Presentation of multiple midface fractures combined with intracranial injury treated conservatively

doi:10.4236/ojem.2013.11001

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Vol.1, No.1, 1-3 (2013) Open Journal of Emergency Medicine

Presentation of multiple midface fractures combined

with intracranial injury treated conservatively

Talal Rane1, Firas Nasser2, Samir Taha2*

1Department of Oral & Maxillofacial Surgery, Al-Ahli Hospital, Doha, Qatar

2Department of Oral and Maxillofacial Surgery, Hamad Medical Corporation, Doha, Qatar; *Corresponding Author: [email protected]

Received 17 July 2013; revised 19 August 2013; accepted 1 September 2013

permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Midface injuries are normally the result of high

forces impacted on the fac e , that can bypass the

power of the connection buttresses, which are

thick and strong, base of skull is also a rigid and

tough structure which requires significant forces

to break. In our case, multiple midface and cra-

nial base fractures are presented, which reflect

injury caused by high forces and norma lly, these

result in instability in the facial skeleton, or

cause CSF rhinorrhea, or sharp spicules to en-

danger the orbit or the anterior cranial fossa, or

the presence of any other indication of surgery.

It is unusual to find such an extent of facial

trauma and such a multiplication of fractures on

the midface and cranial base levels, yet they

were st able enough an d without a re al indication

to require surgical interference.

Keywords: Midface Fracture; Upp er Face Fracture;

Conservative Management

1. INTRODUCTION

Combined intracranial injury with midface and upper

face multiple fractures signify severe force involved [1-

4], published work on forces calculated to produce a

fracture of each craniofacial bone structure is well docu-

mented [1,2], normally, this results in severe injuries to

the face [1-3]. Hodgson, V.R. et al. presented detailed

work on the tolerance of facial bones to impact [3], and

indicated that impacts produce fracture near 200 pounds,

but that is closely related to the length of the pulse of

impact measured in milliseconds.

A lot of work is presented in the literature about treat-

ment [5-8], sequencing of which bone to fix first [6,7],

timing of treatment [6,7].

We present a case of facial trauma that resulted in

multiple midface and upper face fractures combined with

a base-of-skull fracture, but all were undisplaced and not

mobile therefore, did not require any intervention, and

were managed conservatively, together with the intracra-

nial hemorrhage being minor, that did not require surgi-

cal treatment as well.

2. CASE REPORT

A (46) years old year old male was brought to the A &

E Department of Hamad General Hospital on 12 May

2009, he was lowering a swimming pool basin down into

a pre-dug site in a house garden, when the edge of the

basin hit him on the face.

Patient was conscious, oriented with GCS 15/15, his

BP was 146/82 and Oxygen saturation of 98%, airway

was stable and neck is clear of injury.

Craniofacial examination revealed bilateral periorbital

ecchymosis, active oronasal bleeding, and oro-facial lac-

erations.

Pupils were round, equal and brisk reactive, directly

and consensually, visual acu ity intact with mild p roptosis

of right eye, no obvious restriction of ocular movements.

CT scan showed left small foci of frontal subarachno id

hemorrhage and bleeding into the anterior part of the

interhaemospheric fissure and very small pneumocepha-

lus of the frontal region (Figure 1) plus fracture of the

anterior cranial fossa, both orbital roofs (Figures 1 and 2)

and right side of the frontal bone (Figure 3) with fracture

of the left zygoma and a lefort I (Figure 2), nasal bone,

both medial walls and floors of orbits (Figures 2 and 3),

as reported on CT by radiologist and confirmed by the

maxillofacial team responsible for patient.

Initially patient was managed in the trauma room by

bilateral anterior nasal packs, and oro-facial lacerations

were closed as appropriate, under an umbrella of intra-

venous Augmentin plus Dexamethasone, patient was

shifted to Trauma ITU for neurological and eye observa-

tion.

T. Rane et al. / Open Journal of Emergency Medicine 1 (2 013) 1-3

Figure 1. Fractures seen in orbits and posterior wall of frontal

sinus, small pneumocephalus.

Figure 2. Fractures in both medial walls, both floors, both or-

bital roofs, lefort I level.

Figure 3. Fractures seen in orbital floor, roof, medial wall.

Secondary re-assessment revealed that interestingly all

facial fractures were undisplaced and mobility of the

midface was very minimal with no apparent impact on

vision, aesthetics, nor occlusion, and therefore, did not

warrant any maxillofacial surgical intervention, and pa-

tient was treated conservatively with antibiotics, Dexa-

methasone for three days, and close monitoring.

Full recovery was achieved without any functional,

aesthetic, or neurological deficit. Recovery time was

around 3 weeks from injury, which is time necessary for

bone healing to achieve stability, surgical interv ention on

the other hand would have been attempted after at least

48 hours of neurological observation to ensure that he is

neurologically fit to undergo a non-life saving major

surgery, also, midface repair is generally done after few

days to allow edema to subside first [6,7], taking the

above into consideration, one week of waiting is ex-

pected plus one week of post op recovery is needed, and

this phase might be slightly quicker than the period nec-

essary for conservative treatment, but the time difference

is small enough not to pull the d ecision making one way

or the other.

3. DISCUSSION

The patient was placed on soft diet for the period nec-

essary for bone initial phase which was 3 weeks, surgical

intervention affords faster rehabilitation to normal diet,

but on the other hand, predisposes to all the surgical

morbidities associated with major procedure, which

should be avoided if surgical treatment is not the only

option, generally soft diet restriction in case of open re-

duction is only applied for few days.

Other post op issues would be neurological monitoring

for 48 - 72 hours initially, and long term out-patient

based follows up to monitor any frontal sinus pathology,

intracranial pathology, exclude signs of developing men-

ingeal disease. These issues have to be monitored equally

whether surgical or conservative treatment followed.

Literature review shows that not all midface fractures

need surgery [9,10]. Conservative treatment however

seems to be a much less likely modality in the case of

midface trauma, Adeyemo, W.L. and co-workers estima-

ted that to be around 2.6% of all cases [11]. It is also

known that fractures of the posterior wall of the frontal

sinus need cranialization, unless undisplaced and not

associated with CSF rhinorrhea or nasofrontal duct injury

[12], this case presented as a wide magnitude of injury

which went to involve most facial bones and skull base,

i.e. midface and upper face fractures. This is normally

caused by high force or known as high velocity injuries

[1,3], yet none of the bones of the face required surgery

as they were non displaced nor mobile, which made

conservative management possible and indeed, indicated,

therefore careful assessment and reassessment after most

of the initial edema has subsided, has a lot to command

for in the management of facial injuries.

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T. Rane et al. / Open Journal of Emergency Medicine 1 (2 013) 1-3

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