This document provides a summary of key information about trauma to the head and face: 1. Various types of facial fractures are described, such as orbital floor fractures which can be missed on axial CT scans. Parotid duct injuries may cause buccal branch facial nerve weakness. 2. Certain clinical signs help diagnose specific fractures. A "spectacle" hematoma indicates a superior orbital rim fracture. One cc volume increase is needed per mm of globe displacement. 3. Pediatric facial fractures differ from adults due to lack of sinus development and more cancellous bone. "Growing skull fractures" enlarge due to brain pulsations. Orbital floor trapdoor fractures in children are emergencies.

1. TRAUMA MINIMAL READ
PART 1
Dr Arjun Shenoy

2. 1) Injury to the optic nerve, if partial, may present as a Marcus Gunn pupil. The Marcus Gunn
pupil implies paradoxicalpupillary dilation when a light is swung between the intact and
the injured eyes.
2) Medial orbital fractures commonly produce ipsilateral epistaxis
3) Bilateral epistaxis is seen in bilateral midface fractures
4) Cervical spine fractures commonly accompany maxillofacial soft tissue or bony injuries and
are frequently seen on frontal impact and mandibular fractures
5) The presence of a nondisplaced fracture (classically of the ramus of the mandible) is one of
the most difficult to identify in computed tomographic (CT) scans. The orbital floor
fracture is missed in axial CTs. The frontobasilar fracture is also missed on axial CT scans.
6) Some patient may demonstrate a “spectacle” hematoma, a hematoma in the upper lid
confined to the distribution of the orbital septum. Therefore the bruise abruptly stops
where the orbital septum attaches to the superior orbital rim and produces a classic
hematoma of the upper eyelid. Such hematomas are diagnostic of a fracture within the
superior orbit; therefore it is an anterior cranial fossa fracture.
7) Generally, an increase of 1 cc in orbital volume is required for each millimeter
displacement of the globe.
8) Inferior globe displacement is called ocular dystopia.
9) lacerations that present with buccal branch facial nerve weakness should raise suspicion
for parotid duct injuries.
10) Appearance of saline in the wound is diagnostic of a canalicular laceration.
11) Three-dimensional CT scans are not as useful in the orbit because they are not sensitive to
orbital wall displacement
12) Orbital volume enlargement of more than 5% to 10% justifies open reduction

3. 13) Approximately 10% of frontal sinus repairs are complicated by infection
14) Stranc plane II nasal fractures are displaced posteriorly and typically require dorsal
augmentation
15) The majority of zygomatic fractures require a limited open reduction. Approximately 20%
of zygomatic fractures are so minimally displaced that perception of significant deformity
is difficult. Therefore these zygomatic fractures do not need a reduction.
16) The majority of greenstick fractures are high (Le Fort II or III) with a small displacement
17) Fractures of the palatal vault and alveolus of the maxilla occur in approximately 10% of
patient with maxillary fractures.
18) One of the few indications for obtaining plain x-rays in trauma is to determine the
presence and location of foreign bodies and better visualization of injury to tooth
structure.
19) Increased intracranial pressure cannot be assessed radiologically. The presence of a
copper-beaten skull is not necessarily indicative of raised intracranial pressure.
20) Mandible fractures are the most common pediatric facial fracture.. Midface fractures are
rare because of the lack of maxillary sinus development, the immaturity of bone with an
increased cancellous to cortical bone ration, and thepresence of tooth buds in the maxilla,
which cushion the impact
21) Growth Centres of Paediatric Cranio-facial Skeleton
• Cranium: Cranial sutures
• Upper face: Orbits
• Midface: Sphenoethmoidonasal , vomeropremaxillary & pterygopalatomaxillary region
• Lower face: Mandibular condyles

4. 22) Growing skull fractures are skull and skull base/orbital fractures that are associated with a
defect in the dura. When these fractures are present, the pulsations of the brain actually
push the fractures further apart, resulting in an enlarging and nonhealing fracture.
23) The pediatric orbital floor trapdoor fracture, with entrapped extraocular muscle, is
considered a true surgical emergency.
24) Foramina of Breschet are sites of intracranial venous drainage with mucosal invaginations
that can serve as a route of intracranial infection or mucocele formation
25) Involvement of anterior and posterior tables of frontal sinus invariably leads to
frontonasal duct injury, as do concomitant nasoethmoidal complex and medial orbital rim
fracture patterns
26) Fractures typically occur in the distal nasal bones
27) The rhinion is the junction of the bony and cartilaginous nasal framework
28) The incidence of septal fractures in simple nasal bone fractures is 96%
29) Which is the only bone that exists entirely within the orbital confines? - The lacrimal bone.
30) The most frequent intraorbital fracture involves the orbital floor just medial to the
infraorbital canal
31) What is the most common orbital fracture? - Zygomaticoorbital or malar complex fractures
32) Which anatomic structure is most useful when assessing whether the zygomatic complex
is appropriately reduced - The lateral orbital wall
33) A posttraumatic carotid cavernous sinus fistula (CCF) is a pathologic connection between
the internal carotid artery and the venous channels that make up the cavernous sinus.
They occur in 1% of patients with facial fractures and result from a tear in the wall of the
internal carotid arter

5. Bibliography
Clark N, Manson P: Complication in maxillofacial trauma.In Maull KI, Rodriguez A, Wiles CE III (eds):
Complications in Trauma and Critical Care. Philadelphia, WB Saunders, 1996, PP 239–269.
David DJ, Simpson DA: Craniomaxillofacial Trauma. New York, Churchill Livingstone, 1995.
Dufresne C, Manson P: Pediatric facial injuries. In Mathes S (ed): Plastic Surgery, 2nd ed. New York,
Elsevier, 2006, pp 381–463.
Fonseca R, Walker R: Oral and Maxillofacial Trauma. Philadelphia, WB Saunders, 1991.
Manson P: Facial fractures.In Mathes S (ed): Plastic Surgery, 2nd ed. New York, Elsevier, 2006, pp
77–381.
Manson PN: Midface fractures. In Georgiade N Riefhohl R, Barwick W (eds): Plastic, Maxillofacial and
Reconstructive Surgery, 2nd ed. Baltimore, Williams & Wilkins, 1992, pp 409–433.
Manson PN: Reoperative facial fracture repair. In Grotting J (ed): Reoperative Aesthetic &
Reconstructive Plastic Surgery. St. Louis, Quality Medical Publishing, 2006, pp 903–1013.
Mueller RV: Facial trauma: Soft tissue injuries. In Mathes S (ed): Plastic Surgery, 2nd ed. New York,
Elsevier, 2006, pp 1–45.
Rowe NL, LI Williams:Rowe & Williams’ Maxillofacial Injuries. Edinburgh, Churchill Livingstone, 1994.
Wolf A, Baker SA: Facial Fractures. New York, Thieme Medical Publishers, 1993.
Potter JK, Muzaffar AR, Ellis E, et al: Aesthetic management of the nasal component of naso-orbital
ethmoid fractures. Plast Reconstr Surg 117:10e–18e, 2006.
Tuite GF, Evanson J, Chong WK, et al: The beaten copper cranium: A correlation between intracranial
pressure, cranial radiographs, and computed tomographic scans in children with craniosynostosis.
Neurosurgery 39:691–699, 1996.
Amaratunga NA de S: Mandibular fractures in children—A study of clinical aspects, treatment needs,
and complications. J Oral MaxillofacSurg 46:637–640, 1988.
Taub PJ, Kawamoto HK. Orbital injuries. In Thaller SR, McDonald WS (ed): Facial Trauma. New York,
Marcel Dekker, 2004, pp 235–260.
Whitaker L, Yaremchuk M: Secondary reconstruction of post-traumatic orbital deformities. Ann Plast
Surg 25:440–449, 1990.
Yaremchuk M: Changing concepts in the management of secondary orbital deformities. Clin Plast
Surg 19:113–124, 1992.
Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985.
Jimenez D, Bernard C: Posttraumatic carotid cavernous sinus fistulae. In Holck DEE, Ng JD (eds):
Evaluation and Treatment of Orbital Fractures. Philadelphia, Elsevier Saunders, 2006, pp 341–350.