5.8 Special Fractures and Complications |
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•In craniofacial trauma, a timely control and diagno- sis of additional injuries is essential
Extra attention should be paid to additional compression fractures and to luxations or fractures of the spine, particularly the cervical spine in unconscious patients or in patients with initial neurological symptoms. Sur gical treatment has priority and the polytrauma protocol is followed (Potthoff 1985; Schweiberer et al. 1987; Ruchholtz et al. 1997; Piek and Jantzen 2000; Kuttenberger et al. 2004).
•Cornea, globe, optic nerve, ocular muscles
•Lacrimal drainage system
•Medial canthal tendon
•Lid margins
•Lateral canthal tendon
•Levator muscle and aponeurosis
•Penetrating trauma of the eyelids and periocular region
5.7.2 Eye Injuries
Nearly 20% of the craniofacial trauma patients have serious eye injuries (Ioannides et al. 1988). These are mainly cornea-eyelid injuries, perforated eyeballs and injuries of the canthal ligaments (Neubauer 1987; Hardt 1989; Brandes et al. 1997; Brown et al. 1999; Rohrbach et al. 2000).
Complex periorbital trauma should be approached systematically by an ophthalmologist. The ocular and periocular traumas listed beneath are a suggested order of priority in addressing orbital and periorbital injuries (Fig. 5.4):
5.7.3 Facial Soft-Tissue Injuries
Midface fractures often involve the facial soft tissues due to the traumatic impact. Contusions, skin abrasions, lacerations, tissue avulsions or burns and extensive and deep penetrating injuries are commonly seen in craniofacial injuries (44%) (Joos et al. 2001; Eppley and Bhuller 2003) (Figs. 5.5 and 5.6).
5.8 Special Fractures and Complications
5.8.1 Penetrating Injuries
A very special pattern of craniofacial injuries is related to spin-off-fragments of various sizes while milling or sawing different materials. These fragments are loaded with high energy and can penetrate through the eye or demolish facial structures and penetrate intracranially (Figs. 5.7 and 5.8).
Fig. 5.4 Perforating injury of the orbital globe by a glass splinter (arrow). Periorbital soft-tissue laceration
5.8.2 Gunshot Wounds and Tissue
Avulsion
Gunshot wounds and tissue avulsions can lead to disastrous wounds due to softand hard-tissue defects. After primary wound closure, a plan for defect reconstruction has to be set up. Bone and soft-tissue transplants may be necessary to reconstruct the anatomy as far as possible.
A functional prosthetic rehabilitation based on im plants is as important as epitheses in reconstructing
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Fig. 5.5 Extensive soft-tissue laceration in the midface with subtotal amputation of the nose and naso-maxillary fracture (prepostoperative)
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Fig. 5.6 Severe injury to the central midface with soft-tissue laceration and complex naso-orbito-maxillary fracture (caused by a fraise). Preoperative situation and final result after reconstruction. There is residual ptosis of the left eyelid caused by nerve damage
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Fig. 5.7 (a) Perforating subcranial medio-orbital injury caused by a piece of wood. (b) Coronal and transverse CT images demonstrating the wooden splinter and substantial hematoma in the
inferomedial quadrant of the orbit with perforation of the nasoethmoidal wall (arrow). The globe is displaced laterally
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Fig. 5.8 (a) CT image: perforating foreign body (wooden knot) injury from the left naso-orbital groove across the right orbit (arrow) with transsection of the optic nerve. (b) After binasal exploration and removal of the foreign body: amaurosis, ophthalmoplegia, and exophthalmus
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Fig. 5.9 Craniofacial gunshot wound. Destruction of the lateral midface and the skull base in the ethmoido-sphenoidal complex (arrows)