlusal load are demonstrated (thick arrows). Under reduction, stable fixation and immobilization of frag-
function, the mandible exhibits the greatest tensile forces across ments, maintaining blood supply, and early function.10
the superior border and compression at the inferior border. The As noted, primitive methods of internal fixation devel-
neutral zone lies at approximately the level of the inferior alveolar oped from the 1800s. Advancements in techniques and
canal. B, When using compression plating at the inferior border, biomaterials and an understanding of biophysics have
tensile forces at the superior border may be exaggerated. A greatly changed how we currently apply fixation to facial
tension band or arch bar is required to counteract these forces. fractures. Internal fixation with titanium hardware is still
the most commonly used method of treating facial skel-
etal injuries and a plethora of systems are available to
from bilateral muscle contracture on a unilateral fracture carry this out. Various sizes and shapes of plates and
produce rotation and torques that cannot be easily screws exist to meet the needs of the surgeon and to
described by simple beam mechanics.5,6 Varying bone tailor treatment to each individual patient and fracture
thickness, occlusal arrangements, and multiple vectors of type.11
muscle contraction also cannot be accounted for in this Adequate exposure of fracture segments is carried out
model. For the purposes of understanding rigid fixation while not compromising the adjacent blood supply.
across fractures, beam mechanics applies. Maintaining vital periosteum aids in fracture healing,
When loaded, the mandible exhibits maximum preventing postoperative wound breakdown and decreas-
tension at the superior border and maximum compres- ing the rate of hardware infection. Fracture segments can
sion at the inferior border (Fig. 33-4). This is a gradient be reduced using various methods, including bone
and, between the zones of tension and compression, lies reduction forceps, manual anatomic reduction, inter-
a neutral zone in which opposite forces total zero. In this dental fixation, and a combination of these. The fracture
model, it would be mechanically advantageous to apply segments are stabilized by bending and adapting plates
rigid fixation hardware along the zone of tension, or directly to the bony segments and fixated with screws.
superior border.7 Biologically, this is complicated by the Primary closure of the wound may or may not require
presence of teeth, thin cortical bone, and thin overlying local flaps to maintain well-vascularized soft tissue
soft tissue. The neutral zone is dynamic and depends on coverage.
Cases in which surgical exposure of fracture sites may provide reduction and stabilization of the fracture in a
interrupt blood supply, such as severely comminuted much shorter, less technique-sensitive manner.14 Hand
fractures or contaminated wounds, pose a risk for hard- articulation of the jaws has also been described and
ware infection and may be an indication for skeletal pin deemed successful by some authors. These methods are
external fixation.12 This technique works especially well also more hygienic than the use of standard arch bars,
in comminuted and contaminated mandibular fractures prevent excessive biofilm accumulation, are less trau-
requiring control of non–tooth-bearing proximal seg- matic to the periodontium, and can be removed rela-
ments. Transcutaneous access to the mandible with stab tively quickly.15 Although not as rigid and mechanically
incisions and blunt dissection is achieved. The mandible stable as arch bar MMF, with appropriate patient selec-
is drilled using a drill guide to protect the soft tissue and tion, screw and/or interdental wire MMF can provide
skeletal pins are inserted into the fractured segments. excellent results for the nonoperative management of
Ideally, two pins with a large distance between them mandibular fractures.16 A retrospective cohort of 75
should be placed into each large segment to prevent patients with 83 mandibular angle fractures treated by
rotation. To ensure optimum biomechanics, each pin Bell and Wilson17 has described three different methods
should be as large as possible and placed close to fracture of intraoperative intermaxillary fixation prior to the
lines (but not closer than 1 cm to prevent the risk of application of a single, 2.0- mm miniplate via the Champy
segment shearing). The external components of the skel- technique. There were no significant differences in out-
etal pins are stabilized by being fastened to a rigid exter- comes, reoperation rates, and complications among the
nal bow or linking segments with the use of other, smaller Erich arch bar, Stout interdental wire, and manual reduc-
subunit bars. Smaller shards of comminuted bone gener- tion groups.
ally do not require fixation because they can be immobi- MMF is still used as a primary modality of fracture
lized as they are sandwiched between larger externally treatment in patients for whom internal fixation may not
fixated segments. Care is taken not to devitalize these be indicated. Minimally or nondisplaced biomechani-
small bone segments by avoiding aggressive débride- cally favorable fractures in patients with a sufficient com-
ment. Maintaining blood supply is essential to the healing plement of teeth to provide a stable premorbid occlusion,
of these fractures. In cases in which internal fixation severely comminuted fractures, or intracapsular condylar
cannot be applied without devitalizing bone segments, fractures in which occlusion can be reestablished are
such as a grossly contaminated open mandibular frac- some common scenarios for which 2 to 8 weeks of MMF
ture, external fixation may serve as a temporary measure without surgery may be indicated. MMF is considerably
to immobilize and stabilize the segments while the wound less invasive and more cost-effective and reduces compli-
is washed out and sterilized over a period of days to cations associated with open surgery; however, it poses its
weeks. This can be ultimately converted to internal plate own unique set of risks and complications. MMF invokes
fixation to avoid prolonged skeletal pin hardware an aspiration hazard in patients such as those with severe
application.13 gastroesophageal reflux, nausea, seizure disorder, alco-
Maxillomandibular fixation (MMF) or interdental holism and dysphagia. Patient compliance is essential to
fixation is widely used in the management of almost all prevent loosening or cutting of wires and mobilizing the
injuries affecting the jaws. As described, this is an excel- forming callus. There is a great deal of evidence from
lent method for achieving fracture reduction. Prior to orthopedic literature demonstrating ill effects on the
the development of modern internal fixation, MMF skeletal system from prolonged immobilization and
was the mainstay of facial fracture treatment. By stabiliz- disuse of long bones. These effects are demonstrable not
ing the dentition in its known pretraumatic occlusion, only on the immobilized bone itself, but on the associ-
bone segments will assume an anatomically acceptable ated muscles, vasculature, and joints. Bone immobiliza-
configuration. Because MMF compresses fractures at the tion results in hypomineralized osteoporotic cortices and
alveolus, the inferior border of the mandible may still trabeculae and an overall decreased oxygen tension and
demonstrate a gap. By combining this method with com- pH of the nutrient vessels. Muscles inserting on this bone
pression of the inferior border with bone reduction also atrophy with disuse and usually require extensive
forceps and application of internal fixation methods, an physical therapy for the patient to return to full strength
ideal reduction can be achieved. Several hardware and mobility.18,19 Decreased muscle demand inevitably
designs and techniques are available for MMF including results in hypovascularity and protein loss over time. Sur-
arch bars, Ivy loops, Stout interdental wires, and MMF rounding immobilized joints demonstrate pericapsular
screws. The advantage of MMF with the application of contractures and synovial hyperplasia, which decrease
arch bars is that they provide a tension band at the alveo- range of motion. Over time, the formation of intracap-
lar component of maxillomandibular fractures. This aids sular adhesions can result in pain, inflammation, and
in resisting tensile forces of the fracture near the teeth. derangements in joint function. The dreaded complica-
Also, arch bars have numerous fixation points (lugs), tion of TMJ ankylosis may follow prolonged immobiliza-
allowing more precise control of fracture segments and tion of displaced or comminuted condylar fractures.20,21
application of force vectors when placing the patient into Condylar fractures are surrounded by controversy in
MMF. In fractures not involving dentate portions of respect to closed versus open treatment. Internal fixation
bone—that is,. mandibular angle, ramus, or condyle tends to produce superior results in regards to anatomic
fractures—arch bar application may not be necessary to reduction, but studies have shown variability in postop-
obtain MMF. If a stable and reproducible occlusion can erative mandibular function, symmetry, and joint pain.
be obtained, the use of MMF screws or Ivy loops can Variability in fracture patterns of the condyle,
concomitant mandibular fractures, occlusal stability, reduces operative time, risk of dental injury, and cost, it
patient compliance, postoperative physiotherapy, and is not ideal in all situations. Concomitant fractures of the
operative technique have significant effects on study out- mandible must be treated rigidly to prevent motion at
comes of closed and open fracture treatment and have multiple sites. The Champy method relies on the contra-
led to opposing viewpoints. A meta-analysis of several lateral condyle being seated correctly in the glenoid
studies has failed to show any overwhelming overall fossa, without disruption of the temporomandibular rela-
benefit of closed versus open treatment due to lack of tionship. If a contralateral fracture is present and not
consistency in reporting the variables described.22,23 treated rigidly, bite forces across the angle can transmit
to the distal segment, causing rotation around the oppo-
site fracture line. This may result in widening of the
RIGID VERSUS FUNCTIONALLY mandible and subsequent malocclusion and facial width
STABLE FIXATION alteration. By treating the other fracture site rigidly, the
angle can essentially be treated as an isolated injury.
Internal fixation can be subclassified in several ways, but
perhaps the most appropriate would be delineating COMPRESSION PLATE OSTEOSYNTHESIS
between rigid and nonrigid. Rigid fixation can be defined
as any type of directly applied bone fixation that prevents The use of compression plating systems in the maxillofa-
interfragmentary movement between fracture segments cial skeleton has been used to treat mandibular fractures
when that bone is under active load.24 Examples of rigid for many years. Although many surgeons prefer the ease
fixation of a fracture include application of a reconstruc- of use of locking bone and reconstruction plates, com-
tion plate, two bone plates, two lag screws, or a compres- pression and dynamic compression plating, if applied
sion plate and arch bar across a fracture. With the correctly, can be advantageous in immobilization and
exception of the use of a load-bearing reconstruction fixation of mandible fractures.
plate, rigid fixation techniques rely on two point The goal of compression osteosynthesis, as described
fixation—a stabilizing unit, such as a bone plate at the by AO, is establishing absolute stability across a fracture.
inferior border, and a tension band, such as a miniplate This is defined as zero movement occurring between
or arch bar superior to that.25,26 On a histologic level, the bones across the fracture, as well as complete immobility
benefit of rigid internal fixation with minimal gap of the hardware against the bone. This creates an ideal
between the bone segments allows for primary bone environment for primary bone healing by generating
healing via haversian remodeling. The fracture gap is friction between the bone segments in compression and
traversed by osteoclasts and then undergoes angiogene- minimizing the gap between them.28 Linear compression
sis, followed by deposition of osteoid by adjacent osteo- between the segments counteracts torsional forces pro-
blasts. The bone remodels over time to create mature duced by the masticatory apparatus during function and
haversian bone. This is in contrast to fractures with a prevents interfragmentary motion. Traction perpendicu-
significant gap or interfragmentary motion, which heal lar to the fracture line is maintained by the plate itself,
by secondary intention and formation of an intermediary which shares the load under function and maintains
hematoma and bone callus. compression of the segments.29
Nonrigid fixation is just that—fixation that allows for Today, most mandibular plating modules include
movement between the bone fragments across a fracture dynamic compression plates for surgeons who wish to use
line. Many older techniques, such as interosseous wiring compression osteosynthesis (Fig. 33-5). Although effi-
or interdental bridal wiring, stabilize fractures to approx- cient in creating absolute stability in mandibular frac-
imate segments but do not prevent interfragmentary tures, compressive plating techniques, even with the
movement. Depending on the magnitude of movement advent of the dynamic compression plate, are extremely
across the fracture, nonrigid fixation may result in non- technique-sensitive and prone to operator error. If the
union or malunion. With the methods and materials
available today for maxillofacial trauma surgery, many
types of nonrigid fixation are no longer in use. Perhaps
the most important nonrigid technique in mandibular
trauma is the Champy method for the fixation of angle
fractures. In 1978, Champy described the use of a single
miniplate adapted to the superior border of mandibular
angle fractures, with excellent results. This technique has
been termed functionally stable because it allows for activa-
tion of the mandible during healing, even with interfrag-
mentary motion.27 Due to the rostral force vectors of the
pterygomasseteric sling and caudal pull of the suprahy-
oid muscles, the superior border of the mandibular angle
is under tension and the inferior border is under com-
pression. Because the monocortical miniplate is applied
to the superior border, the mechanical advantage favors
stabilization of the fracture under active forces. Although
functionally stable fixation of the mandibular angle FIGURE 33-5 Dynamic compression plate.
0 0.8 0.8 0
FIGURE 33-6 The holes on dynamic compression plates have an

inclined plate, with the lowest edge closest to the bone surface.
When screws are tightened in the active position, the head glides
down the inclined plane, causing translation of the bone segment
toward the fracture.
A B
holes are not drilled in the proper location and screws

are not placed in the correct sequence, the hardware can
distract the fracture, creating gaps in bone, malocclu-
sion, and excessive torsional forces across the plate.30
Dynamic compression plates are designed with eccen- C
tric holes with inclined planes. On either side of the FIGURE 33-7 The drill guide for compression plating has two
midline of the plate, the plate holes are elongated, with positions, active and passive. In the passive position (A), the drill
the lateral side having the highest portion of the inclined hole and screw are placed in the center position of the plate hole,
plane and the medial with the lowest portion, or closest essentially acting as a noncompression system. In the active
to the bone, of the inclined plane (Fig. 33-6). The plate position (B), the screw is placed at the upper incline position of
should be adapted so that one eccentric hole is on each the plate and, as it is tightened (C), it moves down the inclined
side of the fracture, closest to the fracture line. The outer plane, resulting in compression of segments toward the fracture
planes of each hole are the active, or compression, sites. line.
As screws are drilled and fastened into this high point of
the inclined plane, they follow the plane down toward
the bone as friction is created between the screw head
and plane surface. When completely tightened, they lie
on the innermost portion of the hole closest to the bone.
Because this is completed on either side of the fracture,
the bone segments are compressed toward each other
while the plate remains static, minimizing the bone gap A B
and achieving compression. The remainder of the holes
distal to the fracture line are then drilled and secured
with bone screws in a passive position so as to not com-
press or distract the bones and hardware further.
To instrument the dynamic compression plate prop-
erly and achieve successful compression, the plate must
first be bent and accurately adapted to the bony seg- C
ments. The fracture must be stabilized and reduced by FIGURE 33-8 As each screw closest to the fracture line is
MMF, a superior border miniplate, bone reduction tightened in the active position, the mandible translates across the
forceps, or a combination of these techniques prior to plate toward the midline (A, B). When both active compression
bending the dynamic compression plate. Once adapted screws are tightened completely (C), compression across the
to the reduced fracture, the compression elements can fracture is complete.
be drilled. Drill guides provided by the manufacturer for
compression plating are helpful in placing the screw hole will migrate down the plane approaching the fracture
correctly to achieve maximum compression. The drill line and draw the bone segment toward its counterpart.
guide has active and passive positions, with arrows to The first screw is then tightened completely, producing
indicate the orientation (Fig. 33-7). The first hole adja- the same effect on the opposite side and creating com-
cent to the fracture is drilled in a bicortical fashion with pression between the bony segments. The remainder of
a drill guide with the active, or compression, arrow facing the holes are then drilled in the passive position and
the fracture. This corresponds to the outer, or high, bicortical screws are inserted to stabilize the plate to the
incline of the hole. A depth gauge is used to measure the fractured mandible (Figs. 33-8 and 33-9). These serve to
desired screw length and the screw is inserted partially share the load further and reduce forces that would tend
to stabilize the position of the plate. The most proximal to counteract interfragmentary compression.
hole on the opposite side of the fracture is drilled in the Dynamic compression plates actively draw fractured
same fashion in the active position and the screw is segments together. The resultant compression at this site,
inserted and tightened completely. As noted, the screw typically the inferior mandibular border, may result in
N3
0 0.8
A B
E2
N N1
N
0.8
0
C D 0 0
0.8
0.8
1 2 4
3 5
0.8 0.8 0 0
0 0.8
0 0
0.8 0.8
25° 25°
F
E
FIGURE 33-9 A, After adaptation of the plate to the mandible, the holes are drilled in the active or lateral positions of the holes adjacent to
the fracture. B, Each screw is inserted and partially tightened. C, Each screw is then completely tightened, thereby accomplishing
compression osteosynthesis. D, Screws are placed in the passive position in the remaining holes for increased stability. E, Order of
screw placement for a dynamic compression plate (DCP). Note that positions 1 and 2 have screws engaged in the active position. F, In
an oblique fracture of the symphysis, a DCP can be combined with a lag technique to ensure maximum reduction and compression of
the fracture. The center screw (N3) traverses the fracture using a lag technique and using the passive or neutral position in the plate. The
eccentric hole is used adjacent to the fracture (E2) to draw segments together in the horizontal plane; the remainder of screws are
placed neutrally.
excessive tension at the superior border or alveolus. It is bone-plate interface, which can accentuate the amount
necessary to neutralize these forces to prevent gap forma- of splay at the opposite cortex. To minimize this ill effect,
tion in the zone of tension of the mandible. This is typi- one can slightly overbend the plate on the buccal aspect
cally achieved by the use of a tension band. An arch bar, of the mandible so that when activated, compression is
superior lag screw, or monocortical miniplate can be also achieved at the lingual cortex. In cases in which
used as a tension band to reduce the distraction at the there is avulsion of bone at the fracture site, compression
superior border. This applies to any load-sharing internal plating can distort the premorbid anatomy and contours
fixation system but holds especially true for compression of the mandible, leading to malocclusion and increased
plating. stress across the TMJs.
Compression osteosynthesis is best applied in trans-
verse fractures of the mandibular symphysis or body NONCOMPRESSION OSTEOSYNTHESIS
without comminution or bone loss. Obliquely oriented
fractures can pose problems in this technique due to the Noncompression osteosynthesis is widely used in manag-
nonsymmetrical nature of the fracture line. Plates are ing traumatic injuries to the maxillofacial skeleton. This
adapted and applied to the outer, or buccal, cortex of can be accomplished with a variety of methods including
the mandible. Compression is applied parallel to the non-compression bone plates and reconstruction plates,
plate; equal distribution of forces occurs best in fractures both of which are available with locking mechanisms.
that are completely perpendicular to the compression These methods have broader applications and less degree
plate. Compression of obliquely oriented fractures may of operator error when compared with compression
result in excellent compression near the plate, but dis- osteosynthesis.
traction and unwanted force vectors elsewhere. An
example of this is lingual cortical splaying of the man- MANDIBULAR FIXATION
dible when fixation is applied. Although this can occur The mandible lends itself to a number of fixation tech-
with the use of standard internal fixation osteosynthesis, niques secondary to its geometry, length, bicortical struc-
the effect may be more pronounced in compression ture, and complex applied muscle forces. Unlike most
osteosynthesis. Compressive forces are maximized at the bones of the facial skeleton, the mandible is repeatedly
stressed and strained by the function of the masticatory LOCKING PLATES

apparatus. Fixation must be sufficient to withstand these Modern plating systems are designed with fracture plates
forces during the healing period. Fracture plates are that accept standard bone and locking screws. This can
manufactured in various widths and universal fixation be useful in securing plates that cannot be perfectly
systems generally allow interchangeable screw diameters adapted to fractures or if bone quality is poor.32 Locking
to be used in multiple plates, depending on the level of screws are double-threaded; the head of the screw has
fixation desired. Other factors that should be taken into an additional larger diameter thread that secures into
account when selecting the width of the fracture plate the thread pattern of the plate hole. With this design, the
are quantity and quality of overlying soft tissue, patient screw actually locks into the plate irrespective of the
compliance, and risk of reinjury. Thicker plates provide bone. This prevents shifting of bone segments and defor-
more stability than thinner counterparts, but may be mation of the plate as the screws are tightened, which is
palpable under soft tissue, may require more dissection, particularly important in plates that are not well adapted
are more difficult to adapt, and have higher rates of to the underlying bone. Locking plate and screw systems
dehiscence. The stress-shielding effect, especially when prevent loosening and extrusion of the screw from the
using thick reconstruction plates, has been evidenced in plate, even if it does not integrate to the mandible and
animal models of mandibular fixation, but has never resists mechanical yielding under stress.33
been proven to occur in human craniomaxillofacial
studies.31 MINIPLATES
After selecting the appropriate plate, the mandible Miniplates have several applications in mandible fracture
fracture is exposed and reduced (see earlier) and the fixation; the most important is the Champy method of
plate is adapted to the inferior border of the buccal mandibular angle fracture fixation and its use as a tension
cortex of the mandible. The plate may be overbent, if band. These methods call for monocortical fixation of
desired, to compensate for lingual segment splay, and is miniplates, but bicortical fixation of miniplates has appli-
held in place with plate-holding forceps or the desired cations in the mandible as well. These plates accept the
instrument. Two (ideally three) screws are required on same screws as standard mandibular fracture plates. Most
each side of the fracture to ensure stability and prevent miniplates are also of the locking variety if locking tech-
rotation of bone segments. niques are desired, but hold less significance in that
Although not as crucial as when applying dynamic application given the thin width and greater malleability
compression plates, the sequence of drilling and screw as compared with traditional fracture plates.
placement is important. Screws are placed first on the The Champy method of mandibular angle fixation
sites most proximal to the fracture line and secured. involves exposing and reducing a fracture, as described
When using bone screws, this prevents shifting of the earlier, and using the biomechanical advantage to place
plate on the mandible as screws are first secured to either a miniplate at the zone of tension—that is, the superior
side of the fracture because the plate may bend to adapt border. Depending on the exact location of the fracture,
to the underlying bone as the screw is tightened. In a the plate is adapted to the external oblique ridge and
well-adapted plate, this is of less clinical significance but ascending ramus with at least two screw holes on each
the plate may still warp. Holes are drilled bicortically with side. To avoid damage to dental and neurovascular struc-
the use of a drill guide to prevent whipping of the drill tures, monocortical drill holes are created with a pro-
bit and precise placement of osteotomies in the middle tected burr of the desired diameter and the respective
of each plate hole. Many drill guides can snap or screw monocortical screws are secured. Adaptation of this plate
into the plate hole at a 90-degree angle to allow for commonly requires three-dimensional bending because
precise perpendicular drilling into bone. Hole lengths the external oblique ridge has in-plane and out of plane
are measured with a depth gauge from the plate surface curvatures (Fig. 33-11). This method has been proven to
to the lingual cortex. If the exact screw size is not exhibit enough stability to withstand tensile forces at the
available—many systems increase in length by incre- superior border under function during the healing
ments of 2 mm—it is best to round up to the next size period.
to ensure capture of the lingual cortex. Previously, drill As a tension band, the monocortical application of the
holes had to be threaded with a bone tap prior to accept- miniplate resists distracting forces at the superior border
ing a screw. Modern mandible fixation screws eliminate of the mandible. After application of an inferior border
this step with the use of self-tapping screws that create a fracture plate, a miniplate can be adapted to the man-
thread pattern in the bone as they are screwed in. When dible superior to the neutral zone and secured with
placing screws, the same angle used to drill should be monocortical bone screws (Fig. 33-12). Care must be
replicated to prevent distorting the osteotomy or break- taken to place this plate in the zone of tension while
ing the screw. Because most plates are designed to accept avoiding tooth roots. Even with monocortical fixation,
two or three diameters of screw, a rescue or emergency damage to dental structures can occur because the rela-
screw can be used in the event that the initial one does tionship of teeth to the mandibular buccal cortex vary
not engage. If the osteotomy is widened by whipping of from patient to patient. In the edentulous mandible,
the burr or poor bone quality, a larger diameter screw tension bands should be placed at the superior border
may engage in the same site. When the screws most to maximize tensile force resistance. Miniplates are also
proximal to the fracture are secured, the remainder are more prone to screw loosening and infectious complica-
drilled and placed with the same method in an alternat- tions due to decreased stability and strength compared
ing fashion in regard to the fracture (Fig. 33-10). with thicker hardware.
A B
Depth
gauge
D
C
FIGURE 33-10 A, Four-hole fracture plate with bicortical locking screws used to fixate a mandibular symphysis fracture. The arch bar was
left on as a tension band. B, Mandibular fracture locking plates of different designs. These particular plates accept 2.0- and 2.3-mm
locking and nonlocking screws. C, A depth gauge should be used after drilling screw holes to ensure proper bicortical screw selection.
The figure on the right shows a bicortical osteotomy with a poorly selected screw that only engages the outer cortex. D, Slight
overbending of fracture plates can prevent lingual splaying of fracture segments as screws are tightened. Note the lingual gap when the
plate is contoured to the bone surface without overbending.
FIGURE 33-11 Postoperative orthopantomogram of a

miniplate used in the Champy method for a
mandibular angle fracture.
D
FIGURE 33-12 A, Four-hole miniplate with 2.0-mm monocortical screws used as a tension band to augment the stability of the fracture
plate. B, Postoperative orthopantomogram showing position of the miniplate in relation to the dentition. Note that screws are angled
away from tooth roots. C, Miniplates are available in several shapes and configurations. D, Use of a superior border fracture plate (Left)
or bonded dental brackets and wire (Right) as tension bands.
A B
C
FIGURE 33-13 A, Low-profile reconstruction plate to fixate edentulous atrophic mandible fracture. B, Heavy reconstruction plate used to
bridge a segmental defect. In this case, the plate is load-bearing. C, Heavy reconstruction plate in combination with miniplates and lag
screws to fixate a severely comminuted mandible fracture secondary to a gunshot wound.
RECONSTRUCTION PLATES a nonlocking bone screw, bone segments can easily be

Mandibular reconstruction plates are thicker and have a distracted from their desired positions, resulting in mal-
longer span than fracture plates, and are designed to be occlusion or segment splay. The locking mechanism
load bearing to span gaps and defects. In addition to proves to be essential in large spans with complex
reconstructing mandibular defects with or without bone contours for which perfect plate adaptation is not pos-
grafts, reconstruction plates can be used to treat man- sible. Rigid fixation with reconstruction plates is a reli-
dibular fractures that are comminuted, atrophic, or able method, with relatively low complications in
grossly unstable. When used to span a gap, four screws reconstructing mandibular defects with or without
should be placed on each side of the defect to allow the comminution.34,35
plate to bear the most, if not all, the load of the mandible
(Fig. 33-13). LAG SCREWS
Due to their size and thickness, reconstruction plates
frequently pose problems in adapting to the mandible. Lag screw osteosynthesis is highly effective and efficient
Fortunately, the built-in locking mechanism can circum- when used in the proper setting and eliminates the need
vent the need for perfect adaptation to bone. Unlike for plate bending and the use of several screws. Lag screw
fracture plates or miniplates, which both allow for some osteosynthesis is a fracture compression technique that
degree of malleability when secured with bone screws, can be carried out by using true lag screws or a lag tech-
reconstruction plates exhibit a high degree of elastic nique with long bone screws (Fig. 33-14). The classic
deformation. If a reconstruction plate is not perfectly application of this technique is in fixation of transverse
adapted to bone and is thoroughly tightened down with mandibular symphysis and parasymphysis fractures36 or
the inferior border. This hole is of a larger diameter than

the screw to be used to ensure that it does not actively
engage this cortex. Next, a long drill guide is inserted
into the glide hole and, using a drill of smaller diameter
than the screw threads, the osteotomy is completed from
the fracture line to the distal cortex. This is the traction
portion of the osteotomy. The entire drill hole must not
only traverse the fracture and both cortices, but should
be perpendicular to the fracture. A depth gauge is used
to measure the distances between the cortices and the
appropriate screw length is selected. The near-cortex
entry site may also be countersunk to allow for more
broad distribution of the forces from the screw head
because a large amount of compression will be gener-
A B ated. A long bone screw or true lag screw (a screw in
which the proximal portion of the shank is unthreaded)
FIGURE 33-14 True lag screws have a smooth shank segment that
is inserted passively through the gliding hole and pur-
does not engage the proximal cortex, allowing threading of the
chased into the traction hole. When completely tight-
distal cortex and subsequently compressing it proximally.
ened, the engaged distal cortex will be drawn proximally
and create compression at the fracture line. This process
should be repeated with a second screw or second
method of fixation to prevent rotation around a single
axis (Figs. 33-16 and 33-17). When treating transverse or
sagittal fractures of the symphysis, the screws should be
placed through the outer cortex on either side. In
oblique fractures, it may be necessary to engage the outer
cortex proximally and inner cortex distally.
A
MIDFACE AND UPPER FACE FIXATION
Unlike the mandible, most of the facial skeleton is not
subject to major muscular forces. The zygoma is the only
other bone that displays significant effects from the mas-
ticatory musculature.9 This must be taken into account
when fixating zygomaticomaxillary complex fractures.
Complex craniomaxillofacial trauma involving the
frontal sinus, orbits, naso-orbito-ethmoid (NOE)
complex, zygomaticomaxillary complex, and maxilla are
B best managed with the use of miniplate or microplate
FIGURE 33-15 When using a true lag screw, the nonthreaded
fixation40 (Fig. 33-18). Because the necessity for plate
portion does not engage, resulting in compression of the strength and stability decreases in midfacial fractures,
segments across the screw. If using a standard full thread screw one must take into account the adverse effects associated
in a lag technique, the proximal segment must be overdrilled so with overzealous fixation. Thin soft tissue and overlying
that the screw can fit passively without the threads engaging the skin encasing the orbital and nasal complexes requires
near segment. The distal segment is engaged by the screw low-profile plates to prevent show-through, palpability, or
threads. dehiscence. In these areas, microplates provide adequate
fracture stability and preserve patient comfort and aes-
thetics more than larger plates.41 Compared with the
obliquely oriented body and angle fractures. The premise mandible, midface and upper facial bones are thinner
of this technique is its ability to engage and pull, or lag, and more fragile. It is important to take advantage of the
the distal cortex toward the proximal cortex across a facial buttresses in fixating fractures to achieve screw and
fracture. This method provides a high degree of fracture fracture stability42 (Fig. 33-19). Even with the pull of the
compression, resulting in very stable fixation (Fig. 33-15). masseter attachment at the zygoma, zygomaticomaxillary
If done properly, this can be completed faster than with complex fractures can be managed with miniplate or
compression or noncompression plate osteosynthesis, microplate fixation at multiple points, with stable results.
with fewer postoperative complications.37-39 Controversy exists regarding the ideal number of fixation
Unlike plate osteosynthesis, lag screw osteosynthesis points for zygoma fractures, but most studies have shown
directly traverses the fracture line, more evenly distribut- that miniplates or microplates provide sufficient stability.
ing compressive forces between segments and resulting Outcomes measured by malar stability, orbital volume
in excellent stability and minimal to no lingual splay. changes, facial asymmetry, or nonunion have shown vari-
After the fracture is exposed and reduced, a gliding hold ability in studies advocating one, two, or three points of
is prepared from the near-cortex to the fracture close to fixation43-46 (Fig. 33-20). The contraction of the masseter
A B C
D E
1 2
3 4
5
F
FIGURE 33-16 The steps in the lag screw technique. A, The outer segment is drilled to the fracture line with a large-diameter drill. The
screw should fit passively in this segment, with only the screw head engaging the outer cortex. B, The inner or distal segment is drilled
with a smaller diameter drill using a drill guide that fits the length of the first hole. The outer cortex is then countersunk with a special drill.
C, A depth gauge is used to select the appropriate length screw. D, E, The screw is placed, resulting in compression. F, A combined
approach with lag technique and plate osteosynthesis may be used in oblique or free-floating fractures. In fracture (1), the two proximal
screws are engaged with a lag technique to draw the free lingual segment toward the outer cortex (2). An oblique fracture (3) may be
treated with plate osteosynthesis (4) or combined with a lag technique (5). When using the combined technique, smaller length spans
result between screws, reducing the amount of torsion across the plate.
muscle produces distracting forces at the zygomatico- them unstable, but the direction and degree of
frontal and zygomaticomaxillary sutures, both of which displacement.
are important points of fixation, with adequate bone
stock for screw stability. Increased points of fixation resist BIOABSORBABLE PLATE FIXATION
these forces but may or may not make a clinical differ-
ence.47 Most studies have shown that it is not necessarily With the advent of titanium internal fixation plates, rates
the method of fixation of zygoma fractures that makes of hardware infection and screw loosening have
A B
90°
90°
D
FIGURE 33-17 A, 22-year-old man with a transverse mandibular symphysis fracture. B, Application of two lag screws across the fracture.
C, Postoperative orthopantomogram demonstrating correct hardware placement and compression of the fracture. D, To maximize the
benefits of lag screw fixation, screws should be placed at an angle that bisects the lines perpendicular to the fracture and perpendicular
to the bone surface where the screw will enter.
significantly declined when compared with less biologi- a hypovascular fibrous envelope, diminishing immune
cally compatible metals. Even so, late hardware failure cells from migrating to the area and clearing bacterial
requiring operative removal is still an active issue in max- contamination. If the plate becomes inoculated with
illofacial trauma and subjects patients to additional risks microbial pathogens, an infection may ensue, creating
associated with secondary surgery. The ideal implant inflammation, necrosis, and hardware loosening. In
should be completely biocompatible and resist infection, some European countries, it is commonplace to remove
but as a nonbiologic alloplast, titanium is still subject to hardware routinely once stable bone healing is complete
these effects. Unlike the surrounding bone, metal to prevent late infection, plate palpability, translocation
implants do not remodel or undergo angiogenesis. Fre- during osseous growth, and/or impingement of dental
quently, surgical sites surrounding metal plates develop prostheses. The advent of bioabsorbable fixation devices
negates the need for hardware removal and can prevent
many complications associated with long-term retention
of permanent hardware.
Bioabsorbable implants were initially developed and
used for pediatric craniofacial surgery in 1996, but have
been described in the literature as early as 1971 for appli-
cation in the facial skeleton. Traditional titanium plates
are notorious for migrating into growing bone and can
impinge on vital structures, depending on for which ana-
tomic site they are used. Several reports of intracranial
plate migration during bone growth drove the develop-
ment of nonpermanent implants.48,49 The advantage of a
resorbable system for pediatric fractures lies in absorp-
tion of the plate in vivo before it can translocate to an
unfavorable area. It has also been hypothesized that non-
resorbing metal plates can restrict growth of the sur-
rounding bone, leading to facial osseous hypoplasia and
developmental defects. Bioabsorbable systems have been
used and studied extensively in pediatric craniofacial
surgery.
There are several varieties of bioabsorbable materials;
FIGURE 33-18 Microplates used for upper and midfacial fixation. the most modern are permutations of a polylactic acid
The gold plates accept 1.7-mm screws and are best used for and/or polyglycolic acid polymer. Differences in lactic-
midface fractures; the blue plates accept 1.2-mm screws and are to-glycolic acid ratios, molecular weights, and polymer-
designed for upper face fixation. These plates are available in ization mechanics may account for variability in resorption
varying degrees of thickness and malleability. rates and handling characteristics. Polylactic acid resorbs
A B
FIGURE 33-19 A, 40-year-old woman status post–six-story fall, sustaining head trauma and multiple facial fractures. This three-
dimensional CT scan shows reconstruction after the initial decompressive craniectomy. B, Postoperative CT scan demonstrating
microplate fixation of the midface and upper face, with concomitant bone grafting. Note the plate positions and segment reduction
across all the major facial buttresses.
A B
Axis of
rotation
Masseter
muscle
pull
D
FIGURE 33-20 A, Microplate fixation of a combination of Le Fort I and zygomaticomaxillary complex (ZMC) fractures. Reduction and
fixation across the zygomaticomaxillary and piriform buttresses provides maximum stability with the use of small hardware. Note that
MMF was achieved with MMF screws. B, Microplate fixation of the zygomaticomaxillary buttress of a comminuted ZMC fracture with
linear plates. C, MMF screws. Each screw has a hollow head design with slots in the same direction of the driver cross in which wires
can be passed. D, Effects of the masseter muscle on ZMC fractures.
into lactate and takes longer than the hydrolysis of poly- surgical procedures, complications exist. Many of these
glycolic acid into carbon dioxide.50 Reported resorption are exclusive to internal fixation and care must to be
rates for these materials range from 12 to 36 months, as taken to minimize these risks.
described by manufacturers, but many reports indicate
that these plates can be palpated past the 3-year mark. SURGICAL SITE INFECTION
The most commonly reported complications associated Surgical site infection is multifactorial in nature and has
with this technique include not only plate palpability, but patient- and surgeon-dependent factors. Surgical site,
foreign body reactions, effusions, and infections. access, type of hardware, technical errors, fracture mobil-
A 5-year, multicenter prospective-retrospective study ity, and medical comorbidities are all elements that con-
conducted by Eppley et al51 have analyzed 1883 cranio- tribute to postoperative infection.55 Fractures of the
synostosis patients younger than 2 years of age undergo- mandibular angle seem to carry the highest rate of infec-
ing surgery with fixation by poly-l-lactic polyglycolic tion regardless, of fixation technique. This may possibly
copolymer plates. Various devices composed of the same stem from decreased bone to bone contact as compared
compound were used, including plates, meshes, threaded with other mandibular sites. Teeth present in fracture
screws, and threadless push screws. Much of this lines without pathology or dental injury that do not
depended on surgeon preference and evolution of hard- impinge on fracture reduction and fixation may be left
ware types from the manufacturer. They found device- in place without increasing the risk of infection.56 Various
related complications in 0.5% of patients; 0.3% of approaches to facial bone fractures have not been con-
patients required reoperation. sistently shown to have significant differences in infec-
Ahmad et al52 have examined 146 cases of cranial vault tion rates, but combined transoral-transfacial approaches
reconstructions treated with LactoSorb plates in patients to a single mandibular fracture site may increase the
ranging from 2 months to 16 years of age. Outcomes overall complication rate.57
similar to those of previous studies were analyzed, includ- There is no consensus on the use of antibiotics for
ing plate palpability, wound infection, and wound fracture surgery. The use of perioperative versus extended
healing. Six patients had palpable plates, two patients antibiotics after fracture surgery has not shown any sta-
had palpable screws, and five patients developed surgical tistical differences in infection rates in some groups,58
site infections over the course of a 1-year follow-up but others have reported that single-dose or single-day
period. antibiotic therapy is superior in regard to infection rate
As noted, bones of the upper and midfacial skeleton reduction when compared with controls.59 Many authors
do not experience significant effects of muscle forces, have questioned the need for postoperative antibiotics
allowing them to be fixated with minimal hardware. after internal fixation of the fracture, advocating that
From a pure strength and stability standpoint, bioabsorb- patient factors are more important in the development
able hardware is inferior to titanium.53 In cranial vault of surgical site infection.60
surgery, these differences have not been shown to be Application of excess hardware that does not change
clinically relevant because hardware failure from stress the clinical stability of the fracture may also be associated
and strain has not been reproducibly demonstrated. with increased complication and infection rates.61
Most large-scale studies have shown that complication Severely contaminated open fractures tend to have
rates of bioabsorbable fixation are less than or equal to higher rates of infection due to gross colonization of
those with metal fixation. The mandible, however, poses pathogenic bacteria. Poorly adapted plates or screws
entirely different problems. AO principles dictate that placed with weak purchase prevent adequate compres-
fracture stability is essential for proper bone healing, sion of fractures, increase interfragmentary mobility, and
which is mostly dependent on the type of fixation. eventually may lead to hardware failure and site infec-
Controversy exists regarding postoperative complication. Screw holes should be drilled linearly under copious
tions, infection rates, and hardware failure in the use of irrigation to prevent widening and thermal necrosis.
bioabsorbable implants for mandibular trauma; much of Medical comorbidities associated with suppressed
this may be attributed to operator technique, variations immune function include diabetes mellitus, acquired
in hardware composition, and surgical patient popula- immunodeficiency syndrome, malnourishment, and
tion. Polylactic acid and polyglycolic acid plates, on chronic alcoholism, which lead to an increase in overall
average, provide half the strength of a traditional bicorti- infection rates.62 Hypovascularity of tissues secondary to
cally fixated bone plate across a fracture. In the mandi- multiple surgeries or radiotherapy prevent adequate
ble, this can produce negative outcomes. Although more immune proliferation at the surgical site and should be
large-scale clinical trials and long-term follow-up are taken into account; medical optimization prior to surgery
needed to address the use of bioabsorbable plating in the may be useful in reducing the risk of infection.
lower face, many studies have shown rates of infection, When infections do occur after fixation, the adminis-
bone union, and complications to be on par with tita- tration of antibiotics, with or without surgical débride-
nium fixation. Proper case selection is essential to avoid ment, irrigation, and hardware removal, may be necessary
adverse outcomes.52,54 (Fig. 33-21).
COMPLICATIONS OF INTERNAL FIXATION DENTAL INJURY

In fractures of the maxilla or mandible, proper preopera-
Modern methods of internal fixation provide many ben- tive imaging can prevent iatrogenic tooth injury. Dental
efits over closed reduction of fractures but, as in all structures are usually damaged by misguided drilling or
A B
FIGURE 33-21 A, 55-year-old man with diabetes mellitus and chronic alcoholism presenting 2 years status post– open reduction and
internal fixation (ORIF) of bilateral mandibular fractures and complaining of purulent drainage from bilateral neck. Note the orocutaneous
fistula from infected plates. B, CT scan shows chronically infected hardware and extensive osteolysis, resulting in a free-floating anterior
segment.
malpositioned screws. Bicortical fixation of the mandible Full-thickness incisions to bone should be avoided in the
should occur at the inferior border to avoid tooth roots premolar area until the main trunk of the mental nerve
and monocortical fixation of the maxilla and mandible is identified from the subperiosteal pocket by gentle dis-
should be placed just apical to the apex of teeth. In situ- section. Once located, it can be protected with an instru-
ations in which bone height is diminutive, it may be ment while the remainder of the mucosa is incised above
necessary to secure screws just between tooth roots by it. Skeletonization of the mental nerve branches may be
approximating their location. Dental radiography or required to slide a plate below the foramen to adapt to
computed tomography (CT) can be useful for measuring the inferior border. Aggressive retraction in this area may
distances between teeth to prevent drilling into a tooth. also produce traction injury, resulting in neuropraxia or
If placing a screw is likely to damage a tooth, other axonotmesis. Excessive retraction may also avulse the
methods of fixation can be considered to prevent this, mental nerve from its foramen, resulting in permanent
including a single load-bearing inferior border plate or sensory deficits. Postoperative sensory deficits following
using an arch bar as a tension band. Placing arch bars internal fixation of the mandible have been reported at
may also damage periodontium and result in extrusion widely variable rates, likely due to differences in the sur-
or avulsion of teeth. Care should be taken to place inter- geon’s experience and technique.63,64 Similar precau-
dental steel wire apical to the heights of contour of the tions should be taken when fixating maxillary, inferior,
dentition. Passing wires between embrasures should be and superior orbital rim fractures to avoid damage to the
completed without macerating gingiva and may be facili- infraorbital and supraorbital nerves.65
tated by placing a gentle curve at the end of the wire.
When ligating it to the arch bar, the vector of force MALOCCLUSION
should be applied apically and parallel to the long axis As described earlier, establishing the correct premorbid
of the tooth to prevent iatrogenic luxation or avulsion. occlusion prior to the osteosynthesis of jaw fractures is
essential in maintaining correct three-dimensional rela-
NERVE INJURY tionships of the teeth and bones. Appropriate measures
The inferior alveolar canal harbors the neurovascular should be taken to establish a stable occlusion prior to
bundle that supplies the mandibular dentition and soft osteosynthesis. This may require the application of arch
tissues of the lip, chin, and associated gingiva. As noted, bars and MMF. Once established, accurate bending of
this is in the neutral zone of the mandible and should plates and application of screws perpendicular to the
be avoided to prevent postoperative paresthesia, dyses- plate can prevent splaying at the alveolus. Distraction of
thesia, or anesthesia. It is important to note that the canal segments by poorly bent plates or overtightening bone
runs approximately 2 mm inferior and 2 mm anterior to screws in a poor sequence can result in a malocclusion.
the mental foramen. Bicortical fixation should follow the Even the slightest of discrepancies can be detected by the
inferior border and tension bands should be secured patient and result in patient dissatisfaction, TMJ disor-
just above the neutral zone to avoid the inferior alveolar ders, parafunctional dental habits, and damage to teeth
nerve. In transoral approaches to the mandibular and periodontium secondary to misdirected occlusal
body and parasymphysis, the mental nerve should be forces. Malunion, or misalignment, of the jaws, and
identified and protected throughout the operation. nonunion will result in a malocclusion. Surgeon
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5. Daegling DJ, Hylander WL: Experimental observation, theoretical 30. Levine PA: Dynamic compression plating of the mandible. Otolar-
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6. van Eijden TM: Biomechanics of the mandible. Crit Rev Oral Biol effect of rigid internal fixation plates on mandibular bone grafts.
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A biomechanical comparison of locking and nonlocking plates. complications based on experience with resorbable plates in pedi-
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postoperative complications. J Oral Maxillofac Surg 65:1180–1185, internal fixation of mandibular fractures: A clinical and radiologic
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40. Strong EB, Sykes JM: Zygoma complex fractures. Facial Plast Surg lactic antibiotics versus postoperative extended regimen prophylac-
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48. Duke BJ, Mouchantat RA, Ketch LL, Winston KR: Transcranial 65. Kloss FR, Stigler RG, Brandstätter A, et al: Complications related
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51. Eppley BL, Morales L, Wood R, et al: Resorbable PLLA-PGA plate
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CHAPTER
Minimally Invasive Oral and
34
Maxillofacial Surgery Trauma
Paul E. Gordon
| Leonard B. Kaban
| James R. Tagoni
|
Maria J. Troulis
OUTLINE
Endoscopic Treatment of Subcondylar Fractures Endoscopic Repair of the Zygomatic Complex Fracture
Extraoral Approach Surgical Technique
Endoscopic Intraoral Approach Discussion
Endoscopic Treatment of the Frontal Sinus Endoscopic Repair of the Orbital Floor Fracture
Surgical Technique Surgical Technique
Outcomes Summary
Summary
reduction with some period of maxillomandibular fixa-
M
inimally invasive endoscopy in oral and maxil- tion (MMF) and physical therapy; and open reduction
lofacial surgery has evolved significantly over and internal fixation (ORIF). Most patients with condy-
the past several decades. Many patients have lar fractures have a satisfactory outcome measured by
benefited from this technology, because they often expe- mandibular motion with nonoperative management.4
rience less pain and swelling, shorter hospital stays, and The overall complication rate for treating subcondylar
fewer overall complications when compared with the fractures by closed reduction or observation is only near
standard maximally invasive procedures. With improved 7%.2 Not surprisingly, the vast majority of condylar frac-
instrumentation and surgeon experience, many new, less tures are treated in this manner. Anatomic reduction is
invasive techniques and approaches have been devel- rarely achieved with this approach, and post-treatment
oped for treating a broad scope of maxillofacial surgical TMJ function is often dependent on adaptation of the
procedures, such as orthognathic surgery, temporoman- altered condylar morphology with physical therapy, neu-
dibular joint (TMJ) surgery, sialoendoscopy, facial cos- romuscular training, and guiding elastics.5,6 Nevertheless,
metic surgery, and trauma. there are several instances in which ORIF is the preferred
The management of maxillofacial trauma has bene- treatment, as described by Zide and Kent7, and later by
fited significantly from these advances. There are well- Haug and Assael8 in their reports regarding indications
described minimally invasive approaches to the ramus for the open reduction of condylar fractures. Most agree
condyle unit, thus allowing for repair of most subcondy- that significant condylar displacement and ramus height
lar fractures. Treating orbital floor fractures, frontal instability are the two main indications to treat subcon-
sinus fractures, and zygomatic complex fractures with dylar fractures via an open approach.9 In addition, many
endoscopy have also been described. There are many surgeons supporting open reduction cite decreased
advantages using these techniques over standard proce- treatment and rehabilitation time, improved anatomic
dures involving open reduction. In this chapter, we reduction,10 consistent occlusal results,11 and preserva-
describe these advantages as well as the indications, tech- tion of facial symmetry.12 Furthermore, patients appreci-
niques, and outcomes of treating maxillofacial trauma ate not having to have their jaws immobilized with MMF.
patients with minimally invasive techniques. The topic of open versus closed reduction of subcon-
dylar fractures remains controversial. However, when
open reduction has been decided, options include using
ENDOSCOPIC TREATMENT OF the submandibular, retromandibular, or preauricular
SUBCONDYLAR FRACTURES incision. All these approaches allow appropriate access
to the subcondylar region, thus enabling proper reduc-
Condylar fractures are very common, making up almost tion and fixation. However, these incisions do not come
one third of all mandibular fractures. There is extensive without risks, such as facial scars, intraoperative or post-
literature on the management of condylar fractures, operative bleeding, salivary fistula, infection, and tempo-
which is a subject of significant controversy.1-3 In general, rary or permanent facial nerve injury.13-16
there are three treatment modalities for the manage- With these open approaches, the incidence of facial
ment of condylar fractures—observation, closed nerve injury reported is as high as 30%.17 In Ellis et al’s
828
Minimally Invasive Oral and Maxillofacial Surgery Trauma CHAPTER 34 829
review of the literature, less than 1% of the 455 patients ensues to the masseter muscle bluntly. The muscle and
who underwent open treatment of condylar fractures pterygomasseteric sling are incised with needlepoint
had permanent facial nerve injury, whereas 12% had cautery. Careful subperiosteal dissection occurs along the
transient weakness.13 Furthermore, in this series of 93 inferior border and a subperiosteal blind sweep is per-
patients with subcondylar fractures treated open, 17.2% formed along the lateral surface of the mandible using a
developed temporary facial nerve weakness, with no suction-assisted endoscopic elevator (Snowden-Pencer,
cases of permanent weakness in patients that followed Tucker, Ga), thus creating an optical cavity. The position
up. In this same series, 7.5% of patients developed wide of the incision and mobility of the soft tissue in this region
or hypertrophic scars postoperatively. allow the 2.7-mm diameter, 30-degree Hopkins endo-
Although rare, the risks for treating subcondylar frac- scope (Karl Storz, Carver City, Calif) to be placed in the
tures with standard ORIF are not benign. The benefits wound and oriented parallel to the posterior border with
of ORIF in treating subcondylar fractures often outweigh direct access to the entire RCU, thus allowing the surgeon
these risks. Some surgeons have sought to minimize the to visualize and work on the area of interest en face.
risks of treating subcondylar fractures further by develop- Using the elevator, subperiosteal dissection continues
ing minimally invasive approaches to the ramus condyle as the anatomic landmarks of the RCU are identified,
unit. With the aim of minimizing the risks in treating including the posterior border, anterior border, sigmoid
subcondylar fractures with ORIF, while still benefiting notch, coronoid process, and condylar neck. A curved,
from the advantages seen in rigid fixation, some sur- long-handled retractor is positioned to maintain the
geons have turned their attention to minimally invasive optical cavity (Synthes CMF, Pa). Irrigation is performed
approaches to the ramus condyle unit.18-20 through the endoscopic irrigation port.
Treating subcondylar fractures with endoscopy pro- With endoscopic visualization, the proximal and distal
vides the surgeon with excellent visibility, magnifying and fragments of the fracture are identified and mobilized.
illuminating the operative field. A smaller incision and In the case in which the fracture is laterally overriding,
less dissection are needed, resulting in less postoperative a 24-gauge wire is passed through a 1.5-mm drill hole at
swelling, less pain, shorter hospital stay, quicker postop- the mandibular angle to distract the distal segment infe-
erative recovery, lower risk to the nerve and smaller riorly, enabling the reduction of the fracture. The proxi-
inconspicuous scars.21-23 Nevertheless, the surgeon must mal segment is reduced with the condylar neck head
invest a significant amount of time to learn and master positioned in the glenoid fossa. The fracture is reduced
these techniques and the cost of equipment is often high. and the distracted distal segment is released, wedging the
Both intraoral and extraoral endoscopic approaches two segments together. The reduction is verified by
have been described for the treatment of subcondylar directly visualizing the fracture lines at the posterior
fractures. Advocates for the intraoral approach cite ben- border and sigmoid notch. The fracture is fixated using
efits such as lack of visible scars and low risk of facial a 2.0-mm, five-hole titanium miniplate. The plate may be
nerve injury.24 However, its use is limited for some types positioned into place with a plate holder, and screwed to
of subcondylar fracture, particularly the medially dis- the proximal fragment first, enabling the surgeon then
placed or dislocated fracture.25 The extraoral endoscopic to remove the plate holder and control the proximal
approach has made the treatment of medial overriding fragment while aligning the distal segment for fixation.
and dislocated fractures much easier, with minimal risk Reduction at the posterior border is verified and the
for facial nerve injury and a small, 1.5-cm submandibular distal screws are placed, either through the incision or
scar.18 Here we describe the extraoral and intraoral endo- with the aid of a percutaneous trocar (Figs. 34-1 and
scopic approaches for treating subcondylar fractures. 34-2).
When the proximal segment is medially displaced, an
EXTRAORAL APPROACH attempt is made endoscopically to visualize the proximal
The extraoral approach described here was developed at segment, and manipulate it into the lateral overriding
the Massachusetts General Hospital (MGH) to gain position. Typically, this is accomplished endoscopically
access to the ramus condyle unit (RCU) for a variety of (Fig. 34-3). If unsuccessful, an endoscopic vertical ramus
procedures, including vertical ramus osteotomy with osteotomy can be performed to permit access to the
rigid fixation for mandibular setback, condylotomy for condylar fragment.22
condylar sag, high condylectomy, condylectomy, costo-
chondral graft reconstruction, coronoidectomy, and Outcomes
open reduction and rigid fixation of subcondylar frac- At MGH, in a retrospective analysis of 20 consecutive
tures. The technique used in all minimally invasive ORIF patients with subcondylar fractures (n = 22 sides) who
cases at MGH is the extraoral approach described underwent endoscopic ORIF, 1 patient had temporary
below.18,26 marginal mandibular nerve weakness at 1 week follow-up,
which resolved several weeks later. There were no perma-
Surgical Technique nent postoperative injuries to the marginal mandibular
Surface landmarks are first drawn on the skin, including nerve and no unacceptable facial scars were encoun-
the outline of the mandible and the clinically and radio- tered.18,26 In all cases, there were no cases of postopera-
graphically identified fracture site. The patient is placed tive malocclusion and all patients had normal TMJ range
into maxillomandibular fixation (MMF) in the proper of motion without pain. Miloro has found similar results
occlusion. A 1.5-cm incision is made one finger-breadth in a series of six consecutive subcondylar fractures treated
below the angle of the mandible, and then dissection with extraoral endoscopic ORIF.27
Of the 20 patients in the series treated at MGH, 14 tations, particularly for the management of medially
were treated initially with endoscopic ORIF and 6 were displaced subcondylar fractures.29 It has also been
treated after failed MMF. Of these fractures, 14 were shown to be technically challenging, requiring a steep
displaced and eight sides were dislocated. Four patients learning curve, even for those experienced in endo-
with medial displacement required a vertical ramus oste- scopic oral and maxillofacial surgery.30 Since its initial
otomy with subsequent ex vivo removal and fixation of description, there have been several modifications
the proximal segment and condyle. In all cases, the RCU described with the aim of easing the technical chal-
heights were restored and there were no abnormalities lenges encountered.26,31,32
in healing, facial or trigeminal nerve injury, jaw motion,
occlusion, facial asymmetry, or pain. None of the patients Surgical Technique
required MMF postoperatively and all were discharged An intraoral incision is made in the posterior mandibular
from the hospital in less than 23 hours after the buccal sulcus, with subsequent subperiosteal dissection
procedure.26 along the lateral ramus, angle, and posterior border of
the mandible, thus creating an optical cavity for a 4-mm,
ENDOSCOPIC INTRAORAL APPROACH 30-degree angle scope (Karl Storz, Tuttlingen, Germany).
Jacobovicz and Lee first described the intraoral endo- A percutaneous, 40-mm guarded trocar is placed trans-
scopic approach to subcondylar fractures in 1998.28 This buccally, perpendicularly at the level of the subcondylar
approach showed promising results and those who sup- fracture. The optical cavity is maintained by retraction
ported it cited benefits such as lack of visible scars and with the guarded trocar, the endoscope is placed through
low risk of facial nerve injury. The approach has its limi- the intraoral incision, and the proximal fragment of the
A B
C D
FIGURE 34-1 A, Right subcondylar fracture. B, Left parasymphysis fracture. C, D, Right subcondylar fracture with lateral override.
E F
G H
I J
FIGURE 34-1, cont’d E, Displaced left parasymphysis fracture. F, Left parasymphysis fracture reduced + plated. G, H, Percutaneous
screw placement with endoscopic guidance, with rigid fixation. I, J, CT scan, Immediately postoperatively.
A B
C
FIGURE 34-2 A, B, Right parasymphysis, left subcondylar fracture. C, Panorex, left subcondylar fracture, right parasymphyseal fracture.
D E
G
FIGURE 34-2, cont’d D, Left subcondylar fracture. E, Left subcondylar fracture with rigid fixation. F, G, Immediately postoperatively.
Continued
H I J
M
FIGURE 34-2, cont’d H-M, 6 weeks postoperatively.
subcondylar fracture is visualized and dissected under the trocar for initial stabilization of the segments. A fixa-
direct endoscopic vision (Fig. 34-4). tion plate is then used for definitive fixation. The patient
The patient is then placed into temporary elastic is released from MMF postoperatively (Fig. 34-6).
MMF, thus facilitating reduction of the fracture. The
proximal segment can be reduced into position by apply- Outcomes
ing a medially directed force against the lateral surface With this technique, the authors confirmed good ana-
of the proximal segment with the trocar (Fig. 34-5). The tomic reduction, mandibular projection, lower face
anatomic reduction is verified with direct endoscopic width, facial height, premorbid occlusion, and a maximal
visualization and positional screws are placed through incisal opening of 39 mm without pain. Lee et al
A B
C D
E
FIGURE 34-3 A, B, Right subcondylar fracture with medial override. C, D, Medial override converted to lateral override, with fixation after
reduction. E, Right subcondylar fracture ORIF postoperatively.
followed this with a longitudinal study of 20 patients with (2 of 22) were challenging to repair and required a much
22 fractures that were repaired using this technique.33 longer operative time (269 ± 139 minutes)33.
Functionally, all patients had restoration of their premor- Since 1998, there have been several reports describing
bid occlusion and an average maximal incisal opening of modifications of the intraoral endoscopic subcondylar
43 ± 6 mm at 8 weeks postoperatively. All patients were fracture repair. Sandler used two separate trocars for
pleased with the aesthetic results of the repair, including improved reduction and fixation.34 The first trocar was
chin projection, jaw line, and symmetry; 21 of the 22 placed 20 mm anterior to the tragus along the canthal-
fractures showed radiographic evidence of fracture tragal line and the second was placed 10 mm below the
reduction. One patient with medial override showed an first site. In 2002, Schon et al used angulated drills and
improved but imperfect reduction and there was no evi- screwdrivers, eliminating the need for percutaneous
dence of late condylar remodeling in any of the patients. trocar incisions.35 Kellman described an additional 1-cm
Operative times were also measured. Fractures with submandibular incision for easier viewing and reduc-
lateral override (20 of 22) were easily reduced and fixated tion.32 Chen et al used a bone clamp to distract the distal
endoscopically (131 ± 39 min). Medial override fractures segment inferiorly for easier reduction and fixation.36
FIGURE 34-6 The plate is placed through the intraoral incision and
FIGURE 34-4 Via an intraoral incision, the endoscope is used to the screws are placed through the percutaneous trocar.
visualize the fracture and the proximal segment (P) is dissected.
unsatisfactory fixation of a miniplate secondary to osteo-
porotic bone. Facial nerve injury occurred in 10 ORIF
patients and 5 endoscopic patients. A 50% recovery of
facial nerve injury occurred in the ORIF group, whereas
80% recovered from the endoscopic group.
Discussion
The intraoral endoscopic technique for treating subcon-
P dylar fractures can be used for many simple subcondylar
fractures, particularly with lateral override and minimal
displacement. Advocates of the intraoral approach cite
numerous benefits, including decreased facial nerve
injury and lack of visible scars. It is clear from most of
the literature that the technique can be extremely chal-
lenging, and even the most experienced surgeons have
difficulty learning this technique1,32,38 The intraoral
approach results in viewing the fracture from a parallel
view of the mandible rather than en face, making it chal-
lenging. It is also evident that when compared with the
T extraoral endoscopic approach, the intraoral endoscopic
approach leads to more complications with medial
override fractures. However, some authors still advocate
FIGURE 34-5 A percutaneous trocar (T) is used to help reduce the use of the transoral endoscopic approach, even with
proximal segment (P). medial override, and attribute the difficulty to surgeon
training.30
In 2009, Schmelzeisen et al performed a randomized With the extraoral approach, most patients easily
controlled trial with 34 patients who underwent tradi- accept a 1.5-cm submandibular scar and the risk of facial
tional ORIF of subcondylar fractures and 40 underwent nerve injury (4.5%) is clearly lower than the traditional
intraoral endoscopically assisted ORIF.37 They evaluated extraoral approach (30%), although not as low as the
the functional and cosmetic outcomes, operative time, intraoral endoscopic approach (1.04%).*
and intraoperative and postoperative complications. Finally, some predict that the extraoral endoscopic
Using the Helkimo dysfunction score, there was no sta- procedure will eventually be performed in the outpatient
tistically significant difference between the two treatment setting with IV sedation, significantly decreasing opera-
groups. The median operative time of the traditional tive time, cost, and manpower.
ORIF group was 33 minutes faster than the endoscopic Both the intraoral and extraoral endoscopic tech-
group. Two intraoperative complications for the endo- niques have their advantages and disadvantages, but
scopic group included an anterior open bite that was
fixed with a period of MMF and guiding elastics and *References 19, 29, 30, 32, 34-36, and 38.
this should not distract from the ultimate goals of ORIF— an endoscopic approach depends on careful patient
return of premorbid occlusion, pain-free range of motion selection. The surgeon must invest a significant amount
>35 mm, facial asymmetry, minimal scarring, and no of time mastering the techniques, which pays off for the
postoperative facial nerve dysfunction. patient who benefits from its use.26
ENDOSCOPIC TREATMENT OF SURGICAL TECHNIQUE

THE FRONTAL SINUS The incisions for the endoscopic repair of frontal sinus
fractures (isolated anterior table fractures) are similar to
Frontal sinus fractures make up 5% to 15% of all facial that of the endoscopic brow lift. Two 2-cm long longitu-
fractures and are typically the result of high-velocity dinal hairline incisions are made approximately 2 cm
blunt force trauma to the maxillofacial area.39 The frontal behind the hairline, one over the midline of the scalp
sinus is one of the thickest bones of the craniofacial and the other at the injury site (Fig. 34-7). In patients
region and can withstand almost 400 to 1000g of force with a prominent forehead or receding hairline, the inci-
before fracturing, twice the force tolerated by any other sions should be closer to the hairline to allow easier
facial bone. Hence, head trauma, cervical spine injury, visualization of the fracture around the curvature of the
and other concurrent facial fractures are commonly seen forehead. The incisions are made down to bone and a
in association with frontal sinus fractures, thus affirming periosteal elevator is used to create subperiosteal pockets
the potential for injury severity. As such, the operative for each optical cavity. A blind subperiosteal dissection is
morbidity for repair of these fractures can be severe. performed through each incision for the first 3 to 4 cm.
Therefore, the importance of developing a less morbid, A 4-mm diameter, 30-degree Hopkins II endoscope (Karl
minimally invasive approach to repair these fractures is Storz, Tuttlingen, Germany), with an external sheath for
of interest. retraction of the soft tissue, is inserted in the midline
The management of frontal sinus fractures has been incision (Fig. 34-8). Curved endoscopic dissectors are
well described and various algorithms have been devel- used to tunnel and connect each incision (Fig. 34-9). The
oped to guide decision making for treatment.40-42 Opera- tissue is elevated inferiorly to the supraorbital rim and
tive treatment depends on a number of factors, including the fracture is visualized directly with the endoscope. The
the following: (1) nasofrontal duct involvement; (2) bone fragments can then be elevated and repositioned
degree of anterior table depression; (3) degree of poste- into place. A stab incision can be made in the eyebrow
rior table fracture; (4) neurologic status; and (5) cere- region to help reduce the segments, if necessary.26,46-48
brospinal fluid (CSF) leak. Based on the degree and type If the fracture is stable after reduction, fixation may
of injury, treatment options may include observation, not be necessary. Often, however, fixation is required for
anterior wall reconstruction, osteogenesis, obliteration stabilization of the segments. After inserting miniplates
or exenteration of the sinus, and cranialization. through one of the port incisions, a percutaneous stab
If operative management is necessary, a coronal inci- incision is used to pass screws, thus allowing the plates to
sion is the typical approach used, although gull wing and stabilize the fractured segments (Figs. 34-10 to 34-12).
open sky incisions have been described.43 These are not
without risks, because they often cause scarring, alopecia,
facial nerve weakness, and paresthesia.44,45 Minimally
invasive endoscopic approaches to the frontal sinus have Retractor
been developed with the aim of decreasing or eliminat-
ing these risks.46 Some of these techniques were origi- Arthroscope
nally developed for use in brow and forehead lifts.47 The
severity and degree of involvement of the frontal sinus
fracture dictate whether one can use the minimally inva-
sive techniques that have been developed. If osteogene- Facial nerve
sis, obliteration or exenteration, or cranialization is (frontal branch)
required, the traditional approach is preferred. Only iso-
lated anterior table fractures can be treated with endos-
copy.48 It has been reported that one third of all frontal
sinus fractures are isolated to the anterior table,49,50
although some have reported an incidence as high as
72.5%.51 Operative interventions in isolated anterior
table fractures often create a depression defect, which
may be an aesthetic concern for some patients. This is a
common indication for operative intervention in these
fractures.
Treating frontal sinus fractures with endoscopy pro- Intraoral
incision
vides the surgeon with a magnified, direct visualization
of the operative field. Smaller incisions with less dissec-
tion are required, which makes for an easier postopera-
tive course, with less swelling and pain, shorter hospital FIGURE 34-7 Incision lines (red) for an endoscopic approach for
stays, and smaller inconspicuous scars. The decision for left side frontal sinus repair.
FIGURE 34-9 Curved dissectors. (Courtesy Arnulf Baumann.)
FIGURE 34-8 Endoscope (above) and sheathed retractor (below).

(Courtesy Arnulf Baumann.)
A B
FIGURE 34-10 A, B, Depressed left frontal sinus fracture, with endoscopic view. (Courtesy Arnulf Baumann.)
FIGURE 34-11 Miniplate held in place with a clamp. The drill is

inserted through a percutaneous stab incision. (Courtesy Arnulf FIGURE 34-12 Percutaneous placement of screw to fixate the
Baumann.) plate. (Courtesy Arnulf Baumann.)
In some cases, if the fractures are unstable after an management of zygomatic complex fractures include
attempt is made at endoscopic repair, or if great difficulty facial asymmetry resulting from depression of the
is encountered trying to plate the fractures, conversion complex and/or trismus resulting from impingement of
to a standard open coronal approach may be necessary. the coronoid process by the depressed arch. Depressed
or rotated fractures can be treated with one or a combi-
OUTCOMES nation of multiple approaches, including a maxillary ves-
Since its initial description in 1996,46 endoscopic frontal tibular incision, supratarsal fold incision, transconjunctival
sinus fracture repair has evolved and there have been incision, and coronal incision. Historically, classification
several modifications published. Hewitt et al52 have systems have been developed to guide the surgical
described using a urethral sound to help reduce an iso- approach based on fracture anatomy.55,56 If the arch frac-
lated anterior table fracture. After making a small 2-cm ture is isolated, the conventional approach to treatment
Lynch incision, a 4-mm trephine burr was used to drill a would be closed reduction with a Gillies57 or Keen58
hole to allow a 45-degree endoscope into the sinus. After approach. If the arch is comminuted and cannot be
visual examination with the endoscope, a urethral sound reduced with closed reduction, or if it is associated with
is placed through the trephine hole, maneuvered under a complicated ZMC fracture, a coronal incision has tra-
the fracture, and pushed up to elevate the fracture while ditionally been the approach for performing ORIF of the
molding the fracture externally with digital palpation. arch.
The reduction can then be confirmed with endoscopic The coronal incision has few limitations in terms of
visualization. access, but it certainly is considered maximally invasive
Chen et al have described removing the reduced seg- and can result in significant postoperative pain and
ments by an endoscopic grasper and used as free grafts.53 swelling. The potential for scarring, alopecia, and pares-
The fragments are assembled on the table and fixated thesia does exist.45 Facial nerve injury is also possible,
with miniplates, being sure to extend the miniplates especially with zygomatic arch access, because a preau-
beyond the segments so that they can be secured to bone ricular extension is required. Because of this, surgeons
in situ. The frontal sinus mucosa can be stripped off and have been interested in minimally invasive techniques at
the nasofrontal duct can be visualized with the endo- repairing zygomatic complex and isolated zygoma
scope. After the segments are assembled, it can be placed fractures.59
back through the wound and secured with percutaneous
screws. SURGICAL TECHNIQUE
Even with these modifications, it is evident that iso- The endoscopic approach to the zygomatic arch typically
lated anterior table fractures with significant comminu- involves a maxillary vestibular incision and two temporal
tion are challenging to treat endoscopically and a coronal incisions (Figs. 34-13 and 34-14). Preoperative mapping
approach should be considered in these cases. Shum- of the frontal branch of the facial nerve should be drawn,
rick’s series has shown successful endoscopic repair of which is helpful particularly if percutaneous screw fixa-
anterior table fractures in 12 of 19 patients.54 In the seven tion is needed for arch fixation. The two scalp incisions
unsuccessful cases, the procedure required conversion to are 2 cm in length and located behind the temporal
a coronal incision due to the degree of anterior table hairline, superior and anterior to the helix of the ear.
comminution. Dissection is carried out to the temporalis fascia and then
continued bluntly to the temporal line of fusion, where
SUMMARY the temporalis fascia splits into the superficial and deep
There is credibility for using minimally invasive tech- layers. The superficial temporal fat pad is adherent to
niques to treat frontal sinus fractures when indicated. the superficial fascia but not to the deep fascia. Thus, the
These fractures must have minimal comminution and be fat pad and superficial fascia can be reflected while
isolated to the anterior table. If there is concern for
nasofrontal duct obstruction or a CSF leak, the conven-
tional coronal approach is preferred. Ideally, the frag-
ments should be large and there should be a depression
defect that is noticeable and of aesthetic concern to the
patient. When indicated, the endoscopic approach for
repairing frontal sinus fractures is a safe alternative to
the conventional approach, with less postoperative pain
and swelling and decreased risk for scarring, nerve injury,
and alopecia.
ENDOSCOPIC REPAIR OF THE ZYGOMATIC

COMPLEX FRACTURE
Zygomatic complex fractures are not uncommon and
their treatment is dictated by the type and severity of the
fracture. Nondisplaced fractures are typically treated FIGURE 34-13 Schematic endoscopic approach to the right
with observation. Two major indications for the operative zygomatic arch with intraoral and hairline incision.
FIGURE 34-16 Reduction and fixation with percutaneous screw

placement. (Courtesy Arnulf Baumann.)
FIGURE 34-14 Endoscope inserted through temporal incision (left),

with the curved dissector inserted from above. (Courtesy Arnulf
Baumann.)
DISCUSSION
Zygomatic complex fractures are typically repaired with
multiple approaches. If the zygomatic arch requires open
reduction, a coronal incision is typically necessary unless
using minimally invasive endoscopic techniques. Lee
et al60 first showed an endoscopically assisted approach
for repair of the zygomatic arch. In their series of 25
patients, a preauricular incision with a small temporal
extension was used for endoscopic access. In 8 of 25
patients, there was temporary frontal branch weakness
from retraction.
Chen et al61 used a temporal approach for endoscopic
repair of zygomatic arch and ZMC fractures. The dissec-
tion was superficial to the deep temporal fascia and of
the 15 patients studied, only 2 developed temporary
facial nerve weakness. The subfascial dissection, as
described earlier, involves exposing the temporalis
muscle directly, with the plane of dissection deep to the
muscle. In Lee et al’s study,60 25 patients had successful
repair of their fracture without any facial nerve injury.
In conclusion, the endoscopic technique is a mini-
FIGURE 34-15 The zygomatic arch is exposed between the
mally invasive alternative to treating isolated arch frac-
endoscopic retractor (left) and spatula (right). (Courtesy Arnulf
tures or comminuted ZMC fractures without the use of
Baumann.)
a coronal incision. The risk of facial nerve injury is low
if the deep subfascial dissection is used.62 With further
preserving the middle temporal artery, which is within advances and surgeon experience, new modifications to
the fat pad. This prevents bleeding during the endo- this approach will surely improve the results in repairing
scopic dissection. The superficial fascia and fat pad, and these fractures.
temporalis muscle if necessary, are reflected with the
retractor. The periosteum of the zygomatic arch is then
incised and the arch is exposed and dissected anteriorly ENDOSCOPIC REPAIR OF THE ORBITAL
(Fig. 34-15). An intraoral maxillary vestibular approach FLOOR FRACTURE
is also done with the endoscope, connecting the tempo-
ral incisions so that the arch is exposed with one tunnel- Maxillofacial trauma can result in fractures of the orbital
ing dissection. Reduction and fixation is done with floor, roof, medial wall, or lateral wall. Orbital floor frac-
miniplates, using percutaneous screw placement with tures are common sequelae of orbital trauma due to the
endoscopic visualization (Fig. 34-16).59,62 floor’s inherent weakness.63 Conventional orbital floor
Infraorbital nerve/artery
1.0
cm
Endoscopic cm
notch 2.0
FIGURE 34-17 Caldwell-Luc osteotomy for endoscopic orbital floor

access. (Courtesy R. Mueller.)
fracture repair involves access via the infraorbital, sub

ciliary, or transconjunctival incision, with or without a
lateral canthotomy with inferior cantholysis.64,65 These
approaches are relatively safe, with a 5% mean complica- FIGURE 34-18 Endoscopic view of the orbit from below, showing
tion rate.66-68 Possible complications associated with these comminuted bone fragments and periorbital contents. (Courtesy
Michael Miloro.)
incisions include visible scar formation, ectropion, entro-
pion, lower lid retraction, prolonged lower lid edema,
granuloma formation along the incision line, and iatro-
genic injury to the lacrimal system and/or globe. Sur-
geons have developed minimally invasive techniques with
endoscopy to help reduce the morbidity of orbital floor
fracture repair.69-72 An intraoral transantral approach is
used, which eliminates many of the risks seen in the
conventional open approach.
Indications for orbital floor fracture repair include
entrapment, enophthalmos, or a large floor defect
(>50%). The indications for endoscopic orbital floor
fracture repair are similar, but should only be attempted
by surgeons experienced in the techniques.
SURGICAL TECHNIQUE
A standard 3-cm maxillary vestibular incision is made
5 mm above the mucogingival junction and a subperios-
teal dissection is performed, thus exposing the anterior
sinus wall. The infraorbital nerve is identified and pro-
tected. A Caldwell-Luc osteotomy window is then made
in the canine fossa region, being careful to avoid the
tooth roots. The window should be 1 cm in height and
2 cm in length. This can be done with a piezo electric
drill or the osteotomy should be designed to accommo- FIGURE 34-19 Endoscopic view of the orbit from below, after the
bone fragments have been removed. (Courtesy Michael Miloro.)
date the fracture. The bony window should be removed
and placed in saline. An endoscopic notch should also
be created at the inferior horizontal osteotomy to allow severity of the defect can be appreciated. With a trapdoor
for stability when navigating the endoscope (Fig. 34-17). fracture of the medial or lateral portion of the floor, it
A 4-mm, 30-degree Hopkins endoscope (Karl Storz, may be possible to see that all the orbital contents are
Carver City, Calif) is then used to inspect the maxillary reduced back into the orbit. A Medpor implant may then
sinus, which is the optical cavity. The maxillary sinus be used on the sinus side to reduce the floor. The frac-
lining must be carefully removed, being sure to remove ture is often comminuted and this may not be possible
all of the Schneiderian membrane without injuring the (Fig. 34-18). In this case, removal of all small commi-
ostium. Once this is accomplished, an unobstructed view nuted bony pieces must be done endoscopically (Fig.
of the orbital floor is possible and the location, size, and 34-19). After removal of all bony fragments, a retractor
complications, such as ectropion or scarring. Neverthe-

less, there is a learning curve required to master this
technique. The technique is dependent on a well-trained
surgeon. As more surgeons become familiar with the
technique, the potential for further development
and modification improves, and hopefully endoscopic
repair of orbital fractures will become routine at most
centers.
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ERRNVPHGLFRVRUJ Index
Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
A Abuse, consideration, 250f Afterload, pressure/resistance, 133 Airway (Continued)
Abbe-Estlander flap, 537f Accessory nerves, 150 Age-related cardiovascular manipulation, requirements, 692
Abbe flap, 537f Acid-base balance, 58 changes/diseases, 750t mechanical ventilation, 694
Abbreviated Injury Scale (AIS), 168 control, 32 Age-related cellular changes, medical history, usage, 684
Abdomen, radiographic examination, Acid-etched wire composite splint, observation, 749-750 Midazolam, metabolism, 693
251 usage, 282f Aging neuromuscular blocking agent,
Abdominal area, force Acid etch resin splint, 280-281 advancement, risk factor, 742 administration, 689
(concentration), 167 Acidosis, 74 biology, 735 oroendotracheal intubation,
Abdominal examination, 167 Acrylic burr, usage, 783 cardiovascular system, 736-737 691-692
Abdominal trauma, 66-67 Acute epidural hematomas (EDHs), nutrition, 737-745 periodic examination, 687
adjunctive diagnostic studies, 169 158 psychosocial issues, 737 physical examination,
assessment/management, 167 computed tomography, imaging question, 736 685-688
computed tomography (CT), modality, 158 renal system, 737 postoperative support,
usage, 170 Acute protein depletion, respiratory system, 736-737 693-694
contrast studies, 170 indication, 39 suboptimal wound healing factor, benzodiazepines, usage, 693
cystography, usage, 170 Acute pulmonary embolism, 22 Dexmedetomidine, usage, 693
diagnostic laparoscopy, usage, 171 clinical manifestations, system changes, 735-736 Etomidate, usage, 693
diagnostic peritoneal lavage 72 Air, exchange, 56 Propofol infusion, 693
(DPL), 170 Acute renal failure, result, 6 Air emphysema, crepitation sedation techniques, 689-690
diagnostic workup, 169-171 Acute respiratory distress, 688 (impact), 360 thermal injury, 692-693
endoscopic retrograde Acute SCI, cervical spine Airflow, nasal resistance triage, 688
cholangiopancreatographic involvement, 160 (determination), 494-495 Airway, Breathing, and Circulation
techniques, usage, 170 Acute subdural hematomas (acute Airfree, 97 (ABC), 68
epidemiology, 167 SDHs), 159 Air medical transport trauma care, 110
examination, 168-169 Adenosine triphosphate (ATP), impact, 51 Airway maintenance Breathing and
focused assessment sonography in body requirement, 33 value, 50-51 ventilation Circulation
trauma (FAST), 169 Adjunctive scar revision Airway Disability Exposure (ABCDE),
performance, steps, 170b procedures, 603-605 adjuncts, 79-83 54, 77
gastric tubes, usage, 169 Adrenocorticotropic hormone analgesia techniques, 689-690 algorithm, 112
imaging studies, 169-170 (ACTH), pituitary release, 2-3 anatomy, 78f usage, 143
injury Adson-Brown forceps, usage, anesthesia induction, 689 Airway management, 690
algorithm, mechanism, 168f 519-520 anesthetic strategies, 688 acute care considerations,
mechanisms, 167 Adult respiratory distress syndrome aspiration risk, decrease, 690 708-709
laboratory studies, 169 (ARDS), 5-6 assessment, difficulty (rule), 80b approach, 77
laparotomy, 171 commonness, 65-66 awake endotracheal intubation, chin lift, 82f
indications, 171 result, 6 689-690 head tilt, 82f
penetrating injuries, incidence, treatment, mechanical ventilation blind nasoendotracheal initial airway management,
171t (usage), 6 intubation, 691 maneuvers, 81f
physical examination, adjuncts, 169 Advanced Cardiac Life Support blunt trauma, 686 initial assessment, 77-79
plain radiography, 169 (ACLS) guidelines, 84 cervical spine protection, 220 jaw thrust, 82f
retrograde urethrography (RUG), Advanced Cardiovascular Life compromise patient position, 688
usage, 170 Support (ACLS) protocols, 136 maxillofacial injuries, 67 phases, 692
rigid sigmoidoscopy, 170 usage, 139 signs, 78t principles, 688-693
scores/indices, 168 Advanced life support (ALS) control, 688 systematic approach, 77-103
ultrasonography, 169 ambulances, usage, 50 rapid-sequence tracheal Airway obstruction
urinary catheters, usage, 169 importance, 59 intubation OETT, usage, evaluation, 417
Abdominal vascular injury, 172 Advanced Trauma Life Support 55 fractured/displaced nasal
classification, 172 (ATLS) edema, concern, 70 septum, impact, 503
Abdominal visceral injuries, 124 approach, development, 143 evaluation, 56 recognition, 77-79
Abducens nerve, 148 blunt chest trauma, 112 examination, 684 signs, 56
palsies, head injury, 148 guidelines, 68 fiberoptic laryngoscopy, success, Airway-related medical
supply, 213 protocols, 51, 136, 620, 766-767 691 interventions, 77
Abrasions process, 683 importance, 683-684 Alar cartilages, characteristics, 214
epithelialization, completion, 525 system, development, 167 inhalation injury, 692-693 Albumin
result, 525 Advancement flaps, 531 initial assessment, 684 serum albumin, 39
soft tissue wound, 525 bipedicle advancement flap, 532 initial examination, 685 storage, 39
Abscess formation, rarity, 541 scalp, 554 injuries, 685-687 Alcohol abuse, 700
Absorbable sutures, 515-517 single-pedicle advancement flap, causes, maxillofacial trauma Alcoholism, impact, 324-325
glycolic acid (Maxon), 516 532 (impact), 78t Alert, Confused, Drowsy,
glycolic acid homopolymer V-Y advancement flap, 532-533 treatment, 691-693 Unresponsive (ACDU),
(Dexon), 516 Aerobic bacteria, animal bites intensive care unit, postoperative 144
irradiated polyglactin 910 (Vicryl (association), 618-619 sedation/analgesia, 693 Alert, response to Verbal stimuli,
Rapide), 516-517 Aerobic metabolism, perfusion intracranial injury, 690-691 response to Painful stimuli,
placement, 521-525 (impact), 58 intubation, mandating, Unresponsive (AVPU), 144
polydioxanone (PDS II), 517 Aerodigestive tract, injuries (signs), 691-692 ATLS usage, 145
Polyglactin 910 (Vicryl), 506 228 maintenance Allergies Medications Past history
surgical gut sutures, 516 Afghanistan, penetrating soft tissue cervical spine control, 54-56 Last meal Events (AMPLE)
Vicryl Plus (polyglactin 910 coated injuries/fractures (incidence), failure, 85 history, 221-222
with Triclosan), 517 707-708 maneuvers, 79-83 method, 60
845
846 INDEX
AlloDerm Animal bites (Continued) Antidiuretic hormone (ADH) Atrophic mandible, reconstruction,
availability, 605 domesticated cat, teeth, 618f release, 73 760f
usage, 25 domesticated dog, teeth, 618f syndrome of inappropriate ADH Atrophic mandibular fractures,
Allograft fillers, 605 domesticated horse, teeth, 619f (SIADH), 73 758-759
Alloplastic materials, availability, facial bite injuries, classification, vasopressin, 133 Auricle, anesthesia, 540
436 622t Anti-inflammatory medications, Auriculotemporal nerve, 206
Alveolar bone forensic bite mark recognition/ usage, 15 trigeminal nerve, relationship,
comminution, 277-279 evidence/analysis, 625-629 Antioxidants, enteral formulation, 343-344
height, augmentation, 666-667 infections, 800 6 Autogenous bone, rib cage source,
Alveolar fractures, 737-738 microbiologic features, 800 Antipersonnel IEDs, components, 432
dentition, supporting bone injury 705-706 Autografts, 605
(involvement), 737-738 consideration, 619 Antiseptic agents, usage, 511 Autologous fat graft/injection, 605
Alveolar process, fracture, 259, initial presentation, 620-621 Antiseptic solution, spillage, 511 Automobile-pedestrian collisions,
278-279 severity scales, 615 Antisialagogues, usage, 643 113
anterior mandibular teeth, treatment, 620-625 Antitension lines (ATLs), 572 Avascular bed, pedicle rotational
association, 278f microorganism transmission, Aorta intraoral flap, 729f
follow-up, 278-279 620b acute rupture (diagnosis), Avascular cartilage, central area,
treatment, 278 postsurgical treatment, 624-625 aortograph (usage), 128f 538f-539f
Alveolar socket pulsatile irrigation system, 625f injury Avulsed medial canthal tendons,
comminution, 257-259 puncture wounds, treatment, MVA cause, 126 wire support stabilization, 430f
wall, fracture, 259, 277-278 624 repair, recommendation, Avulsed midfacial/upper facial
Alveolar spaces, pleura surgical management, 621-624 127-128 hard tissue defects,
(communication), 113 tetanus, 619 rupture, 126 reconstruction (challenges),
Ambulances, 49f treatment, 533-534 Arachidonic acid metabolism, 784
fixed-wing air ambulance, 51 wounds, evaluation, 534 cyclooxygenase products, 3 Avulsed tissue, infection
system, establishment/ Anisocoria, 224f-225f Arch bars, 313-314 (possibility), 800f
standardization, 48-49 Ankylosis, 348 equipment, 313 Avulsion (exarticulation), 270-277
transport, types, 50-51 Ankylosis (replacement resorption) procedure, 313-314 Avulsion injuries, 526
Union Medical Department condylar fractures, impact, 310f versatility/usage, 313f MVA involvement, 252f
usage, 48-49 usage, 274 Arginine, cell division role, 32 Avulsive craniomaxillofacial injuries
vehicle, building/creation Anterior chamber Arterial blood gas (ABG), 111-112 (management), middle/upper
(Hess-Eisenhardt Company), depth, abnormality, 457 data, 684 facial third reconstruction
49 injuries, 456-457 list, 112t (importance), 781
Ambulancia, deployment, 48 Anterior deep temporal artery, serial ABG determinations, Avulsive forehead wound, 535f
American Association for Surgery 199 111-112 Avulsive hard tissue
of Trauma (AAST) Anterior ethmoidal artery, 212-213 tests, 59 injuries, reconstruction, 772-781
acute care surgery initiative, 51 Anterior facial vein, 201 Arterial blood supply, 197-201 mandibular reconstruction,
organ injury scale Anterior ilium, mandibular defects, Arterial dissection, 155 772-773
liver, 173t 774-775 Arterial hypotension, impact, 60 maxillofacial injuries, 767
spleen, 173t Anterior jugular vein, 202 Arteries, location, 552f Avulsive injury
American Board of Forensic Anterior lacrimal crest, medial Arteriography grading scale, 155 eyelids (treatment), full-thickness
Odontology (ABFO) canthal ligament (attachment), Arteriovenous anastomosis, 467-468 skin grafts (usage), 548-549
cutaneous human bite mark 212 Artery, laceration, 154-155 repair, 528f
definition, 625 Anterior mandible Artery of the pterygoid canal, 200 soft tissue, loss, 530f-531f
no. 2 reference scale, 628f avulsive injury, two-dimensional Articaine hydrochloride Avulsive lip injuries, reconstructive
American Burn Association, injury CT scan, 767f (Septocaine), 514 flaps (usage), 537f
severity grading system, 561b, symphyseal region, impact point, pharmacologic/toxic effects, Avulsive maxillofacial injuries,
722t 742 association, 514 initial surgical management,
American College of Surgeons Anterior mandible, low-energy usage, advantage, 514 768-769
Committee on Trauma low-velocity gunshot wound Articular capsule, attachment, 188 Avulsive scalp wound, 527f
(ACS-COT), acute care surgery (clinical appearance), 705f Articular cartilage, damage Avulsive soft tissue
initiative, 51 Anterior mandibular teeth, alveolar (healing response), 19-20 injuries, reconstruction, 770-772
American Spinal Cord Association process teeth (association), Articular disc (meniscus), 188 options, initial determinations,
(ASCA) grading system, 160 278f Ascending palatine branch (facial 770
Amino acids, 32 Anterior maxilla artery), 198 maxillofacial injuries, 767
Anaphylactic shock, 136 avulsive loss, virtual surgery Ascending pharyngeal artery, 199 wounds (debridement), pulsatile
Anergy, 793 (usage), 786f Aspiration risk, decrease, 690 jet irrigation (usage), 771
Anesthesia avulsive trauma, 272f Asplenic patients, infection Awake endotracheal intubation,
anesthesia-related medicolegal Anterior open bite, cause, 227f susceptibility, 800 689-690
claims, 283 Anterior segment, examination, Association for Osteosynthesis/ benzodiazepines, usage, 689
induction, 689 453 Association for the Study of opioids, usage, 689
strategies, 688 Anterior table fractures, Internal Fixation (AO/ASIF) Awake intubation, success, 689
factors, 690-691 management, 483-484 principles, 296, 321 Awake laryngoscopy, 92
usage, 303, 369 Anterior tympanic artery, 199 usage, 322 Awake Voice Pain Unresponsive
Angiogenesis, 10-12 Anterolateral thigh (ALT) flap, Atlanto-occipital dislocation, 161 (AVPU) method, 59
Angle, mandibular defects, 774 771-772 rarity, 161 Axial anchor screw, 336-338
Angle recession, 458 anatomy, 771f Atlas fractures, 161-162 photograph, 345f
Angular artery, 199 marking, 772 Jefferson fractures, 161 usage, 346
Animal bites, 533-534, 615-620 selection, 771-772 types, 162f Axial repositioning screw, insertion,
aerobic bacteria, association, Anthropometric measurements, Atmosphere, pleural space (direct/ 347
618-619 33 indirect communication), 113 Axis fractures, 162
antibiotic prophylaxis, 621 Antibiotics Atrophic edentulous mandible, Axonal degeneration, impact, 159
controversy, 627 administration, amount bilateral fracture, 758f Axonal response, nerve injury,
antibiotic therapy, importance, (alteration), 796 Atrophic edentulous mandibular 662-663
534 decision, factors, 796 fractures, incidence, 739 Axonotmesis, 20
bite mark recognition, 625-627 usage, 321-322 Atrophic fracture, 298 Axonotmesis, examples, 661f
INDEX 847
B Bilateral Le Fort 2 fracture, Bleeding (Continued) Body region, displaced unfavorable

Babinski sign, 61-62 sustaining, 738f nasal bleeding, trauma (impact), fractures, 311
Bacitracin zinc ointment, 25-26 Bilateral mandibular fractures 545 open reduction, requirement,
Bacterial infection criteria, post-ORIF, 825f persistence, evaluation, 506-507 312f
quantitative wound culture preoperative CT scan, 746f source, 463 Body surface area (BSA), burns,
(basis), 22t Bilateral rotational scalp skin graft, discovery, 58 725
Bacterial killing, disorders, 793 730f-731f superolateral nasal wall, 437 Bone healing, 14-15
Bacterial lysis, occurrence, 792 Bilateral type II fractures, 427f Blind nasoendotracheal intubation, biology, 808-809
Bacterial meningitis, impact, 157 Bimanual palpation test, 223f usage, 691 categorization, 808-809
Bag-valve-mask (BVM) example, 84f Bimaxillary mouthguard, 286 Blindness, 406, 442-443 complications, 15-19
Bag-valve-mask (BVM) ventilation, Binocular diplopia fracture repair, relationship, 406 growth factors, role, 27
83-85 permanence, 440 Blood polypeptide growth factors, 15t
airway adjuncts/maneuvers, presentation, 405 clot, formation, 10 soft tissue healing, comparison,
combination, 84 result, 224f-225f glucose level, elevation, 2 14
esophagus/stomach insufflation, Binocular single vision (BSV), 465 horizontal fluid level, 457f trauma, repetition, 15
avoidance, 90 Binocular visual field testing, pressure, pulse indication, 58 Bone plates, 295-296
one-hand EC technique, 85f 452-453 products, 139t goal, 318
problem, MOANS test, 85b Bioabsorbable implants, replacement, 59 placement, 390
techniques, 84 development/usage, 822 vessels, aging, 750-751 usage, 295-296, 370f-374f
two-hand technique, 84f Bioabsorbable materials, varieties, volume, preservation, 2 Bones
alternative, 84 822-824 Blood loss biology, 808-809
Ballistic injuries Bioabsorbable plate fixation, indication, rapid pulse (usage), changes, geriatric population,
acute care considerations, 820-824 58 754
708-710 Biodegradable fixation devices, result, 61 contact, achievement/assessment,
epidemiology, 696-700 usage, 257 Blood oxygenation level-dependent 809f
management, debridement Biodegradable plates (BOLD) images, 660 defects, 775
(importance), 710 dimensions, comparison, 296 Blow-in fractures, 436 fixation, methods, 810-812
postoperative complications, 713 usage, 296 axial CT scan, 436f fractures
stereolithography models, 711f Biofilm, removal, 24 Blowout fractures, 434-436, 464-466 mucosal tears, association, 541
Ballistics, impact kinetic energy, Biosynthetic dressings, 726 clinical signs, 464-465 pattern, 355
704 Bipedicle advancement flap, 532 demonstration, coronal CT scan, fragments
Bandages, usage, 293-294 Biphasic external pin appliance, 434f avulsion, 238f
Barton, John Rhea, 294f demonstration, 757f diagnosis, 434-435, 465 management, 156
Barton bandage, 294f Biphasic pin fixation technique, extension, 442 genial bone graft harvest, impact,
Basal energy expenditure (BEE), 315f illustration, 434f 666f
sum, 33 Bite marks medial wall blowout fracture, 465 hook, usage, 389f
Basal epithelial cells, leading front ABFO no. 2 reference scale, 628f noncontrast CT scans, usage, 435 loading models, 17f
(division/migration), 567f analysis, 629 orbital blowout fracture, plating, loss, 390
Basic fibroblast growth factor results, 629 435f matrix proteins, secretion, 16f
(bFGF), 26 evidence, 627-629 terms, usage, 434 reconstruction, 711-713
Basilar artery occlusion (BAO), 142 evidence recovery, 628-629 treatment, 435-436 screws, usage, 318, 388, 390f,
Battle sign protocol, 629 goals, 465-466 815
mastoid process, 60 impressions, 628 Blunt abdominal injury, 171-173 structure, organization, 808
retroauricular ecchymosis, 61 metric analysis, 629 Blunt aortic injury, site, 127 Bony orbit, composition, 208
suspicion, 150 overlays, fabrication, 629 Blunt cardiac injury, 66 Bony reconstruction, occurrence,
Baxter formula (Parkland formula), photographs, usage, 628 Blunt cerebrovascular injuries 710-711
usage, 725 photography, usage, 628 (BCVIs) Borges’ lines, 572
Bedside weaning parameters, 70-71 recognition, 625-627 causes, 154-155 Botulinum toxin (Botox), 605
list, 71t swabbing, 628 risk factors, 155b complications, 605
Bell’s palsy, 149 tissue specimens, 628-629 screening criteria, 155b usefulness, 605
Benzodiazepines, usage, 62, 693 victim, example, 630f Blunt chest trauma Bougie-assisted cricothyrotomy
Berlin’s edema (commotio Bites advanced trauma life support, technique, rapid four-step
retinae), 460 antibiotic prophylaxis, 621 112 technique (comparison), 97
Beta blockers, 514 class characteristics, 627 impact, 123f Bowel ischemia, vascular/
Beta endorphins, release, 57 forensic bite mark recognition/ management, 110-112 mesenteric injury, 172f
Bicortical locking screws, usage, evidence/analysis, 625-629 mortality rate, 109-110 Bowstring test, 223f
816f incidence, 615-617 motor vehicle collisions (MVCs), performing, 223
Bicortical screw individual characteristics, 627 impact, 109 Box wires, 313
overpenetration, 669f injuries radiographic examination, 112 Bradykinin, release, 57
usage, 348f classification, 622t sequela, 117 Braided nonabsorbable sutures, 517
Bifrontal craniotomy, 479f initial presentation, 620-621 steering wheel injuries, Brain
Bilateral angle fractures treatment, 620-625 association, 123-124 glucose, usage, 31
open bite, 303f pathophysiology, 617-620 Blunt neck trauma, 98-99 herniation, 61-62
trauma, 302f postsurgical treatment, 624-625 Blunt trauma, placement, 54-55 perfusion, 54
Bilateral condylar fractures pulsatile irrigation system, 625f Body Brain-injured patients,
displacement, 274 puncture wounds, treatment, 624 mandibular defects, 774 management, 2
examples, 332f, 743f surgical management, 621-624 mass, early loss (deceleration), Brainstem, assessment, 62
Bilateral fractures, 162f Blast injuries, 113 30-31 Brainstem regulatory centers,
atrophic edentulous mandible, patient, embedded material, nonunion, result, 15 disruption, 142-143
758f 714f Body fractures, 745 Breathing, 56-57
symphysis, inferior/posterior Bleeding, 436-437 case studies, 746-747 evaluation, accomplishment, 56
displacement, 301f cessation, topical hemostatic medial/lateral positions, injuries, impact, 687-688
Bilateral interfacetal dislocation agents (necessity), 795 mandibular occlusal view, recognition, 77-79
(BID), hyperflexion injury, 163 control, 437 305f ventilation, 220-221
Bilateral laryngeal nerve injury, midfacial bleeding, Body mass index (BMI), 33 Breath sounds, 63
impact, 102 manifestation, 437 management, 101 reduction, patient evaluation, 64
848 INDEX
Bridle wire, 313 Burns (Continued) Carbon monoxide (CO) Cerebral hypoxia, cause, 60
equipment, 313 pain control, 725 (Continued) Cerebral perfusion pressure (CPP),
procedure, 313 partial-thickness burns (second- increase, 139-140 range, 154
Bright light sign, 239f degree burns), 720 poisoning, concern, 561 Cerebrospinal fluid (CSF)
Bromfield, William, 109 classification, 561 toxicity, 724-725 fistula
Brow burn, 727 healing, failure, 726 Cardiac complications, risk appearance, 157
Bruised eyelids, 455 pathophysiology, 718-720 (detection), 130f bacterial meningitis, impact,
Brush stroke directional patients, reconstructive surgery, Cardiac dysrhythmias, 129 157
discrimination, performing, 693 Cardiac function, alteration, 750 leakage, 49, 149
672-673 perinasal/perioral burns, Cardiac output (CO), calculation, development, 157
Buccal artery, 200 example, 724f 133 head, elevation, 158
Buccal branch (facial nerve), 208 prehospital care, 724 Cardiac rupture, 124 management, 479-481
Buccal fat pad, parotid duct primary burn wound Cardiac tamponade, 65-66 repair, 480-481
(impact), 633-634 management, 725-726 occurrence, 65 surgical causes, 480
Buccal nerve (BN), 653-654 radiation burns, 718 pulmonary contusions, otorrhea, 150, 437-439
Burn depth respiratory changes, 720 treatment, 65-66 rhinorrhea, 437-439
anatomic layer, 719f rule of nines, 723 surgical intervention, 65 clinical suspicion, 480
classifications, 720-722 example, 723f Cardiogenic shock, 135 endoscopic repair, 480
list, 722t scalp injuries, 728-729 causes, 135 surgical treatment, meta-
Burns, 560-562 secondary burn wound list, 135b analysis, 480
airway management, 724 management, 726-729 treatment, 139 tracer, intrathecal fluorescein
assessment, 722-723 second-degree burns, Cardiovascular depression, (usage), 480
rule of nines, 723f classification, 561 management, 136 Cervical airway injury, 686
biosynthetic dressings, 726 severity index, 720-723 Cardiovascular diseases, clinical Cervical branch (facial nerve), 208
body responses, 719-720 silver-containing dressings, manifestations/prognosis, 750 Cervical injury, diagnosis, 686
carbon monoxide toxicity, 725-726 Cardiovascular system, aging, Cervical pulpotomy, indication, 262
724-725 size, 723 750-751 Cervical spine (C-spine)
cardiovascular changes, 720 skin anatomy, 718-719 Caroticocavernous sinus fistula, clearance, direct laryngoscope
chemical burns, 718 small burns, treatment, 562 467-468 technique, 87
chlorhexidine, usage, 726 systemic responses, 719-720 chemosis/blood vessel dilation, control, airway maintenance,
ear injury, 727 tetanus, considerations, 725 photograph, 468f 54-56
electrical burns, 718 thermal injury, 718 Carroll-Girard bone screw, 390f divisions, 160
electric burns, 592 third-degree burns, 561 Carroll-Girard screw, usage, 388 classification, 235
epidemiology, 717-718 wounds fixation, absence, 397f-398f films, 234-236
escharotomy, 726 dressing, 725-726 Cartilage fractures, 160
experience, 560 evaluation, 561 healing, 19-20 axis fractures, impact, 162
eye burn injury, 726-727 silver sulfadiazine (SSD), late cartilaginous callus stage, injury, 160, 686
facial burns, 726 usage, 725-726 19f assumption, 54-55
example, 731f topical antibiotics, usage, metabolic activity, 19 manual in-line immobilization
first-degree burns, 561 725-726 Catabolic phase (flow phase), 2 (MILI), usage, 692
fluid replacement, 724 treatment, wound dressings Catecholamines, release, 57 respiratory complications, 686
fluid resuscitation, 725 (usage), 562 Cathepsin G, activation, 10 treatment, 691-692
modified Brooke formula, zone of coagulation, 719 Causative blow, direction (impact), protection/stabilization, 54-55
usage, 725 zone of hyperemia, 719 189 radiographs, clinical decision
Parkland (Baxter) formula, zone of stasis, 719 Cellular changes, 132 rules, 153b
usage, 725 Burow’s triangle, 575-576 Cellular response, nerve injury, Cervical tracheal disruption, 124
fourth-degree burns, 722 662-663 Cervical transection, 56-57
full-thickness burns (third-degree C Central apparatus, motor system Chance fractures, observation, 174f
burns), 561, 720-722 Cadexomer iodine, 25-26 division, 150-151 Cheek region, laceration
healing, failure, 726 Calcineurin inhibitors, usage, 12-14 Central dislocation (intrusive (debridement/examination),
gastrointestinal interventions, Calcium, dialysis (impact), 75 luxation), 257 555f
725 Calcium hydroxide liner, usage, 261 Central incisor Cheek wall, outward retraction, 641
heat source, elimination, 724 Calcium treatment, AV block avulsion, 278f Chemical burns, 718
hospital admission criteria, refractory, 74 traumatization, 267f Chemical peels, 598-600
723-724 Caldwell-Luc osteotomy, 841f Central midface, NOE region, 768 chemical peeling, application,
hospital care, 724-725 window, creation, 841-842 Central nasoethmoid complex, 425f 598
immunologic changes, 720 Caldwell posteroanterior view, 305f Central nervous system (CNS) deep chemical peels, 600
inhalation injury, 724-725 Caloric requirements, geriatric fat conversion, 31 medium chemical peels, 599-600
injury, mechanisms, 718 patient, 752t function, level (assessment), 52 superficial chemical peels, 599
injury severity Canadian Computed Tomography injuries, 111 types, 599-600
American Burn Association Head Rule (CCHR), 153 sensitivity, increase, 751 Chemosis, conjunctiva swelling, 456
grading system, 561b, 722t clinical decision rules, 152 Central neurogenic hypotension, Chemotactic factor inhibitor (CFI),
body surface area, relationship, design, 153 136 presence, 793
556 Canadian C-Spine Rule, 153 Central venous catheter, usage, 2 Chemotaxis, defects, 793
local responses, 719 Canalicular lacerations, 467 Central venous pressure, central Chemotherapeutic agents, usage,
Lund-Browder chart, 723t Canaliculus, lacerated ends hemodynamic monitoring 15
mafenide acetate, usage, 726 (location/repair), 552 catheter placement, 138f Chemotherapy, suboptimal wound
management, 723-729 Cancellous bone, curetting, 774 Central visual field, assessment, 453 healing factor, 24
initial assessment, 723 Capillary endothelial integrity, Central visual function, testing, 452 Chest
metabolic changes, 720 disruption, 4 Cerebellar disease, points, 151 auscultation, 55
microstomia, inhibition device, Capnometry devices, 88 Cerebral blood flow (CBF) bony integrity, 65
730f Carbon dioxide (CO2) lasers, decrease, 690-691 closed pneumothorax, 63-64
mouth injuries, 729 availability, 602 maintenance, 154 expansion, 56
nasal injuries, 727-728 Carbon monoxide (CO) Cerebral contusions, 159-160 exposure, 56
necrotic tissue, formation, 562 binding, 23 Cerebral cortex, functional flail chest, 65
oxygen administration, 724 combustion product, 687 capacity, 61 injuries, 63-66
INDEX 849
Chest (Continued) Civil War, medical transport Combat-Gauze, usage, 709-710 Computer-aided craniomaxillofacial
open pneumothorax, 63 development, 48-49 Combustion products, 687 surgery, categories, 446
radiographic examination, 251 Class characteristics, bites, 627 Comminuted fracture, 298 Computerized surgical stents, 785
sucking chest wounds, 116-117 Class II hemorrhage, 134 Comminuted frontal sinus fracture, Concomitant maxillary fracture,
trauma, history, 109 Class III hemorrhage, 134 bone reconstruction, 483f 536f
tube Class IV hemorrhage, 134 Comminuted mandibular body Concussion, 257, 267-277
anterior placement, 63-64 Class 1 fractures, 333 fracture, loading force Condylar base fractures, 333
insertion, 64-65 Class 2 fractures, 333 (dissipation), 19f illustration, 334f
Chest wall Class 3 fractures, 333 Comminuted NOE fracture, wire/ Condylar displacement, 331
blunt forces, 110-111 Clay shoveler fracture, 162-163 plate fixation/dorsal basal radiographs, 335f
compression, 111 example, 163f bone graft (placement), 429f Condylar fractures, 310
damage, pneumothorax Clean wounds, 507 Comminuted orbital fracture, classification, 299-301
development, 113f Cleared cervical spine (cleared repair, 594f illustration, 302f
exposure, 111 C-spine), 87 Comminuted ZMC, treatment closed/open treatment,
injuries laryngoscopy, positioning, 88f (absence), 363 controversy, 811-812
computed tomography, usage, Clinical neurosensory testing, Comminution areas, impact, 390 CT scanning, usage, 305f
112 672-673 Common facial vein, 201 impact, 310f
treatment, 110-111 algorithm, 672f Commotio cordis, 129 management, classification, 333
treatment process, 111 protocol, 672-673 Commotio retinae (Berlin’s occlusion, 332f
trauma algorithm, 110f Closed apex avulsion, flow charts, edema), 460 open treatment, determination,
wounds, 116 275f-276f Complete avulsion (exarticulation), 334-335
Cheyne-Stokes respirations, Closed fracture, 298 257 patterns, 333f
characterization, 152 Closed head injury Complete blood count (CBC), test, physical therapy, 350-351
Chiasm, 146-147 maxillary sinusitis, risk, 799 59 postimmobilization findings, 350
injury, rarity, 146-147 olfactory recognition Complete bone contact, radiographic evaluation, 333
Children impairment, 146 achievement/assessment, 809f surgeon perspective, 331
airway, anatomy, 103-104 Closed pneumothorax, 63-64, Complete soft tissue avulsions, surgical treatment, nonsurgical
condylar fractures, 349 113-114 adjunctive therapy, 772 treatment (contrast),
direct laryngoscopy, 104 blunt trauma, impact, 63 Complex fracture, 298 335-336
ETT selection, 104 expiratory chest radiograph, 114f Complex nasal fractures treatment, 335-346, 745
injury severity scales, 615 treatment, 687 MVA, impact, 500f complications, 347-349
intubation procedures, 104 Closed reduction (CR) Complex nasal fractures, open Condylar head, 187-188
mandibular fractures, dentition accomplishment, 739 approaches, 499 anterior/medial displacement,
(development), 309-310 indications, 307-310, 339 Complicated crown fracture, 257 lateral pterygoid muscle
treatment, 310f condylar fractures, 310 periapical radiograph, 263f (impact), 301f
nasal fractures, treatment, 503 coronoid process fractures, 310 pulp capping, indication, 262 Condylar neck fractures, 332-333
needle cricothyrotomy, 104 edentulous mandibular Complicated crown-root fracture, illustration, 302f, 334f
physical therapy, illustrations, fractures, 309 257 medial displacement, reverse
350f-351f fracture exposure, soft tissue Complicated fracture, 298 Towne view, 264f
primary dentition, 737 loss (impact), 308-309 Composite grafts, failure, 541 Condylar neck region
tracheostomy, 104 grossly comminuted fractures, Composite tissue allograft biomechanics, 331
visual acuity, 452 308 cadaver harvest, 787f Condylar regions, surgical
Chin nondisplaced favorable transplant, 785 approaches, 336-346
anterior blow, trauma, 302f fractures, 307-310 Compound comminuted midfacial Condylar resorption, 348-349
fan, impact, 744f open reduction, contrast, 321 fractures, 417f Condyle
Chin lift, 82f treatment, usage, 336b Compound fractures, 298 medial displacement, reverse
procedure, usage, 54 usage, 307, 323t bone fragments, management, Towne view, 305f
thumb, placement, 54 Closed tube thoracostomy 156 reduction, 346-347
Chipmunk bite, 620 example, 115f-116f Compression fracture, example, Confusion, 144t
Chlorhexidine, usage, 726 indications, 115-116 163f Congenital eyelid ectropion, 592
Chorioretinal necrosis/hematoma, Coagulation Compression osteosynthesis Conjunctiva
462f factors, determination, 59 application, 814 injuries, treatment (absence),
Choroidal effusion, 461 zone, 719 goal, 812 549
Choroidal injury, 459-461 Coagulopathy, 59 Compression plate osteosynthesis, swelling, chemosis, 456
Choroidal tear, 461 correction, 172 812-814 Conjunctiva, injuries, 456
Chromic catgut sutures, 516 Coated polyester, monofilament Compression plates Conjunctival injection, 224f-225f
Chronic pain, 349 nonabsorbable suture, 517 disadvantage, 318 Connective tissue layers, vascular
Cicatricial eyelid ectropion, 592 Cochran, John, 48 fixation, mandible nonunion supply (schematic
post-traumatic cicatricial Cold caloric responses, tests, (incidence), 324t representation), 655f
ectropion, management, 151-152 gap healing, 18f Consciousness
593f Cold exposure (frostbite), 718 usage, 318 assessment, 144
Ciliary body, 458-459 Collagen Compression plating neurologic scales, 145t
damage, 458-459 cross-linking, increase, 750-751 drill guide, positions, 813f levels, alteration (assessment),
prolapse, 461 framework, 654-655 systems, usage, 812 144-145
Circular defect, closure, 532f matrix, 566-567 Computed tomography (CT) loss, maxillofacial injuries, 691
Circulation, 221 types, 14t maxillofacial injuries, 236 Consensual pupillary reflexes, 453
management, 57-58 Collagenases, activation, 10 three-dimensional Contact healing, occurrence, 18f
nose, 221 Collagen deposition reconstruction, 236f Contaminated wounds, 507
oral cavity, 221 increase, 14 multidetector CT, usage, 236 Contusions, 61
priority, 57 nicotine, impact, 23 spiral CT, usage, 236 soft tissue wound, 525
scalp, 221 Collagen fibers usage, 657 Cornea
Circulatory compromise orientation, 512 Computed tomography erosion, 456f
causes, 58 tensile strength, 512 angiography (CTA), injuries, 456
effects, 58 Coma, 144t maxillofacial injuries, 236-237 protection, 376-377
Circumdental wires, placement, 313 anatomic description, 151-152 Computed tomography cone beam Corneal abrasion, 455
Circumpalatal wiring, usage, 755 definition, 152 (CBCT) technology, usage, 657 treatment, 455
850 INDEX
Corneal epithelium, loss, 456 Cricothyrotomy (Continued) Debridement, 24 Dentoalveolar structures

Corneal foreign body, 455 performing, tracheal transection concept, 710 clinical examination, 227
treatment, 455 (presence), 99 Deciduous teeth, crowns (contour indirect trauma, 249f
Coronal flap sequence, 431f perioperative complications, heights), 735 injuries, 248
Coronal fragments, displacement 97-98 Deep auricular artery, 199 palpation, 227
(reduction), 264-265 postoperative care, 98 Deep chemical peels, 600 Dentoalveolar trauma
Coronal incision, limitations, 839 postoperative complications, 98 complications, 600 function, restoration, 283f
Coronary artery bypass grafting Critically ill patient, nutritional infection, impact, 600 result, 248
(CABG), 139 support (initiation), 46 postoperative care, 600 root resorption, association, 260f
Coronoid process fractures, 310 Cross-matching, 59 toxicity, reduction, 600 Dentulous maxilla, closed
Corrective osteotomies, 432 Crowns Deep lingual artery, 198 reduction/fixation, 313-314
Corticocancellous block graft, blood/debris, cleaning, 255f Deep tendon reflexes, examination, Dentures
obtaining, 774 cleansing, 252-254 151 placement, palatal screw (usage),
Cosmesis, improvement, 156 complicated crown fracture, 257 Deep vein thrombosis (DVT) 314f
Cover-uncover test, 454-455 complicated crown-root fracture, prophylaxis, 6 unavailability, 315
Cranial bone graft, 433f 257 Definitive hemorrhage control/ Depressed fractures, presence, 156
Cranial fractures, intracranial contour heights, 735 resuscitation, 58-59 Depressed left frontal sinus
lesions (association), 156 crown-root fractures Definitively secured airway, fracture, endoscopic view, 838f
Cranial grafts, usage, 784f restoration, 283 indications, 86t Depressed scar, 591-592
Cranialization, 476 treatment, 262 Delayed closure, decision, 794 Dermabrasion, 574-575
techniques, 482-483 fractures Delayed primary closure/wound complications, 601
Cranial nerves pulp tissue, involvement, 263f repair, 25 function, 600
clinical examination, 229 treatment, 260-262 Delayed primary wound closure, indications, 600
cranial nerve III palsy, 464 full crown coverage, 267f 526-527 mechanical dermabrasion,
cranial nerve IV palsy, 464 infraction, 257 Delirium, 144t 600-601
cranial nerve VI palsy, 464 treatment, 259-265 Dementia, 144t postoperative care, 601
examination, 145-151 root fracture, 257 Denaturing proteins, impact, 9 postoperative edema, resolution,
injury, 150, 464 uncomplicated crown fracture, Denis classification, C-spine 601
neurologic function, 62 257 division, 235f treatment, planning, 601
VII, exposure, 337f uncomplicated crown-root Dens fractures usage, 600-601
Craniocervical injuries, atlas fracture, 257 prevalence, 162 Dermal layer, wound extension,
fracture percentage, 161 Crusted wound healing, 568 types, 162f 525
Craniofacial fractures Curved dissectors, 838f Dental extraction sites, healing, 15 Dermalon
dorsal support, absence, 503f Custom-fabricated, patient-specific Dental implants monofilament nonabsorbable
type 2 fracture, 739 implants/endocultivation, 785 impact, 297 suture, 517
Craniofacial reconstruction, Custom-fitted intraoral dental surgery, 665-667 nylon suture, 515
osseous graft types splint, usage, 256 usage, 283f Dermal papillae, 511
(advantages/disadvantages), Custom-fitted splint, vulcanite Dental impressions, usage, 711-712 Dermis
773t (usage), 295f Dental injuries, 283 components, 513
Craniofacial skeleton, injury details, Custom-made mouth protectors, Ellis classification, 737 frictional resurfacing, 601
500f 287-288 internal fixation complication, layers, division, 512
Craniomaxillary suspension, usage, photograph, 287f 824-826 reticular layer, 512
755 stone model, creation, 287 Dental trauma, 736 Descending palatine artery, 200
Craniomaxillofacial complex strap, attachment, 288f fractures, types, 737 Descending thoracic aorta, injuries,
avulsive defects, classification Custom-made protectors, 285 Dentition 127-128
system, 767 Cutaneous fistula, treatment, development, 309-310 diagnosis, 127
burn wounds/disfigurement, 643-644 loss, 306 treatment, 127-128
impact, 785 Cutaneous grafting, mandibular premature occlusion, 332f Desiccated wound healing, 568
Craniomaxillofacial complex, defects (relationship), 774-775 primary dentition, permanent Deviated septum, coronal/axial
avulsive injuries, 766-767 Cutaneous human bite mark, successor development, 299 sections, 493f
Craniomaxillofacial trauma, study, ABFO definition, 625 Dentoalveolar fractures, 244-246 Dexmedetomidine, usage, 693
766 Cuticular surgical needles, 519 involvement, 281f Diabetes
Craniotomy, example, 485f Cyanide Dentoalveolar injuries, 249-250 suboptimal wound healing factor,
Cranium-to-face ratio, 735 combustion product, 687 abuse, consideration, 250f 23
Crepitation, 303, 419 interference, 687 acid etch resin splint, usage, wound healing, compromise, 23
impact, 360 Cyanoacrylate (Histoacryl), glue 280-281 Diabetes mellitus, bilateral
Crepitus, depression, 224 (usage), 525 classification, 257-259 mandibular factures (post-
Cribriform plate, 183-184 Cymetra, availability, 605 domestic physical abuse, ORIF), 825f
Cricoid pressure, 90-91 Cytokines, 3-4 evidence, 250f Diacapitular fracture, 302f, 332
Sellick maneuver, performing, cascade, 57 emergency visit, primary goal, illustration, 334f
90-91 receptors/receptor agonists, 271-272 Diagnostic laparoscopy
surgical anatomy/procedures, sequential release, 4f examination/diagnosis, 251-256 importance, 171
96-97 stress response, hormones, hard dental tissue/pulp, injuries, usage, 171
Cricothyroid space, anatomic interactions, 4 257 Diagnostic peritoneal lavage (DPL),
landmarks (identification), 96 survival-enhancing effects, 4 healing 170
Cricothyrotomy, 96-98 Cytotoxic medications, usage, 15 ankylosis (replacement usage, 169
anatomy, 94f resorption), usage, 274 Dialysis, 75
complications, 97-98 D periodontal ligament (PDL), calcium, 75
contraindications, 96 Dacron usage, 273-274 hypercalcemia, 75
devices, analysis, 97 monofilament nonabsorbable surface resorption, 274 hypocalcemia, 75
dilator/tracheal hook, removal, suture, 517 periodontal tissue, injuries, 257 Diaphragm
97 suture usage, 515 restoration, 282-283 injuries, 66, 125-126, 173
history, 96 Dacryocystorhinostomy (DCR), 445 semirigid splint, 281-282 rupture
incision, 96-97 technique, 446f supporting bone, injuries, example, 126f
indications, 96 Damage control surgery, 174 257-259 herniation, 126f
list, 96t Death, leading causes, 764f treatment, 259-283 traumatic disruption, 125-126
INDEX 851
Diarrhea Draf III procedure, 483 Electrical oral commissure burn, Endotracheal tubes (ETTs)
cause, 45 Drain placement, 341f example, 718f location, 100-101
complication, 45 Dressings, 25-27 Electric burns, 592 observation, 55
Diffuse axonal injury (DAI), 159 categorization, 25 Electrogustometry testing, usage, 149 placement, 91
axonal degeneration, impact, 159 change, goals, 794 Electrolyte management, 72-75 confirmation, 87-88
causes, 159 growth factors, 26-27 magnesium, usage, 75 positioning, 89f
cognitive deficits, presence, 159 types, 25 potassium, usage, 74 presence, 100
Digastric muscle, 194-195 Drug abuse, 700 sodium, usage, 72-74 securing, tape (usage), 91f
components, 194 Duodenal injuries, 66, 172-173 Electrolyte requirements, 32 selection, 104
Digitalis toxicity, 74 Dynamic compression plates, 812f Electrolyte therapy, understanding, types, 86
Dilated pupils, ophthalmoscopy, design, 813 68 End-stage renal disease (ESRD),
453-454 fractured segment combination, Elevator muscles, 196-197 dialysis, 751
Dilators, 196-197 813-814 Ellis type dental trauma, 737 End-tidal carbon dioxide
removal, 97 holes, inclined plate (inclusion), Embryonic development, monitoring device, 55
Diphenhydramine, adverse 813f transforming growth factor β Energy depletion, indication, 39
reactions, 513 instrumentation, 813 (TGF-β) role, 26-27 Energy expenditures, 33-38
Diplopia, 360-361 Dysesthesia, usage, 303 Emergency care, 416-418 calculation, 33
cause, differentiation, 360 Dyspnea, bilateral laryngeal nerve Emergency medical services (EMS) estimation, 33
persistence, 405-406 injury (impact), 102 development, 48-49 stress factor modifiers, usage,
Direct fixation, 338 foundations, alteration 38t
lag screw technique, usage, 338f E (landmark events), 49 indirect calorimetry, 33
Direct intraoral trauma, 154-155 Early scar revision, 574 Emergency medical technicians total energy expenditure (TEE),
Direct laryngoscopy, 86-87 Early splint therapy, importance, 592 (EMTs), 52 33
anatomy, 80f Early wound healing, chronology, Emergency percutaneous Enophthalmos, 361, 406
initiation, 87 515f cricothyrotomy, percutaneous anteroposterior displacement,
positioning, 87 Ears dilatational tracheostomy 455
technique, 87 avulsions, 770-771 (comparison), 103 bird’s eye view, 441f
Direct light, reflex/ blocks, 541f Emergency response personnel, causes, 406
accommodation, 444 blood supply, 538f information, 684 correction, difficulty, 406
Direct puncture, method, 95 burn injury, 727 Emergency room visits, dog bites left eye elevation, limitation, 465f
Direct pupillary reflexes, 453 clinical examination, 227 (relationship), 557f orbital floor defect, 466
Disability, 59, 221 deformity (development), Emergency tracheostomy, difficulty, Enteral diets, 42-45
AVPU method, 59 hematoma formation 102 Enteral feeding
Displaced bilateral condylar (control problem), 540f Emergent airway control advantages, 40
fractures, 311 hematomas, aspiration, 540 indication, 690 contraindications, 40
Displaced left parasymphysis injuries patient requirement, 688 mechanics, 42
fracture, 830f-831f assessment, 538 Endaural incision, initiation, method algorithm, 40f
Displaced unfavorable fractures, treatment, 538-540 190-191 tubes, transcutaneous enteral
311-312 partial avulsion, 770f End-diastolic volume (EDV), 133 feeding tubes, 41-42
Distal implant, placement, 666f partial-thickness burns, 728f Endodontic therapy, calcium Enteral formulas
Distal pancreatic duct injuries, wounds, debridement, 770-771 hydroxide paste (usage), 266f delivery, 42
visualization, 170 Ebb phase Endoscope energy sources, 42-43
Distraction osteogenesis, usage, 712 characterization, 2 intraoral incision, 345f monomeric enteral formulas, 42
Distributive shock, 135-136 occurrence, 1 photograph, 838f oligomeric enteral formulas, 42
Diuresis, usage, 74 Ecchymosis, 303 submandibular incision, 346f osmolarity, 42
Dobhoff tube, usage, 230 Echocardiography, advantages, 139t temporal incision insertion, 840f polymeric enteral formulas, 42
Dog bites Ectropion usage, intraoral incision, 836f Enteral nutrition, 72
domesticated dog, teeth, 618f extrinsic medial ectropion, cause, Endoscope-assisted intraoral Enteral nutritional therapy
emergency room visits, 557f 592 approach, 344 complications, 43-45
facial injury classification, Ectropion, incidence, 404 disadvantages, 344f list, 43b
623f-624f Edentulous mandible, 314-316 Endoscope-assisted osteosynthesis, diarrhea, complication, 45
impact, 619f atrophy, absence, 312f 345 results, 43
infection, 626f Edentulous mandible fractures, Endoscope-assisted transoral Enteral nutrition therapy,
injuries, 617t 296-297, 311 reduction, 335 complications, 44t-45t
lacerations, 622f management, biphasic external Endoscopic orbital floor access, Entubulation, principle, 677f
mouth commissure closure, 536f pin appliance, Caldwell-Luc osteotomy, 841f Epidermal growth factor (EGF), 10
nonfatal dog bite-related injuries, demonstration, 757f Endoscopic repair, 319 Epidermal pegs, 511
616t Edentulous mandibular fractures, Endoscopic retrograde Epidermis, frictional resurfacing,
postoperative results, 627f 296-297 cholangiopancreatographic 601
scalp lacerations, 619f atrophy, 309f techniques, usage, 170 Epidural hematomas, 61, 158
Doll’s eyes, test, 151-152 Gunning splint, usage, 315f Endoscopic retrograde clinical presentation, 158
Domesticated cat, teeth, 618f Edentulous maxilla, mandibular cholangiopancreatography example, 158f
Domesticated dog, teeth, 618f fracture (opposition), 311-312 (ERCP), usage, 173 Epiglottis, 86f
Domesticated horse, teeth, 619f Edentulous patients, restorative Endosteum, vascular supply, 14 Epineurial sutures, diagram, 676f
Domestic physical abuse, evidence, treatment, 297 Endothelium, nitric oxide Epistaxis, 360
250f Edentulous posterior fracture production, 132 control, absence, 437
Dopamine, effects, 139-140 segment, maintenance, 306 Endotracheal intubation, 55-56, impact, 503-504
Dorsales linguae artery, 197 Edinger-Westphal nucleus, 62 85-91 problem, 221
Double-balloon tampon, Eicosapentaenoic acid, enteral complications, 93 Epithelialization, completion, 525
placement, 546 formulation, 6 contraindications, 86 Erich arch bars, 313-314
Double miniplate method, success, Elective incisions, skin line direct laryngoscopy, 86-87 usage, 280
346 recommendations, 178f indications, 85-86 Er:YAG laser, 602
Double miniplate technique, 341f Elective tracheostomy, horizontal performing Erythrocyte sedimentation rate
Double-rotation (O-Z) flaps, 532f incision, 100 questions, 85-86 (ESR), increase, 804
Double tissue expander, Electrical burns, 718 tracheal transection, presence, Escharotomy, 726
application, 733f treatment, 592 99 Esophageal detection devices, 88
852 INDEX
Esophageal-tracheal Combitube Extracorporeal life support (ECLS), Eyelids (Continued) Face (Continued)
distal tube/cuff, placement, 93f usage, 6 perforation, 461 structures, complete/partial
rescue airway device, 92 Extracorporeal membrane swelling, 467 avulsions, 772
Esophagus oxygenation (ECMO), usage, 6 upper eyelid, injury, 548f total facial reconstruction, 733f
blunt injury, 125 Extraocular muscles, actions, 454f vertical shortening, supraciliary/ treatment, 596-597
injuries, 125 Extraoral appliances, usage, 294 subciliary incision wounds, closure, 794
Ethibond Extraoral open reduction, (approach), 592-593 Face guards, National Alliance
Dacron suture, 515 morbidity, 322 Eyes Football Rules Committee
monofilament nonabsorbable Extraoral surgery, intraoral surgery anterior chamber, blood usage requirement, 284
suture, 517 (contrast), 322 (horizontal fluid level), 457f Face injuries, 60-62
Ethilon Extraoral surgical approaches, anterior chamber injuries, diagnostic testing/evaluation,
monofilament nonabsorbable 190-191 456-457 61-62
suture, 517 Extraorbital osseous defects, bone burn injury, 726-727 types, 61
nylon suture, 515 graft, 376 chemical burns, 726-727 Facial aesthetic units, 572-573
Ethmoidal arteries, ligation, 437 Extrarenal potassium loss, 74 convergence, impairment/ division, basis, 573
Ethmoid bone, 208 Extrathoracic injuries, 111 failure, 463 Facial artery, 198-199, 336
frontal section, 183f Extravascular space, leukocyte corneal erosion, 456f cervical division, 198
illustration, 183f migration, 10 disorganized anterior segment, ascending palatine branch, 198
unpaired bone, 183-184 Extremities, fractures, 67-68 456f glandular branch, 198
Ethylene vinyl acetate (EVA) Extrinsic medial ectropion, cause, distortion, 456f submental branch, 198
mouthguards, 285 592 embryonic derivation, 460 tonsillar branch, 198
Etomidate Extrinsic systems, vascular network, examination, clinical findings, facial division, 198-199
induction agent, 89 655 225t-226t angular artery, 199
usage, 693 Extrusive luxation (peripheral images, fusion (loss), 463 inferior labial artery, 198
Exarticulation (complete avulsion), dislocation/partial avulsion), injuries, maxillofacial injuries lateral nasal branch, 199
257, 270-277 257, 269 (relationship), 468 superior labial artery, 198-199
Excisional scar revision, planning, Extubation, 93 lateral canthus, injuries, 550 location, 191
573 Exudative retinal detachment, 460 lateral gaze palsy, 463 vein, exposure, 337f
Exophthalmos, 455 Eyebrows, 546-547 lens, subluxation, 458f Facial asymmetry, 149
External carotid artery, 197-201 avulsive injury, 530f-531f minor injuries, 455 depression, 224
ascending pharyngeal artery, 199 burns, 727 movements Facial bite injuries, classification,
branches, 197-200 maintenance, 547f central control, disorders, 622t
facial artery, 198-199 reconstruction, difficulty, 546-547 463-464 Facial bite wounds, treatment
cervical division, 198 Eyelid ectropion, 592-594 examination, 454-455 protocol, 627b
facial division, 198-199 cicatricial eyelid ectropion, 592 nonperforating eye injuries, Facial bone fractures, 311
ligation, 437 congenital eyelid ectropion, 592 455-461 antibiotics
lingual artery, 197-198 lateral lower eyelid ectropion, Parinaud’s syndrome, 464 surgeon selection, 802
deep lingual artery, 198 Z-plasty (usage), 593f perforating injuries, 461-462 therapy, 802
dorsales linguae artery, 197 lower eyelid ectropion, repair, post-traumatic nystagmus, 464 infection, 801-805
sublingual artery, 197-198 594f right eye elevation, limitation, association, 803-804
suprahyoid artery, 197 neurogenic eyelid ectropion, 592 465f Facial bone injuries, 634-635
maxillary artery, 199-200 senile eyelid ectropion, 592 skew deviation, 464 Facial burns, 726
mandibular part, 199 types, 592 acute/chronic management, 717
occipital artery, 199 upper eyelid ectropion, cause, F example, 731f
posterior auricular artery, 199 593-594 Fabricius, Hieronymus, 98 maxillofacial trauma, association,
superficial temporal artery, 199 Eyelids, 547-549 Face 727f
superior thyroid artery, 197 avulsion, 467 aesthetic units, 572-573 Facial contour, change, 303
External ear avulsive injuries (treatment), animal bites, factors, 624 Facial edema, 418f
abrasion/total avulsion, 765f full-thickness skin grafts anterior mandibular avulsion, Facial examination, 418-419
avulsive injuries, 538 (usage), 548-549 gunshot wounds (impact), importance, 494
complete avulsion, 770f bruising, 455 709f Facial expression, muscles, 192-193
MVA example, 785f burns, 727 avulsive injuries, lethality, 766f illustration, 192f
injuries, otohematoma, 540 cross-section, 179f burns, acute/chronic weakness, 229f
prosthetic rehabilitation, 538-540 anatomy, dissection, 380f management, 717 Facial fractures, 239-246
skin, loss, 540 disorders, 739 dog bite lacerations, 622f epidemiology, 735-736
total amputation, 538 full-thickness eyelid avulsions, examination, 418-419 management
External hemorrhage, 548-549 frontal views, 573f geriatric patient, 754-759
management, 58 full-thickness eyelid burns, 727f gunshot injuries, ophthalmologic rigid fixation, usage, 432
External jugular vein, 202 hematoma, 467 evaluation, 710 mandibular fractures, association,
External nasal anatomy, 213-215 injuries, 467 gunshot wounds 298
External nasal splint, application, treatment, 547 consequence, 709f post-treatment infection, 322
498 intrinsic contracture, 592-593 management, 710-713 Facial incisions, 575
External nose laceration, 461, 467 incisions, 575 Facial injuries
arterial supply, 214 categorization, 547-548 lacerations, prophylactic bright light sign, 238
sensory nerves, 215f closure (preparation), antibiotics (usage decision), image, 239f
substructure Povidone-iodine 800 causes/classification, 233
composition, 213-214 (Betadine) solutions profile views, 573f cervical spine films, 234-236
illustration, 214f (usage), 549 reconstruction, skin graft/ classification, 220
External pelvic stabilization, debridement/examination, forehead flap (usage), computed tomography, 236
binders (usage), 173-174 555f 732f computed tomography
External pressure dressing, surgical repair, 467 relaxed skin tension lines, 572f angiography, 236-237
application, 641f lower eyelid, progressive skin, 179 dog bite classification, 623f
Extra-axial CSF space, increase, shortening, 467 graft, patient dissatisfaction, examination, clinical/
159 margin 730f-731f radiographic evaluation
Extracellular matrix (ECM), injuries, 552 soft tissue lacerations, 799-800 (usage), 523f
deposition (excess), 594 wound involvement, 547-548 stab wounds, 229f IED characteristics, 708f
INDEX 853
Facial injuries (Continued) Facial widening, 324 First-degree burns (superficial Flow rate (demonstration),
magnetic resonance imaging, 237 Facial width, malar projection burns), 561 Poiseuille’s law (usage), 138f
occurrence, 143-144 (reciprocal relationship), 367f First-degree nerve injury, 20 Flow-sensitive pulse sequences, 237
radiographic evaluation, 237-239 Facial wounds First rib fractures, 120 Fluid-attenuated inversion recovery
diagnosis, 232 closure, 519-520 arteriography, indications, 120 (FLAIR) images, 237
sharpness, 238 contracture, 556 Fistula formation, occurrence, Fluid status, determination, 136-138
sinus, 238-239 debridement rule, 510 467-468 Fluid therapy, understanding, 68
symmetry, 238-239 infections, prosthetic valve Fitzpatrick classification types, 574 Fluoroquinolone antibiotics, usage,
railroad track sign, 239f endocarditis (reports), 797 Fixation 15
right maxillary antrum, repair, 519 device, application, 375 Focused assessment with
opacification, 239f illustration, 508f-509f procedures, 316-319 sonography for trauma (FAST)
soft tissue, 239 tissue, loss, 526 Y plate, usage, 343f implementation, 66
trap door sign, 238f Factor XIII, activation, 525 Fixed dilated pupil, illustration, performance, steps, 170b
Facial lacerations, electric grinder Falls 224f-225f ultrasonography, 169
injury, 753f lacerations, result, 250f Fixed-wing air ambulance, 51 usage, 58
Facial nerve, 149-150, 206-208, 339 presentation, 262f Flail chest, 65, 120-124 Foley catheter, usage, 546f
branches, parotid duct/gland False aneurysms, 325 adjunctive treatment, 122 Forced duction test, 361f
(relationship), 642f Farm injuries, 765 appearance, visual inspection, clinical demonstration, 440f
buccal branch, 208 Fascicles, number, 655t 65 performance, 440f
damage, parotid duct Fasting-induced malnutrition arterial blood gas measurements, usage, 455
lacerations (impact), 549f physiology, 30-31 122 Forehead
cervical branch, 208 Fasting starvation, spectrum, 31 diagnosis, 121-122 avulsive wound, 535f
distribution, 207f Fatal firearm injuries, 697 injury (diagnosis), physical clinical examination, 222
functional testing, performing, Fat embolism syndrome, 2 examination (usage), 121 flap, example, 732f
641 long bone fractures, association, management, 65 post-traumatic forehead scar
illustration, 337f 68 mechanical ventilation treatment (depression), W-plasty
injury, 229 Feeding tube, unclogging, 45 absence, elements, 122b excision (usage), 580f
possibility, 839 Fe Fort III fracture, illustration, 417f indications, 122b scalp, oblique laceration, 553f
recognition, 768 Female ideal weight, U.S. National mortality rate, variation, 123 Foreign bodies
inner auditory meatus, Center for Health Statistics, occurrence, 65 evidence, 461
relationship, 207 38t ribs, fracture, 121f removal, 24
main trunk, proximity, 207 Fever pain control, provision, 123 indications, 510b
mandibular branch, 208 cause, 798 pathophysiology, 121 irrigation under pressure,
marginal mandibular branch, noninfectious causes, 799 physiologic alterations, 121 usage, 791
336 Fiberoptic-assisted intubation, 92 problem, 121 Forensic bite mark recognition/
facial artery, relationship, 208f Fiberoptic laryngoscopy, success, 691 result, contiguous ribs evidence/analysis, 625-629
inferior mandibular border, Fibroblast-derived extracellular (fractures), 120-121 Four-hole fracture plate, bicortical
relationship, 191f matrix, deposition (excess), 594 stages, 65 locking screws (usage), 816f
relationship, 283f Fibroblast growth factor (FGF), 10 treatment, 122-123 Four-hole miniplate, monocortical
palsy, 149 Fibroblast growth factor 2 (FGF2), dependence, 122 screws (usage), 817f
paralysis, 150 mediation, 566-567 unilateral paradoxical motion, Four-point fixation, 421f
position, 340f Fibroblasts, impact, 14 122 Fourth-degree burns, 722
temporal branch, 207 Fibrocartilage, 187-188 volume-cycled respirator, usage, Fourth-degree nerve injury, 20
Facial palsy, 468 Fibroplasia, 10-12 65 causes, 662
Facial paralysis, 149 Fibula Flame injury, 718 Fractured maxilla (reduction),
Facial reconstruction, skin graft/ anatomy, 778f Flaplike lacerations, 526 Hayton-Williams forceps
forehead flap (usage), 732f free fibula flap, 778f Flaps, 531-533 (positioning), 422f
Facial region, wounds (repair), 520 grafts, consequence, 778 Abbe-Estlander flap, 537f Fractured sternum, 123-124
Facial scarring, forces, 713 recipient site, mandible Abbe flap, 537f injuries, 123-124
Facial sensation, examination, 229 replacement, 779f advancement flaps, 531 Fractured teeth, infection, 306
Facial series, 234f Fifth-degree nerve injury, 20 double-rotation (O-Z) flaps, 532f Fractures
Facial skeleton Seddon’s neurotmesis, free radial forearm flap, 780-781 anatomic location, Hendrickson
biophysics, 809-810 correspondence, 662 free scapula flap, 781 palatal classification system,
fractures, radiographic Figure-eight wiring, usage, 280 iliac crest free flap, 780 423f
examination (Trapnell Filler materials, 604-605 interpolated flap, 532 angulation/direction, fracture
lines), 238f allograft fillers, 605 Karapandzic flap, 537f angulation/direction
internal rigid fixation, 296 autografts, 605 maintenance, 537f (variation), 189-190
middle third, 179-180 Finger to nose ability, loss, 151 microvascular anastomotic flaps, biphasic pin fixation technique,
structural strengths/weaknesses, Firearm injuries, 765 531 315f
232 fatal firearm injuries, 697 reconstructive flaps, usage, 537f blunt chest trauma, impact, 123f
surgical approaches, 644-646 nonfatal firearm injuries, 697 rotational flaps, 531-532 callus, growth factors, 27t
traumatic injuries, management/ pediatric firearm injuries, 697-700 single-pedicle advancement flap, contamination, 319
treatment, 810 risk factors, 697-700 532 contralateral side, posterior open
Facial skin resurfacing, 595-596 unintended firearm injuries, 697 transpositional flaps, 531-532 bite, 332f
concept, usage, 596 Firearms types, 531 control, direct pressure (usage),
Facial soft tissues death rates (United States), V-Y flaps, usage, 591f 68
injury, 634-635 698f-699f Flap wounds, pressure dressings displacement, anatomic factors,
trauma, 633 firearm homicides, (importance), 526 189-190
Facial structures, complete/partial demographics, 697f Flashlight-pumped pulsed dye laser exposure, 342
avulsions, 772 firearm-related mandibular (PDL) soft tissue loss, impact, 308-309
Facial trauma fractures, 297 indication, 602 extension, 359f
cervical spine injuries, 234 firearm suicide, gender/age data, usage, 594 extremities, 67-68
patients, radiographic 701f Flexion teardrop fracture, 163 fragments, displacement severity,
examination, 245 types example, 163f 311
radiographic evaluation, 233 photograph, 704f Flow phase (catabolic phase), 2 hematoma, 809f
Facial vein, 336 usage, implications, 702-704 effects, 3 infection, 306, 319-323
854 INDEX
Fractures (Continued) Frontal sinus (Continued) Frontal sinus injuries (Continued) Gastrointestinal (GI) systems,
association, 803-804 endoscopic treatment, 837-839 mucopyocele complicating nutritional support methods,
ipsilateral side, dentition surgical technique, 837-839 frontal sinus repair, 39-42
(premature occlusion), 332f epidemiology, 474 487f-488f Gauze packing, layering, 546f
ivy loops, effectiveness, 274f floor, status (assessment), 482 operative treatment, 476-484 Genial bone graft harvest, impact,
lines, 356, 403f fractures, 739 perioperative complications, 485 666f
location, 299 case studies, 740-741 postoperative management, 484 Genial tubercles, 187
evaluation, 298 frontobasilar injury, 479f sinusitis, 485 Geniohyoid muscle, 195
management, challenge, 754 fronto-orbital region, access, 476 treatment, scars/skin creases innervation, 195
medial/lateral displacement, function, 470-472 (usage), 480f Genitourinary injuries, 66
Caldwell posteroanterior drainage, reliance, 472-473 Frontal sinusitis, approach, 473 Geometric broken line closure
view, 305f Glasgow Coma Scale (GCS), Frontobasilar injury, 479f (GBLC), 587-588
mobility, continuation, 803 474-475 Frontonasal region (laceration), drawbacks, 588
patterns, 355-357 heterogeneity, 470-471 MVA (impact), 791f preparation, 588
possibility, physical examination imaging studies, 476 Fronto-orbital region, access, 476 technique, 588
findings, 230 location, 185 Frontozygomatic suture usage, 587f
reduction, 374 operative management, necessity, access, 182 W-plasty, comparison, 587-588
screw placement, 813f 837 supraorbital eyebrow approach, Gerbil bite, 620
segments, exposure, 810 osteoplastic flap approach, 378f Gerdy’s tubercle, location/
sites development, 473 Frost suture identification, 774
immobilization, 14-15 outcomes, 839 placement, 403f Geriatric mandible fracture
surgical exposure, 811 pathophysiology, 472-473 usage, 402-404 management, open reduction
skeletal diagrams, 240f pericranial flap, usage, 482f Full-body review of systems, 222 techniques, 756-758
treatment, history, 808 physical examination, 474-475 Full crown coverage, 267f Geriatric patients
types, 299, 737 pneumatization, 471 Full stomach atrophic mandibular fractures,
Fracture type Location of fracture posterior table fractures, adjunctive techniques/ 758-759
Occlusion Soft tissue damage management, 476-479 pharmacologic agents, bone grafting, advocacy, 759
Infection Displacement posterior wall, removal, 473-474 availability, 690 caloric requirements, 752t
(FLOSID), 299 proximity, 471 anesthesia, strategies, 690 cardiovascular patients, 750-751
Free fatty acids, mobilization, 2 region complications, risk, 690 dentures, usage, 754
Free fibula flap, 776-778 debridement, 482f traumatic injuries, 690 facial fracture management,
advantages, 776-778 surgical access/incisions, 478f Full-thickness burns (third-degree 754-759
graft, inset/securing, 780f Reidel’s procedure, 473 burns), 561, 720-722 fractures, management, 754
Free grafting, 528-529 right frontal sinus, endoscopic eyelid burns, 727f maxillary fractures, 754-755
Free radial forearm flap, 780-781 view, 484f healing, failure, 726 midface fractures, 755-756
Free scapula flap, 781 skull base defects, treatment, 480 house fire example, 721f nutrition, 751-752
Free scapula graft, bone supply, 781 trauma Full-thickness calvarial graft, psychosocial issues, 752-753
Free skin grafts complications, 473 harvest, 784 renal system, 751
classification, 529 presence, 475f Full-thickness eyelid avulsions, respiratory system, 751
pressure dressings, usage, 529 treatment 548-549 soft tissue injuries, 753
thickness classification, 529f goals, 474 Full-thickness skin grafts (FTSGs), system changes, 750-751
usage, 529 history, 473-474 20-21 Geriatric population, bony changes,
Frequency-to-volume ratio, 70 Frontal sinus fractures, 499 defatting, 22 754
Fresh-frozen plasma (FFP), 138-139 approach, 473 revascularization, slowness, 22 Geriatric trauma, outcome/
Frey’s syndrome (gustatory causes, 474 tissue color, 529 survivability, 759-760
sweating), representation, 644 classification, 474 usage, 548-549 Gilles half-buried corner stitch, 576
Frontal bone, 184-185, 208 facial fracture percentages, 837 Function, restoration Gingiva
fractures, 240 management, 837 (optimization), 9 abrasion, 259
axial view, CT scan, 240f repair, coronal incision Functionally stable fixation, rigid contusion, 259
inferior view, 184f (postoperative result), 478f fixation (contrast), 812 injuries, 259
demonstration, 471f treatment, 240 Functioning gastrointestinal laceration, 259
orbit, roof, 184-185 endoscopy, usage, 837 systems, nutritional support Ginglymoarthrodial joint, 343
right superior orbit, three- Frontal sinus injuries methods, 39-42 Glandular branch (facial artery),
dimensional CT scan, 738f anterior table fractures, Fusiform excision, Z-plasties 198
Frontal process, origin, 180 management, 483-484 (combination), 585f Glandular injury
Frontal recess fractures antibiotic therapy, 476 Fusiform incision, distance, 578f isolation, 639
(management), nasofrontal complications, 484-487 Fusiform neuroma-in-continuity, primary management, 639
outflow tract (involvement), cosmetic irregularities, 486 diagram, 663f Glasgow Coma Score (GCS), 52
481-483 decongestants, usage assessment tool, 144
Frontal sinus (consideration), 484 G description, 152
access, 476-479 diagnosis, 474-476 Gait grading, 52t
anatomy, 470-472 fine cut CT scans, 477f disturbances, fibula graft grading consciousness, 61
arterial supply, 472 history, 474-475 consequence, 778 rating, impact, 54-55
central injuries, 474 early complications, 485-486 testing, 151 scoring, repetition, 60
cerebrospinal fluid leaks, endoscopic approach, 483 Galea aponeurotica, aponeurosis usage, 144-145
management, 479-481 lacerations, 479f layer, 553 Glenoid fossa, surgical access,
clinical decision making, late complications, 486-487 Gamma-linolenic acid, enteral 775-776
overview, 474 left ethmoidal mucoceles, formulation, 6 Glezer classification, development,
component, 470 sagittal/coronal CT images, Gap healing, occurrence, 18f 704-705
cranialization, 476 486f Garre’s osteomyelitis, coronal cone Globe
craniomaxillofacial examination, management, 476-484 beam CT, 671f anteroposterior displacement,
474-475 fine cut CT scans, 477f Gastric tubes, usage, 169 455
development, 470-472 meningitis, 485-486 Gastrointestinal (GI) prophylactic anteroposterior injury, 456f
correlation, 471f mucocele formation, 486-487 medications, usage, 71 displacement, 466-467
developmental complexity, mucopyelocele formation, Gastrointestinal (GI) stress ulcer enophthalmos, 466
470-471 486-487 prophylaxis, 71 horizontal displacement, 455, 466
INDEX 855
Globe (Continued) Half-life secretory proteins, acute Head injuries (Continued) High condylar fractures, 302f
injuries, 459 protein/energy depletion diagnostic testing/evaluation, classification, 301
perforation, 461 (indication), 39 61-62 High-energy right ZMC fracture,
position, 455 Hamster bite, 620 epidemiology, 717-718 sustaining, 394f-396f
traumatic herniation, 466-467 Handgun injuries, soft tissue hearing loss, 150 High-energy ZMC fracture, CT
vertical displacement, 455, 466 impact characteristics, 704 management, 154-160 scans, 364f
Glomerular filtration rate (GFR), Hangman’s fracture (pars olfactory nerve injury, 145-146 High extracellular volume, sodium,
751 interarticularis), 162 outcome, prediction, 153-154 73
Glossopharyngeal nerves, 150 dens fracture types/bilateral result, 56-57 High-frequency oscillatory
Glucocorticoid hormones, fractures, 162f setting, 147-148 ventilation, usage, 6
secretion, 2-3 Hank’s balanced salt solution types, 61 High-resolution MRI (HR-MRI), 658
Glucocorticoids, usage, 15 (HBSS), 271 Healing application, 659
Glucose, requirements, 32 Hard callus, 809f delay, 323 MEG, combination, 659
Glutamine, amino acid importance, Hard dental tissue/pulp impact, 324-325 usage, 659-660
32 complicated crown fracture, optimization, 9 High velocity, term (usage),
Glycolic acid (Maxon), suture, 516 257 primary intention, 25 701-702
Glycolic acid homopolymer complicated crown-root fracture, secondary intention, 25 High-velocity projectiles, wounding
(Dexon), 516 257 Hearing loss, occurrence, 150 potential, 702
Golgi process, appearance, 18f crown fractures, treatment, Heart, aging, 750-751 Hippocrates, 293
Graft donor sites, selection, 21-22 260-262 Heart rate, increase, 57 Histamine, release, 57
Graft neovascularization, crown infraction, 257 Heel to shin ability, loss, 151 Histoacryl (cyanoacrylate), glue
occurrence, 22 treatment, 259-265 Helical CT (HCT), usage, 304-305 (usage), 525
Grafts crown-root fractures, treatment, Helicopters History of present illness, 221-222
composite grafts, failure, 541 262 advantages, 50 Hollow organ injury, 171-172
elevation, acrylic burr (usage), injuries, 257 ambulance transport, 50-51 Homeostasis, maintenance, 751-752
783 treatment, 259-265 injured patient transport, 50 Hopkins endoscope, usage, 829
failure, causes, 531 root fracture, 257 rescue helicopter, transport, Hopkins II endoscope, usage, 837
immobilization, 529-531 treatment, 262-265 50f Horizontal buttresses, 233f
Granulation tissue production, uncomplicated crown fracture, transport, 51 Horizontally favorable fracture,
limitation, 10-12 257 usage, 50 300f
Granulocyte-macrophage uncomplicated crown-root Hematomas, 61, 303 Horizontally unfavorable fracture,
colony-stimulating factor fracture, 257 contusion, 61 300f
(GM-CSF), impact, 3 Hard tissues epidural hematomas, 61 Horses
Greenstick fracture, 298 deficits/anatomic variations, formation, 531 bite, 620
Grossly comminuted fractures, ballistic injury control, problems, 540f domesticated horse, teeth, 619f
308 (stereolithography models), intracerebral hematomas, 61 Hospitalization, physiologic stress,
Grossly comminuted mandibular 711f maxillary vestibule, 227f 71
fractures, 308f gunshot wounds, impact, 710-711 otohematoma, external ear Host
Growth factors, 26-27 immediate/early reconstruction, injuries, 540 organism invasion, 792
bone healing role, 27 advocacy, 712 risk, reduction, 21-22 resistance, impairment (factors),
origins/actions, 26t multiple injuries, 248 scars, 588 507-508
Guinea pig bite, 620 replacement, distraction soft tissue injury, 588 list, 510b
Gunning splint osteogenesis (usage), 712 subdural hematomas, 61 Human activated protein C,
treatment, 755f Harelip suture (twisted suture), Hemodynamic status, update, 69 approval, 5
usage, 315f example, 519f Hemopericardium, 124 Human bites, 615
Gunning’s splint, securing, 754-755 Harris-Benedict equation, 33-38 Hemopneumothorax, 118 anatomic location, knowledge,
Gunpowder tattooing (prevention), Hayton-Williams forceps, Hemorrhage 625
early dermabrasion (usage), positioning, 421f control, 709-710 attention, 621
713 Head direct pressure, usage, 68 bite mark
Gunshots arterial blood supply, 197-201 contusion, 160 circular pattern, 627f
caliber specifications, 701 illustration, 198f management, 709-710 evidence, 627-629
injuries burns, 561 shock, pediatric signs/symptoms, evidence recovery, 628-629
categorization, 701-706 injuries, 726 135t recognition, 625-627
patterns, 706-708 contralateral rotation, types, 134 commonness, 615
tissue loss, 712-713 hyperextension, 154-155 Hemostasis, 10 cutaneous human bite mark,
Gunshot wounds CT scanning, usage, 60-61 achievement, 794 ABFO definition, 625
anterior mandibular avulsion, cutaneous sensory distribution, obtaining, 581 facial injury classification, 623f
709f 148f Hemothorax, 64-65, 117-118, 124 impact, 620
bone reconstruction, 711-713 neurologic anatomy, 202-208 blood collection, 64, 117f infection, 800-801
hard tissue involvement, 710-711 radiographic examination, 251 blunt chest trauma sequela, 117 injuries, 615
management, 710-713 radiographs, clinical decision diagnosis, 117 microorganism transmission,
residual continuity/volume rules, 153b management, 117-118 617b
deficits, 711-712 regional anatomy, 208-213 problem, 117-118 partial avulsion, 623f
soft tissue tilt, 82f surgical exploration, pathophysiology, 617-620
involvement, 710-711 tissues, wound repair, 14-22 thoracotomy (usage), 64-65 treatment, aesthetic results, 801
reconstruction, 711-713 trauma, sustaining, 822f thoracotomy, indications, 118 wound, avulsion impact, 801f
Gustatory sweating (Frey’s veins, 201-202 treatment, 64-65 Human diploid cell vaccine
syndrome), representation, illustration, 202f Hemotympanum, presence, 60 (HDCV), 534
644 wounds, hemorrhage Hendrickson palatal classification Human immunodeficiency virus
Gutta-percha, description, 296-297 (association), 506 system, 423f (HIV) infection, 324-325
Head injuries, 60-62 Hepatic gluconeogenesis, carbon Human saliva, bacteria (presence),
H classification, 62 source, 30-31 617-618
Hair apposition technique (HAT), components, 60 Hepatic protein markers, 39t Humerus, major fractures, 57
553 computed tomography, imaging Hess-Eisenhardt Company, medical Hutchinson’s pupil (unilateral
Half-buried horizontal mattress modality, 152 transport vehicle (building), mydriasis), importance,
suture, 526f diagnostic studies, 152-154 49 147-148
856 INDEX
Hyperbaric oxygen Hypothalamic-pituitary axis, Infection (Continued) Infrahyoid muscles (Continued)

therapy, 772 stimulation, 2-3 microbiologic features, 800 omohyoid muscle, 196
usage, 804 Hypothermia, prevention, 59 oral/maxillofacial trauma, sternothyroid muscle, 196
Hypercalcemia Hypotonic hyponatremia, 73 impact, 800 thyrohyoid muscle, 196
clinical manifestations, 75 Hypovolemia presence, 299 Infraorbital artery, 200
dialysis, usage, 75 cause, 67 confirmation, patient Infraorbital foramen, right
treatment, 75 management, 136 temperature (indication), infraorbital nerve
Hypercarbia, prevention, 54 responses, 58 798 (intraoperative view
Hyperemia, zone, 719 Hypovolemic shock, 134-135 prevention, local wound compression), 669f
Hyperflexion injury, occurrence, classification, 134b management (importance), Infraorbital groove/canal, fractures
163 hemorrhages, types, 134 791 (extension), 359f
Hyperglycemia result, 134 pus, formation, 798 Infraorbital nerve (ION), 204, 654
control, 5 Hypoxia rate, 321 anesthesia, 465
impact, 32, 59 exacerbation, 23 reduction, preoperative stay branch/termination, 654
Hyperkalemia, 74 impact, 154 (reduction), 795 disorders, 404-405
AV block refractory, 74 risk, factors, 794 injury, risk, 667
complication, 751 I suboptimal wound healing factor, position, consideration, 209
digitalis toxicity, 74 Iatrogenic CSF leak, intraoperative 22-23 Infraorbital rim (exposure),
electrocardiographic changes, 74 endoscopic view, 482f susceptibility, 800 incisions (usage), 379f
occurrence, 74 Iatrogenic injury, 349 systemic factors, 792-793 Inhalational injury, factors/signs,
postacute phase, 74 minimization, 9 systemic responses, 797 560
pseudohyperkalemia, contrast, 74 Ideal body weight (IBW), 33 teeth, fracture, 319-323 Inhalation injury, 686-687
succinylcholine, impact, 692-693 calculation, 33 third-day fever, indication, 799 airway, 692-693
treatment, 74 Iliac crest urinary tract infection, burns, 724-725
Hypermetabolic catabolism, 31 autograft source, 432 consideration, 799 risk, 687
Hypermetabolism, 30 free flap, 780 viral infection, treatment, Initial trauma management,
starvation composite graft, 781f 805-806 resuscitation, 142-143
comparison, 32t ossification, 774 Inferior alveolar artery, 199 Injectable local anesthetics,
physiologic summary, 31t Ilium, anatomy (microvascular illustration, 200f dosages/properties, 514t
Hypernatremia, 72-73 grafting usage), 780f Inferior alveolar canal Injuries
causes, diagnosis algorithm, 73f Illness cone beam CT scan, 657f algorithm, mechanisms, 168f
Hyperphosphatemia, 75 history, 221-222 distal implant (placement), catabolic phase (flow phase), 2
calcium acetate tablets, usage, 75 metabolism, phases, 2f Panorex (usage), 666f death cause, 167
treatment, 75 physiologic stress, 71 neurovascular bundle, presence, ebb phase
Hyperpigmentation (scars), 589 Immature teeth, low-force 825 characterization, 2
sun exposure, impact, 589 orthodontic repositioning, 269 position, 206f occurrence, 1
Hypertonic saline (HTS), 138 Immobilization root proximity hematomas, 61
Hypertrophic contracted scars, custom-fitted intraoral dental Panorex, usage, 665f high mortality, anatomic factors
554-556 splint, usage, 256 Rood radiographic predictors, (correlation), 54b
Hypertrophic scarring, therapies, failure, 531 panoramic radiographs, intracranial lesions, 61
589-590 Immunonutrition, concept, 6 656f mechanism, 53, 222
Hypertrophic scars, 12-14 Immunosuppression Inferior alveolar nerve (IAN), 206 foreign body presence,
appearance, keloid comparison, impact, 324-325 access, diagram, 675f association, 791
14 reasons, 24 anatomy, 650-652 information, 53
formation, tendency, 560 suboptimal wound healing factor, continuation, 652 tracheobronchial injuries,
keloids, usage, 594-595 24 furcation types, 653t 124
lasers, usage (advocacy), 594 Impacted fracture, 298 iatrogenic injury, diagram, 664f metabolic response, attenuation,
lower lip retraction, 583f Impacted maxillary fracture, injury, 664 6
nonsurgical options, 595 mobilization problem, 420 risk, Ramus graft procedure, metabolism, phases, 2f
self-limitation, 556 Implant-related nerve injury, 666f scoring systems, 53
treatment, silicone gel (usage), diagram, 666f risk assessment, 657 severity
595 Improvised explosive devices neuroma-in-continuity, clinical description, trauma scoring
Hypervolemic hyponatremia, 74 (IEDs), 705-706 example, 663f systems (usage), 52
treatment, diuresis (usage), 74 antipersonnel IEDs, Inferior cantholysis, illustration, grading system, American
Hyphema, 456-457 characteristics, 705-706 443f Burn Association, 561b
illustration, 224f-225f facial injuries, characteristics, Inferior constrictors, 196 skull fractures, 61
Hypocalcemia 708f Inferior distraction, bicortical screw systemic effects, 1
cardiovascular manifestations, 75 Incomplete type I fracture, 427f (usage), 348f systemic responses, 797
clinical manifestations, 75 Indirect calorimetry, 33 Inferior labial artery, 198 types, 61
dialysis, usage, 75 Indirect fixation, 338 Inferior nasal concha, 184 Injury Severity Score (ISS)
neuromuscular excitability, 75 lag screw technique, usage, 339f Inferior oblique muscle, 212 patient percentage, 53f
treatment, 75 Indirect fracture, 298 Inferior orbital fissure, 356 range
Hypoglobus, photograph, 466f Indirect neurorrhaphy, materials Inferior rectus average hospital length of stay,
Hypoglossal nerve, 150, 208 usage, 676-677 entrapment, 440 53f
illustration, 209f Individual characteristics, bites, 627 muscle, forced duction test deaths percentage, 53f
injury, 150 Infection (clinical demonstration), Injury severity score (ISS), 53
Hypoglycemia, impact, 59 bacteria, requirement, 790 440f Inner auditory meatus, facial nerve
Hypokalemia, 74 causes, 790-793 Inferior rim, approaches, 182-183 entry, 207
treatment, 74 control, vascularity (impact), Inflammation, impact, 797-798 Insulin-like growth factor 1 (IGF-1),
Hyponatremia, 73-74 790-791 Inflammatory cell exudate, 10
hypervolemic hyponatremia, 74 fever, cause, 798 interactions, 792f synthesis, 26
hypotonic hyponatremia, 73 foreign bodies, impact, 791 Inflammatory resorption process, Insulin-like growth factor 2 (IGF-2),
isovolemic hyponatremia, 73 incidence retardation, 277 synthesis, 26
pseudohyponatremia, 73 difference, absence, 320 Infrahyoid muscles, 195-196 Insulin requirements, 32
Hypophosphatemia, 75 factors, 321-323 illustration, 195f Insult, body response, 1
Hypotension, impact, 154 local factors, 790-791 innervation, 196 Intact tooth, maintenance, 307f
INDEX 857
Intensive care unit (ICU) Intra-abdominal fluid (assessment), Intubation (Continued) Keloids (Continued)
admission, 50 DPL/CT (usage), 169 endotracheal intubation, 55-56, intralesional corticosteroid
Airway, Breathing, and Intracath stent, passage, 641 85-91 injection, 594-595
Circulation (ABC), 68 Intracerebral hematomas, 61 fiberoptic-assisted intubated, 92 lasers, usage (advocacy), 594
analgesia, 693 Intracranial hematoma, introducer, 91-92 radiation therapy, usage, 594
nonrespiratory issues, 71-75 development (risk), 156 lighted stylet, 92f shave excision, 595
past medical history, necessity, 69 Intracranial hemorrhage, 6 nasal intubation, 55 silicone gel, usage, 595
postoperative sedation, 693 Intracranial hypertension, 160 nasotracheal intubation, 88-89 steroid injection regimens,
reevaluation, dynamics, 69 Intracranial injuries, 690-691 oral intubation, 55 560t
survival rates, 98 emergency room example, procedures, children, 104 usage, 594-595
team, treatment evaluation, 69 508f-509f rapid-sequence intubation, 89-91 Keratocystic odontogenic tumor,
trauma, initial management, 72 Intracranial lesions, 61 requirement, 86 impact (Panorex), 670f
initial/ongoing assessments, Intracranial lesions, cranial rescue airway devices, 91-92 Ketamine, induction agent, 89
68-69 fractures (association), 156 retrograde intubation, 92 Kiesselbach’s area, 545
types, 69 Intracranial pressure (ICP) techniques, 92 Kinetic energy (KE), 704
vascular access, 71 elevation, 153-154 Ipsilateral angle, impact, 303f relationship, 763-765
indications, 71 increase, continuation, 61 Iraq, penetrating soft tissue Kirschner wires, 346
Intensive insulin therapy (IIT), measurement, 52 injuries/fractures (incidence), Knots
requirements, 5 reduction, barbiturates (usage), 707-708 placement, 543f-544f
Intercanthal distance, 691 Ireton-Jones equation, 38 tying, 577f
measurement, 426 Intralesional corticosteroid Iridodialysis, 457f Knot tying, principles, 520
Interdental fixation, usage, 811 injections Iris, 457-458
Interdental wiring techniques, 280 combinations, 12-14 angle recession, 458
L
Interfragmentary displacement, keloid treatment modality, prolapse, 461 Lacerations
radiographic analysis, 299 594-595 sympathetic/parasympathetic closure, 543f-544f
Interleukins, release, 4 Intralesional steroid injections, fiber supply, 62 flaplike lacerations, 526
Interleukin-1 (IL-1) usefulness, 605 Iron wire, ligation, 294 ragged lacerations, 526
circulation/detection, 4 Intranasal region, skeletal anatomy Irradiated polyglactin 910 (Vicryl simple lacerations, 525-526
tumor necrosis factor (TNF), (midsagittal view), 471f Rapide), 516-517 soft tissue wounds, 525-526
contrast, 3-4 Intraneural scarring, 674-675 Irrigation under pressure stellate lacerations, 526
Interleukin-6 (IL-6), circulation/ Intraocular foreign body, impact recommendation, 791 Lacrimal apparatus, 551-552
detection, 4 site, 462f solution, selection (importance), Lacrimal bone, 208
Intermaxillary fixation (IMF), 46 Intraocular pressure (IOP) 791 Lacrimal branch, 213
application, 46 changes, 459 Island advancement flap (V-Y Lacrimal gland, tears (production),
contraindication, systemic increase, 241, 459 plasty), 534f 551
conditions, 312 reduction, 459 Isolated glandular injury, 639 Lacrimal system, 444-445
removal, 323 Intraoperative cone beam CT, Isovolemic hyponatremia, 73 anatomy, 444-445
requirement, 67 usage, 446-447 Ivy loops, 313 illustration, 444f
time, variation, 306-307 Intraoperative navigation, 446 effectiveness, 313f evaluation, 445
Intermaxillary fixation (IMF) Intraoral appliances, usage, 294 maxillomandibular fixation, injury, incidence, 444
screws, 314 Intraoral approach, 344-346 313 Lag screws, 818-819
disadvantages, 314 advantages/disadvantages, 344 osteosynthesis, plate
equipment, 314 endoscope, usage (absence), 344 J osteosynthesis (contrast),
procedure, 314 indications, 344 Jackson, Chevalier, 96 819
Intermaxillary wiring, usage, 294 pertinent anatomy, 344 understanding, increase, 98 shank, smoothness, 819f
Intermittent mandatory ventilation Intraoral axial anchor screw, 345f Jacobson’s nerve, transtympanic technique
(IMV), 65 Intraoral incision sectioning, 643 steps, 820f
weaning, 71 endoscope, usage, 836f Jaguar, mauling attack, 765f usage, 338f
Internal carotid artery (ICA), plate, placement, 836f Jaw immobilization, 756 usage, 319
200-201 Intraoral mouthguards, usage, Jaw thrust, 82f nonthreaded portion,
dissection, occurrence, 155 283-284 procedure, usage, 54 nonengagement, 819f
injury, management, 155 Intraoral open reduction, Thomas Jefferson fracture, type III burst Lambotte, Albin, 808
Internal cortical surface, elevation, principle, 295f fracture, 161 Lamina orbitalis, fracture, 184
187 Intraoral surgery, extraoral surgery Jessner’s solution Lamina papyracea, 183-184
Internal fixation (contrast), 322 TCA, combination, 599-600 Langer’s lines
classification, 812 Intraoral surgical approaches, 192 usage, 589 illustration, 513f
complications, 824-826 Intraorbital hemorrhage, 408 Joint capsule, dissection, 343-344 indication, 512
dental injury, 824-825 Intrathoracic large arteries/veins, illustration, 344f tension lines, 572
hardware, application, 824 damage, 66 Joint exposure, 344f Laparotomy, 171
malocclusion, 825-826 Intravascular volume (decrease), Joint rehabilitation, 336 indications, 171
medical comorbidities, 824 hemorrhage (impact), 134 Laryngeal mask airway (LMA)
nerve injury, 825 Intravenous pyelogram (IVP), K components, 91
surgical site infection, 824 usage, 170 Kaolin-impregnated gauze insertion, 92f
sutures, usage, 257 Intrinsic systems, vascular network, dressings, usage, 709-710 placement, 92f
Internal jugular vein, 201 655 Karapandzic flap, 537f usage, 55-56
Internal nose, innervation, 215 Introducer, 91-92 Keen technique, 386-387 usage, ease, 91-92
Internal orbital reconstruction tracheal tube introducer, 91f Kehr’s sign, presence, 172 ventilation/intubation, problem,
necessity, 369 Intrusive luxation (central Kelly clamp, usage, 63-64 688
absence, 396f dislocation), 257, 267-269 Kelly hemostat, insertion, 100 Laryngoscope blades, 87f
usage, 375-376 Intubation Keloids, 12-14 Laryngoscopy
Internal orbit exploration, 369 adjuncts, 91-93 formation, genetic causes, 12-14 awake laryngoscopy, 92
Interpersonal violence (IPV), 297 attempt, 689 growth, increase, 556 difficulty, assessment, 79
Interpolated flap, 532 complications, 93t nonsurgical options, 595 direct laryngoscopy, 86-87
planning/revascularization, 534f criteria, 70b surgical excision, 12-14 anatomy, 80f
Interpupillary distance, difficulty (assessment), LEMON characterization, 594 positioning, 88f
measurement, 426 (usage), 55 treatment Laryngotracheal trauma, 98-99
858 INDEX
Laser Doppler flowmetry (LDF), Le Fort III fracture Lens, 458 Local inflammatory response, 3-4
usage, 254-255 cranial cavity, communication, 805 dislocation, 458 Local wound management,
Lasers result, 685 subluxation, 458 importance, 791
clinical application, 602t LeFort III fracture, severity, 244 photograph, 458f Locking plates, 815
complications, 603 Le Fort type I fractures, 419-421 result, 458 Locking screw-plate systems,
postoperative care, 603 treatment, 421 Lesch-Nyhan syndrome, 288 stability, 318-319
side effects, 603 Le Fort type II (pyramidal) Lethargy (somnolence), 144t Lockwood’s suspensory ligament,
systems, scanner generator fractures, 422 Leukocyte migration, 3-4, 10 displacement, 440
(usage), 603 infraorbital incision, 422 Levator muscle, insertion, 547 Long bone fractures, fat embolism
usage, 601-603 subciliary/lower blepharoplasty Levator palpebrae superioris, 212 syndrome (association), 68
American National Standards incision, 422 Levator veli palatini, 196 Look externally Evaluate
Institute safety standards, subtarsal/mid-lower lid incision, Lidocaine Opioids Atropine Mallampati scale Obstruction
602-603 422 Defasciculating agent (LOAD) Neck mobility (LEMON), 55,
wavelength selection, 601-602 transconjunctival incision, 422 method, 89 79
Late cartilaginous callus stage, 19f treatment, 422 Life-threatening injuries, 66 chart, 55t
Lateral canthotomy Le Fort type III fractures, 429-431 factors, correlation, 53b test, 80b
illustration, 443f complications, 431 Light amplification by stimulated Loop wiring, usage, 280
retroseptal transconjunctival coronal approach, 430 emission of radiation (LASER), Loosening (subluxation), 257, 267
approach technique, coronal flap sequence, 431f 601 Low condylar fractures, 302f
combination, 381-382 repair sequence, 429-430 Lighted stylet, 92f classification, 301
transconjunctival incision, 756f surgical approaches, 430-431 Linea innominata (innominate Low-energy low-velocity gunshot
Lateral cartilages, characteristics, treatment, 429-431 line), 238 wound, clinical appearance,
214 Left cheek Linear scar revision, principles, 705f
Lateral cephalic view, 233-234 catheter, suture placement, 641f 575-576 Low-energy ZMC fracture
imagery, 234f Left cheek, through-and-through Lines of Langer, 177-178 CT scans, 364f
Lateral cephalometric image, laceration, 641f natural skin lines, contrast, 178 treatment, reduction (usage),
parotid sialogram (impact), Left ethmoidal mucoceles, sagittal/ Lines of maximum extensibility 397f-398f
636f coronal CT images, 486f (LMEs), 572 Carroll-Girard screw/bone
Lateral exophytic neuroma Left eye Lingual artery, 197-198 plate fixation (usage),
clinical example, 664f elevation, limitation Lingual nerve (LN), 206, 652-653 399f
diagram, 664f (enophthalmos), 465f furcation types, 653t Lower blepharoplasty incision, 422
Lateral gaze palsy, 463 relative afferent pupillary defect, high-resolution MRI, 658f Lower cervical process, oblique
Lateral incisor, avulsion, 273f 146f injury, 664 avulsive fracture, 162-163
Lateral lower eyelid ectropion, Left frontal sinus fracture, intraoral approach, 674 Lower cervical spine fractures,
Z-plasty (usage), 593f extension, 740f mandible, distances/relationship, 162-163
Lateral luxation, 257, 269-270 Left globe, NOE fracture/avulsion, 653t Lower eyelid
Lateral nasal branch (facial artery), 741f passage, 653 ectropion, repair, 594f
199 Left inferior alveolar canal posterior division, 652-653 medial third, lacerations (injury
Lateral nasal complex, blood (displacement), keratocystic repair, surgical access (diagram), suspicion), 551
supply, 545f odontogenic tumor (impact), 674f postsurgical deformities, 404
Lateral nasal wall innervation, 670f in situ position, documentation, progressive shortening, 467
216f Left lingual never neuroma, clinical 658 retraction, repair, 594f
Lateral orbit, subperiosteal example, 676f submandibular duct, Lower face, 186-190
dissection, 384f Left mandible angle fracture (open relationship, 635f fractures, 244-246
Lateral orbital rim, supratarsal fold displacement), Panorex Wharton’s duct, relationship, 653 displacement, anatomic
approach, 379f (usage), 669f Lingual splint factors, 189-190
Lateral pterygoid branches, supply, Left mandibular body, multiple fabrication, 279f mandible, 186-187
212 myeloma involvement requirements, 280 mandibular fracture location,
Lateral pterygoid muscle, 194 (Panorex), 671f usage, 280 189
illustration, 193f Left medial orbital wall, Lipid-derived mediators, 3 temporomandibular joint,
impact, 301f intraoperative photograph, 407f Lipopolysaccharide (LPS), 187-189
Lateral rectus muscle Left neck (lower face burn gram-negative cell wall Lower face burn reconstruction,
abducens nerve supply, 213 reconstruction), tissue component, 136 tissue expander (application),
innervation, 212 expander (application), 732f Lips 732f
Le Fort classifications, 416 Left orbital blowout fracture, fall avulsive injuries, 537-538 Lower facial injuries, cadaveric
LeFort fractures, 243-244 (impact), 756f reconstructive flaps, usage, specimen, 787f
classification, 244 Left parasymphysis fracture, 537f Lower lateral cartilages
pattern, noncontrast CT scan, 830f-831f injuries, treatment, 534-554 (disarticulation), open
coronal view, 244f Left renal laceration, 174f laceration, concomitant maxillary rhinoplasty (usage), 502f
Le Fort fractures, pterygoid plate Left-sided ZMC fracture, periorbital fracture/tooth avulsion, 536f Lower left alar rim, burns, 729f
disruption, 685 ecchymosis (association), 227f repair challenges, 534-536 Lower lip
Le Fort I fracture, 181-182 Left side frontal sinus repair, trauma, repair, 535f anesthesia/paresthesia/
illustration, 417f endoscopic approach (incision Little’s area, 545 dysesthesia, 303
zygomaticomaxillary complex lines), 837f Liver, organ injury scale (American avulsion, human bite (impact),
fractures, combination Left subcondylar fracture Association for the Surgery of 801f
(microplate fixation), 823f CT scans, 645f-646f Trauma), 173t laceration, 793f
LeFort I fracture, lateral cephalic right parasymphysis, 832f-834f Loading force, dissipation, 19f Lower lip retraction, hypertrophic
view, 235f Left superior orbital rim, left Local anesthesia, 513-515 scar, 583f
Le Fort II fracture frontal sinus fracture, 740f delivery, 513 Lower spine, 160
coronal CT scan, 422f Left ventricular assist device injectable local anesthetics, Low extracellular volume, sodium,
cranial cavity, communication, (LVAD), 139 dosages/properties, 514t 72
805 Left ZMC fracture maximum dosages, 514t Low tidal volume ventilation
cribriform plate, 686 surgical correction, clinical toxic reactions, 513 (superiority), National
illustration, 417f appearance, 407f Local anesthesia-related nerve Institutes of Health Acute
LeFort II fractures, 241 treatment, transconjunctival injuries, 664b Respiratory Distress Syndrome
radiographic signs, 244 approach, 404f Local flaps, 531 Network identification, 6
INDEX 859
Low velocity, term (usage), 701-702 Mandible (Continued) Mandibular branch (facial nerve), Mandibular fractures, 244-246,
Lumbar puncture, avoidance, 62 displaced unfavorable 208 742-745
Lund-Browder chart, 723t fractures, 269-270 Mandibular canal, 652 alcoholism, impact, 324-325
Lungs bilateral fractures, symphysis Mandibular canines, maintenance, antibiotics, 321-322
pleura, laceration, 113f (inferior/posterior 306 arches, usage, 294
wounds, fractured rib (impact), displacement), 301f Mandibular condylar fractures, bandages, usage, 293-294
113f body 333-347 bars, usage, 294
Luxation displacement unfavorable anatomic landmarks, 343f biodegradable plates/plating
extrusive luxation (peripheral fractures, 273-274 ankylosis, 348 systems, 296
dislocation/partial avulsion), support, 187 asymmetry, 348 bone plates, 295-296
257 class III lever, 809f chronic pain, 349 causes, 297
intrusive luxation (central clinical examination, 227 condylar resorption, 348-349 change, 297
dislocation), 257 closed reduction/fixation, condylar/subcondylar regions, variables, 297
lateral luxation, 257 313-314 surgical approaches, 336-346 classes, definition, 299
composition, 186-187 dysfunction/degeneration, 348 classification, 298-301
M condylar approaches, 190-191 iatrogenic injury, 349 anatomic region, 298-301
Macrophages, chemoattractant endaural incision, initiation, indirect fixation, lag screw clinical examination, 302-304
substances (release), 10 190-191 technique (usage), 339f complications, 323-325
Macular hole, 460 exposure, 342 intraoral approach, 344-346 demographics/epidemiology,
blunt ocular injury, impact, 460f extraoral surgical approaches, advantages/disadvantages, 344 297-298
Mafenide acetate, usage, 726 190-191 indications, 344 causes, 297
Magnesium, 75 preauricular/condylar pertinent anatomy, 344 dentition, development, 309-310
deficiency, 75 approaches, 190-191 surgical technique, 345-346 treatment, 310f
excess, 75 fixation, 814-815 osteosynthesis, 336-338 diagnosis, 301-305
presentation, 75 Garre’s osteomyelitis, coronal closure, 339 approach, 306
replacement therapy, 75 cone beam CT, 671f direct fixation, 338 panoramic radiograph, 304f
Magnetic resonance angiography inferior border indirect fixation, 338 dictionary classification, 298
(MRA), 236-237, 660 surgical access, 775-776 visibility/reduction, 336-338 dolor/tumor/rubor/color, 304
Magnetic resonance inferior border, palpation/ pertinent anatomy, 336, 341 edentulous mandibular fractures,
cholangiopancreatography isolation, 191 preauricular approach, 342-343 296-297
(MRCP), usage, 173 intraoral surgical approaches, 192 advantages/disadvantages, edentulous maxilla, opposition,
Magnetic resonance imaging (MRI) angle, 192 342-343 311-312
facial injuries, 237 parasymphysis/body, 192 pertinent anatomy, 343 endoscopic repair, 319
technology, 237 lateral oblique view, 304f surgical technique, 343-344 exposure, soft tissue loss
usage, 173 usefulness, 304-305 reduction, indications, 333-335 (impact), 308-309
Magnetic resonance neurography lingual nerve, distances/ restitutional remodeling, 744 external appliances, usage,
(MRN), 660 relationship, 653t retromandibular approach, 293-294
Magnetic source imaging (MSI), minor alveolar defects, 773-774 339-341 extraoral/intraoral appliances,
659 movements, abnormality, 303 advantages/disadvantages, 339 usage, 294
Magnetoencephalography (MEG), nonunion, incidence, 324t indications, 339 extraoral/intraoral surgery,
659 palpation, 227 pertinent anatomy, 339-340 contrast, 322
Major salivary gland injuries, preauricular approaches, 190-191 surgical technique, 340-341 facial contour, change, 303
complications, 643 ramus, quadrilateral structure, rhytidectomy approach, 341 facial fractures, association, 298
Malar (zygoma) 187 submandibular approach, 336 facial widening, 324
area, clinical examination, 224 right body, replacement, 779f advantages/disadvantages, fixation, 295-296
articulations, 182f Risdon approaches, 191 336 force direction, knowledge, 302
fractures, 356 strength, 186, 189 indications, 336 grossly comminuted mandibular
prominence, flattening, 358 appearance, 187 surgical/nonsurgical treatment, fractures, 308f
Malar depression, evaluation structural forces, creation, 187 contrast, 335-336 heating/nonunion, delay, 323
(bird’s-eye view), 227f submandibular approaches, 191 surgical technique, 336 fixation techniques,
Malar eminence surgical approaches, 190-191 dissection, 336 relationship, 323
depression, 224 tension, maximum, 810 exposure, 336 historical considerations, 293-297
displacement, axial scan, 364f Mandible fractures, 259, 279 incision, 336 history, 293
Malar fractures, term (usage), 356 number, 298 transmasseteric-anteroparotid immunosuppression, impact,
Malar projection, facial width periapical radiograph, 256f approach, 341-342 324-325
(reciprocal relationship), 367f treatment advantages/disadvantages, infection, incidence (factors),
Malar tissue, appearance, 377f goals, 742 341 321-323
Male ideal weight, U.S. National Gunning splint, usage, 755f indications, 341 intermaxillary wiring, 294
Center for Health Statistics, Mandibular anatomy, weaknesses, pertinent anatomy, 341 internal fixation, 294-295
38t 244-245 surgical technique, 341-342 Kruger classification, 299
Mallampati assessment, 79 Mandibular angle fixation, Champy treatment, 335-346 location, 189, 298
Mallampati classifications, 81f method, 815 Mandibular condyle management, closed technique
Mallampati scale, 55, 79 Mandibular angle fracture, 745 defects, 775-776 (usage), 754, 756
Mallampati score, 79 angulation/direction, variation, prosthetic joint reconstruction, mandibular arch form, change,
Malnutrition 189-190 775-776 303
prevalence, 752 case studies, 746-747 fractures, 742-745 mandibular movements,
result, 31 Champy method, 816f case studies, 743-744 abnormality, 303
spectrum, 31 infection, presence, 321-322 osteosynthesis, 345-346 mastication muscles, impact, 300f
suboptimal wound healing factor, positions, 189f Mandibular defects monomaxillary wiring, usage, 294
23-24 Mandibular arch form, change, 303 cutaneous/mucosal grafting, nerve disorders, 325
Malocclusion, 347-349 Mandibular body fractures absence, 774-775 nonmaxillofacial trauma,
internal fixation, 825-826 coronal CT scan, 657f soft tissue coverage, requirement, association, 298
Malunion, 312 displacement, preoperative 776-781 nutritional needs, monitoring,
Mandible, 186-187 panoramic radiograph, 747f Mandibular dentoalveolar fracture, 307
adaptations, 814f nonunion, post-ORIF CT scan, traumatic injury, 279f occlusion, change, 302-304
angle, 277 826f Mandibular fixation, 814-815 occurrence, frequency, 186
860 INDEX
Mandibular fractures (Continued) Masseter Maxillary central incisor, Maxillofacial region (Continued)
open reduction, 294-295 division, 342f uncomplicated crown fracture, exposure, 221
osteomyelitis, development, 803f muscle sling, closure, 342 261f horizontal buttresses, 232-233
patient history, 301-302 Masseteric artery, 199-200 Maxillary central incisors, trauma partial soft tissue avulsions,
posteroanterior (PA) view, 235f Masseteric sling, division, 342 (association), 250f adjunctive therapy, 772
prevalence, 244 Masseter muscles, 193 Maxillary fractures, 738-739 Maxillofacial skeleton, 232-233
radiologic examination, 304-305 composition, 193 craniomaxillary suspension, skeletal diagrams, 240f
rigid fixation techniques/systems, heads, 193f usage, 755 Maxillofacial surgery
321 Massive transfusion protocol geriatric patient, 754-755 compromise, 39
sensory nerve deficit, 325 (MTP), 139 management, closed reduction controversy, 366
splints, usage, 294 Mass lesions, detection, 60-61 techniques (usage), 754 minimally invasive endoscopy,
substance abuse, impact, 324-325 Mast cells older adults, 754-755 828
teeth chemical mediator derivation, Maxillary incisors, exposure, 249f usage, 667
involvement, studies, 320t 12t Maxillary nerve, 204-205 Maxillofacial trauma, 30
management, 802-803 vasoactive amines, release, 12f infraorbital nerve, 204 airway, importance, 683-684
treatment, 306, 312-316 Mastication, muscles, 193-194 pterygopalatine nerve, 204 antibiotic recommendations,
approach, 306 illustration, 193f, 300f zygomatic nerve, 204-205 802t
arch bars, usage, 313f lateral pterygoid muscle, 194 Maxillary sinus, globe (traumatic clinical examination, 222-229
closed reduction, usage, 307 masseter muscle, 193 herniation), 466-467 compromised host,
complications, 319-325 medial pterygoid muscle, 193-194 Maxillary sinusitis, risk, 799 consideration, 797
evolution, 293 temporalis muscle, 193 Maxillary vestibule, hematoma, facial burn, association, 727f
history, 293-297 Masticatory apparatus, effects, 810f 227f impact, 78t
intraoral approach, 322 Mastoid process (Battle sign), 60 Maxillofacial anatomy, trauma, 144 inflammation, impact, 797-798
principles, 306-316 Mature teeth, low-force orthodontic Maxillofacial ballistic/missile initial airway management,
techniques, 739 repositioning, 269 injuries, characteristics, maneuvers, 81f
viselike devices, usage, 294f Mauling victim, jaguar attack, 765f 700-708 local wound changes, 797
wire osteosynthesis, rigid fixation Maxilla, 180-182, 208 Maxillofacial complex management, 828
(contrast), 322-323 blood supply, 419 facial soft tissues/facial fractures, midfacial fractures, 805
Mandibular fragments, body, description, 180 trauma, 633 nosocomial infections, 805
immobilization, 295f clinical examination, 227 fractures, 685 patient, 54
Mandibular growth, continuation, denture, securing, 739 Maxillofacial complex, avulsive head/neck ROS, performing
349 displacement (reduction), Rowe injuries (sequence), 222t
Mandibular hypomobility, 348 disimpaction forceps assessment, 766-767 pediatric considerations,
Mandibular/midfacial upper facial (usage), 421f causes, 763-766 103-104
hard tissue reconstruction, 784 examination, 228f classification, 767 physical examination, findings,
Mandibular movements, fractures, 259, 279 incidence, 766 230
abnormality, 303 anatomic considerations, life-threatening injuries, 767 plain radiographs, 230
Mandibular nerve, 205-206 419-420 medical management, 766-767 postoperative considerations,
auriculotemporal nerve, 206 frontal process, origin, 180 Maxillofacial injuries, 67, 685-686 230
buccal nerve, 206 Gunning’s splint, securing, airway compromise, 67 prophylactic antibiotics, 796-797
inferior alveolar nerve, 206 754-755 anterior segment, examination, radiographic evaluation,
lingual nerve, 206 lateral aspect, 181f 453 229-230
Mandibular notch, location, 187 medial aspect, 181f cervical spine films, 234-236 review of systems (ROS), 222
Mandibular occlusal view, 305f minor alveolar defects, 773-774 clinical examination, 452-453 surgery, patient preparation,
Mandibular osteology neurosensory supply, 419-420 computed tomography, 236 795-796
anterior view, 186f paired bone, upper jaw, 180 scan, three-dimensional usage, 667
lingual view, 186f palatine process, origin, 180 reconstruction, 236f viral infection, treatment,
oblique view, 186f palpation, 227 computed tomography 805-806
Mandibular plating modules, vertical plate, relationship, 184 angiography (CTA), 236-237 wounds, management, 793-795
components, 812-813 zygomatic buttress, deformity, diagnostic imaging, 233-239 Maxillofacial trauma infection
Mandibular range of motion, 359 eye injuries, relationship, 468 causes, 790-793
restoration, 350 zygomatic process, origin, 181 forced duction test, 455 evaluation, 798f
Mandibular reconstruction, 772-773 Maxillary artery, 199-200 hemorrhage, presence, 685 local factors, 790-791
Mandibular surgical approaches, anterior deep temporal artery, imaging modalities, 233-237 systemic factors, 792-793
190-191 199 lateral cephalic views, 233-234 Maxillomandibular fixation (MMF),
Mandibular symphysis fracture anterior tympanic artery, 199 ophthalmic assessment, 451-455 230
(fixation), bicortical locking branches, 200f orbital examination, 224 achievement, 313
screws (usage), 816f buccal artery, 200 patient treatment, 220 description (Hippocrates), 758
Mandibular trauma, radiographic deep auricular artery, 199 plain films, 233-234 fracture treatment, primary
examination, 245 descending palatine artery, 200 structural disorders, examination, modality, 811
Manual in-line immobilization inferior alveolar artery, 199 453-455 necessity, 711-712
(MILI), usage, 160-161 infraorbital artery, 200 submentovertex (SMV) view, 233 oral nutrition, maintenance
Manual in-line stabilization, 692 mandibular part, 199 sustaining, 691 (inability), 751-752
Marcus Gunn pupil, 221 masseteric artery, 199-200 Towne’s view, 233 release, 334-335
illustration, 224f-225f middle meningeal artery, 199 treatment, 9 requirements, 745
Marginal lacerations, repair, 548 posterior deep temporal artery, visual function, assessment, 452 study, 766
Marshall CT classification, 154t 199 Maxillofacial missile projectiles, usage, 294, 811
groups, 153-154 posterior superior alveolar artery, delivery, 705-706 Maxillomandibular pathology,
MASH units, usage, 49 200 Maxillofacial pathology, 667-669 treatment, 669
Mask seal Obstruction/obesity Age pterygoid branches, 200 Maxillofacial region Maximal incisal opening (MIO)
No teeth Stiffness (MOANS) pterygoid canal, artery, 200 avulsive defects, cranial grafts rehabilitation, 349
test, 85b second part, 199-200 (usage), 784f restoration, 335, 349
usage, 84-85 sphenopalatine artery, 200 ballistic injuries, epidemiology, Maximal inspiratory pressure, 70
Massachusetts General Hospital third part, 200 696 Maximum inspiratory pressure,
(MGH), extraoral approach Maxillary buccal sulcus, ecchymosis, complete soft tissue avulsions, calculation, 71
description, 829 359 adjunctive therapy, 772 McGill pain questionnaire, 673
INDEX 861
Mean arterial pressure (MAP) level, Mesangial cell progenitors, Midface fractures, 241-244, 311 Minor salivary glands, 634
127-128 phenotypic changes, 751 bleeding, 436-437 injuries, 637
change, 139 Mesencephalopontine junction, blindness, 442-443 occurrence, 637
decrease, 133 avulsion/stretching, 147 cerebrospinal fluid rhinorrhea/ Missile injuries
difference, 154 Mesenteric injury, vascular injury otorrhea, 437-439 acute care considerations,
Mechanical dermabrasion, 600-601 (combination), 172f compound comminuted 708-710
Mechanical ventilation, 69-71 Metabolic response, flow phase midfacial fractures, 417f epidemiology, 696-700
bedside weaning parameters, (effects), 3 computed-based imaging maxillofacial ballistic/missile
70-71 Metabolic support, term (usage), techniques, advances, injuries, characteristics,
indications, 70, 122b 31 446-447 700-708
intermittent mandatory Metabolism, phases, 2f corrective osteotomies, 432 postoperative complications,
ventilation (IMV) weaning, Michael Reese Hospital, ambulance cranial bone graft, 433f 713
71 donation, 49 CT scans, 420f Mitochondria
T-piece weaning, 71 Microdermabrasion, 601 emergency care, 416-418 appearance, 18f
usage, 6 complications, 601 endoscopic management, life span, 749-750
weaning, 70-71 epidermal frictional resurfacing, 445-446 Mitochondrial cytochrome
methods, 71 601 enophthalmos, 441-442 function, cyanide interference,
Medial canthal ligament, 212 function, 600 facial examination, 418-419 687
anterior lacrimal crest, postoperative care, 601 Le Fort classifications, 416 Mixed fracture, 149
attachment, 212 postoperative edema, resolution, malunion, 431-434 Mobile facial landmarks, Z-plasty
attachment, 425f 601 midface reconstruction, (usage), 592
evaluation, 425-426 treatment, planning, 601 microvascular free tissue Mobile landmarks
Medial canthal tendon (MCT), usage, 600-601 transfer, 433f distortion, 589
223 Microendocrine response, midfacial reconstruction, bone trauma, 589
tarsal plates, fibrous extension, mediation, 31 grafting (usage), 432-434 Modified Brooke formula, usage,
425 Microneurosurgery, 673-677 nasogastric tubes, usage, 41 725
transnasal reduction, 430f indications/contraindications, neurologic complications, 444 Modified Kligman formula, usage,
Medial orbital wall, composition, 673b ocular complications, 439-444 598
436 time frame, recommendation, older/geriatric patients, 755-756 Modified Lothrop technique,
Medial palpebral ligament, 212 674b orbital apex syndrome, 443-444 483
illustration, 211f usage, 674-677 retrobulbar hematoma, 442-443 Monoamine oxidase (MAO)
Medial pterygoid muscles, 193-194 Microplates, usage, 822f rigid fixation, usage, 432 inhibitors, 514
illustration, 193f Microstomia stabilization, 419 Monocytes, circulation, 792
location, 193 device, 730f superior orbital fissure syndrome, Monofilament nonabsorbable
Medial table, separation, 774 relief/prevention, early splint 443-444 suture, 517
Medial walls, 208-209 therapy (usage), 592 surgical techniques/materials, braided sutures, 517
anatomy, 437f Microvascular anastomotic flaps, 445-447 coated polyester, 517
blowout fractures, 465 531 traumatic diplopia, 439-441 Dacron, 517
dissection, 436 Microvascular disease, impact, 23 traumatic optic neuropathy, Dermalon, 517
fractures, 436 Microvascular flaps, scalp, 554 443 Ethibond, 517
diagnosis, 436 Microvascular free tissue transfer, treatment, 432-434 Ethilon, 517
treatment, 436 433f complications, 436-444 Mersilene, 517
Mediators, release (interactions), usage, 433 Midfacial bleeding, manifestation, polyester, 517
792f Microvascular grafting, ilium 437 silk, 518
Medical transportation, history, anatomy, 780f Midfacial bones, fractures stainless steel, 517-518
48-50 Microvascular reconstruction (existence), 390 surgical cotton, 517
Medicinal leech (Hirudo medicinalis) radius anatomy, 782f Midfacial buttresses, stabilization, Tycron, 517
photograph, 772f scapula anatomy, 783f 421f uncoated polyester, 517
therapy, 772 Midaxillary site, preference, Midfacial complex, 416 Monofilament sutures,
Medium chemical peels, 599-600 63-64 Midfacial fixation, microplates composition, 515
agents, usage, 599b Midazolam (usage), 822f Monomaxillary wiring, 294
Medpor implant, usage, 841-842 induction agent, 90 Midfacial fractures, 738-739 Monomeric enteral formulas, 42
Melanocyte-stimulating hormone metabolism, 693 classification, 357 Motor function, assessment,
(MSH), abnormality, 556 Middle constrictors, 196 infection, 805 61-62
Melker cuffed cannula, 97 Middle facial injuries, cadaveric intraorbital hemorrhage, 462 Motor nerves, 213
Melker emergency specimen, 787f ocular injury, presence, 418-419 Motor system, 150-151
transcricothyrotomy catheter Middle lamellar graft, harvest, Midfacial reconstruction, bone divisions, 150-151
kit, 95 593-594 grafting (usage), 432-434 dysfunction, 151
Meningitis Middle meningeal artery, 199 Midfacial third reconstruction, Motor vehicle accident (MVA),
complication, 439 Middle third root, fractures 781-784 109-110, 297
frontal sinus injuries, 485-486 (prognosis), 266f Midglobe abrasion, severity, 765f
Meniscus (articular disc), 188 Midface, 179-185 axial CT scan, 397f-398f avulsion injuries, 252f
Mental foramen, apical ethmoid bone, 183-184 axial scan, 364f bilateral condylar fractures,
characteristic, 651-652 fixation, 819-820 Midline, molar (presence), 743f
Mental nerve (MN), IAN frontal bone, 184-185 253f-254f complex/cranial injuries, 500f
continuation, 652 inferior nasal concha, 184 Mineral trioxide aggregate (MTA), intracranial/neurologic injuries,
Mental status, 144-145 maxilla, 180-182 usage, 261 558f-559f
alteration microplate fixation, 822f Miniplates, 815 number, increase, 109
involvement, 144 nasal bones, 183 fixation, 345 total avulsion, 765f
terms, 144t palatine bones, 184 monocortical application, tension victims, 50-51
Meperidine hydrochloride reconstruction, microvascular resistance, 815 maternal/fetal mortality rates,
(Demerol), overdose, 59 free tissue transfer, 433f placement, clamp (usage), 838f increase, 175
Mersilene sphenoid bone, 185 postoperative necessity, 49
monofilament nonabsorbable vertical buttresses, 232 orthopanthomgram, 816f pulmonary contusions, 118
suture, 517 vomer, 184 systems, 346 Motor vehicle collisions (MVCs),
usage, 512 zygoma, 182-183 Minor eye injuries, 455 impact, 109
862 INDEX
Mouth (floor), 218 Myocardial contusion, 124, 128-129 Nasal injuries Naso-orbital-ethmoid (NOE)
anatomy, 635f diagnosis, 129 evaluation, 492-496 injuries, 424-429
burn injuries, 729 diagnostic tool, 129 general anesthesia (GA), 496 anatomy, 425
commissure incidence, determination induction, 498 assessment, 424-425
closure, challenge, 536f (difficulty), 128-129 local anesthesia (LA) classification, 426
left cheek, through-and- symptoms, 129 injection, 498 diagnosis, 425
through laceration, 641f toleration, 129 usage, 496 imaging, 426
ecchymosis, 304f treatment, 129 open treatment, 499 physical examination, 425-426
fingers, placement, 81f M16 rifle, NATO 7.62-mm round prevention, 504 surgical approaches, 426
illustration, 218f (firing), 702f-703f skin laceration, 542f systematic management, 426-428
protectors, 283-288 treatment, 496-499 traumatic telecanthus, 424f
requirement, 284-285 N Nasal intubation, performance, 55 treatment, 426-429
types, 285-288 Nagel, Eugene, 50 Nasal obstruction, 541-544 Naso-orbital-ethmoid (NOE)
right side, ranula, 638f Naloxone hydrochloride (Narcan), Nasal packs, removal, 498 involvement, 240
submandibular duct, usage, 59 Nasal patency, airflow dynamics, Naso-orbital-ethmoid (NOE)
marsupialization, 638f Nasal air passages, impact, 492 494-495 maxillary fracture complexes,
Mouth-formed protectors, 285-286 Nasal anatomy, 213-215 Nasal region, coronal/axial 240
arch coverage, 286 Nasal avulsions, 771 sections, 493f Naso-orbital-ethmoid (NOE)
types, 286f Nasal bleeding, trauma (impact), Nasal septal cartilage, articulation, midface fractures, occurrence,
Mouthguards 545 214 240-241
construction, 285 Nasal bones, 183 Nasal septal deviations Naso-orbital-ethmoid (NOE) region
extension, 288f characteristics, 213-214 (assessment/treatment), Asch central midface, 768
fabrication, easiness, 288 fracture, 543f-544f forceps (usage), 498 Naso-orbital-ethmoid (NOE)
National Collegiate Athletic illustration, 183f Nasal septal hematoma, region, components, 425
Association guideline, 284b location, 425 detachment, 223 Nasopharyngeal airway (NPA)
stone model, creation, 287 pairing, 491-492 Nasal septum, 183f devices, effectiveness, 82
trimming, 287-288 repositioning, 498 abscess formation, rarity, 541 examples, 83f
types, 285 Nasal burn injuries, 727-728 blood supply, 215 insertion, 84f
usage, 285 Nasal cartilage, nasal tip division, 215 OPA alternative, 83
National Alliance Football positioning/telescoping, 426 innervation, 216f placement, technique, 83t
Rules Committee Nasal cavity medial wall, 215 Nasotracheal intubation, 88-89
requirements, 284 anatomy, 215 Nasal tip edema, concern, 492 failure, 96
M-plasty, usage, 578f cleaning/inspection, 475 Nasal tip positioning/telescoping, 426 Nasotracheal tubes, sizes, 88-89
Mucocele knots, placement, 543f-544f Nasociliary branch, 213 National Alliance Football Rules
incision, 638f lateral wall, 437f Nasoethmoid complex fractures, Committee, mouthguard/face
salivary extravasation lining, 215 481-482 guard usage requirement, 284
phenomenon, atypical Nasal complex Nasofrontal duct, involvement National Collegiate Athletic
location, 637f dog bite (impact), open (evidence), 241f Association (NCAA),
Mucopyocele complicating frontal approach (requirement), Nasofrontal outflow tract mouthguard guideline, 284b
sinus repair, 487f-488f 501f-502f drainage, 472f National Confidential Enquiry into
Mucosal grafting, mandibular examination, 223 involvement, 481-483 Patient Outcome and Death,
defects (relationship), 774-775 holding, 228f patency, absence, 482 trauma report, 77
Mucosal layer (suturing), neuroanatomy, 494f status, assessment, 482 National Emergency X-Radiography
absorbable sutures (usage), vascular supply, 495f Nasofrontal sutures, exposure, 431 Utilization Study (NEXUS)
543f-544f Nasal dorsum, observation, 492 Nasogastric feeding tubes, 40-41 Low-Risk Criteria (NLC), 153
Mucosal margins, skin margin Nasal fractures, 738 usage, 41 clinical decision rules, 152
apposition, 533 closed reduction, 496-499 Nasogastric tube insertion, 40-41 decision instrument, 153
Mucosal tears, bone fractures/ complications, 503-504 guidelines, 40-41 National Trauma Data Bank
penetrating objects displacement, axial CT scan, Nasolabial muscles, restitution, (NTDB), scoring system
(association), 541 497f 377-378 (usage), 53
Muller’s muscle, eyelid elevation, dorsal support, absence, 503f Nasolacrimal injuries, 467 National Trauma Databank team,
62 epidemiology, 491 Nasolacrimal system 50-51
Multidetector CT, usage, 236 epistaxis, impact, 503-504 anatomy, 551f NATO 7.62-mm round, M16 rifle
Multiple fractures, 298 external nasal splint, application, disruption, 444-445 fire (ballistic representation),
Multiple organ dysfunction 498 Naso-orbital-ethmoid (NOE) 702f-703f
syndrome (MODS), 1 general anesthesia (GA), complex, 222-223 Natural nonabsorbable sutures, 515
Multiple traumas, evaluation induction, 498 fractures, 240-241, 499 Natural skin lines, 178f
(difficulty), 142-143 local anesthesia (LA), injection, inspection, 223 lines of Langer, contrast, 178
Multiple Z-plasty, 582-585 498 palpation, 223 Near-infrared spectroscopy (NIRS),
closure, 585f nasal packs, removal, 498 Naso-orbital-ethmoid (NOE) usage, 2
design, 585f nasal patency, airflow dynamics, fractures, 223, 739 Neck
Multisystem trauma, 30 494-495 bone reconstruction, 483f arterial blood supply, 197-201
cervical spine injury, assumption, nondisplaced nasal fractures, case studies, 740-741 illustration, 198f
54-55 healing, 504 classification, difficulty, 240 burns, 561
Muscle of Horner, 211 operative management, 496 cribriform plate fracture, 686 injury, 726
Muscle of uvula, 196 pediatric patients, considerations, impact point, injury, 241f injury, epidemiology, 717-718
Muscles, 192-197 499-503 knowledge, 425 clinical examination, 227-229
groups, power, 151 physical examination, 738-739 left globe, 741f concomitant examination, 67
strengthening/endurance, post-traumatic deformity, 499 midface, skeletal diagrams, 240f contents, 125t
351 presentation, regional transnasal wiring technique, cutaneous sensory distribution,
Mutlifilament sutures, 515 differences, 491 428-429 148f
Myelinated peripheral nerve, radiographic examination, type I fractures, 426 direct blow, 154-155
structure, 20f 495-496 type II fractures, 426 injuries, 63
Mylohyoid muscle, 195 secondary rhinoplasty, benefit, type III fractures, 426 lower face burn reconstruction,
innervation, 195 499 types, 427f tissue expander
location, 195 treatment, 738 wiring technique, 430f (application), 732f
INDEX 863
Neck (Continued) Neurologic evaluation, 144-151 Nondisplaced favorable fractures, Nosocomial infections, 805
mobility, 79 history, 143-144 307-310 Novofil (polybutester),
movement, potential, 691 initial assessment, 142-144 panoramic radiograph, 308f nonabsorbable suture, 518
neurologic anatomy, 202-208 Neurologic examination, 143t Nondisplaced nasal fractures, Nurilon, nonabsorbable suture, 517
penetrating neck injuries, 228 quality, 142 healing, 504 Nutrition
penetrating neck trauma, 125 Neurologic injury Nonfatal dog bite-related injuries, aging, 751-752
preparation, 100 anatomic signs, 151-152 616t therapy role, 6
radiographic examination, 251 assessment, head CT scanning treatment percentage, 617f Nutritional failure
regional anatomy, 208-213 (usage), 60-61 Nonfatal firearm injuries, 697 clinical assessment, 33-38
structures, 228t functional signs, 152 Nonfractured maxilla, prosthesis diagnosis, assessment tools
tissues, wound repair, 14-22 mortality, increase, 2 (securing), 755 (usage), 33-39
vasculature, 99f severity, grading, 151-152 Non-hair-bearing skin, blade laboratory assessment, 38-39
veins, 201-202 Neurologic management (angle), 521f Nutritional intake, absence, 30
illustration, 202f history, 143-144 Nonmaxillofacial trauma, Nutritional status, importance, 23
vertical scar band, 587f initial assessment, 142-144 mandibular fractures Nutritional support regimen, goal
wounds, hemorrhage Neuroma formation, 675-676 (association), 298 (positive nitrogen balance),
(association), 506 Neuromuscular blocking agent Nonorganic intraorbital foreign 38-39
zones, 227-228 administration, 689 bodies, 462 Nutritional therapy
illustration, 228f selection, 692 Nonpenetrating chest trauma, nonoral methods, 40
Needle cricothyroidotomy, 56, Neuropraxia, 20 injuries, 111b oral methods, 40
94-96 Neurorrhaphy, epineurial sutures Nonpenetrating trauma, usage, indications, 39-40
anatomic landmarks, (diagram), 676f occurrence, 153 Nutrition-focused physical
identification, 95 Neurosensory supply, 419-420 Nonperforating eye injuries, 455-461 examination, 34t-37t
complications, 95 Neurosensory tests (NSTs) Nonprotein calorie/nitrogen ratio, Nylon
direct puncture, method, 95 accuracy, evaluation, 672 stress level, 43t nonabsorbable suture, 517
example, 94f usage, 672 Nonrigid fixation, 323 suture, usage, 515
history, 94 Neurotmesis, 20 explanation, 812
indications, 94 Neurovascular bundle, presence, Nonunion, 323 O
percutaneous cricothyrotomy, 825 incidence, 324t Oblique avulsive fracture, 162-163
contrast, 95 Neutrophils Nonurgent trauma injuries, 51 Observer scar assessment scale,
placement, importance, 95 aggregation, thromboxane A2 Nonvital tissue, removal, 24 571t
technique, 94-95 (impact), 3 Normal extracellular volume, Obstructive shock, 135
explanation, 94 constituents, 13t sodium, 72-73 treatment, 139
Negative-pressure dressing, impact, mobilization, 792 Nose, 540-546 Obtundation, 144t
25 New Orleans Criteria (NOC) airflow dynamics, 494-495 Occipital artery, 199
Negative-pressure wound therapy, clinical decision rules, 152 anatomy, 491-492 Occipital condyle fractures (OCFs),
25 criteria, 153 anesthesia, 544-545 161
Nerve injuries CT scanning, usage, 153 anterior packing technique, Anderson and Montesano
axonal/cellular response, NFOT, pedicled soft tissue 438f-439f, 546f classification, 161
662-663 coverage, 487f-488f avulsions, 771 diagnosis, difficulty, 161
axonal fibers, involvement, 663 Nicotinamide-adenine dinucleotide avulsive wounds, 541 Occlusal disharmony, 227f
categorization, Seddon/ phosphate (NADPH), bone, illustration, 492f Occlusal splint, usage, 420
Sunderland classification, interactions (reduction), 793 burn injuries, 727-728 Occlusion
20 Nifedipine, topical agent, 589 cartilage structures, illustration, change, 302-304
classification/findings, 662t Nitric oxide, endothelium 492f characteristic, 299
description, 20 production, 132 cauterization, silver nitrate dressing, effects, 568f
facial photographs, usefulness, Nitrogen (usage), 545 reestablishment, 306
651f balance, 38-39 cerebrospinal fluid, emergence, Occlusive dressing, placement,
implant-related nerve injury, equation, 39 62 63-64
diagram, 666f output, equation, 39 circulation, 221 Occult abdominal trauma (OAT),
internal fixation, 825 Nonabsorbable sutures, 515, 517-518 clinical examination, 223 175
nerve continuity defects, 676 braided construction, 517 dorsal support, absence, 503f Occupational injuries, 765
nerve-injured patient, HR-MRI categorization, 517 field block, 544f Ocular examination
(usage), 659-660 monofilament design, 517 fractures, 738 primary survey, 221
pain, 673 nylon, 517 function, 491 pupillary responses, abnormality,
site, cellular debris (clean-up polybutester (Novofil), 518 injury 147f
process), 662-663 polyester, 517 evaluation, 492-496 Ocular injury, presence, 418-419
Nerves polypropylene (Prolene), 518 history/physical examination, Ocular media, opacification, 461
continuity defects, 676 silk, 518 492-494 Ocular motility
disorders, 325 stainless steel, 517-518 skin laceration, 542f assessment, 148, 376
healing, 20 surgical cotton, 517 internal structures, 493f disorders, 463-466
lateralization, usage, 667 Nonanimated facial areas, W-plasty mucosal disruption, 498 orbital injury, impact, 464
organization, schematic (usage), 581f neurosensory innervations, 492 physical impediment
representation, 655f Noncommunicating physical examination, 492-494 (determination), forced
sensibility, abnormality, 359 pneumothorax, 113-114 posterior nosebleed, 545-546 duction test (usage), 361f
stretching, examples, 661f Noncompression osteosynthesis, post-traumatic deformity, 499 Ocular protection, scleral shell
stump, preparation (diagram), 814-818 radiographic examination, (usage), 375f
676f Noncontacting displaced fracture 495-496 Ocular trauma score, 462
transection injuries, 20 fragments, soft tissue saddle nose deformity, 499 Oculocephalic responses, tests,
Neurapraxia, examples, 661f treatment/interposition septoplasty, requirement, 499 151-152
Neuroendocrine response, (delay), 277-279 septum manipulation, 498 Oculomotor nerve, 147-148
manifestations, 31 Nonconvulsive status epilepticus, skeletal nasal width, avulsion/stretching, 147
Neurogenic eyelid ectropion, 592 142 measurement, 503 Edinger-Westphal nucleus, 62
Neurologic anatomy, 202-208 Nondepolarizing neuromuscular skin Oculovestibular response test,
Neurologic deficits, examination, blocking agent (NMBA), attachment, 179 151-152
228-229 usage, 692 lacerations, closure, 541 usage, 62
864 INDEX
Oklahoma City bombing (1995), Open reduction and internal Orbit Organ injury scale, American
705-706 fixation (ORIF)(Continued) anatomy, 464 Association for the Surgery of
Older adults mandibular angle fracture, approaches, 423f Trauma
caloric requirement, decline, 752 submandibular swelling, clinical examination, 223-224 liver, 173t
cardiovascular system, 750-751 647f-648f endoscopic views, 841f spleen, 173t
cognitive abilities, objective patients, mobilization/ injuries, 224 Organs, initial damage, 58
assessment (completion), rehabilitation, 336 perforating injuries, 462 Oroendotracheal intubation,
753 requirement, 739 right orbit, nasal aspect (wood 691-692
dentures, usage, 754 silver wire, usage, 758 splinter), 462f Oropharyngeal airway (OPA)
edentulous mandibles, fracture surgical approaches, 316-318 Orbital anatomy, 208-213 devices, effectiveness, 82
management, 757f sutures, usage, 294-295 Orbital apex, 205f examples, 83f
facial lacerations, electric grinder usage, 297 anatomy, 443f insertion, 83f
injury, 753f Open rhinoplasty, repositioning Orbital apex syndrome, 443-444 placement, technique, 83t
maxillary fractures, 754-755 usage, 502f Orbital blood supply, 212-213 usage, 82-83
midface fractures, 755-756 Open wounds Orbital blowout fracture, plating, Orotracheal intubation, failure,
nutrition, 751-752 healing, 527 435f 96
pharmacologic treatment, 751 treatment, 526-527 Orbital contents Orthodontic bands/arches, usage,
postoperative mental status Operation Iraqi Freedom- entrapment, presence, 360-361 294
changes, 753 Operation Enduring Freedom herniation, 440 Orthognathic surgery, impact, 667
psychosocial issues, 752-753 (OIF-OEF), battlefield Orbital emphysema, 419 Osmolarity, 42
renal system, 751 conditions report, 766 presence, 465 Osseointegrated implants, 784
respiratory system, 751 Operative site, hair (presence), 795 Orbital floor Osseous defects, 776
soft tissue trauma, 753-754 Operative team, infection access, Caldwell-Luc osteotomy, Osseous graft types, advantages/
system changes, 750-751 transmission (prevention 841f disadvantages, 773t
wound healing, 753-754 strategies), 806b blowout fracture, 434f Osseous structures, significance,
Olfactory nerve, 145-146 Ophthalmic assessment, 451-455 demonstration, coronal CT 232-233
injury, head injury (impact), Ophthalmic injuries, indirect scan, 434f Osteoblasts, synthesis process, 16f
145-146 consequences, 467-468 defect, 466 Osteoclastic cutting cones, cone
Olfactory recognition, impairment, Ophthalmic nerve, 204 disruption, impact, 435f production, 18f
146 nasociliary branch, 213 endoscopic view, 842f Osteoclasts
Oligomeric enteral formulas, 42 Opposite eye, status, 363 exposure, incisions (usage), photomicrograph, 18f
Omohyoid muscle, 196 Opsite (dressing), 568 379f resorption pit location, 16f
One-hand EC technique, BVM Op-Site, usage, 25 fracture, endoscopic repair, Osteocytes, cytoplasmic processes
ventilation, 85f Optic chiasm, 146-147 840-842 (photomicrograph), 17f
Open apex avulsion, flow charts, Optic disc, photograph, 454f surgical technique, 841-842 Osteology, 179-190
275f-276f Optic nerve (CN II), 146-147 reconstruction, silicone implant mandibular osteology, 186f
Open bite, bilateral angle fractures artery, 212 (usage), 405f Osteomyelitis
(impact), 303f avulsion, 461 Teflon implants, usage, 405 commonness, 15-19
Open fractures, 15-19, 298 photograph, 461f Orbital fractures, 241-242, 739 development, 803f
Open gastrostomy, PEG procedures injury CT imaging, 241-242 extent, increase, 804
(contrast), 42 operative/nonoperative midface, skeletal diagrams, 240f hyperbaric oxygen, usage, 804
Open pneumothorax, 63, 116-117 management, 146 plain radiography, accuracy, 241 radiographic signs, 804
chest tube, anterior placement, treatment, 146 type 3 fracture, 739 risk factors, 803b
63-64 involvement, 408 upward sequelae, 223-224 trauma/infection, 15-19
occlusive dressing, placement, 63 orbit entry, 213 Orbital implant, principles, 393 Osteoplastic flap approach,
threat, 687-688 Oral cavity Orbital margin, deformity, 359 development, 473
treatment, 63 bleeding, management, 221 Orbital muscles, 211-212 Osteoprogenitor cells,
Open reduction circulation, 221 inferior oblique muscle, 212 proliferation, 14
absolute indications, 335 Oral dietary supplementation levator palpebrae superioris, 212 Osteosynthesis, 340
closed reduction, contrast, 828 (ODS), usage, 40 orbicularis oculi muscle, 211-212 axial anchor screw, 336-338
endaural approach, 317 Oral endotracheal tube (OETT), rectus muscles, 212 usage, 345
evidence, 335 usage, 55 superior oblique muscle, 212 closure, 339
fixation procedures, 316-319 Oral feedings, functioning GI tract Orbital musculature, frontal view, compression plate osteosynthesis,
incisions, 421 (usage), 40 211f 812-814
indications, 310-312 Oral health/prevention, Orbital nerves, 213 development, 808
list, 335b importance (education lateral view, 205f direct fixation, 338
proximal segment, superior example), 289f motor nerves, 213 endoscope-assisted osteosynthesis,
displacement, 311f Oral injuries, mucosal/gingival sensory nerves, 213 345
intraoral access, 317-318 lacerations, 249 Orbital osteology, 210f indirect fixation, 338
mandible angle, displaced Oral intubation, performance, 55 Orbital reconstructions, materials miniplate fixation, 345
unfavorable fractures, Oral LLC, usage, 25 (usage), 392-393 noncompression osteosynthesis,
311-312 Oral/maxillofacial surgery, Orbital roof, fractures, 466 814-818
modality, acceptance, 349 traumatic nerve injuries Orbital soft tissue preauricular transcutaneous
preauricular approach, 316-317 (examples), 20 orbicularis oculi, separation, trocar insertion, 345
requirement, 272f Oral mucosa, 549 209-211 screw fixation, 345
retromandibular approach, 316 abrasion, 259 status, 361 visibility/reduction, 336-338
submandibular approach, 316 contusion, 259 Orbital trauma Osteotomy
sutures, usage, 257 injuries, 259 signs, 418 acrylic burr, usage, 783
techniques, 756-758 laceration, 259, 549 upper eyelid, laceration, 467f Caldwell-Luc osteotomy, 841f
usage, 349 Oral nutrition, maintenance Orbital volume (increase), Otohematoma
treatment, usage, 336b (inability), 737 zygomatic injury (impact), 361 aspiration, 540f
wire osteosynthesis, 318 Oral surgery Orbital wall fractures, 434-436 external ear injuries, 540
Open reduction and internal compromise, 39 ophthalmic complications, 434 incision/drainage, 540f
fixation (ORIF) minimally invasive endoscopy, 828 sections, division, 434 Otorrhea, 437-439
absolute indications, 334 Orbicularis oculi muscle, 211-212 Organ hypoperfusion, hypoxic Overwhelming postsplenectomy
indications, 333 illustration, 210f environment, 132 infection (OPSI), result, 172
INDEX 865
Oxygen Parotid duct (Stensen’s duct) Pediatric abdominal trauma, Percutaneous stab incision, drill
consumption, measurement, 33 (Continued) 174-175 (insertion), 838f
delivery, importance, 795 impact, 549f Pediatric airway, treatment, 103 Percutaneous tracheostomy,
glycosylated hemoglobin, affinity, occurrence, 551 Pediatric condylar fractures, open 102-103
23 primary repair, steps, 640f reduction (absolute advocacy, 103
intake, compromise, 77 visualization, 641f indications), 745 bronchoscopic guidance, usage,
interactions, reduction, 793 presence, 550f Pediatric facial fractures 103
saturation (monitoring), pulse proximal portion, identification, anatomic considerations, 735 usage, 836f
oximetry (usage), 687 641 clinical examination, 736-737 Percutaneous transluminal
Oxygenation repair, 551 diagnosis, 736-737 coronary angioplasty (PTCA),
failure, 85-86, 142-143 Prolene sutures, usage, 641f history, obtaining, 736 139
maintenance, 54 severing (cannulation), Silastic initial examination, 736-737 Percutaneous trocar
preoxygenation, 89 tubing (usage), 706f nasal fractures, 738 screws, placement, 836f
Oxygen/metabolites, osteocyte swelling, 551 panoramic/dental radiography, usage, 836f
transfer, 17f Parotid fistula, appearance, 644f 737 Perforating eye injuries, 461-462
Parotid gland, 215-216 radiologic examination, 737 Perfusion, problems, 58
P anatomy, 633-634 Pediatric firearm injuries, 697-700 Periapical root surgery, 670
Packed red blood cells (PRBCs), characteristics, 633-634 Pediatric maxillofacial complex, 735 Pericardial laceration, 124
138-139 composition, 216 Pediatric orbital trauma, treatment, Pericardium, blood (presence), 65
Palatal fractures, 422-424 duct, injury, 634f 739 Pericranial flap, usage, 482f
classification, 422-424 facial nerve branches, Pediatric patients Pericranial tissue, 553
list, 424b relationship, 642f management, 745 Pericranium
orbit, approaches, 423f injuries, 550, 637-643 nasal considerations, 499-503 loss, 553
treatment, 422-424 evaluation/repair, 550 Pediatric Trauma Score (PTS) vascularization, 553
occlusion reduction, 424 risk, 634f method, 53 Perinasal burns, example, 724f
Palatal screw, usage, 314f treatment method, Pediatric trauma victim, clinical Perinasal tissues, roles, 491
Palatine bones, 184, 208 determination, 642-643 evaluation, 251f Perineurial damage, 20
horizontal portion, 181f location, 190 Pedicle rotational intraoral flap, Perineurium, 654-655
medial aspect, 181f submandibular gland, reconstruction, 729f Periodontal health, evaluation,
nasal/palatal aspects, 184f relationship, 217-218 Pelvic fractures, 67 259
Palatine process, origin, 180 Parotidomasseteric fascia, description, 173 Periodontal ligament (PDL)
Palatoglossus muscle, 196-197 undermining, 342 Pelvic injuries, 173-174 healing, 273-274
Palatopharyngeus muscle, 196 Parotidomasseteric region, layers, damage control surgery, 174 widening, periapical radiograph,
Palpebral fissure, displacement, 360 341 surgical intervention 256f
Pancreatic injuries, 173 Parotid region, 215-218 (evaluation), seat belt marks Periodontal ligament fibroblast
MRI/MRCP/ERCP, usage, 173 injury, 639f (impact), 174f (PDLF) cells, vitality
Pancreaticoduodenal hematoma, Parotid regional anatomy, 217f Pelvic ring disruptions, 173-174 (preservation), 271
exploration, 172 Parotid sialocele, 646 Pelvic trauma, 61 Periodontal tissue
Panfacial fractures Parotid sialocele, development, Penetrating Abdominal Trauma avulsion (exarticulation), 270-277
axial CT reconstruction, 417f 645f-646f Index (PATI), 168 concussion, 257, 267-277
CT scan, 244f Pars interarticularis (hangman’s Penetrating injuries exarticulation (complete
Panoramic radiographs, obtaining, fracture), 162 evaluation, 171 avulsion), 257, 270-277
245 bilateral fractures, 162 incidence, 171t extrusive luxation (peripheral
Papilledema, 468 dens fracture types/bilateral Penetrating neck injuries, 228 dislocation/partial avulsion),
Parasymphyseal fracture fractures, 162f Penetrating neck trauma, 125 257, 269
impact, 303f Pars lacrimalis, 211 vascular injury, 125 injuries, 257, 267-277
subcondylar fracture, panoramic Partial avulsion (extrusive Penetrating soft tissue injuries/ illustration, 258f
film, 245f luxation), 257 fractures, incidence, 707-708 intrusive luxation (central
Parasymphyseal region, displaced Partial facial paralysis, 325 Percussion, evaluation, 64 dislocation), 257, 267-269
unfavorable fractures, 311 Partially edentulous mandibles, 314 Percutaneous cricothyrotomy, 95-96 lateral luxation, 257, 269-270
Parasymphysis, 317-318 atrophy, absence, 312f procedure, 95 retained root fracture, 257
intraoral approach, 192 Partial scalp avulsions, 771 steps, 103 subluxation (loosening), 257,
Parenteral nutritional therapy, Partial soft tissue avulsions, Percutaneous dilatational 267
45-46 adjunctive therapy, 772 tracheostomy (PDT) Perioral burns
Parenteral therapy, forms, 45 Partial-thickness burns (second- advantages, 103 example, 724f
Paresthesia, usage, 303 degree burns), 561, 720 emergency percutaneous microstomia relief/prevention,
Parinaud’s syndrome, 464 ear burns, 728f cricothyrotomy, comparison, early splint therapy
Parkland formula (Baxter formula), flash burn, 721f 103 (importance), 592
usage, 725 healing, failure, 726 performing, avoidance, 103 Periorbital ecchymosis (raccoon
Parotid duct (Stensen’s duct), 216 Partial thromboplastin time (PTT), Percutaneous endoscopic eyes), 61
anatomy, 633-634 determination, 59 gastrostomy (PEG), 41-42 depression, 224
defect, 642 Past medical history (PMH), 68 advantages, 41 edema, relationship, 358
facial nerve branches, obtaining, 68-69 anesthetic/tracheal intubation, left-sided ZMC fracture,
relationship, 642f Patent airway, establishment, 54 induction, 41 association, 227f
injuries, 639-643 Pathologically cupped optic disc, 459f complications, 41-42 photograph, 418f
anatomic classification, 636f Pathologic fracture, 298 contraindications, 41 Periorbital incision problems,
detection, 643 Patient scar assessment scale, 571t procedure, 41 402-404
diagnosis, problem, 635-636 Patient-specific comorbidities, 9 open gastrostomy, Periorbital injuries, sequelae,
inspection, 636 Patient-specific implants, CAD-CAM contradiction, 42 223-224
site, localization, 639-640 (usage), 785 usage, 230 Periorbital lacerations, repair, 594f
support, radiographic imaging Patient transport, 48-51 Percutaneous endoscopic Periosteum, closure, 342
(usage), 636-637 PDS II (polydioxanone), jejunostomy (PEJ), 42 difficulty, 382
surgical management factors, absorbable suture, 517 Percutaneous screw placement, Peripheral apparatus, motor system
639 Pectoralis major muscle flap 838f division, 150-151
lacerations reconstruction, Z-plasty endoscopic guidance, 830f-831f Peripheral dislocation (extrusive
duct ends, location, 550-551 treatment, 587f reduction/fixation, 840f luxation), 257
866 INDEX
Peripheral limb, central limb Platelet-activating factor (PAF) Posterior epistaxis (management), Preauricular transcutaneous trocar
(angle increase), 584f impact, 10 Foley catheter (usage), 546f insertion, 345
Peripheral motor nerves, magnetic release, 3 Posterior ethmoidal artery, 212-213 Prebent titanium reconstruction
resonance neurography Platelet counts, determination, 59 Posterior ilium, 775 bar, temporary condylar head
(research), 660 Platelet-derived growth factors Posterior mandible prosthesis (attachment), 777f
Peripheral myelinated nerve (PDGFs), 3, 26 mastication muscles, impact, 189 Pregnancy, abdominal trauma,
organization (demonstration), modulation, 566-567 surgical approaches, 190f, 283f 175
hematoxylin/eosin/silver stain Platelets Posterior mandibular edentulism Prehospital advanced life support
(usage), 654f interleukin release, 10 (bone height insufficiency), (prehospital ALS), usage, 59
Peripheral nerves vasoactive amines, release, 12f Panorex (usage), 668f Preload, determination, 133
distinction, 655 Plate osteosynthesis, lag screw Posterior nasal packing, Premolar, location (chest
healing, stages, 21f osteosynthesis (contrast), 819 performing, 221 radiograph), 254f
Peripheral parenteral nutrition Plating systems, usage, 296 Posterior nosebleed, 545-546 Pressure dressings
(PPN), 45-46 Pleuripotential mesenchymal cells, Posterior orbit, coronal scan, 364f importance, 526
indication, 45-46 impact, 14 Posterior skin, transection, 778 securing, 530f-531f
Peripheral trigeminal nerve system, Pneumatic antishock garment Posterior superior alveolar artery, Presurgical enophthalmos, 391
regional anatomy, 652f (PASG), usage, 136 200 Pretracheal fascia, location, 99-100
Peripheral visual field, testing, 453 Pneumothorax, 113-117, 124 Posterior table fractures, Primary bone healing, 808-809
Permanent teeth closed pneumothorax, 63-64, management, 476-479 Primary burn wound management,
reimplantation, 272 113-114 Postexposure prophylaxis (PEP), 725-726
root fractures, 264 continuation, 66 621t, 768t Primary central incisor, root
treatment, principles, 264-265 development, 113f Postinjury neural assessment, fracture (occlusal radiograph),
Persistent diplopia, 405-406 hemopneumothorax, 118 HR-MRI (application), 659 265f
occurrence, 405-406 noncommunicating Postoperative airway support, Primary dentition, permanent
Pertrach kit, 95 pneumothorax, 113-114 693-694 successor development, 269
Petrous fractures, 148-149 occurrence, 102 Postoperative edema, resolution, Primary incisors, trauma
Phagocytic vacuole, pH open pneumothorax, 63 601 (treatment), 259
(reduction), 793 presence, suction (impact), Postoperative hemorrhages, Primary intention, healing, 25
Phagocytosis 124-125 occurrence, 101 Primary parotid duct repair,
actions, requirements, 792 simple pneumothorax, 114-116 Postoperative mental status, sequencing, 640
augmentation, antibody presence, symptoms, 115 changes, 753 Primary teeth, root fractures, 264
792 tension pneumothorax, 64 Postoperative parotid sialocele, Primary wound closure, 25
disorders, 793 trauma, association, 115 diagnosis/management, 646 decision, 794
polymorphonuclear leukocytes, Poiseuille’s law, 138f Postoperative tracheostomy Pro Air mouthguard, bimaxillary
impact, 13f Polybutester (Novofil), aspiration, problem, 102 mouthguard, 287f
Pharyngeal musculature, 196-197 nonabsorbable suture, 518 care, aspects, 102 Progressive neurologic
dilators, 196-197 Polydek, usage, 515 Post-ORIF right mandibular angle deterioration, 160
elevator muscles, 196-197 Polydioxanone (PDS), 515 fracture, 647f-648f Prolene (polypropylene), 515
illustration, 197f Polydioxanone (PDS II), 517 Post-ORIF scan, 826f nonabsorbable suture, 518
inferior constrictors, 196 Polyester, monofilament Postsurgical enophthalmos, 391 usage, 641f
middle constrictors, 196 nonabsorbable suture, 517 Postsurgical ocular examination, Prone positioning, usage, 6
palatoglossus muscle, 196-197 Polyfascicular nerve, low-power 376 Prophylactic antibiotics, 796-797
palatopharyngeus muscle, 196 cross section, 655f Post-traumatic cicatricial ectropion, administration
salpingopharyngeus muscle, 196 Polyglactic acid (Vicryl), 515 management, 593f decision, speed, 796
stylopharyngeus muscle, 197 Polyglactin 910 (Vicryl), suture, 516 Post-traumatic CSF leakage, 481 indications, 796b
superior constrictors, 196 Polyglactin 910 coated with Post-traumatic deformity (nose), usage, 307, 369-376
Phase-encoded time reduction triclosan (Vicryl Plus), 517 499 Propofol
acquisition (PETRA), 658 Polyglycolic acid (Dexon), 515 Post-traumatic enophthalmos, axial induction agent, 89
Phenol, contraindication, 600 Polymeric enteral formulas, 42 CT scan, 441f infusion, 693
Phenylephrine, impact, 140 Polymeric formulas, macronutrients Post-traumatic forehead scar Proptosis, 466
Phosphorus, 75 (distribution), 42 (depression), W-plasty excision Prostacyclin
binding, promotion, 75 Polymorphonuclear leukocytes, (usage), 580f formation, 23
hyperphosphatemia, 75 impact, 13f Post-traumatic nystagmus, 464 impact, 10
hypophosphatemia, 75 Polymorphonuclear neutrophils Post-traumatic premature posterior Prostaglandins, impact, 10
Phosphorus-dependent metabolic (PMNs), 4 dental contact, 302-303 Prosthetic valve endocarditis (PVE),
pathways, 32 immature forms, presence, 804 Post-traumatic scalp avulsion, reports, 797
Physical examination Polypeptides, release, 4 reconstruction, 580f Protein-energy malnutrition (PEM),
adjuncts, 169 Polypropylene Potassium, 74 definition, 752
components, 68 Prolene, nonabsorbable suture, AV block refractory, 74 Protein requirements, 32
findings, 230 518 depletion, 74 Prothrombin time (PT),
initiation, soft tissue injury suture usage, 515 digitalis toxicity, 74 determination, 59
evaluation, 67 Polytrauma patient, maxillofacial electrocardiographic changes, 74 Proton density-weighted (PD)
nutrition-focused physical surgeon involvement, 67 hyperkalemia, 74 images, 237
examination, 34t-37t Portex cricothyroidotomy kit, 97 hypokalemia, 74 Proximal condylar dislocations,
Physiologic stress, 71 Positive end-expiratory pressure postacute phase, 74 difficulty, 347
Pinhole occluded, usage, 452f (PEEP), 116-117 Preanesthetic dentoalveolar Proximal segment (reduction),
Pinna, 538 Positive pressure ventilation, evaluation/consultation, percutaneous trocar (usage),
components, 538f-539f impact, 114 recommendation, 250f 836f
Plain gut suture, 516 Postanoids, cascade, 57 Preauricular approach, 342-343 Pseudohyperkalemia, hyperkalemia
Plain tomograms, usage, 304-305 Posterior auricular artery, 199 advantages/disadvantages, (contrast), 74
Planimetric Z-plasty, 582 Posterior belly, innervation, 342-343 Pseudohyponatremia, 73
transposition angles, 584f 194-195 indications, 342 Pseudoptosis, 465
Plastic surgical needles, 519 Posterior body fractures, diagnosis, pertinent anatomy, 343 Psychosocial issues, 737
Plate fixation 304f surgical technique, 343-344 Pterygoid branches (maxillary
cases, 296 Posterior deep temporal artery, Preauricular incisions, 316f artery), 200
impact, 421 199 surgical approaches, 317f Pterygoid canal, artery, 200
technique, development, 296 Posterior elevator, removal, 386 Preauricular swelling, presence, 742 Pterygoid plates, disruption, 685
INDEX 867
Pterygomandibular space, lingual Radiation Rehabilitation, closed/open Retromandibular approach, 339-341

nerve passage, 653 burns, 718 reduction treatment (usage), advantages/disadvantages, 339
Pterygomasseteric sling suboptimal wound healing factor, 336b indications, 339
dissection, 340, 342 24 Reidel’s procedure, 473 pertinent anatomy, 339-340
division, 340 therapy, impact, 24 Reimplantation, 270f Retromandibular incision,
Pterygopalatine nerve, 204 Radiographic evaluation, 237-239 Relative afferent pupillary defect 645f-646f
Ptosis, 224f-225f sharpness, 238 (RAPD), 221 description, 646
Pulmonary artery catheter (PAC) sinus, 238-239 illustration, 224f-225f Risdon approach, 283f
advantages, 139t symmetry, 238-239 Relaxed skin tension lines (RSTLs), Retromandibular vein, 202
usage, 2 Radius, anatomy (microvascular 572 importance, 340
Pulmonary contusions, 118-119, reconstruction), 782f face, 572f Retroseptal transconjunctival
124 Ragged lacerations, 526 guide, 579-581 approach technique, lateral
definition, 118 Railroad track sign, 239f long axis, parallelism, 577-578 canthotomy (combination),
injuries, association, 118-119 Ramus, 318 parallel scar, segments, 582-585 381-382
management, steps, 119 diagnosis, mandible lateral Renal loss, 74 Reverse Towne view, 305f
MVA victims, 118 oblique view (usage), 304f Renal system, aging, 751 Review of systems (ROS), 222
pathophysiology, 119f graft procedure, 666f Renin, release, 133 Revised Trauma Score, 52-53
treatment, 65-66, 119 height, loss (radiograph), 335f Replacement resorption Revision nasal surgery, septoplasty
Pulmonary dysfunction, 111 inferior distraction, 346 (ankylosis), usage, 274 (requirement), 499
Pulmonary parenchymal injury, mandibular defects, 774 Rescue airway devices, 91-92 Rhytidectomy approach, 341
121 quadrilateral structure, 187 esophageal-tracheal Combitube, Rhytidectomy incision, 341f
Pulmonary wedge pressure, central shortening, 331, 345-346 92 Rib fractures, 119-120
hemodynamic monitoring Ramus condyle unit (RCU), access, Rescue helicopters, transport usage, complication, 120
catheter placement, 138f 829 50f diagnosis, 120
Pulp Raney clips, usage, 60 Residual continuity, 711-712 first rib fractures, 120
oral trauma, fractures, 260-261 Rapid four-step technique (RFST), Resorbable plating systems, usage, number, factors, 120
tissue, exposure, 261 97 296 occurrence, 119-120
Pulp capping bougie-assisted cricothyrotomy Respiratory distress, chest pain, 114 treatment, 120
indication, 262 technique, comparison, 97 Respiratory rate, rapid pulse Ribs
procedure, execution, 261 quickness, 97 indication, 58 cage, autogenous bone source,
Pulp vitality Rapid pulse, indication, 58 Respiratory status, monitoring, 56 432
measurement, laser Doppler Rapid-sequence intubation (RSI), Respiratory support, indications, cartilaginous component,
flowmetry (LDF), 254-255 89-91 112t carving, 775
testing, 254 cricoid pressure, 90-91 Respiratory system delivery, rib cutter (usage), 776f
Pulsatile irrigation system, 625f endotracheal tube, placement, aging, 751 Right eye elevation, limitation, 465f
Pulsatile jet irrigation, usage, 771 91 changes, 751 Right frontal sinus, endoscopic
Pulsed dye laser (PDL), usage, etomidate, 89 Resting energy expenditure (REE), view, 484f
594 induction, 89-90 33 Right inferior alveolar nerve,
Pulseless electrical activity (PEA), induction agents, 89-90 changes, 3f discontinuity (clinical
usage, 65 ketamine, 89 increase, bolus feedings example), 677f
Punctate entry wounds, example, LOAD method, 89 (impact), 42 Right infraorbital nerve (trigeminal
707f midazolam, 90 Restitutional remodeling, 744 branches), intraoperative view
Puncture wounds, treatment, 624 postintubation care/ Resuscitation compression (usage), 669f
Pupillary dilation, management, 91 blood replacement, necessity, 59 Right lower lobe, teeth (coronal
contraindications, 454 premedication, 89-90 initial trauma management, CT image), 253f-254f
Pupillary levels, inequality, 360 list, 90t 142-143 Right mandible, arteriovenous
Pupillary reflexes, 453 preoxygenation, 89 necessity, 59 malformation (Panorex), 670f
Pupils, 453, 457-458 preparation, 89 patient response, 59 Right mandibular body fracture
activity, light direction, 62 propofol, 89 prehospital advanced life (fixation), Panorex (usage),
asymmetry, 461 rocuronium, 90 support, usage, 59 669f
reactivity, 59 sodium thiopental, 90 Retained root fracture, 257 Right maxillary antrum,
rechecking, 60 steps, 89 Retina opacification, 239f
Pure orbital fractures, Type 1 succinylcholine, 90 injury, 459-461 Right orbit, nasal aspect (wood
fracture, 739 contraindications, 90b macular hole, 460f splinter), 462f
Purtscher’s retinopathy (traumatic Rapid-sequence tracheal intubation photograph, 454f Right parasymphysis, left
retinal angiopathy), 467 OETT, usage, 55 traumatic retinal edema, 460f subcondylar fracture, 832f-834f
Pus Rat bite, 620 Retinal artery, involvement, 408 Right subcondylar fracture,
formation, 798 Ravussin cannula, 97 Retinal detachment, 459-460 830f-831f
local abscess/collection, Ready-made mouthguards, 285 exudative retinal detachment, medial override, 835f
development, 799 photograph, 285f 460 Right ZMC fracture
Rebleeding, causes, 803 treatment, 460 orbital floor/medial wall,
Q Recombinant human bone Retinal dialysis, peripheral retinal comminution, 392f
QuickClot, usage, 709-710 morphogenetic protein photograph, 460f sustaining, 394f-396f
Quicktrach, 95 (rhBMP-2)-assisted grafting, Retinal hemorrhage, 460 treatment
Quicktrach II, 97 development, 433-434 Retroauricular ecchymosis (Battle transconjunctival approach,
Reconstructive flaps, usage, 537f sign), 61 403f
R Reconstructive plates, 818 Retrobulbar hematoma, 442-443 Right zygomatic arch (schematic
Rabbit bite, 620 Rectal examination, performance, Retrobulbar hemorrhage, 408, endoscopic approach),
Rabies, 619-620 62 462-463 intraoral/hairline incision
incidence, decrease, 619 Rectus muscles, 212 clinical features, 462 (usage), 839f
infection, 800 origin, 212 management, 463 Rigid fixation, 318-319
postexposure prophylaxis (PEP) Red scars, immaturity, 574 signs/symptoms, 408 functionally stable fixation,
guide, 621t Refractory salivary fistulas/ Retrognathic occlusion, 303 contrast, 812
schedule, 768t sialoceles, surgical technique, Retrograde intubation, 92 miniplates, usage, 323
virus, host entry, 619-620 644 Retrograde urethrography (RUG), techniques/systems, 321
Rabies immune globin (RIG), 534 Regenerative medicine, 25 usage, 169 wire osteosynthesis, contrast,
Raccoon eyes (bruising), 60 Regional flaps, 531 Retrohepatic hematomas, 172 322-323
868 INDEX
Rigid sigmoidoscopy, 170 Salivary glands, 549-551 Scars (Continued) Scars (Continued)
Risdon approach, 191 anatomy, 633-634 antitension lines (ATLs), 572 preoperative considerations,
illustration, 191f iatrogenic injuries, 644-647 assessment scale, 571t 597-598
Risdon wire, 314 minor salivary glands, 634 body, ellipse (removal), 579 preoperative consultation, 569
usage, 314 Salpingopharyngeus muscle, 196 camouflage, difficulty, 574 primary closure, achievement,
Road abrasions, infection Save-A-Tooth emergency tooth- chemical peeling, application, 575-576
(possibility), 800f preserving system, 271f 598 procedures, 577-588
Rocuronium, indication agent, 90 Scalds, thermal injury, 718 closure, hemostasis (obtaining), red scars, immaturity, 574
Root canal Scalp, 178-179, 552-554 581 release, 590-591
filling material, periapical film, 672f advancement flaps, usage, 554 collagen matrix, 566-567 resurfacing procedures, 595-603
medications, 672 avulsions, 771 color, 573-574 serial excision, 578-579
therapy, completion (indication), avulsive injury, 530f-531f complications, 588-591 skin preparation, 598-599
262 burn contour, continuum, 571 S-shaped scars, development, 572
Root formation, radiographic injuries, 728-729 contraction standing cone deformity,
examination, 255-256 reconstruction, double tissue treatment, 590 avoidance, 576f
treatment, follow-up expander (application), V-shaped incision, 591f subcutaneous tissue, abundance,
examination, 265 733f contracture, recurrence, 590-591 578
Root fracture, 257 circulation, 221 depressed scar, 591-592 sun exposure, response
impact, 264 clinical examination, 222 depression, occurrence, 591-592 (consideration), 597
occlusal radiograph, 265f complete avulsion, 770f dermabrasion, 600-601 sun-reactive skin type, Fitzpatrick
retention, 257 connective tissue layer, early scar revision, 574 classification, 574t
treatment, 262-265 subcutaneous vascular elevation surgical options, 575-588
Root middle third, fractures supply, 221 local anesthesia, usage, 596f suturing technique, 576
(prognosis), 266f epidermis/dermis, thickness patterns, 572 tensile strength, maximum, 567f
Root preservation, 277 (variation), 552-553 elliptical excisions, 578f tension lines, 572
Root proximity, Rood radiographic injuries epithelium, excision, 590f terminology, 569t
predictors (panoramic evaluation, 553 excision, 582f treatment
radiographs), 656f MVA, impact, 524f blade, beveling, 576f algorithm, 597f
Root resorption innervation, cause, 179 procedure, 577-578 techniques, 598-603
complication, 274 lacerations, 221 serial scar excision, 604 types, 573-574, 591-595
dentoalveolar trauma, dog bites, impact, 619f excisional scar revision, planning, widening
association, 260f motor vehicle accident, 573 demographic factors, 589
Rotation-advancement flaps, 554 association, 558f-559f Fitzgerald skin type, recurrence, 589-590
Rotational flaps, 531-532 treatment, hair apposition consideration, 597 W-plasty, usage, 579f
movement, 531-532 technique (usage), 553 fusiform excisions, 578f wrinkles, 572
usefulness, 532f layers, 178-179 GBLC technique, usage, 587f Scar tissue
Rough endoplasmic reticulum illustration, 178f hematomas, 588 excision, W-plasty (involvement),
(RER), appearance, 18f understanding, 552f hyperpigmentation, 589 556-557
Rowe disimpaction forceps, usage, microvascular flaps, 554 incision surgical excision, combination
421f oblique laceration, 553f length (decrease), M-plasty therapy, 557
Rowe zygomatic elevator position, post-traumatic scalp avulsion, (usage), 578f Schirmer’s test, usage, 149
386 reconstruction, 580f placement, 572 Schwann cells, proliferative activity,
Rule of nines, burn assessment, 723f rotation-advancement flaps, 554 infection, 588 663
soft tissue lacerations, 799-800 treatment, 588 Scleral rupture, 461
S superficial burn, 720f intervention, 574-575 Scleral show, incidence, 404
Saddle nose deformity, 499 transpositional flaps, 554 lasers, usage, 597, 601-603 Screw fixation, 345
Sagittal split osteotomy (SSO), 667 wounds lengthening, 582-585 impact, 421
stabilization, bicortical screws avulsive scalp wounds, 527f gain, 585 Seat belt marks, evaluation, 174f
(usage), 669f extension, 509 V-shaped incision, 591f Secondary assessment, 60-68
Salicetti, Guglielmo, 294 Scapula, anatomy (microvascular lines of maximum extensibility AMPLE method, 60
Salicylate, topical agent, 589 reconstruction), 783f (LMEs), 572 initiation, 60
Saliva, bacterial count (impact), 801 Scar formation, 554-560 local anesthesia, usage, 596f objective evaluation, 60
Salivary ducts abnormality, comparison, 556t location, 574 subjective evaluation, 60
injuries Scar revisions massage, advocacy, 595 Secondary bone healing (indirect
support, radiographic imaging adjunctive scar revision medical history, obtaining, bone healing), 808-809
(usage), 636-637 procedures, 603-605 597-598 Secondary brain injury
injuries, mechanisms, 634-635 linear scar revision, principles, medication history, hypotension/hypoxia, impact,
secondary repair, difficulty, 643 575-576 determination, 598 154
Salivary extravasation phenomenon management, flow diagram, 570f microdermabrasion, 600-601 occurrence, 154
(mucocele), atypical location, multiple Z-plasty, usage, 582-585 mobile landmarks, distortion, Secondary cicatricial alopecia, 580f
637f planning, 588 589 Secondary intention, 25
Salivary flow, internalization steps, 575b necrosis, 589 Secondary pressure wave,
technique, 644 technique selection, factors, 570b observer scar assessment scale, formation, 702
Salivary gland injuries, 633 timing, 574-575 571t Secondary rhinoplasty, benefit, 499
complications treatment plan, development pain, 571-572 Second-degree burns, 561
initial treatment, 643-644 factors, 570 patient preparation, 598 Second-degree burns (partial-
complications, management, Scarring patient scar assessment scale, thickness burns), 561, 720
643-644 healing progression, 566 571t Second-degree nerve injury, 20
diagnosis, 635-637 increase, factors, 555t pattern, 573-574 involvement, 662
infrequency, 644 index (Vancouver Scar Scale), perioral resurfacing treatment, Second intercostal space, chest
mechanisms, 634-635 570-571 598 tube placement, 63-64
radiation therapy, usage, 643 Scars peripheral arms, design, 584f Second molar, maintenance, 306
superficial/total parotidectomy, ablative techniques, postoperative postoperative wound care, usage, Seddon classification system, 661
643 care, 603 581 components, 661f
treatment, 637-643 analysis, 569-574 post-traumatic scalp avulsion, Seddon nerve injury classification
antisialagogues, usage, 643 purpose, 569-570 reconstruction, 580f system, 20
INDEX 869
Seddon’s neurotmesis, 662 Shock (Continued) Skin (Continued) Soft palate musculature, 196
Seizure activity, benzodiazepines treatment, 132 recommendation (elective illustration, 196f
(usage), 62 principles, 136-140 incisions), 178f levator veli palatini, 196
Seldinger technique, 95 ultrasonography, training, 138 margin apposition, 533 muscle of uvula, 196
Seldin retractor, usage, 387 urethral disruption, exclusion, non-hair-bearing skin, blade tensor veli palatini, 196
Self-inflicted shotgun wounds, 173 (angle), 521f Soft tissue
suicide attempt, 708f vascular access, attaining, 136 photodamage (treatment), access incisions, usage, 409
Self-threading bone screws, usage, volume loss, 138 topical tretinoin (usage), avulsion, severity, 642
389 whole blood, replication, 139 598 avulsive loss, 771-772
Sellick maneuver Shock states, tissue perfusion preparation, 598-599 clinical examination, 222
cricoid cartilage, identification, (decrease), 2 superficial layers, 99 coverage, requirement, 776-781
91f Shotguns surface damage, 58
cricoid pressure, performing, characteristics, 704-705 increase, 754 extent, 299
90-91 injury types, 704-705 landmarks, 829 evaluation, importance, 274f
Semirigid splint, 281-282 wounds sutures, placement, 521 facial injuries, 239
Senile eyelid ectropion, 592 facial appearance, 707f interrupted fashion, 524f foreign bodies
Sensory alterations, terminology, self-inflicted shotgun wounds, thickness, variation, 718-719 radiographic viewing, 256
651t suicide attempt, 708f traumatic injury, burn removal, indications, 510b
Sensory nerves, 213 Sialocele, treatment, 643-644 (definition), 717-718 fractures, penetrating soft tissue
deficit, 325 Silastic tubing, usage, 706f treatment, lasers (usage), 602 injuries/fractures
location, 552f Silicone sheets, oxygen passage, vasoconstriction, 57 (incidence), 707-708
Sensory system, 151 568-569 wounds, tensile strength gunshot wounds, impact,
Sepsis-induced malnutrition Silk, monofilament nonabsorbable (regaining), 521 710-711
physiology, 31 suture, 518 Skin Connective tissue Aponeurotic handgun injuries, impact
Septal fractures, dorsal support Silver sulfadiazine (SSD), 25-26 layer Loose connective tissue characteristics, 704
(absence), 503f cream, 725-726 Periosteal/Pericranial layer immediate/early reconstruction,
Septic shock, 136 Simple alveolar defects, 773-774 (SCALP), 552f advocacy, 712
management, 140 Simple fracture, 298 Skin grafting, 20-22 inspection, clinical examination,
mortality rates, 136 Simple lacerations, 525-526 full-thickness skin grafts (FTSGs), 251-252
Septocaine (articaine margin, involvement (absence), 20-21 lacerations, 799-800
hydrochloride), 514 547-548 split-thickness skin grafts loss, fracture exposure, 308-309
Septoplasty, requirement, 499 Simple pneumothorax, 114-116 (STSGs), 20-21 multiple injuries, 248
Septum manipulation, 498 diagnosis, 115 Skin-grafting open soft tissue reconstruction, 711-713
Sequential compression devices example, 57f wounds, granulation tissue replacement
(SCDs), usage, 72 treatment, 115-116 production (limitation), 10-12 distraction osteogenesis, usage,
Serial ABG determinations, 111-112 Simple sutures, usage, 577f Skin grafts, 527-531 712
Serial excision (scars), 578-579 Simplified Motor Score (SMS), 144 adherence, 22 graft elevation, acrylic burr
Serial scar excision, 604 development, 145 free skin grafts, classification, (usage), 783
Seroma formation, risk Single-pedicle advancement flap, 529 requirement, absence,
(reduction), 21-22 532 usage, 732f 781-784
Serum albumin, estimation, 39 Single-tooth fixation techniques, Skin tension lines, relaxation, resuspension, 376
Serum cardiac troponins, 129 282 572f surgery, rotational flap (usage),
Serum lactate level, measurement, Sinus cavity, harvested/grafted Skull 532f
2 material (packing), 483f base, bone components, 156-157 trauma, older adults, 753-754
Serviceable teeth, presence/ Sinus floor, posteromedial portion, fractures, 61, 156-158 treatment/interposition, delay,
absence, 299 471-472 nasogastric tubes, usage, 41 312
Severe trauma injuries, 51 Sinus function, maintenance, 472 frontal view, 180f Soft tissue healing
Severity Characteristic of Trauma Sinusitis lateral view, 180f abnormalities, 12-14
Score (ASCOT) method, 53 complications, 473 Skull base fractures bone healing, comparison,
Shave excision, 574-575 frontal sinus injuries, 485 CSF leak, development, 157 14
effectiveness, 595 Sinus mucosa, eversion, 479 extension, 146-147 hypertrophic scars, 12-14
Sheathed retractor, 838f Sinus obliteration, 483 meningitis, complication, 439 keloids, 12-14
Shell-lined mouth-formed Six-flap Z-plasty, 586f signs, 61 process, overview, 11f
protector, 286f Skeletal fracture diagrams, 240f Skull injuries, 60-62 repair, 10-12
Shell-liner mouthguard, 286 Skeletal nasal width, measurement, components, 60 Soft tissue injuries
Sherman’s steel plates, usage, 296 503 diagnostic testing/evaluation, 61 bleeding, persistence
Shock Skew deviation, 464 types, 61 (evaluation), 506-507
anaphylactic shock, 136 Skin Small bowel injuries, 67 evaluation, 67
cardiogenic shock, 135 aging, 574 Small burns, treatment, 562 examination, 506-511
categories, 134-136 anatomic layer, example, 719f Small-diameter nasogastric feeding healing (assessment), follow-up
cellular changes, 132 anatomy, 511-513, 718-719 tubes, 45 photographs (usage), 507
diagnostic/management avulsion, 553 Smoking, suboptimal wound hematoma, 588
algorithm, 137f closure, surgical needles (usage), healing factor, 23 hemorrhage, 506
differentiation, 136-138 520t Sodium infection, 588
distributive shock, 135-136 color, pulse indication, 54 deficit, calculation, 74 local anesthesia, 513-515
fluid challenge, receipt, 136 composition, 511 electrolyte management, 72-74 location, impact, 507
hemorrhagic shock, pediatric cross section, 512f high extracellular volume, 73 penetrating soft tissue injuries/
signs/symptoms, 135t face, 179 hypernatremia, 72-73 fractures, incidence, 707-708
hypovolemic shock, 134-135 flaps hyponatremia, 73-74 scar maturation (assessment),
classification, 134b examination, 588 low extracellular volume, 72 follow-up photographs
obstructive shock, 135 salvage, topical agents (usage), normal extracellular volume, (usage), 507
occurrence, 132 589 72-73 tetanus prophylaxis, 507
response, 57-58 lacerations, tissue loss (absence), renal excretion, 133-134 recommendations, 510t
septic shock, 136 521 Sodium thiopental, induction wound contamination, 507-508
signs, 134t levator muscle, insertion, 547 agent, 90 tetanus prophylaxis, initiation,
systemic response, 132-134 lines, 177-178 Soft callus, 809f 507
870 INDEX
Soft tissue wounds Starvation-induced malnutrition Subcondylar fractures (Continued) Substance abuse
classification/management, physiology, 30-31 subperiosteal dissection, 829 documentation, 324-325
525-534 Stasis, zone, 719 treatment impact, 324-325
contusions, 525 Steering wheel injuries, blunt chest endoscopy, usage, 829 Substrate depletion/requirements,
healing, 566-567 trauma (association), 123-124 risks, 829 31-32
lacerations, 525-526 Stellate lacerations, 526 Subcondylar regions Succinylcholine
repair phases, 10t Stensen’s duct (parotid duct), 216 surgical approaches, 336-346 contraindications, 90b
treatment indications, 222 Stereolithographic model, 711 Towne’s view, 235f impact, 692-693
Solid organ injuries, 67, 172-173 example, 711f Subconjunctival ecchymoses, 360 induction agent, 90
Somatosensory evoked potentials illustration, 447f lateral limit, absence, 418f Sucking chest wounds, 116-117
(SSEPs), 656 Stereometric Z-plasty, 582 Subconjunctival hemorrhage, 455 Suction Tools Oxygen Positioning
Space of Burns, entry, 100 Steri-Strips (adhesive bandages), illustration, 224f-225f Monitors Assessment IV access
Spastic miosis, 457 568 photograph, 455f Drugs (STOP MAID), 87
Sphenoid bone, 185, 208 Sternal fractures, Subcutaneous emphysema, causes, Sunderland classification system,
articulation, 185 nondisplacement/treatment, 124b 661-662
body, characteristics, 185 124 Subcutaneous tissue nerve injury representation,
frontal view, 185f Sternothyroid muscle, 196 abundance, 578 661f
midline bone, location, 185 Steroids, 604 superficial layer, 99 Sunderland nerve injury
Sphenopalatine artery, 200 injection regimens, 560t Subcuticular suture, 521-525 classification, 20
Spinal alignment, restoration/ Stock mouth protectors, 285 Subdural hematomas (SDHs), 61, schematic representation, 21f
maintenance, 160-161 photograph, 285f 159 Sun exposure
Spinal column, three-column Stomach example, 158f response, consideration, 597
theory of Denis (impact), 161f enteral formulas, delivery, 42 incidence, 159 Sun exposure, impact, 589
Spinal cord injury (SCI) tube placement, verification, 41 surgical evacuation, 159 Sun-reactive skin type
acute SCI, cervical spine Stone model, creation, 287 terms, consensus (problems), classification, 574
involvement, 160 Storage media, pH/osmolality, 271t 159 Fitzpatrick classification, 574t
morbidity/mortality rate, 160 Strasbourg osteosynthesis research Subjective visual field assessment, Superficial burns (first-degree
Spinal cord protection, 160-161 group, 332-333 453 burns), 561, 720
Spinal stability, establishment, 160-161 Stress Sublingual anatomy, 218f Superficial chemical peels, 599
Spine end-organ response, Sublingual artery, 197-198 Superficial musculoaponeurotic
column divisions, 235 pharmacologic location, 218 system (SMAS), 340
injuries, 124 manipulation, 4-5 Sublingual ducts, 634 depth, 342
trauma, 67 factor modifiers, usage, 38t Sublingual glands, 634 undermining, 342
Spiral CT, usage, 236 gastritis, 6 blunt penetrating trauma, Superficial parotidectomy,
Spleen level, nonprotein calorie/ 637 advocacy, 643
injuries, 172 nitrogen ratio, 43t injuries, 637 Superficial skin closure, reinforced
organ injury scale, American response, 1 Subluxation (loosening), 257, tape (usage), 795
Association for the Surgery hormones, cytokines 267 Superficial temporal artery, 199
of Trauma, 173t (interactions), 4 Submandibular approach, 316 Superficial temporal vessels,
Splenic laceration, capsule modulation, glucocorticoids Risdon description, 316 emergence, 190
disruption, 174f (role), 5 Submandibular dissection, Superior constrictors, 196
Splinting techniques, 313 Stress gastritis (prevention), GI anatomic landmarks, 337f Superior labial artery, 198-199
Splints, 294 prophylactic medications marsupialization, 638f Superior laryngeal notch, fingers
placement, palatal screw (usage), (usage), 71 Submandibular duct (Wharton’s (placement), 81f
314f Stress-induced malnutrition duct), 634 Superior oblique muscle, 212
popularity, 294 physiology, 31 exit, 218 Superior orbital fissure, 205f
Split-thickness graft, thickness, 529 Structural disorders location, 551 syndrome, 443-444
Split-thickness skin grafts (STSGs), examination, 453-455 lingual nerve, relationship, 635f Superior orbital fissure syndrome
20-21 forced duction test, 455 Submandibular fluid collection, (SOFS), 156
Spontaneous breathing, Ireton- Structures (injuries), treatment aspiration, 647f-648f clinical findings, 156
Jones equation, 38 (requirement), 534-554 Submandibular gland, 216-218, traumatic SOFS
Spontaneous fracture potential, 759 Stupor, 144t 634 incidence, 156
Sports-related accidents, treatment, Stylohyoid muscle, 195 injuries, 637 management, 156
297 innervation, 195 evaluation/repair, 550 Superior orbital view, 204f
Sports-related injuries, 297 Stylopharyngeus muscle, 197 mucocele, 646-647 Superior thyroid artery, 197
prevention, dentist involvement, Subarachnoid hemorrhage (SAH), parenchyma, direct injury, 637 Superolateral nasal wall, bleeding,
288 presence, 153-154 parotid gland, relationship, 437
Squirrel bite, 620 Subaxial cervical spine trauma, 217-218 Supporting bone, injuries, 257-259,
St. Vincent’s Hospital treatment, 162 Submandibular incisions, 316f 277-279
advanced life support Subaxial spine, 160 Submandibular regional anatomy, alveolar bone, comminution,
ambulance, usage, 50 Subciliary blepharoplasty incision, 217f 277-279
ambulance operation, 49 422 Submandibular salivary flow, usage, alveolar process, fracture, 259,
Stainless steel, monofilament Subcondylar fractures 149 278-279
nonabsorbable suture, 517-518 endoscopic intraoral approach, Submental branch (facial artery), alveolar socket
Standing cone deformity, 830-837 198 comminution, 257-259
avoidance, 576f discussion, 836-837 Submentovertex (SMV) view, 233 wall, fracture, 259, 277-278
Stapedial reflex, usage, 149 outcomes, 834-836 Suboptimal wound healing illustration, 258f
Staphylococcus-induced toxic surgical technique, 830-834 aging, 22 mandible/maxilla, fractures, 259,
shock, 136 endoscopic treatment, 828-837 diabetes, 23 279
Staples, usage, 60 endoscopic visualization, 829 factors, 22-24 Suprahyoid artery, 197
Starvation extraoral approach, 829-830 immunosuppression, 24 Suprahyoid muscles, 194-195
energy substrates substitution, outcomes, 829-830 infection, 22-23 digastric muscle, 194-195
30-31 surgical technique, 829 malnutrition, 23-24 geniohyoid muscle, 195
patients, nutritional resuscitation open reduction, closed reduction radiation/chemotherapy, 24 illustration, 194f
(treatment), 43 (contrast), 828 smoking, 23 mylohyoid muscle, 195
substrate, usage, 32t panoramic film, 245f Subperiosteal dissection, 829 stylohyoid muscle, 195
INDEX 871
Sural nerve harvest site, clinical T Temporal bone Tetracaine/epinephrine/cocaine

example, 677f Tachycardia, pathognomic sign, components, 148-149 (TEC), availability, 514
Surface flora, restriction, 790 134-135 fractures Tevdek, usage, 515
Surface resorption, usage, 274 Tarsorrhaphy, technique, 375f classification, 157 Thermal injury, 686-687, 718
Surgical airway, 56, 93-103 T cell suppressor population, patterns, types, 149 airway, 692-693
establishment, 93 overactivation, 793 lateral view, 149f cold exposure (frostbite), 718
needle cricothyroidotomy, 56 Teeth longitudinal fractures, 157f flame injury, 718
obtaining, methods, 93-94 apex, extrusive luxation, 269 causes, 149 risk, 687
surgical cricothyroidotomy, 56 avulsion, 536f mixed fracture, 149 scalds, 718
Surgical cotton, monofilament injury, tissue examination, 252f superior view, 149f Thermoplastic material, heating,
nonabsorbable suture, 517 coronal CT image (right lower transverse fracture, 157f 287f
Surgical cricothyroidotomy, 56 lobe), 253f-254f Temporal branch (facial nerve), Thermoplastic mouth-formed
Surgical evacuation, goal, 442 crepitation, palpation, 303 207 protector, 286f
Surgical gut sutures, 516 crowns Temporal fascia strap, attachment, 288f
Surgical needles, 518-519 blood/debris, cleaning, 255f division, 317 Thermoplastic mouthguard, 286
anatomy, 519f cleansing, 252-254 exposure, 386 material, distortion/hardening,
characteristics, 520t drying, avoidance, 271 Temporal incision, endoscope 286f
three-eighths circle needles, 519 ecchymosis, 259 (insertion), 840f Third-day fever, infection
varieties, 519 embedded fragments, soft tissue Temporalis muscle, 193 indication, 799
Surgical plan, preparation, 69 inspection, 251-252 shape, 193 Third-degree burns (full-thickness
Surgical tape, 518 emergency visit, primary goal, Temporal region, layers, 343 burns), 561, 720-722
Surgical wounds, 9 271-272 Temporary cavity, formation, 702 Third-degree nerve injury, 20
description, 24-25 endodontic treatment, Temporary condylar head endoneurium, involvement, 662
Surgilene (polypropylene), 515 indication, 264f prosthesis, prebent titanium Third molar
Surgilon, nonabsorbable suture, 517 evaluation, 272 reconstruction bar impaction, cone beam CT scan,
Survival, self-repair capacity, 9 hematoma, 259 (attachment), 777f 657f
Sutures inflammatory resorption, 274-277 Temporomandibular articulation, removal
absorbable sutures, 515-516 intrusion, panoramic radiograph, anteroposterior view, 188f complications, 664-665
chromic catgut sutures, 516 252f Temporomandibular joint (TMJ), Panorex, usage, 659f
half-buried horizontal mattress intrusive luxation, 269 187-189 surgery, 664-665
suture, 526f involvement, studies, 271t anatomic components, 187f Thomas principle, 295f
materials, 515-518 lacerations, 259 articular capsule, 188 Thoracic aorta
strength, 515 lateral incisor, avulsion, 273f attachment, 188 descending thoracic aorta,
needles, 518-519 lateral luxation, 269-270 articular disc (meniscus), 188 injuries, 127-128
nonabsorbable sutures, 515 looseness, 303 cartilage, presence, 19 rupture, 124
placement, 521 loss, location (radiographs), condylar head, 187-188 traumatic rupture, 126
plain gut suture, 516 253f-254f disc, communication, 775 causes, 126
simple sutures, usage, 577f low-force orthodontic displacement, factors, 190 Thoracic cavity, filling, 113
subcuticular suture, 521-525 repositioning, 269 dysfunction, history, 302 Thoracic injuries, 109-110
surgical gut sutures, 516 mandibular fractures, studies, fibrous capsule, 188 Thoracic spinous process, oblique
twisted suture (harelip suture), 320t fractures, classification, 331-333 avulsive fracture, 162-163
example, 519f maxillary central incisor, nerve supply, 189 Thoracic trauma
types, 515-516 uncomplicated crown planned definitive impact, 109
usage, 60, 294-295 fracture, 261f reconstruction, 777f injury, 687-688
purpose, 515 palpation, 303 surgical approaches, 190f, 283f Thoracic vascular injury,
in vivo degradation, permanent teeth, root fractures, synovial joint, 187-188 radiographic clues, 118b
measurement, 515 264 transcranial lateral views, 304-305 Thoracotomy, indications, 118
Swan-Ganz catheter, usage, 2 premolar, location (chest vascular supply, 188-189 list, 127b
Swinging flashlight test, 453 radiograph), 254f Tendelenburg position, 690 Three-column theory of Denis,
Sympathoadrenal axis, primary incisors, trauma Tendon of Zinn, 212 impact, 161f
upregulation, 2 (treatment), 259 Tension band, monocortical screw Three-eighths circle needles, 519
Symphyseal fracture primary teeth, root fractures, usage, 817f Thromboxane A2, impact, 3
diagnostic sign, 304f 264 Tension pneumothorax, 64, 114 Thrombus, silence, 72
evidence, panoramic film, 245f prognosis, 264 development, 117f Thyrohyoid muscle, 196
Symphyseal region, impact, 742 pulp vitality, testing, 254 example, 57f Tibia, major fractures, 57
Symphysis, 298, 317-318 radiographic appearance, fatality, 64 Tibial harvest technique, Gerdy’s
anteroposterior displacement, importance, 256 illness, 114 tubercle (location/
305f reimplantation, 270f positive pressure ventilation, 114 identification), 774
fractures, 745 success, 272 trauma, impact, 114f Time-sensitive interventions, usage,
case studies, 746-747 reimplantation, achievement, 277 Tensor veli palatini, 196 2
inferior/posterior displacement, removal, clinical progress, Tetanus, 619, 805 Tissue
301f 253f-254f burn considerations, 725 avulsion, 9
mandibular defects, 774 root formation, radiographic cause, 619, 805 damage, inflammatory reaction,
Syndrome of inappropriate ADH examination, 255-256 diagnosis, clinical signs (usage), 1
(SIADH), 73 Save-A-Tooth emergency 805 ears, blood supply, 538f
Synthetic absorbable sutures, 515 tooth-preserving system, 271f prophylaxis, summary guide, engineering applications, 25
Synthetic suture, usage, 516 splinting, 272 769f expanders
Systemic hypotension, 3-4 storage media, pH/osmolality, wound evaluation, 805 application, 732f
Systemic infections, occurrence, 271t Tetanus immune globulin (TIG), placement, absence, 604
790 transportation, 272 administration, 805 expansion, 603-604
Systemic inflammation, traumatic injuries, 248 Tetanus-prone wounds, technique, 604
management, 136 traumatization, root fractures characteristics, 509t fibrin adhesives, components,
Systemic inflammatory response (impact), 264 Tetanus prophylaxis 525
syndrome (SIRS), 1 Tegaderm (dressing), 568 guide, 620t flaps, maintenance, 537f
Systemic vascular resistance (SVR), Tegaderm, usage, 25 initiation, 507 free grafting, 528-529
increase, 139-140 Telomere attrition, 749 recommendations, 510t handling, 568
872 INDEX
Tissue (Continued) Tracheostomy (Continued) Trauma Traumatic brain injury (TBI)

hypoperfusion, smoking history, 98 ABCDEs, 54 intracranial hemorrhage, 6
(impact), 23 hook, placement, 100 ABCs, 58 Marshall Computed Tomography
injury indications, 98-99 abdominal examination, 168, classification, 154t
blood flow, reduction, 795-796 infection, complication, 101 174 Mayo head injury classification
reactions sequence, 12f involvement, 101 abdominal trauma, 61 system, 152
loss, gunshot injuries (impact), monitoring/suctioning, impact, adult respiratory distress occurrence, 142
712-713 102 syndrome (ARDS), 5-6 outcomes, 145
oxygen delivery, 795 neck, preparation, 100 Airway, Breathing, and pathophysiology, complexity,
penetrating projectile, impact, percutaneous tracheostomy, Circulation (ABC), 68 154
702 102-103 airway management, 77 Traumatic carotid-cavernous fistulas
pH, alteration, 9 perioperative complications, assessment, 58 (TCCFs), 155
pieces, saving, 524f 101 assessment principles, 51-54 Traumatic choroidal tear, 461f
remodeling, 12 pneumothorax, occurrence, 102 hospital phase, 52 Traumatic cyclodialysis, 459
trauma, 519-520 postoperative care, 102 preparation/communication, Traumatic diaphragmatic injury, 66
wound repair, 14-22 postoperative hemorrhages, 52 Traumatic diplopia, 439-441
Titanium trauma splinting bars, occurrence, 101 care, ABCs, 110 diagnosis, 439-440
282f preparation, 100 clinical implications, 4-6 imaging, 441
Tongue, 549 surgical anatomy/procedures, cytokines, 3-4 pathologic features, 441-442
blood supply, 549 99-101 exposure, 59-60 physical examination, 441
ventral surface, mucocele tracheal stenosis, 101-102 FAST examination, 138 secondary repair, 442
(atypical location), 637f tube fixation, methods, 810-812 treatment, 440-441
Tongue blades, presence, 251-252 aspiration, 102 high mortality, anatomic factors Traumatic enophthalmos, 464
Tonsillar branch (facial artery), 198 cleaning, 102 (correlation), 54b Traumatic esophageal rupture, 66
Tonsillar suction, usage, 54 Transalveolar wiring, 754-755 hospital phase, 52 Traumatic facial palsy,
Topical agents, 25-27, 514-515 Transcellular shift, 74 initial assessment, 51-54, 68-69 management, 150
growth factors, 26-27 Transconjunctival incisions, 422 initial management, 68-71 Traumatic force, type/direction,
Topical hemostatic agents, illustration, 381f-382f injuries, categories, 51 302
necessity, 795 Transcutaneous enteral feeding lipid-derived mediators, 3 Traumatic injury
Topical tretinoin, usage, 598 tubes, 41-42 metabolic changes, management, cause, 9
Total burns surface area (TBSA), Transesophageal echocardiography 4 response, pharmacologic
717-718 (TEE), 138 metabolic response, effects manipulation, 5
Total energy expenditure, BEE Transforming growth factor β (separation), 2 Traumatic intracranial injuries,
sum, 33 (TGF-β), 10 neuroendocrine response, 2-3 classification, 153
Total facial reconstruction, 733f embryonic development role, ongoing assessment, 68-69 Traumatic iritis, 457
Total parenteral nutrition (TPN), 26-27 past medical history (PMH), 68 Traumatic mydriasis, 457f
45-46 modulation, 566-567 obtaining, 68-69 blunt eye injury, 457
complications, 46 Transient cavitation, impact, 171 pediatric considerations, 103-104 Traumatic nerve injuries, examples,
indication, 46 Translaryngeal jet ventilation, pelvic trauma, 66-67 20
Total parotidectomy, advocacy, 643 94-96 physiologic response, 1-2 Traumatic occlusion, indirect
Towne’s view, 233 anatomic landmarks, pneumothoraces, association, trauma, 250f
subcondylar region, 235f identification, 95 115 Traumatic optic neuropathy, 443,
Toxicity, signs/symptoms, 513 complications, 95 polymorphonuclear neutrophils 463
T-piece weaning, 71 direct puncture, 95 (PMNs), 4 Traumatic pigmentary retinopathy,
Trachea history, 94 pregnancy, relationship, 684 460
diameter, importance, 63 indications, 94 primary survey, 54-60 Traumatic posterior subcapsular
intubation placement, importance, 95 procedure, focused assessment cataract, 458f
induction, 41 technique, 94-95 sonography, 169b Traumatic retinal angiopathy
success, 709 Transmasseteric-anteroparotid repetition, 15 (Purtscher’s retinopathy),
placement, bronchoscopy approach, 341-342 response 467
(usage), 124 advantages/disadvantages, 341 mediators, 2-4 Traumatic retinal edema, 460f
stabilization, 95 indications, 341 modulation, 4-5 Traumatic SOFS
surgical entrance, 100 pertinent anatomy, 341 scoring, 52-53 incidence, 156
transection, presence, 99 surgical technique, 341-342 scoring systems, 53 management, 156
Tracheal hook, removal, 97 Transmasseteric incision, 342f descriptions, 52 Traumatized spine, management
Tracheal lumen, presence, 100 Transnasal wiring technique, secondary assessment, 60-68 principles, 160-161
Tracheal stenosis, 101-102 428-429 chest radiograph, usage, 65 Travois, photograph, 49f
Tracheal tube introducer, 91f Transplant placement, principles, severity, Mallampati assessment, Triage
Tracheobronchial injuries, 124-125 393 79 goal, 688
mechanisms, 124 Transport systemic diseases, 684 usage, 688
Tracheobronchial tree air medical transport, value, treatment, 58-59 Trichloroacetic acid (TCA) peels
description, chest/cervical spine 50-51 planning, 750 concentration, 599-600
plain films (usage), 124 helicopters, 50-51 Trauma-induced malnutrition impact, 598
injury, 66 types, 50-51 physiology, 31 treatment, usefulness, 599
rupture, fatality, 66 Transpositional flaps, 531-532 Trauma Injury and Injury Severity Tricyclic antidepressants, 514
Tracheostomy, 98-102 flap base, parallelism, 533f Score (TRISS) method, 53 Trigeminal nerve (CN V), 148,
aspiration, problem, 102 scalp, 554 Trauma patients 203-206
bleeding, occurrence, 101 Transthoracic echocardiography cervical spine/head radiographs, anatomy, 650-655
complications, 101-102 (TTE), 138 clinical decision rules, 153b auriculotemporal nerve, 343-344
historical results, 101 Transverse mandibular symphysis infection, cause (evaluation), branches
incidence, 101 fracture, lag screws 798f diameter, 655t
contraindications, 98-99 (application), 821f prophylactic antibiotic injury, 148
elective tracheostomy, 100 Trap door administration, indications, brush stroke directional
emergency tracheostomy, description, 238 796b discrimination, performing,
difficulty, 102 sign, 238f Trauma Score, 52-53 672-673
example, 99f Trapnell lines, 238f Revised Trauma Score, 52-53 characteristics, 650-651
INDEX 873
Trigeminal nerve (CN V) Trigeminal nerve (CN V) Unilateral type II fractures, 427f Vascular supply
(Continued) (Continued) Unintended firearm injuries, 697 nutrients/body warmth, 770
clinical neurosensory testing, T1W three-dimensional fast field Unintentional firearm injuries, schematic representation, 655f
672-673 echo (T1W 3D-FFE), deaths, 697 Vasoactive amines, release, 12f
algorithm, 672f 657-658 Unintentional firearm mortality, Vasoactive hormones, release, 57
collagen, framework provision, ultrasonography, 658 gender/age data, 700f Vasoconstriction
654-655 postinjury assessment, 660 Union Medical Department importance, 133
computed tomography, 657 Trimalar fractures, 356 horse-drawn wagons, ambulance, phenylephrine, impact, 140
postinjury assessment, 658-659 Tripod fractures, 356 49f Vasoconstrictors, impact, 514
computed tomography cone Trismus, 359 usage, 48-49 Vasodilation, 10
beam (CBCT) technology, Trochlea, trauma, 466 stretcher litters/pack animal Vasopressin, antidiuretic hormone
usage, 657 Trochlear nerve, 148 cacolets, 49f (ADH), 133
cutaneous distribution, sensation, injury Upper cervical spine, 160 VCT01, usage, 25
148 diagnosis, 148 Upper eyelid Veins
cutaneous sensory distribution, incidence, 148 abrasion/total avulsion, 765f anterior facial vein, 201
203f Trolamine, topical agent, 589 avulsive injury, 530f-531f anterior jugular vein, 202
dental implant surgery, 665-667 Trousseau dilator, placement, 100 ectropion, cause, 593-594 common facial vein, 201
dissection, 674 True lag screws injury, 548f external jugular vein, 202
fascicles, number, 655t shank, smoothness, 819f laceration, 467f head/neck, 201-202
high-resolution magnetic usage, 819f repair, 467 illustration, 202f
resonance imaging, 657-658 Tumor necrosis factor (TNF) Upper face internal jugular vein, 201
postinjury assessment, 659-660 description, 3-4 fixation, 819-820 retromandibular vein, 202
imaging, 656-660 impact, 3 microplate fixation, 822f Veirs rod, usage, 553
implant placement (facilitation), interleukin-1 (IL-1), contrast, 3-4 Upper face fractures, 240-241 Venous blood gas (VBG), data,
nerve lateralization (usage), T waves, flattening/inversion, 74 frontal bone fractures, 240 684
667 Twisted suture (harelip suture), naso-orbital-ethmoid complex Venous sinusoids, fatty acid/fat
inferior alveolar nerve, 650-652 example, 519f fractures, 240-241 globule entry, 2
injuries Two-dimensional Z-plasties, Upper facial third reconstruction, Venous thromboembolism (VTE)
classification, 660-663 alternatives, 587 781-784 prophylaxis, 72
mechanisms, 663-672 Tycron Upper fixation, microplates physician consideration, 72
microneurosurgery (usage), Dacron suture, 515 (usage), 822f Ventilation
674-677 polyester monofilament Upper lip coverage, incompetency, air, exchange, 56
outcomes, 677-678 nonabsorbable suture, 517 249f breathing, 220-221
intraneural scarring, 674-675 Tympanic neurectomy (Jacobson’s Upward gaze (clinical limitation), failure, 86
local anesthetic injection, 664 nerve transtympanic orbital floor disruption inadequacy, 56
macroanatomy, 650-654 sectioning), 643 (impact), 435f Ventilation-perfusion deficit,
magnetic resonance neurography Type III comminuted fracture, 427f Urban trauma patients, HIV occurrence, 113-114
(MRN), 660 T1-weighted images, 237 infection (incidence), 805 Ventilator-dependent patients,
magnetic source imaging (MSI), T1W three-dimensional fast field Urethral disruption, exclusion, 173 Ireton-Jones equation, 38
postinjury assessment, 659 echo (T1W 3D-FFE), 657-658 Urethral injuries, 173 Ventilators, usage, 50
mandibular division, 201f Urgent trauma injuries, 51 Ventilator support, misconceptions,
maxillofacial trauma, 667 U Urinary catheters, usage, 169 70b
microanatomy, 654-655 Ultrasonography, focused Urinary output, pulse indication, Vermillion skin junction, crossing,
microneurosurgery, 673-677 assessment sonography in 58 536f
indications, 673-674 trauma, 169 Urinary tract infection, Vertical buttresses, 233f
microneurosurgical Uncoated polyester, monofilament consideration, 799 Vertically favorable fracture, 300f
reconstruction, success, 678 nonabsorbable suture, 517 U.S. National Center for Health Vertically unfavorable fracture,
neuroma formation, 675-676 Uncomplicated crown fracture, 257 Statistics, male/female ideal 300f
neurosensory tests (NSTs), usage, Uncomplicated crown-root fracture, weight, 38t Vestibulocochlear nerve, 150
672 257 Uvula, muscle, 196 Viaspan, 271
ophthalmic division, nasociliary Uncomplicated intraoral wound, U waves, presence, 74 Vicryl (polyglactin 910), absorbable
branch, 215 antibiotics (usage), 799 suture, 516
orthognathic surgery, 667 Unconsciousness, Mallampati V Vicryl Plus (polyglactin 910 coated
panoramic radiography, 656-657 assessment, 79 Vagus nerves, 150 with Triclosan), absorbable
postinjury assessment, 658 Unconscious patient, visual Vallecula, 86f suture, 517
peripheral branches, injuries, inspection, 65 Vancouver Scar Scale, 570-571 Vicryl Rapide (irradiated
677-678 Undernutrition, enteral nutrition list, 571t polyglactin 910), absorbable
postinjury assessment, 658-660 impact, 5f Vascular access, 71 suture, 516-517
postinjury functional assessment, Unfavorable fractures, attaining, 136 Vinyl polysiloxane (VPS)
660 displacement, 273-274 indications, 71 impression material, injection,
postinjury imaging, divisions, 656 Unilateral Babinski sign, 61-62 Vascular endothelial growth factor 628-629
preoperative risk assessment, Unilateral extracapsular condylar (VEGF), 10 Viral infection, treatment,
656-658 fractures, 334-335 mediation, 566-567 805-806
sagittal split osteotomy (SSO), Unilateral fracture (fixation potency, 27 Virtual surgery, example, 786f
667 treatment), three-point Vascular injury, 154-155 Visceral protein reserves,
Seddon classification, 661f fixation hard signs, 228 estimation, 39
somatosensory evoked potentials requirement, 428f hemorrhage, evidence, 685 Visual acuity device, usage, 452f
(SSEPs), 656 usage, 428f mesenteric injury, combination, Visual evoked potential (VEP) test,
stumps, preparation (diagram), Unilateral maxillary fractures, 172f 146
676f treatment, 420 penetrating neck trauma, impact, Visual fields, 452-453
Sunderland classification system, Unilateral mydriasis (Hutchinson’s 125 binocular visual field testing,
661f pupil), importance, 147-148 types, 155 452-453
surgical exposure, 674 Unilateral open bite, ipsilateral Vascular insufficiency, concern, 492 peripheral visual field, testing,
surgical intervention, 677-678 angle/parasymphyseal Vascularity, impact, 790-791 453
terminal branches, 209 fractures (impact), 303f Vascular response, interactions, subjective visual field assessment,
third molar surgery, 664-665 Unilateral paradoxical motion, 122 792f 453
874 INDEX
Visual function Wounds (Continued) W-plasty, 579-581 Zygomatic arch (Continued)

assessment, 452 cleansing, 508-509 excision, 580f ORIF requirement, 400
central visual function, testing, hydrogen peroxide, usage geometric broken line closure postoperative axial CT scan,
452 (avoidance), 510 (GBLC), comparison, 397f-398f
Visual recovery, 146 closure, 519-525 587-588 subperiosteal dissection, 384f
Vitality tests, interpretation, 254 care, 393 markings, 581f vertical radiopaque band,
Vitamin B complex, impact, 23-24 examination, 520 scar tissue excision, 556-557 superimposition, 243
Vitamin C, deficiency, 23-24 method, impact, 794 technique, 579-581 Zygomatic arch fracture
Vitamin D deficiency, 23-24 contamination, 222, 507-508 advantages, 579 coronoid process tissues,
Vitamin deficiencies, commonness, tetanus prophylaxis, initiation, usage, 579f impingement, 243f
23-24 507 nonanimated facial areas, 581f evidence, submentovertex view,
Vitamin E, components, 23-24 contracture, forces, 713 243f
Vitamin K deficiency, impact, 23-24 creation, crush type, 512f X radiographic signs, 243
Vitreous hemorrhage, 460 debridement, 24, 508-511 Xeroform, usage, 25 reduction, protection methods,
Volume-cycled respirator, usage, 65 thoroughness, 534 403f
Volume deficits, 711-712 delayed closure, decision, 794 Y stabilization, 403f
Vomer, 184 delayed primary closure/wound Y plate, usage, 343f Zygomatic arch fractures, 400
illustration, 183f repair, 25 reduction, 400
V-Y advancement flap, 532-533 divisions, 507 Z intraoral route, 401f-402f
V-Y flaps, usage, 591f dressings, 25-27, 725-726 Zigzag-plasty, results, 557 stabilization, 400
V-Y plasty (island advancement usage, 562 Zone of coagulation, 719 Zygomatic bone, foramina, 182
flap), 534f early wound healing, chronology, Zone of hyperemia, 719 Zygomatic branch (facial nerve),
515f Zone of stasis, 719 207-208
W evaluation, animal bites, 534 Z-plasty, 581-587 Zygomatic buttress, deformity, 359
Wallerian degeneration, 20 extension, 525 description, 557 Zygomatic complex fractures, 742
Water, renal excretion, 133-134 final layered closure, 641f design, 583f discussion, 840
Water’s view, 233 foreign bodies, impact, 791 flap divisions, 586f endoscopic repair, 839-840
facial series, 234f foreign material inspection, fusiform excisions, combinations surgical technique, 839-840
ZMC fracture, repair, 242f 509-510 (usage), 585f Zygomatic fractures, 354
Weighted nasogastric feeding tubes, hemorrhage, association, 506 limbs, 560f diagnosis, 357
entry, 41 infection length, equality, 582 incidence, surgical treatment
Wharton’s duct (submandibular development, concern, 507 multiple Z-plasty, design, 585f (absence), 363t
duct) host resistance, impairment six-flap Z-plasty, 586f term, usage, 356
exit, 218 (factors), 507-508 technique, 582-587 Zygomatic injury, orbital volume
lingual nerve, relationship, 653 rates, 511 variation, 585 increase, 361
looping, 653 treatment, 799 two-dimensional Z-plasties, Zygomatic nerve, 204-205
Whitnall’s orbital tubercle, 211 inflammation, 9-10 alternatives, 587 Zygomaticofrontal sutures,
Whole blood, replication, 139 injury location, 507 variations, 582 exposure, 431
Wire extension, repositioning role, irrigation, 534 Zygoma, 182-183, 208 Zygomaticomaxillary articulations,
347 laceration, extension, 509 anatomic position, 355f fracture (involvement), 242f
photograph, 349f management, 24-27, 793-795 anatomy, 355 Zygomaticomaxillary buttress
Wire osteosynthesis, 318 dressings, 25 bilateral fractures, 354 fracture, holes (vertical
rigid fixation, contrast, 322-323 organisms, presence characteristics/processes, 355 placement), 390f
usage, 318 (reduction), 794 composition, density, 242 Zygomaticomaxillary complex
Witnall’s tubercle, disruption, 440 principles, 567-569 disarticulation, 355f (ZMC)
Work-related accidents, 297 tetanus prophylaxis guide, elevation, Gillies temporal alignment problems,
World War II, plate fixation cases, 620t, 769f approach, 385f repositioning, 410f
257 margins, 522f evaluation, accuracy, 243 anatomic details, difficulty, 365
Wound healing nonvital tissue, invading examination, 358 elevation
cell interactions, impact, 13f organisms (presence), 791 fracture bone hook, usage, 389f
complexity, 738-739 open wounds misunderstanding, 365 bone screw, percutaneous
compromise, 555t healing, 527 patterns, 355-357 insertion, 390f
concepts, 10-14 treatment, 526-527 Gillies approach, 182 eyebrow approach, elevation, 388f
crusted wound healing, 568 polymyxin B sulfate ointment, inferior displacement, 360f inferior/medial rotation, 365f
desiccated wound healing, 568 usage, 509-510 inferior rim, approaches, 182-183 posterior displacement,
early wound healing, chronology, primary wound closure, 25 lateral brow approach, 182 assessment method, 358f
515f decision, 794 lateral midface structure, 355 reduction, intraoperative
hyperglycemia, impact, 32 proliferation, 9-10 malar, articulations, 182f three-dimensional
impediments, 22t puncture types, closure malunion, 409 reconstructions, 370f-374f
inflammatory phase, 10 (avoidance), 534 problem, confrontation, 409 stabilization, bone plates (usage),
occurrence, 9-10 remodeling, 9-10 mobilization, 409 370f-374f
older adults, 753-754 repair, 25 paired bone, cheek prominence, Zygomaticomaxillary complex
process, 26 facial region, 520 182 (ZMC) fractures, 242
proliferative phase (fibroblastic inhibition, chemotherapeutic reduction, determination, anatomic structures, avoidance,
stage), 10-12 drugs (impact), 24 365-366 389
promotion, negative-pressure silver-containing dressings, surgical exposure, 365-366 anatomy, CT scans, 362f
dressing (usage), 25 725-726 temporal fossa approach, 182 anesthesia, usage, 369
understanding, necessity, 566 site, drainage (collection), 798 terminology, 355-357 antiseptic preparation, 369-374
Wounds space, invasion, 511 transconjunctival approach, 183 asymmetry, 238f
bacteria tension (reduction), adhesive transoral approach, 183 autologous grafts, 392-393
irrigation, 511 bandages (usage), 568 Zygomatic arch, 242-243 axial CT, 362f
presence, 507 therapy, negative-pressure wound depression, 359f axial scan, 364f
bed, examination, 588 therapy, 25 displacement, axial scan, 364f blindness, 406
care, dressings, 25 topical agents, 25-27 endoscopic approach, 839-840 bone plates, placement, 390
classification, 9 topical antibiotics, usage, exposure, 840f buccal sulcus approach, 386-387
cleaning, 568-569 725-726 flattening, 359 Keen technique, 386-387
INDEX 875
Zygomaticomaxillary complex Zygomaticomaxillary complex Zygomaticomaxillary complex Zygomaticomaxillary complex

(ZMC) fractures (Continued) (ZMC) fractures (Continued) (ZMC) fractures (Continued) (ZMC) fractures (Continued)
classification, 357 infraorbital rim (exposure), pattern, 357 technique, 378
clinical examination, 357-361 incisions (usage), 379f percutaneous approach, 388 surgical treatment, 374b
forced duction test, 369 injuries, 241 technique, 388 Teflon implants, usage, 405
complications, 402-409 internal orbit periorbital ecchymosis, 358 temporal approach, 383-386
cornea, protection, 376-377 exploration, 369 association, 227f technique, 383-386
coronal approach, 382-383 external approach, 391-392 periorbital incision problems, temporal fascia, exposure, 386
fracture reduction/fixation, internal orbital reconstruction, 402-404 temporary tarsorrhaphy,
accomplishment, 383 391-393 periosteum technique, 375f
incision, 383 necessity, 369 closure, difficulty, 382 transconjunctival approach
technique, 382-383 usage, 375-376 incision, 380 (inferior fornix approach),
coronal CT scan, 362f intraoperative CT scanning persistent diplopia, 405-406 380-382
crepitation, air emphysema availability, 369 plain film evaluation, 242 transconjunctival incisions,
(impact), 360 usage, 370f-374f posterior elevator, removal, 386 381f-382f
diagnosis, 357-361 intraorbital hemorrhage, 408 postsurgical enophthalmos, 391 transplant placement, principles,
dilute epinephrine solutions, 377 lateral coronoid approach, 387 postsurgical images, 376 393
diplopia, 360-361 lateral orbit, subperiosteal postsurgical ocular examination, treatment, 182, 361-400
edema, 358 dissection, 384f 376 algorithm, 396f
enophthalmos, 361, 406 lateral orbital rim, supratarsal presurgical enophthalmos, 391 controversies, 365
epistaxis, 360 fold approach, 379f prophylactic antibiotics, usage, example, 391f
evidence, Water’s view, 242f Le Fort I fractures, combination 369-376 options, diversity, 367-368
exposure (microplates fixation), 823f pupillary levels, inequality, 360 principles, 369-376
coronal incision, usage, 384f lower eyelid approaches, 379-380 radiologic evaluation, 361 trismus, 359
maxillary vestibular/upper malar prominence, flattening, reduction upper eyelid approach, 378-379
eyelid approaches, 358 adequacy, 398-400 technique, 378-379
370f-374f malar tissue, appearance, 377f assessment, 374-375 wounds, closure (care), 393
extraorbital osseous defects, maxilla, zygomatic buttress determination, anatomic areas zygoma elevation, Gillies
bone graft, 376 deformity, 359 (usage), 366f temporal approach, 385f
eyebrow approach, elevation, maxillary buccal sulcus, techniques, 383-388 zygomatic arch
387-388 ecchymosis, 359 result, 363 flattening, 359
technique, 387-388 maxillary vestibular approach, retrobulbar hemorrhage, 408 subperiosteal dissection, 384f
fixation 377-378 retroseptal transconjunctival Zygomaticomaxillary complex
device, application, 375 technique, 377-378 approach technique, lateral (ZMC) injury, fracture pattern,
necessity, determination, 375 nerve deficits, findings, 404-405 canthotomy (combination), 356f
requirement, 366-369 nerve sensibility, abnormality, 359 381-382 Zygomaticomaxillary complex
incidence, 368t ocular motility, assessment, right ZMC fracture, orbital (ZMC) involvement, three-
techniques, 388-390 383-388 floor/medial wall dimensional reconstruction,
forced duction test, 369 ocular protection, scleral shell comminution, 392f 243f
fracture, reduction, 374 (usage), 375f Rowe zygomatic elevator Zygomaticomaxillary compound,
frontozygomatic suture, orbital floor position, 386 356
supraorbital eyebrow exposure, incisions (usage), Seldin retractor, usage, 387 Zygomatico-orbital, 356
approach, 378f 379f self-threading bone screws, usage, Zygomatic orbital complex, 742
Gillies temporal approach, 383 intrasinus approach, 391 389 Zygomaticosphenoid suture,
globe, protection, 369 reconstruction bone plate, series, review, 366-367 alignment, 394f-396f
implant, extrusion/ usage, 394f-396f signs/symptoms, 358-361 Zygomaticotemporal sutures,
displacement/infection, 405 orbital implant, principles, 393 soft tissue resuspension, 376 exposure, 431
implant/transplant orbital margin, deformity, 359 stability, 368-369 Zygomatic process, origin, 181
size, 393 orbital reconstruction, materials subciliary/subtarsal approach,
stabilization, 393 (usage), 392-393 dissection technique,
tension-free placement, 393 pain, 359 379-380
thickness, 393 palpebral fissure, displacement, subconjunctival ecchymoses, 360
volume, 393 360 subtarsal/subciliary incision, 380f
infraorbital nerve disorders, patient treatment, 393-400 supraorbital eyebrow approach,
404-405 example, 368f 378

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oral &

ROBERT V. WALKER, DDS, FACD† MICHAEL P. POWERS, DDS, MS

ORAL AND MAXILLOFACIAL TRAUMA ISBN: 978-1-4557-0554-2

Vice President and Publisher: Linda Duncan

Working together to grow

To Cam, Aubrey, and Katharine with love and admiration.

To my loving wife, Claudia, who stands behind me when

I would like to dedicate this book to my wife, Kymberly;

NORMAN J. BETTS, DDS, MS EDWARD ELLIS, III, DDS, MS

JACOB G. CALCEI RUI FERNANDES, MD, DMD, FACS

BERNARD J. COSTELLO, DMD, MD, FACS DERRICK FLINT, MD, DDS

MICHAEL GLADWELL, DMD, MD DEEPAK KADEMANI, DMD, MD, FACS

LEONARD B. KABAN, DMD, MD JANICE S. LEE, DDS, MD, FACS

STUART E. LIEBLICH, DMD MARIA B. PAPAGEORGE, DMD, MS

MICHAEL T. REYNOLDS, DDS RAQUEL M. ULMA, DDS, MD

1 Metabolic Response to Trauma

venous catheter, near-infrared spectroscopy (NIRS), and

+ form analysis are as effective at guiding therapy.8-10

Estimated caloric intake (MR + 25%) Kcal/day

Estimated metabolic rate Kcal/day

Percent change in metabolic activity

3000 2400 60 patient on ventilator

500 500 400

catabolism, free fatty acid release, and hepatic synthesis

Catabolism Impaired GI motility Starvation for

Insufficient coverage of energy target by EN alone

Negative protein-energy balance Supplemental

the site of injury. As platelets continue to aggregate, they

FIGURE 2-1 Overview of the process of soft tissue healing.

Ab-Ag complex Surfaces:

FIGURE 2-4 Sequence of reactions leading to tissue injury

to 80% of the preinjury tensile strength. Tensile strength

TABLE 2-3 Injurious Constituents of Neutrophils

TABLE 2-4 Different Types of Collagens

Type Tissue Distribution Cells Chemical Characteristics

TABLE 2-5 Polypeptide Growth Factors Involved in Bone Healing

Stage of Bone Healing Growth Factor Function(s)

Matrix Growth Factors:

FIGURE 2-9 Various loading models (stress) seen on

NORMAL CARTILAGE HEALING (REPAIR)

FIGURE 2-14 Structure of a myelinated peripheral nerve.

Axon Epineurium Cell body

Endoneurium Perineurium Myelin sheath Schwann

Cell body and proximal stump of axon

Schwann cells envelop axon

FIGURE 2-15 Sunderland classification system. Shown is a

supraclavicular skin. Skin grafts can be harvested free-

HEALING BY SECONDARY INTENTION Negative-Pressure Wound Therapy

TABLE 2-8 Growth Factors—Origins and Actions

Factor Cells of Origin Action

TABLE 2-9 Growth Factors Found in the Fracture Callus

Growth Factor Source Matrix Location Responding Cells

member of the larger TGF-β superfamily. TGF-β also SUMMARY

urinary excretion, about 10 to 30 g/day. In fasting star-

TABLE 3-2 Substrate Use in Starvation Compared with Hypermetabolism

Substrate Fasting Starvation (Nutritional Support) Hypermetabolism (Metabolic Support)

PROTEIN REQUIREMENTS function, and the release of hormones. Branched-chain

triceps skin fold, and midarm muscle circumference

TABLE 3-3 Nutrition-Focused Physical Examination

ORAL AND MAXILLOFACIAL TRAUMA ISBN: 978-1-4557-0554-2

urinary excretion, about 10 to 30 g/day. In fasting star-

18-24 YR 25-34 YR 35-44 YR 45-54 YR 55-64 YR

100 mL of isotonic saline over 10 minutes, followed by