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Mucosal lining: 4-0 chromic with knots in nasal cavity
Cartilage: 5-0 clear nylon or PDS sutures
Skin: 6-0 nylon in the skin
Avulsion injuries: consider composite graft (replantation if
possible)
50% failure
All grafted material must be within 5 mm of viable
tissue
Ears
Arterial supply: superficial temporal and postauricular
arteries
Great auricular, auriculotemporal, Arnold, lesser occipital
nerves provide sensation
Otohematoma
Evacuate with needle or blade to avoid “cauliflower
ear”
Compression dressing
Xeroform bolster secured with 3-0 Prolene through
and through mattress sutures
Remove in 1 week
Lacerations
May require figure-of-eight sutures in cartilage (clear
nylon or absorbable monofilament)
Evert skin margins in key locations (eg, helix) with
mattress sutures
Amputation
Partial amputation—suture repair
Complete amputation—attempt replantation
Consider leech therapy for venous congestion
Consider dermabrasion of ear part and banking
cartilage in dermal pocket
Mouth
Anatomic landmarks: philtral columns, philtral dimple, Cupid
bow, vermillion border, and white roll
Lacerations: repair mucosa, orbicularis, and skin in layers.
Mark white roll with methylene blue or marking pen prior to
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administration of local anesthetic to prevent distortion which
can be prevented with regional nerve blocks
Tongue
Lingual block: insert needle 6-8 mm inferior to the lingual
gingival margin of the 2nd molar. Depth of injection is 5-8
mm.
Small lacerations can be healed by secondary intention.
Large (>2 cm) and through-and-through lacerations require
suture repair with absorbable sutures (4-0 Vicryl or
chromics).
FACIAL FRACTURE EVALUATION
AND MANAGEMENT
MANDIBLE FRACTURES
Anatomy (Fig. 20-2)
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Figure 20-2 Mandible anatomy. (From
Anatomical Chart Co., 2013.)
Mental nerve (CN V3)
Exits skull base from foramen ovale
Courses 2 mm below foramen
*Exits mental foramen at second premolar
Nerve is closest to buccal cortex at third molar, farthest
from buccal cortex at first molar
Muscles of mastication (CN V3) exert deforming forces of
mandible
*Lateral pterygoid: protracts (lowers) mandible
Medial pterygoid: closes mouth
Temporalis: elevates and retracts mandible
Masseter: elevates mandible
Geniohyoid, genioglossus, mylohyoid, digastric
muscles: depress mandible
Clinical Presentation
Patient may endorse malocclusion
Exam may show floor of mouth ecchymosis, step offs,
tenderness over fracture site, open bite, premature contact
Management Considerations
The mandible is like a pretzel: difficult to break in only one
location; look for second fracture.
Classification of fracture—location on mandible, simple vs
comminuted, open vs closed, and
intracapsular/extracapsular.
Teeth in line of fracture should be retained if roots are not
fractured.
Maxillomandibular fixation (MMF; also called intermaxillary
fixation, or IMF) may be used as a single modality
(controversial) for 4-6 weeks.
Principles of open reduction and internal fixation (ORIF)
Indications: displaced fracture with abnormal occlusion
MMF to restore occlusion
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Subperiosteal dissection to expose fracture line
Reduction of fracture fragments
Rigid fixation using plates/screws, 2.0-mm plating systems
Early, active mobility
Tension band plate placed along alveolar border
Large reconstruction plate along inferior border
General Management of Fracture Subtypes
Symphyseal/parasymphyseal fractures. Miniplate fixation
with at least two points of fixation
Body fractures. Miniplate fixation
Angle fractures. Highest complication rate
Isolated: treat with MMF and/or Champy plate (load
sharing at oblique ridge), strut plate
Complex: treat with MMF, two load-sharing plates, or
one load-bearing plates
If severe, may need external fixation
Coronoid fractures—MMF for 2 weeks is usually enough
Condylar and subcondylar fractures
Intracapsular
Condylar fractures (head and upper neck)
Closed reduction and limited (2 weeks) MMF with
early controlled mobilization; rarely ORIF
Open treatment warranted if: (1) cannot reduce
fracture and it precludes ranging the mandible, (2)
a foreign body is present within the TMJ, (3) the
condyle has displaced into the middle cranial
fossa, and (4) bilateral condyle fractures with
midface fractures to restore vertical height
Extracapsular
Subcondylar fractures
IMF × 4-6 weeks, weekly observation of occlusion
after release
Pediatric mandible fractures
*Avoid immobilization, early active therapy, growth
potential allows improvement of occlusion with
time
May require MMF
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In the absence of permanent dentition
Piriform drop wires
Circum-mandibular wires
Edentulous mandible
Closed fractures with minimal displacement: no
dentures, soft diet
Open fractures or those with displacement: ORIF with
load-bearing plate, may require gunning splint
Dislocations
Anterior displacement of condyle from glenoid fossa
Closed reduction necessary
Conscious sedation
Intraoral downward and posterior pressure at
ramus
Indications for Tooth Removal
Grossly mobile
Severe periodontal disease
Root fracture
Exposed apices
Common Complications
Malocclusion/malunion/nonunion
Increased facial width, rotation of mandible
TMJ ankylosis: stiffness, pain, limited range of motion
Infection: often treated with I&D, hardware removal
generally not required
ZYGOMA FRACTURES
Anatomy
Zygoma has a quadrilateral shape: articulates with maxilla,
sphenoid, temporal, and frontal bones; fractures are,
therefore, “tetrapod fractures”
Muscle attachments: masseter, temporalis, zygomaticus
major and minor
Clinical Presentation
Flattening of malar eminence with downslanting
palpebral fissure: lateral canthus attaches to zygoma via
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Whitnall tubercle.
Zygomatic arch fractures may limit the motion of coronoid,
resulting in trismus.
Enophthalmos.
Infraorbital paresthesia.
ORIF: required to restore facial width, malar projection, and
orbital dystopia
Approaches
Upper blepharoplasty incision: access to
zygomaticofrontal junction
Coronal incision: to expose entire arch and lateral
orbital rim
Gillies approach
Temporal incision behind hair line
*Dissect deep to temporalis muscle fascia
Reduce posteriorly displaced arch fracture with
outward force
Transconjunctival incision: access to
zygomaticomaxillary junction (and orbital floor)
Intraoral incision: Dingman elevator placed under arch
with outward force
Fixation: 1.5- or 2.0-mm plating systems.
Postoperative arch splint: may wrap tongue depressor in
silk tape and bend into bridge shape, secure to face with
tape as buttress to prevent infracturing during sleep (not
needed when plated).
Zygomaticosphenoid articulation is the most important to
assess reduction.
ORBITAL FRACTURES
Anatomy (Fig. 20-3)
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Figure 20-3 Skeletal orbital anatomy
and the relationship of the superior and
inferior orbital fissures and optic
foramen. (From Dalley AF II, Agur AMR.
Moore’s Clinical Oriented Anatomy. 9th ed.
Wolters Kluwer; 2023. Figure 8.44B.)
Orbit is constructed of seven bones—maxilla, zygoma,
sphenoid, frontal, palatine, lacrimal, and ethmoid.
*Conical/pyramid shape: optic nerve is ~4 cm posterior
to orbital rim.
Thinnest region is medial wall (lamina papyracea).
Ophthalmology consult if concern for ocular trauma
Fractures most common in orbital floor and medial wall (lamina
papyracea of ethmoid)
Dystopia occurs if loss of bony support
Enophthalmos
Fractures of orbit result in increased intraorbital volume and
disrupt ligamentous support of globe.
During healing, periorbital takes on shape with smaller
volume.
Clinical Presentation
Periorbital edema
Periorbital ecchymosis
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Diplopia
Infraorbtial nerve paresthesia
Enophthalmos
Orbital rim step-off
Limited globe excursion from edema or entrapment
Indication for ORIF
Persistent diplopia (>2 weeks).
Fractures that involve >50% orbital floor or >2 cm2.
Clinically significant enophthalmos.
*Entrapment of extraocular muscles (requires emergent
intervention, that is, <24 hours, to release ischemic
muscle). Entrapment is determined by assessing
extraocular movements or by forced duction testing
(see above, under ED Evaluation and Physical
Examination) if unconscious.
ORIF
Subciliary, transconjunctival, inferior orbital rim incisions.
*Transconjunctival approach is associated with lowest
rate of postoperative ectropion.
Medpor (porous polyethylene) implant or cranial bone grafts
can be used to reconstruct the orbital floor: secured in place
with screws at infraorbital rim.
Young children may present with a “trapdoor” floor fracture
in which there is no defect but the fracture has entrapped
the extraocular muscle (usually the inferior rectus muscle).
The muscle can be released and the orbital floor usually
needs no implant or reconstruction if it feels stable.
Associated Potential Ophthalmic Consequences
Corneal abrasion
Hyphema: blood in anterior chamber
Sympathetic ophthalmia
Traumatic optic neuropathy: traumatic loss of vision
Requires surgical decompression, and high-dose
steroids
*Superior orbital fissure syndrome
Effects oculomotor, trochlear, abducens, and
trigeminal (lacrimal, frontal, and nasociliary
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branches) nerves and ophthalmic vein
Signs
Ptosis
Proptosis
Ophthalmoplegia
Numbness in VN V1
Dilation and fixation of ipsilateral pupil
*Orbital apex syndrome: same as superior orbital
fissure syndrome but with loss of vision due to injury
to optic nerve
Traumatic carotid cavernous sinus fistula
Proptosis
Ocular bruit
Ophthalmoplegia of CN III, IV, or VI
Treatment: surgical ligation of carotid artery or coils to
block off fistula
NASAL BONE FRACTURES
Nasal Anatomy
Upper one-third of the nose: paired nasal bones
Fractures common in thinner lower halves of paired
nasal bones.
Younger patients experience fracture-dislocations of
larger segments.
Older patients develop comminuted patterns.
Lower two-thirds of the nose: paired upper lateral cartilage,
lower lateral cartilage
Septum consists of quadrangular cartilage, vomer,
perpendicular
Treatment Goals
Restoration of function and appearance.
Wait 6 months before considering revision rhinoplasty or
secondary closed reduction plate of ethmoid bone.
Acutely before edema begins (uncommon) or after swelling
resolves (3-5 days).
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Closed reduction should be accomplished within 2 weeks of
injury to avoid osteotomies.
Principles and Technique
Look for septal hematoma.
Do not misdiagnose NOE for simple fx as NOE is hard to
fix.
Usually treat closed except with complex facial fractures,
inability to obtain good closed reduction, severe
comminution.
External nose anesthetized by regional block 0.5%
lidocaine with 1:200 000 epinephrine.
Internal nose anesthetized by Afrin-soaked pledgets.
Reduce bridge with elevator and septum and Asch forceps
or butter knife.
Nasal bone must be mobilized before reduction.
External thermoplast splint and internal nasal splints placed
after reduction.
Complications
Subperichondral fibrosis with partial obstruction
Synechiae
Obstruction of the nasal vestibule from malunited fractures
or scar contractures from loss of vestibular lining
Osteitis
Malunion of nasal fractures with residual deviation
NOE FRACTURES
Fractures of nasal bones, frontal processes of maxilla, lacrimal
bone, and ethmoid bone
Markowitz Classification: based on central fragment with
medial canthal tendon
Type I: single, noncomminuted, central fragment without
medial canthal tendon disruption
Type II: comminuted central fragment without medial
canthal disruption
Type III: severely comminuted central fragment with
disruption of medial canthal tendon
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