Can be caused by bleeding or massive urinary or gastrointestinal fluid losses.

One or two large bore (≥16 gauge) peripheral IVs should be inserted.

Focused abdominal sonography for trauma (FAST) in a hypotensive patient to rule out intra-abdominal hemorrhage or cardiac tamponade.

Objective measure of patient’s neurological status and used serially to track clinical progress.

Can be applied to patients 5 years of age and above.

Use best response (left vs. right differential).

Score 8 or less, early airway protection encouraged due to concern of respiratory arrest or hypoxia leading to secondary brain injury.

Score minimum is 3.

Requires serial exams and a CT scan of the head.

Bone healing is altered by types of fixation and mobility of the fracture site in relation to function.

Mechanism of injury and loss of consciousness are important points to note. It is difficult to assess a history from an unstable trauma patient and, therefore, witnesses should be questioned.

Confirm ATLS/PALS has been performed. Threshold for intubation should be low. Ensure appropriate consultations have been made, e.g., neurosurgery, ophthalmology, orthopedic surgery, and pediatric surgery, etc., if necessary.

Ensure C-spine has been evaluated and appropriate precautions taken. It’s desirable to have the head and spine cleared prior to surgical intervention if possible.

After confirming the patient is stable and the airway secure, begin the head and neck trauma exam. This should be systematic and concise.

Evaluate general demeanor and responsiveness. Patient cooperation may be extremely difficult with pediatric or inebriated patients.

Evaluate neurological status to determine the level of consciousness (Glasgow scale).

Evaluate for facial asymmetry, lacerations (rule out Stenson duct or facial nerve injury), edema and ecchymosis.

Examine the cranial nerves II–XII and note any paresthesia (V1, V2, V3), or facial nerve deficits.

If the orbit is involved, evaluate extra ocular movements, pupillary reaction, direct and consensual visual reflexes, monocular (indicative of retinal detachment) or binocular diplopia (can be secondary to edema or entrapment and restriction of gaze). Tonometry should be used for evaluating intraocular pressure. A fundoscopic exam is indicated for for evaluating the retina and optic nerve, and hyphema. A slit lamp exam is useful in evaluating the eyelids, lacrimal system, cornea and to rule out the presence of foreign bodies. Exam should assess for the presence of proptosis, dystopia (disturbance in globe position in the vertical and horizontal planes) or enophthalmos. Look for periorbital ecchymosis (Racoon eyes). Evaluate for telecanthus. Consider ophthalmology exam/clearance.

Evaluate the ears for the presence of ecchymosis behind the ears (Battle’s sign) or otorrhea, which may be indicative of a base of skull fracture (if positive neurosurgical consultation is required). Rinne and Weber exam to screen for hearing. Otoscopic exam to evaluate tympanic membrane and EAC (if injury apparent ENT should be consulted).

Evaluate for exit wounds if a projectile was involved.

Evaluate the midface for loss of projection, edema, ecchymosis, and step deformities.

Evaluate the nose for asymmetries, blood, rhinorrhea, and septal hematoma.

Evaluate jaws for range deviations on opening (this may indicate a condylar or subcondylar fracture), arch step deformities, lingual ecchymosis (highly indicative of a mandible fracture), hematomas, and intraoral lacerations.

Evaluate the state of the dentition (dental fractures, missing teeth, changes in occlusion). For a pediatric patient correlate dental development with chronological age.

Evaluate for a chin laceration, preauricular edema, or ecchymosis as these can be suggestive of a condylar fracture.

The floor of mouth swelling or the possibility of airway compromise should be noted.

High-resolution maxillofacial computed tomography (CT) is the gold standard for evaluating facial trauma. Consider obtaining 3D reconstruction for surgical treatment planning and using it as an aid to discuss treatment with the family of the patient.

If trauma is isolated to the mandible or dentition an orthopantomogram can be used.

Plain film X-rays have limited value in the maxillofacial trauma patient.

If teeth are missing or unaccounted for secondary to the trauma then an abdominal X-ray (KUB) and chest X-ray must be performed.

Tenderness over the region of suspected fractures.

Loss of form – bony contour change, soft tissue depressions, deformities.

Edema.

Abrasions/lacerations – the potential for compound fractures.

Ecchymosis – especially floor of the mouth, symphyseal, or body fracture.

Crepitus with manipulation.

Altered sensation/paresthesia.

Loss of teeth – require chest X-ray to rule out aspiration if not accounted.

Implies accessing the fracture through skin or mucosa to aid in visualization and reduction of the fracture.

Usually unilateral, and from indirect trauma from the opposite side of insult.

Will have ipsilateral premature closure and midline pull on side of the fracture.

Condylar fractures (AO classification – see Fig. 7.2):

Gross mobility.

Periapical pathology.

Preventing reduction.

Roots with a fracture.

Exposed root.

Delay in repair from time of fracture.

Recurrent infection at the fracture site despite antibiotic therapy.

Transfacial fracture of the midface, involving the maxillary bone and surrounding structures in either a horizontal, pyramidal, or transverse direction. It involves the pterygomaxillary suture and the nasal septum.

Classified according to the experiments by anatomist Rene LeFort.

Generally, look for increased facial height (equine facies), loss of anterior projection (dishpan facies). Look for edema, lacerations, contusions, hematoma formation, and ecchymosis.

Ocular – pupils, extraocular muscle function, visual acuity, ocular pressure, subconjunctival hemorrhage, infraorbital nerve sensation, and intercanthal distance.

Battle Sign – ecchymosis in the mastoid region, suggestive of a base of skull fracture. Can be seen in midfacial fractures due to high-energy injuries.

Palpate – look for tenderness, crepitus, bony step deformities, mobility of segments at zygomaticofrontal and nasofrontal sutures, or maxillary mobility.

Nasal – rhinorrhea, septal hematoma, epistaxis, mobility of nasofrontal suture.

Intraoral exam – evaluate dentition, relative class III malocclusion, vestibular ecchymosis, tooth loss/fracture, and occlusion and anterior open bite.

Pterygoid plates, strong indication of LeFort fracture.

Lateral margin of nasal fossa, suggestive of LeFort I fracture.

Inferior orbital rim, suggestive of LeFort II.

Zygomatic arch, suggestive of LeFort III.

Nondisplaced fractures without clinical compromise can be managed by a soft diet with observation or 4–6 weeks of IMF.

Edentulous patients may be treated with open treatment or observation.

Treat as soon as possible. The longer open or compound fractures are untreated, the greater incidence of infection and malunion.

Fixate fractures to allow immobilization and optimal healing.

Use buttresses for fixation.

Restore preoperative occlusion.

Ensure to treat nasal complex and orbital fractures as indicated.

Access is via the transoral approach.

Place into IMF (consider using disimpaction techniques if necessary to aid in the alignment of fractures and restoration of occlusion).

Reduce fractures and plate stabilization at piriform rims and zygomaticomaxillary buttresses.

Check occlusion.

Access is via transoral and/or periorbital/coronal approach.

Place into IMF.

Reduce fractures and plate stabilization at the piriform rim, zygomaticomaxillary buttresses, orbital rim, and management of NOE component if necessary.

The orbital floor should be treated last after ensuring that the zygoma and the maxilla are in the proper position to prevent increased orbital volume.

Check occlusion.

Nasal repairs as needed.

Access is usually via a combination of the transoral, lower lid, coronal approaches.

Good mobilization.

Place into IMF.

Reduce fractures ensuring restoration of adequate facial height and width.

Fixate starting at the frontozygomatic suture, nasal region, zygomaticomaxillary buttresses, piriform rims, and zygomatic arch as needed.

Check occlusion.

Reduce/reconstruct orbit.

Nasal reduction as needed.

Length of the incision depends on the area of interest or extent of injury. Can be unilateral or bilateral.

Incision is placed ~3–5 mm superior to the mucogingival junction making sure to leave adequate unattached gingiva for closure. (Usually extends posteriorly to first molar.)

Incise through mucosa, submucosa, and periosteum down to the bone using electrocautery Bovie or #15 blade.

Subperiosteal dissection superiorly and anteriorly to piriform buttress and posterior to zygomaticomaxillary buttress.

May encounter infraorbital canal and neurovascular bundle if dissection extends enough superiorly.

If necessary, may need to dissect nasal mucosa from the lateral wall, floor, or septum using a Freer elevator.

Malocclusion Noted After IMF Is Released – Occlusion may spring open after the IMF is released. Remove fixation and then place patient back in IMF and make sure occlusion is stable and condyles are in the fossa before fixating fractures again; remove from IMF and recheck occlusion.

Malocclusion Noted 1 Week Postoperatively – Most likely loss of fixation. Obtain new imaging to confirm and if fixation failed then return to OR to correct. If malocclusion is minor and fixation appears intact on imaging, then allow full healing of fractures and refer for orthodontic correction of the minor malocclusion.

Bleeding During Mobilization of the Maxilla – If from the pterygoid muscles at posterior maxilla, then treat with surgicel or fibrin sealants. If from the pterygoid plexus, then treat with local anesthesia and packing. If from the terminal branches of the maxillary artery (descending palatine, PSA, or sphenopalatine arteries) treat with vessel clips and/or anterior and posterior nasal packs. If local hemostatic measures are used and bleeding is still not controlled, then consider embolization with interventional radiology. Late bleeding may occur due to pseudoaneurysm formation.

Malunion – May require osteotomies or onlay grafting to address the resulting anatomical anomaly.

Nonunion – Continual mobility noted after 8 weeks after the fixation has been placed. May require removal of faulty fixation, bone grafting, and placement of rigid internal fixation.

The zygoma has four articulations (frontozygomatic, zygomaticomaxillary, zygomaticosphenoid, and zygomaticotemporal). These sutures represent common areas of fracture points.

It should be noted that the weakest portion of the zygomatic arch is not the zygomaticotemporal suture, but a point approximately 1.5 cm posterior to this suture.

ZMC fractures are also orbital fractures. An ocular exam is imperative including visual acuity, assessment of extraocular muscles in the six cardinal fields of gaze, integrity of rim, ecchymosis, hyphema, shape of pupil (traumatic mydriasis or iridodialysis), reactivity of pupil, size of pupil, subconjunctival ecchymosis, periorbital edema/ecchymosis, and chemosis and position of the globe. Deepening of the supratarsal crease is one of the earliest signs of enophthalmos.

Flattening of the malar eminence. Decreased projection is best assessed from a bird’s eye view.

Depression in the preauricular region denoting flattening of the zygomatic arch.

Antimongoloid slanting (due to disruption of the frontozygomatic suture and inferior displacement of Whitnall’s tubercle).

Neurological disturbances over the distribution of the infraorbital nerve.

Step deformities denoting discontinuity of the orbital rim, zygomaticomaxillary buttress, and frontozygomatic region.

Ecchymosis in the maxillary vestibule (Guerin’s sign).

Trismus if coronoid is impinged and possibly spasm of masseter.

Pupillary level – fracture of orbital floor allows for displacement of suspensory ligaments and Tenon’s capsule causing hypoglobus of the affected side.

CT is the gold standard for evaluation of ZMC fractures. It allows for the visualization of all buttresses and to assess the degree of displacement and/or comminution. It also allows for assessing the orbital floor, muscle entrapment, and the integrity of the globe.

CT scans obviate the need for plain radiographs.

Plain radiographs that were used in the past for assessing ZMC fractures were the Caldwell and Submentovertex views (submentovertex views are still used intraoperatively to assess adequate reduction of the zygomatic arch).

Isolated zygomatic arch fractures can be approached via a Keen or Gillies approach.

Some surgeons wire/suture a finger splint or Fox shield over the arch to maintain reduction while healing.

Closed reduction has also been described using a towel clip to aid reduction.

ORIF of zygomatic arch fractures. Not performed for isolated arch fractures. Usually stabilized with miniplates as part of a high-impact ZMC fracture or a panfacial fracture.

It is important to employ a systematic sequence when treating ZMC fractures. Multiple approaches are necessary to expose the frontozygomatic, zygomaticomaxillary, orbital rim, and orbital floor regions. Minimum two points of fixation are required.

Alignment of the sphenozygomatic suture is a good indicator of the three-dimensional position of the zygoma.

Quadrilateral/pyramidal bony cavity with base facing anteriorly. The widest dimension is 1 cm posterior to the orbital rim.

Volume: 30 ml, 4 cm horizontal dimension, 3.5 cm vertical on average [4].

Medial walls parallel to each other ; lateral walls at 90 degrees to each other. Lateral wall to medial wall 45 degrees. (Fig. 7.4).