Craniofacial Trauma (eBook)

Preface 7
Contents 8
Contributors 14
Part I Classification and Diagnosis 15
Anatomy of the Craniofacial Region 16
1.1 Anterior Skull Base 16
1.1.1 Cribriform Plate/Crista Galli 16
1.1.2 Fossa Olfactoria 17
1.1.3 Roof of the Orbit 20
1.1.4 Dura 20
1.1.5 Arterial Supply: Skull Base/Dura 20
1.2 Paranasal Sinuses 20
1.2.1 Frontal Sinus 20
1.2.2 Ethmoid 20
1.2.3 Sphenoid 22
1.3 Midface Skeleton 22
1.4 Subcranial and Midface Skeleton 24
References 24
Radiology of Craniofacial Fractures 27
2.1 Conventional X-Rays 27
2.2 Computed Tomography 27
2.3 Magnetic Resonance Imaging (MRI) 31
2.4 Ultrasonography 31
2.5 Diagnostic Algorithm 2.5.1 General Considerations 32
2.5.2 Craniocerebral Trauma 33
2.5.3 Skull Base Fractures 37
Increased intracranial pressure? 38
2.5.4 Midface Fractures 39
Skull base fractures 39
CT 39
CT 39
CT 39
References 40
Classification of Craniofacial Fractures 42
3.1 Frontobasal: Frontofacial Fractures 42
3.1.1 Anatomical Classification: Skull Base Fractures 43
3.1.2 Topographic Classification: Skull Base Fractures 43
3.2 Midface Fractures 44
3.2.1 Standard Classifications 44
3.2.2 Central Midface Fractures 45
3.2.3 Centrolateral Midface Fractures 46
3.2.4 Skull Base and Fracture Levels in the Region of the Septum 47
3.2.5 Lateral Midface Fractures 47
3.2.6 Midface: Combined Fractures 49
3.2.7 Naso-Orbito-Ethmoidal Fractures ( NOE Fractures) 49
3.2.8 Cranio-Frontal Fractures 51
3.3. Craniofacial Fractures 3.3.1 Skull Base- Related Classification 51
3.3.2 Subcranial Facial Fractures 56
3.3.3 Craniofacial Fractures 3.3.4 Central Cranio-Frontal Fractures 58
3.3.5 Lateral Cranio-Orbital Fractures 58
References 63
Mechanisms of Craniofacial Fractures 66
4.1 Fractures of the Skull Base 66
4.1.1 Burst Fractures 66
4.1.2 Bending Fractures 66
4.2 Frontofacial: Frontobasal Fractures 4.2.1 Fracture Mechanism 67
4.3 Midfacial: Frontobasal Fractures 67
4.3.1 Trauma Factors 67
4.3.2 Impact Forces and Vectors 68
4.3.3 Structural Resistance and Energy Absorption 68
4.3.4 Impact Surface 70
4.3.5 Position of the Skull 71
References 71
Epidemiological Aspects of Craniofacial/ Skull Base Fractures 73
5.1 Epidemiology 73
5.2 Skull Base Fractures/Meningeal Injuries 74
5.2.1 Frequency 74
5.2.2 Localization 74
5.3 Midface: Skull Base Fractures 74
5.3.1 Involvement of the Skull Base in High Midface Fractures 75
5.3.2 Dural Injuries 75
5.4 Cranio-Fronto-Ethmoidal Fractures 76
5.4.1 Frontal Sinus: Midface Fractures 76
5.5 Distribution According to Age 5.6 Distribution According to Gender 77
5.7 Associated Injuries 78
5.7.1 Thoracic, Abdominal, and Cervical Spine Injuries 78
5.7.2 Eye Injuries 79
5.7.3 Facial Soft-Tissue Injuries 79
5.8 Special Fractures and Complications 79
5.8.2 Gunshot Wounds and Tissue Avulsion 79
5.8.3 Complicating Effects 83
References 84
Craniofacial Fracture Symptoms 87
6.1 Combined Skull Base and Midface Fractures 87
6.1.1 Certain Signs of Skull Base and Dural Injuries 87
6.1.2 Uncertain Signs of Skull Base and Dural Injuries 91
6.1.3 Questionable Signs of Skull Base Fractures 104
6.2 Midface Injuries (Clinical Signs) 105
6.2.1 Central Midface Fractures without Abnormal Occlusion ( NOE Fractures) 105
6.2.2 Central Midface Fractures with Abnormal Occlusion ( Le Fort I and II) 105
6.2.3 Centrolateral Midface Fractures with Abnormal Occlusion ( Le Fort III) 106
6.2.4 Lateral Midface Fractures 106
6.3 Orbital Injuries 6.3.1 Orbital Soft- Tissue Injuries 107
6.3.2 Orbital Wall Fractures 107
6.3.3 Fracture Localization 108
6.3.4 Fracture Signs 115
References 116
Neurocranial Injuries in Craniofacial/ Skullbase Fractures1 120
7.1 Intracranial Injuries 7.1.1 Statistics: Intracranial Injuries in CF Fractures 120
7.1.2 Principles of Neurotraumatology ( Rengachary and Ellenbogen 2004) 120
7.1.3 Management of Mild Head Injuries ( GCS 14- 15) 122
7.1.4 Management of Moderate Head Injuries ( GCS 13- 9) 122
7.1.5 Management of Severe Head Injuries ( GCS 8- 3) 122
7.1.6 Neurosurgical Management of Intracranial Hematomas 124
7.2 Management of Skull Base and Dural Injury 130
7.2.1 Skullbase Fractures with CSF Leakage 130
7.2.2 Skullbase Fractures with CSF Leak without Severe TBI 130
7.2.3 Skullbase Fractures with CSF Leak with Severe TBI 130
7.2.4 Combined Frontobasal- Maxillofacial Fractures with CSF Leakage with or without Severe TBI 130
References 131
Part II Therapy 133
Surgical Repair of Craniofacial Fractures 134
8.1 Indications for Surgery 8.1.1 Emergency Surgery ( Probst 1971 Schwab 1995
8.1.2 Semi-Elective Surgery for Frontobasal and Midface Fractures 134
8.1.3 No Surgical Indication 134
8.2 Surgical Timing 134
8.2.1 Evaluation 135
8.2.2 Surgical Timing 136
8.3 Surgical Approaches 137
8.3.1 Strategy for Interdisciplinary Approach ( Decision Criteria) 138
8.4 Transfrontal-Transcranial Approach 140
8.4.1 Indications 140
8.4.2 Transfrontal-Transcranial Approach: Surgical Technique 140
8.4.3 Advantages, Disadvantages, and Risks Associated with the Transcranial Approach 153
8.5 Transfrontal-Subcranial Approach 153
8.5.1 Indications 154
8.5.2 Surgical Principle 154
8.5.3 Subcranial Surgical Technique 154
8.5.4 Advantages, Disadvantages, and Risks Associated with the Subcranial Approach 155
8.6 Transfacial Approach 155
8.6.1 Indications 156
8.6.2 Surgical Principle 156
8.6.3 Transfacial Surgical Approaches ( Denecke et al. 1992 Schwab 1995
8.6.4 Dura Treatment in the Frontal Skull Base 158
8.6.5 Advantages, Disadvantages, and Risks Associated with the Transfacial Approaches 159
8.7 Endonasal-Endoscopical Approach 160
8.7.1 Ethmoid Roof Fractures: Surgical Principles 161
8.7.2 Sphenoid Fractures 161
8.8 Surgical Approaches/ Own Statistics 161
References 161
Methods of Dural and Skull Base Treatment 165
9.1 Principles of Dural Reconstruction 9.2 Dural Substitutes 165
9.2.1 Autogenous Grafts 165
9.2.2 Allogeneic Transplants 166
9.2.3 Alloplastic Synthetic Dural Substitutes 167
9.3 Principles of Skull Base Reconstruction 167
9.3.1 Debridement of the Ethmoid Cells 167
9.3.2 Debridement (Cranialization) of the Frontal Sinus 167
9.3.3 Skull Base Repair 168
9.4 Skull Base Treatment/Own Statistics 172
References 173
Bone Grafts 175
10.1 Indications 175
10.1.1 Midface 175
10.1.2 Frontofacial Region (Gruss and Mc Kinnon 1986 Serletti and Manson 1992
10.1.3 Orbital Region (Jackson et al. 1986 Serletti and Manson 1992
10.2 Autogenous Bone Grafts 176
10.2.1 Split Calvarial Grafts 176
10.2.2 Bone Dust/Bone Chips 180
10.2.3 Autogenous Grafts from the Iliac Crest 181
References 183
Osteosynthesis of Craniofacial Fractures 185
11.1 Biomechanics: Facial Skeleton 185
11.2 Principles of Biomechanical Reconstruction 185
11.2.1 External Midfacial Skeletal Framework 186
11.2.2 Internal Midfacial Skeletal Framework 187
11.3 Osteosynthesis of the Midface 11.3.1 Plating Systems 188
11.3.2 Miniplates: Microplates 188
11.3.3 Screw Systems 189
11.4 Surgical Procedure: Osteosynthesis of the Midface 189
11.4.1 Different Plate Sizes: Indication 189
11.4.2 Fracture-Related Osteosynthesis 190
11.5 Titanium: Mesh-Systems 11.5.1 Mesh- Systems 203
11.5.2 Indications and Advantages 11.5.3 Defect Treatment Using Titanium- Mesh 204
References 208
Surgical Strategy for Complex Craniofacial Fractures 211
12.1 Craniofacial Fractures 211
12.1.1 Concept of Reconstruction 211
12.1.2 Surgical Approaches (Manson 1998 Gruss 1990
12.1.3 Reconstruction of Anterior Skull Base and Frontofacial Compartment ( Manson 1998 Donald 1994, 1998a
12.1.4 Midface Reconstruction ( Yaremchuk et al. 1992 Manson et al. 1995
12.1.5 Own Procedure: Statistics 221
12.2 NOE Fractures 221
12.2.1 NOE-Fractures Without Skull Base Injury ( Prein 1998 Donald 1998a, b)
12.2.2 NOE Fractures with Skull Base Injury ( Prein 1998 Donald 1998a, b)
12.3 Panfacial Fractures (Markowitz and Manson 1989 Manson 1998
12.3.1 Concept of Reconstruction 224
12.4 Zygomatico-Orbito-Cranial Fractures 227
12.5 Craniofrontal Fractures (CCF) 229
12.5.1 Concept of Reconstruction 229
12.5.2 Surgical Approach (Baker et al. 1999 Donald 1994
12.5.4 Fractures of the Posterior Frontal Sinus Wall with Anterior Skull Base Involvement 234
12.5.5 Fractures of the Anterior and Posterior Sinus Walls with Anterior Skull Base Involvement 237
12.5.6 Fractures of the Frontal Sinus with Comminution of the Infundibulum 237
12.6 Own Statistics 238
References 241
Complications and Late Sequelae Following Craniofacial Reconstruction 245
13.1 Infections and Abscesses 245
13.2 Osteomyelitis 247
13.3 Recurrent Liquorrhea 247
13.4 Hematoma: Central Edema 249
13.5 Subdural Hygroma 249
13.6 Frontal Sinus: Complications 251
13.7 Functional Neurological Deficits 251
13.8 Meningitis 251
13.9 Facial Contour Irregularities 255
13.10 Conclusion 255
References 255
Delayed Reconstruction of Frontofacial Defects and Deformations 256
14.1 Reconstruction Materials and Techniques 256
14.1.1 Autogenous Grafts 256
14.1.2 Xenogenous Bone/Allogenous Cartilage Transplants 14.1.3 Alloplastic Bone Substitutes ( Holmes 1990 Leipziger and Dufresne 1992)
14.1.4 Titanium-Mesh 260
14.1.5 Preformed Titanium Implants ( CAD/ CAM Implants) 263
References 263
A Treatment Algorithm in Craniofacial Reconstruction: Future Developments1 265
15.1 Overall Objective 265
15.2 Patient-Related Conditions 265
15.2.1 Size and Location of the Defect 265
15.2.2 General Health Status 266
15.2.3 Neurological Status 15.2.4 Patient’s Wish 269
15.2.5 Treatment Plan 269
15.2.6 Technical Aspects 271
15.3 New Developments 15.3.1 Titanium Selective Laser Melting ( Ti- SLM) 272
15.3.2 PEEK-Implants 273
15.3.3 Outlook 274
References 274
Index 276