Craniofacial injuries

Outline
Anatomy of Cranium and Face
Treatment of craniofacial injuries in
general
Frontal fracture
Orbital fracture

Anatomy of cranium and face

Cranium consists of neurocranium (calvaria and
cranial base) and viscerocranium (facial bones)
There are four aspects and two surfaces of
cranium : facial, lateral, occipital and superior
aspect, and internal and external surface
Face is the anterior aspect of the head from the
forehead to the chin and from one ear to the
other. The face involves in communication
(facial expression) and identity for humans.
Scalp cover the neurocranium that consists of
skin and subcutaneous tissue. The scalp is
composed of five layers (skin, connective
tissue, aponeurosis, loose areolar tissue,
pericranium)
Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott
Williams and Wilkins; 2014. p. 820-980

Facial and lateral aspect of cranium

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Occipital and superior aspect of

cranium

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

External and internal surface of

cranium

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Muscle of face and scalp

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Nerves of face (cranial nerves)

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Cranial nerves and Paranasal

Sinuses

Sumber: Drake RL, Vogl AW, Mitchel AWM. Grays Anatomy for
Students. 3rd ed. USA: Churchill Livingstone Elsevier; 2015

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented
Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p. 820-980

Superficial arteries and veins of face

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Lymphatic drainage of face and

SCALP

Sumber: Moore KL, Dalley AF, Agur AMR. Moore Clinically Oriented Anatomy. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p.

Treatment of craniofacial injuries in

general
Initial Assessment

Preparation prehospital phase and hospital phase

Triage multiple casualties and mass casualties
Primary Survey ABCDEs
Resuscitation
Adjuncts to primary survey and resuscitation ECG monitoring, urinary and gastric
catheters, ventilatory rate, arterial blood gases, pulse oximetry, blood pressure, x-ray
exam and diagnostic studies
Consideration of the need for patient transfer
Secondary survey head-to-toe evaluation and patient history
Adjuncts to secondary survey
Continued post resuscitation monitoring and reevaluation monitoring vital signs and
urinary output, relief of severe pain
Definitive care

Sumber: American College of Surgeons Committees on Trauma. Advance Trauma Life Support Student
Coarse Manual. 9th ed. 2012

Primary Survey (ABCDEs)

Airway maintenence with cervical spine protection chin-lift or jaw thrust
(obstruction?), GCS 8? (require placement of definitive airway), using
immobilization device for protection patients spinal cord (or inline immobilization
techniques)
Breathing and Ventilation expose patients neck and chest (assess jugular venous
distention, position trachea, chest wall excursion), visual inspection and palpation
(detect injuries), auscultation (gas flow in the lungs)
Circulation with hemorrhage control altered levels of consciousness? ashen gray
facial skin (color)? Pale extremities? Irregular, rapid, thready pulse? (blood volume
and cardiac output), external and Interial bleeding (chest, abdomen, retroperitoneum,
pelvis, long bones)?
Disability (neurologic evaluation) values of Glasgow Coma Scale? (level of
consciousness)
Exposure and Environmental control undressed the patient to facilitate a thorough
exam and assessment, covering with warm blankets (prevent hypothermia, more
important than the comfort of the healthcare providers)
Sumber: American College of Surgeons Committees on Trauma. Advance Trauma Life Support Student
Coarse Manual. 9th ed. 2012

Resuscitation
Airway a definitive airway (intubation) should be established if there is any
doubt about the patients ability to maintain airway integrity. If intubation is
contraindicated/cannot be accomplished, an airway should be established
surgically
Breathing, ventilation, and oxygenation chest decompression should follow
immediately in patient suspected tension pneumothorax, supplemental
oxygen for every injured patient, pulse oximeter (monitor adequancy of SaO 2)
Circulation with hemorrhage control (shock and hypothermia) replacement
of intravascular volume (rate of fluid administration based on internal
diameter and length of catheter), type and crossmatch of patients blood,
obtaining blood gasses and/or lactate level (assess the presence and degree
of shock), initiated with IV fluid therapy with crystalloid, IV solutions should be
warmed (37-40C), blood transfusion (if crystalloid therapy is unresponsive).

Sumber: American College of Surgeons Committees on Trauma. Advance Trauma Life Support Student
Coarse Manual. 9th ed. 2012

Secondary Survey
Begin if primary survey is completed, resuscitative
effort are underway, the normalization of vital functions
has been demonstrated
Head-to-toe exam, complete history taking and physical
exam, reassessment of all vital sign, complete
neurologic exam (GCS score, obtained x-ray as
indicated by exam, or special/specific procedure)

Sumber: American College of Surgeons Committees on Trauma. Advance Trauma Life Support Student
Coarse Manual. 9th ed. 2012

Frontal (sinus) fracture

Diagnosis and Exam
Signs and symptoms: obvious contour deformities of the forehead, swelling with
injury blunts, associated with central nervous system Axial cuts of CT Scan
(determine degree of injury, involvement of anterior and posterior table, and
nasofrontal duct)
Anterior table fractures treated by reduction and plate fixation via coronal
incision or through existing cuts in the forehead or obliteration frontal sinus (step:
removing anterior table entirely removing all mucosa from sinus plugging
nasofrontal drainage system from ethmoid sinus and nose below)
Posterior table fractures risk of acute meningitis and late intracerebral mucocele
formation caused by fragment of fracture (trapdoor-type phenomena) leaving
small bits of mucosa within cranical cavity (risk of mucocele formation). Posterior
displacement or cerebrospinal leak frontal craniotomy and removing forehead as
bone flap removing posterior table and mucosa of anterior table.

Complication infection, mucocele formation

Sumber: Chung KC, Gosain AK, Gurtner GC, Mehrara BJ, Rubin JP, Spear SL. Grabb and Smiths Plastic
Surgery. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p. 311-26

Orbital fracture
Orbital Examination:
History of iatrogenic globe penetration(cataract surgery or radial keratotomy) risk globe rupture
increase
visual exam damage optic nerve manifestation of visual field > visual acuity problem
Test color desaturation compression of optic nerve (red color desaturation)
Direct and consensual pupillary response function of second and third cranial nerves
Anisocoria damage of second or third cranial nerves or direct trauma of iris
Swinging flashlight test optic nerve injury
Range of motion of eye function of third, fourth, and sixth cranial nerves

Indication for Surgery: Orbital floor mechanical entrapment of an extraocular muscle,

enophtalmus, defect size of orbital floor > 1 cm2.
Incisions/technique subciliary approach (highest risk of lid retraction), transconjungtival
approach (decrease risk of lid malposition), lateral canthotomy+canthopexy (improves
exposure), subtarsal incision (for older patients with prominent lower lid rhytids)
Floor Implants very large orbital defects (involving medial wall). Disadvantage are
infection and extrusion. Avoid silastic (high risk of infection and extrusion)
Complications lower lid retraction, enophthalmus, persistent diplopia

Sumber: Chung KC, Gosain AK, Gurtner GC, Mehrara BJ, Rubin JP, Spear SL. Grabb and Smiths Plastic
Surgery. 7th ed. USA: Lippincott Williams and Wilkins; 2014. p. 311-26