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Emergency Medicine Atlas > Part 1. Regional Anatomy > Chapter 1. Head and Facial Trauma >

Basilar Skull Fracture

Associated Clinical Features

The skull base comprises the floors of the anterior, middle, and posterior cranial fossae. Trauma resulting in fractures to this basilar area typically does not have localizing symptoms. Plain skull radiographs are poor in identifying these fractures. Indirect signs of the injury may include visible evidence of bleeding from the fracture into surrounding soft tissue, such as a Battle's sign (Figs. 1.1, 1.2) or "raccoon eyes" (Fig. 1.3). Bleeding into other structures—including hemotympanum (Fig. 1.4) or blood in the sphenoid sinus seen as an air-fluid level—may also be seen. Cerebrospinal fluid (CSF) leaks may also be evident and noted as clear or pink rhinorrhea. If CSF is present, a dextrose stick test may be positive. The fluid can be placed on filter paper and a "halo" or double ring may be seen (Fig. 1.5).

Figure 1.1

Battle's Sign Ecchymosis in the postauricular area develops when the fracture line communicates with the mastoid air cells, resulting in blood accumulating in the cutaneous tissue. This patient had sustained injuries several days prior to presentation. (Courtesy of Frank Birinyi, MD.)

Figure 1.2

Battle's Sign A subtle Battle's sign is seen in this patient with head trauma. This sign may take hours to develop fully. (Courtesy of Lawrence B. Stack, MD.)

Figure 1.3

Raccoon Eyes Ecchymosis in the periorbital area, resulting from bleeding from a fracture site in the anterior portion of the skull base. May also be caused by facial fractures. (Courtesy of Frank Birinyi, MD.)

Figure 1.4

Hemotympanum Seen in a basilar skull fracture when the fracture line communicates with the auditory canal, resulting in bleeding into the middle ear. Blood can be seen behind the tympanic membrane. (Courtesy of Richard A. Chole, MD, PhD.)

Figure 1.5

Cerebrospinal Fluid Leak This example, from the nose, can be difficult to distinguish from blood or mucus. The distinctive double-ring sign, seen here, comprises blood (inner ring) and CSF (outer ring). The reliability of this test has been questioned. (Courtesy of David W. Munter, MD.)

Differential Diagnosis

Direct trauma without skull fracture can result in external ecchymosis. Barotrauma can cause hemotympanum. Facial injuries and fractures can cause facial ecchymosis.

Emergency Department Treatment and Disposition

The mainstay of therapy is to identify underlying brain injury, which is best accomplished by computed tomography (CT). CT is also the best diagnostic tool for identifying the fracture site, but fractures may not always be evident. Evidence of open communication, such as a CSF leak, mandates neurosurgical consultation and admission. Otherwise, the decision for admission is based on the patient's clinical condition, other associated injuries, and evidence of underlying brain injury as seen on CT. The use of antibiotics in the presence of a CSF leak is controversial because of the possibility of selecting resistant organisms.

Clinical Pearls

1. The clinical manifestations of basilar skull fracture may take several hours to fully develop.

2. Since plain films are unhelpful, there should be a low threshold for head CT in any patient with head trauma, loss of consciousness, obtundation, severe headache, visual changes, or nausea or vomiting.

3. The use of filter paper or a dextrose stick test to determine if CSF is present in rhinorrhea is not 100% reliable.

Depressed Skull Fracture

Associated Clinical Features

Depressed skull fractures typically occur when a large force is applied over a small area. They are classified as open if the skin above them is lacerated (Fig. 1.6) and closed if the overlying skin is intact. Abrasions, contusions, and hematomas may also be present over the fracture site. The patient's mental status can range from comatose to fully alert depending on the extent of the associated brain injury. Soft tissue bleeding and swelling may be present. Evidence of other injuries such as a basilar fracture or facial fractures may also be present.

Figure 1.6

Depressed Skull Fracture A scalp laceration overlying a depressed skull fracture. Wearing a sterile glove, the examiner should digitally explore all scalp lacerations for evidence of fracture or depression. (Courtesy of David W. Munter, MD.)

Differential Diagnosis

Direct trauma can cause abrasions, contusions, hematomas, and lacerations without an underlying depressed skull fracture. Every laceration to the scalp should be explored and palpated to rule out depression of a fracture. Alterations in mental status may occur with or without fracture. Penetrating injuries to the skull and brain can produce a similar clinical picture.

Emergency Department Treatment and Disposition

Plain films have been suggested for suspected depressed skull fractures and if positive should be followed by CT, which will more accurately demonstrate the degree of depression as well as any underlying brain injury (Fig. 1.7). Others suggest that plain films offer little diagnostic utility and recommend CT with its more accurate bone windows for any suspected depressed skull fracture. When depressed skull fractures are noted on plain films or CT, immediate neurosurgical consultation is required. Open fractures also require antibiotics and tetanus prophylaxis as indicated. The decision to observe or operate immediately is made by the neurosurgeon. Children below 2 years of age with skull fractures can develop leptomeningeal cysts. These cysts, which are extrusion of CSF or brain through dural defects, are associated with skull fractures. For this reason, children below age 2 with skull fractures require follow-up or admission.

Figure 1.7

Depressed Skull Fracture CT demonstrating depressed skull fracture. (Courtesy of David W. Munter, MD.)

Clinical Pearls

1. Gently palpate all scalp injuries including lacerations for evidence of fractures or depression. When fragments are depressed more than 3 to 5 mm below the inner table, penetration of the dura and injury to the cortex are more likely.

2. Children with depressed skull fractures are more likely to develop epilepsy.

3. The index of suspicion for nonaccidental trauma should be raised for children below 2 years of age with depressed skull fractures.

Nasal Injuries

Associated Clinical Features

Clinically significant nasal fractures are almost always evident on examination, with deformity, swelling, and ecchymosis present (Fig. 1.8). Injuries may occur to other surrounding bony structures, including fractures of the orbit, frontal sinus, or cribriform plate. A history of a mechanism with significant force, loss of consciousness, or findings of facial bone injury or CSF leak should alert the clinician to look for these associated injuries. Epistaxis may be due to a septal or turbinate laceration but can also be seen with fractures of surrounding bones, including the cribriform plate. Septal hematoma (Fig. 1.9) is a rare but important complication that, if untreated, may result in necrosis of the septal cartilage and a resultant "saddle-nose" deformity.

Figure 1.8

Nasal Fracture Deformity is evident on examination. Note periocular ecchymosis indicating the possibility of other facial fractures (or injuries). The decision to obtain radiographs is based on clinical findings. A radiograph is not indicated for an isolated simple nasal fracture. (Courtesy of David W. Munter, MD.)

Figure 1.9

Septal Hematoma A bluish, grapelike mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle-nose deformity. An incision, drainage, and packing are indicated. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Nasal fractures may have associated facial injuries—such as orbital, frontal sinus, or cribriform plate fractures—and these more serious injuries must be ruled out. A simple nasal contusion may present identically to a simple nasal fracture with pain, swelling, and ecchymosis. A frontonasoethmoid fracture has nasal or frontal crepitus and may have associated telecanthus or obstruction of the nasolacrimal duct.

Emergency Department Treatment and Disposition

Look for more serious injuries first. Patients with associated facial bone deformity or tenderness may require radiographs to rule out facial fractures. Nasal fractures rarely require radiographs (Fig. 1.10). Obvious deformities are referred within 2 to 5 days for reduction, after the swelling has subsided. Nasal injuries without deformity need only conservative therapy with an analgesic and possibly a nasal decongestant. Septal hematomas must be immediately drained, with packing placed to prevent reaccumulation. In some cases, epistaxis may not be controlled by pressure alone and may require nasal packing. Lacerations overlying a simple nasal fracture should be vigorously irrigated and primarily closed with the patient placed on antibiotic coverage. Complex nasal lacerations with underlying fractures should be referred for closure. Nasal fractures with mild angulation and without displacement may be reduced in the ED by manipulating the nose with the examiner's thumbs into the correct alignment.

Figure 1.10

Nondisplaced Nasal Fracture Radiograph of a fracture of the nasal spine, for which no treatment other than ice and analgesics is needed. This radiograph did not change the treatment or disposition of the patient. (Courtesy of Lorenz F. Lassen, MD.)

Clinical Pearls

1. Rule out any life threats or serious associated injuries.

2. Control epistaxis to perform a good intranasal examination. If there is no epistaxis or deformity, treat the patient with ice and analgesics. If obvious deformity is present, including a new septal deviation or deformity, treat with ice and analgesics and provide ear/nose/throat (ENT) referral in 2 to 5 days for reduction.

3. Although the effectiveness of prophylactic antibiotics to prevent toxic shock syndrome is unproved, every patient discharged with nasal packing should be placed on antistaphylococcal antibiotics and referred to ENT in 2 to 3 days.

4. Consider cribriform plate fractures in patients with clear rhinorrhea after nasal injury, with the understanding that this finding may be delayed.

5. Check every patient for a septal hematoma.

Fractures of the Zygoma

Associated Clinical Features

The zygoma bone has two major components, the zygomatic arch and the body. The arch forms the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to the zygoma are usually the result of blunt trauma. Direct blows to the arch can result in isolated arch fractures (Fig. 1.11). These present clinically with pain on opening the mouth secondary to the insertion of the temporalis muscle at the arch or impingement on the coronoid process. More extensive trauma can result in the "tripod fracture," which consists of fractures through three structures: the frontozygomatic suture; the maxillary process of the zygoma including the inferior orbital floor, inferior orbital rim, and lateral wall of the maxillary sinus; and the zygomatic arch (Figs. 1.12, 1.13). Clinically, patients present with a flattened malar eminence and edema and ecchymosis to the area, with a palpable step-off on examination. Injury to the infraorbital nerve may result in infraorbital paresthesia, and gaze disturbances may result from injury to orbital contents. Subcutaneous emphysema may be caused by a fracture of the antral wall at the zygomatic buttress.

Figure 1.11

Zygomatic Arch Fracture Jug-handle view of the zygomatic arch demonstrating a depressed fracture. In such a case, operative reduction can be delayed for several days. (Courtesy of Timothy D. McGuirk, DO.)

Figure 1.12

Zygomatic Fracture Patient with blunt trauma to the zygoma. Flattening of the right malar eminence is evident. (Courtesy of Edward S. Amrhein, DDS.)

Figure 1.13

Tripod Fracture The fracture lines involved in a tripod fracture are demonstrated in this three-dimensional CT reconstruction. The large defect in the frontal area is artifact from the reconstruction. (Courtesy of Patrick W. Lappert, MD.)

Differential Diagnosis

Other facial fractures, including LeFort II and III fractures, may involve the zygoma bone or orbit. These fractures typically involve more extensive facial trauma. Orbital blowout fractures may present with entrapment and ocular injuries, but the malar eminence appears normal.

Emergency Department Treatment and Disposition

Plain films, including a Waters view and "jug-handle" view (a submental-vertex view of the zygomatic arches), demonstrate the fracture and evaluate the zygomaticomaxillary complex. In the case of a tripod fracture, facial CT will best show the involvement and degree of displacement. Since plain films often do not adequately demonstrate all elements of the fracture, patients with evidence of a tripod fracture should have CT on an urgent basis to help identify the extent of bony injuries. The CT results guide the need for urgent referral. Simple zygomatic arch or tripod fractures without eye injury can be treated with ice and analgesics and referred for delayed operative consideration in 5 to 7 days. More extensive tripod fractures or those with eye injuries should be referred more urgently. Decongestants and broad-spectrum antibiotics are generally recommended for tripod fractures, since the fracture crosses into the maxillary sinus.

Clinical Pearls

1. Tripod fractures are often associated with orbital and ocular trauma. Palpate the zygomatic arch and orbital rims carefully for a step-off deformity.

2. Examine for eye findings such as diplopia, hyphema, or retinal detachment. Check for infraorbital paresthesia indicating injury or impingement of the second division of cranial nerve V.

3. Visual inspection of the malar eminence from several angles (especially by viewing the area from over the head of the patient in the coronal plane, Fig. 1.12) allows detection of a subtle abnormality.

4. Insist on adequate radiographs of the zygomatic arches, which require good positioning of the patient.

LeFort Facial Fractures

Associated Clinical Features

All LeFort facial fractures involve the maxilla (Fig. 1.14). Clinically, the patient has facial injuries, swelling, and ecchymosis (Figs. 1.15, 1.16). LeFort I fractures are those involving an area under the nasal fossa. LeFort II fractures involve a pyramidal area including the maxilla, nasal bones, and medial orbits. LeFort III fractures, sometimes described as craniofacial dissociation, involve the maxilla, zygoma, nasal and ethmoid bones, and the bones of the base of the skull. Airway compromise may be associated with LeFort II and III fractures. Physical examination is sometimes helpful in distinguishing the three. The examiner places fingers on the bridge of the nose and tries to move the central maxillary incisors with the other hand. If only the maxilla moves, a LeFort I is present; movement of the upper jaw and nose indicates a LeFort II; and movement of the entire midface and zygoma indicates a LeFort III. Because of the extent of LeFort II and III fractures, they may be associated with cribriform plate fractures and CSF rhinorrhea. The force required to sustain a LeFort II or III fracture is considerable, and associated brain or cervical spine injuries are common.

Figure 1.14

LeFort Fractures Illustration of the fracture lines of LeFort I (alveolar), LeFort II (zygomatic maxillary complex), and LeFort III (cranial facial dysostosis) fractures.

Figure 1.15

LeFort Facial Fractures Clinical photograph of patient with blunt facial trauma. Note the ecchymosis and edema. This patient sustained a LeFort II/III fracture (a LeFort II fracture on one side and a LeFort III on the other), and associated intracranial hemorrhages. (Courtesy of Stephen Corbett, MD.)

Figure 1.16

LeFort Facial Fractures Clinical photograph of patient with blunt facial trauma. Patient demonstrates the classic "dish face" deformity (depressed midface) associated with bilateral LeFort III fractures. (Courtesy of Robert Schnarrs, MD.)

Differential Diagnosis

LeFort II and III fractures can be difficult to distinguish, and combination LeFort fractures (e.g., LeFort II on one side and LeFort III on the other) are common. Tripod and frontonasoethmoid fractures may be present in blunt facial trauma as well.

Emergency Department Treatment and Disposition

Patients with associated facial bone deformity or tenderness may require radiographs to rule out facial fractures. Plain facial films will reveal the presence of facial fractures but are less helpful in determining the type or extent. Head and facial CT, including three-dimensional re-creations, offer much more useful information. Management of LeFort I fractures may involve only dental splinting and oral surgery referral, but management of LeFort II and III fractures normally requires admission because of associated injuries as well as definitive operative repair. Epistaxis may be difficult to control in LeFort II and III fractures, in rare cases requiring intraoperative arterial ligation.

Clinical Pearls

1. Attention should be focused on immediate airway management, since the massive edema associated with LeFort II and III fractures may quickly lead to airway compromise.

2. Nasotracheal intubation should be avoided because of the possibility of intracranial passage.

3. Any serious facial trauma may also be associated with cervical spine injuries.

4. Associated cranial injuries are common and are best evaluated by CT.

5. If not recognized, an occult CSF leak may result in significant morbidity. Suspected CSF leaks require neurosurgical consultation.

6. The best diagnostic modality for delineation of the extent of injuries is CT of the facial bones.

Orbital Blowout Fracture

Associated Clinical Features

Blowout fractures occur when the globe sustains a direct blunt force. There are two mechanisms of injury. The first is a true blowout fracture, where all energy is transmitted to the globe. The spherical globe is stronger than the thin orbital floor, and the force is transmitted to the thin orbital floor or medially through the ethmoid bones, with the resultant fracture. The object causing the injury must be smaller than 5 to 6 cm, otherwise the globe is protected by the surrounding orbit. Fists or small balls are the typical causative agents. This mechanism of injury is more likely to cause entrapment and globe injury. The second mechanism of injury occurs when the energy from the blow is transmitted to the infraorbital rim, causing a buckling of the orbital floor. Entrapment and globe injury is less likely with this mechanism of injury. Patients with blowout fractures have periorbital ecchymosis and lid edema (Figs. 1.17, 1.18) but may sustain eye injuries as well, including chemosis, subconjunctival hemorrhage, or infraorbital numbness from injury to the infraorbital nerve. Other eye injuries should be sought and ruled out with a careful physical examination; they include corneal abrasion, hyphema, enophthalmos, proptosis, iridoplegia, dislocated lens, retinal tear, retinal detachment, and ruptured globe. If the inferior rectus muscle is extruded into the fracture, it may become entrapped; upward gaze is then limited, with resultant diplopia (Figs. 1.19, 1.20). Because of the communication with the maxillary sinus, subcutaneous emphysema is common.

Figure 1.17

Orbital Ecchymosis Sustained from blunt trauma to the globe, with some of the force directed to the inferior orbital rim. This patient presents with subtle signs only (ecchymosis and swelling with no entrapment or eye injury) yet has the classic signs on plain films (Figure 1.18). This patient demonstrates that orbital floor fractures can present with subtle physical findings. (Courtesy of Kevin J. Knoop, MD, MS.)

Figure 1.18

Blowout Fracture Plain film demonstrating a fracture of the floor of the right orbit, with a teardrop sign due to extruded orbital contents. There is an associated air-fluid level in the maxillary sinus due to blood. Note the two lines seen at the inferior orbit: the infraorbital rim and inferior floor of the orbit. These are well visualized on the unaffected side but disrupted on the affected side. (Courtesy of Kevin J. Knoop, MD, MS.)

Figure 1.19

Inferior Rectus Entrapment The inferior rectus muscle is entrapped within the blowout fracture. When the patient tries to look upward, the affected eye has limited upward gaze. The patient experiences diplopia with this maneuver. (Courtesy of Lawrence B. Stack, MD.)

Figure 1.20

Blowout Fracture with Entrapment CT of the patient in Fig. 1.19 demonstrating the entrapped muscle extruding into the maxillary sinus. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Orbital contusions present with similar physical findings. Fractures of the orbital rim are clinically similar to orbital blowout fractures. Other facial fractures (zygoma, tripod, LeFort) may involve the orbital floor but are associated with more extensive injuries to the face outside of the orbit.

Emergency Department Treatment and Disposition

Plain radiography to include a Caldwell view (showing orbital rim and walls) and a Waters view (orbital floor and roof) demonstrates the fracture. Patients without eye injury or entrapment may be treated conservatively with ice and analgesics and referred for follow-up in 2 to 3 days. Patients with blood in the maxillary sinus are usually treated with antibiotics. Strongly consider an ophthalmology consultation in patients with a true blowout fracture (all energy transmitted to the globe), since up to 30% of these patients sustain a globe injury. Patients with entrapment should receive a CT of the orbits and be referred on a same-day basis. Most specialists will observe fractures with entrapment for 10 to 14 days to allow for resolution of edema prior to operative repair.

Clinical Pearls

1. Enophthalmos, limited upward gaze, diplopia with upward gaze, or infraorbital anesthesia from entrapment or injury to the infraorbital nerve should heighten suspicion of a blowout fracture.

2. Compare the pupillary level on the affected side with the unaffected side, since it may be lower from prolapse of the orbital contents into the maxillary sinus. Subtle abnormalities may be appreciated as an asymmetric corneal light reflex (Hirschberg's reflex).

3. Subcutaneous emphysema on clinical examination, a soft-tissue teardrop along the roof of the maxillary sinus on plain film, or an air-fluid level in the maxillary sinus on plain film should also be interpreted as evidence of a blowout fracture.

4. Some patients present with unusual complaints—for example, of an eye swelling up after the patient blows his or her nose (from subcutaneous emphysema) or air bubbles emanating from the tear duct.

5. Carefully examine the eye for visual acuity, hyphema, or retinal detachment. Remember to assess the nose for a septal hematoma.

Mandibular Fractures

Associated Clinical Features

A history of blunt trauma, mandibular pain, and possible malocclusion is normally seen with mandibular fractures. A step-off in the dental line (Fig. 1.21) or ecchymosis or hematoma to the floor of the mouth are often present. Mandibular fractures may be open to the oral cavity, as manifest by gum lacerations. Dental trauma may be associated. Other clinical features include inferior alveolar or mental nerve paresthesia, loose or missing teeth, dysphagia, trismus, or ecchymosis of the floor of the mouth (considered pathognomonic) (Figs. 1.22, 1.23). Multiple mandibular fractures are present in more than 50% of cases because of the ring-like structure of the mandible. Mandibular fractures are often classified as favorable or unfavorable, depending on the location and resultant displacement forces exerted by the associated musculature. Those fractures displaced by the masseter muscle are unfavorable (Fig. 1.24) and inevitably require fixation, whereas fractures that are not displaced by traction are favorable and in some cases will not require fixation. Injuries creating unstable mandibular fractures may create airway obstruction because the support for the tongue is lost. Mandibular fractures are also classified based on the anatomic location of the fracture (Fig. 1.25).

Figure 1.21

Open Mandibular Fracture The open fracture line is evident clinically. There is slight misalignment of the teeth. (Courtesy of Edward S. Amrhein, DDS.)

Figure 1.22

Sublingual Hemorrhage Hemorrhage or ecchymosis in the sublingual area is pathognomonic for mandibular fracture. (Courtesy of Lawrence B. Stack, MD.)

Figure 1.23

Bilateral Mandibular Fracture The diagnosis is suggested by the bilateral ecchymosis seen in this patient. (Courtesy of Lawrence B. Stack, MD.)

Figure 1.24

Unfavorable Mandibular Fracture Dental panoramic view demonstrating a mandibular fracture with obvious misalignment due to the distracting forces of the masseter muscle. (Courtesy of Edward S. Amrhein, DDS.)

Figure 1.25

Classification of Mandibular Fractures Classification based on anatomic location of the fracture.

Differential Diagnosis

Contusions have a similar presentation and can be differentiated only radiographically. Dislocation of the mandibular condyles may also result from blunt trauma and will always have associated malocclusion, typified by an inability to close the mouth. Isolated dental trauma may have a similar presentation, and underlying mandibular fracture should be ruled out.

Emergency Department Disposition and Treatment

The best view for evaluating mandibular trauma is a dental panoramic view, which should be obtained if available. Plain films should include anteroposterior (AP), bilateral oblique, and Townes views to evaluate the condyles. Nondisplaced fractures can be treated with analgesics, soft diet, and referral to oral surgery in 1 to 2 days. Displaced fractures, open fractures, and fractures with associated dental trauma need more urgent referral. All mandibular fractures should be treated with antibiotics effective against anaerobic oral flora (clindamycin, amoxicillin clavulanate) and tetanus prophylaxis given if needed. The Barton's bandage has been suggested to immobilize the jaw in the ED.

Clinical Pearls

1. The presence of disfiguring facial injuries can be distracting. The primary consideration in the evaluation of the patient with facial fractures is the assessment and treatment of life-threatening injuries.

2. Any patient with trauma and malocclusion should be considered to have a mandibular fracture.

3. The most sensitive sign of a mandibular fracture is malocclusion. The jaw will deviate toward the side of a unilateral condylar fracture on maximal opening of the mouth. A nonfractured mandible should be able to hold a tongue blade between the molars tightly enough to break it off. There should be no pain in attempting to rotate the tongue blade between the molars.

4. Bilateral parasymphyseal fractures may cause acute airway obstruction in the supine patient. This is relieved by pulling the subluxed mandible and soft tissue forward and, in patients in whom the cervical spine has been cleared, by elevating the patient to a sitting position.

External Ear Injuries

Associated Clinical Features

Injuries to the external ear may be open or closed. Blunt external ear trauma may cause a hematoma (otohematoma) of the pinna (Fig. 1.26), which, if untreated, may result in cartilage necrosis and chronic scarring or further cartilage formation and permanent deformity ("cauliflower ear") (Fig. 1.27). Open injuries include lacerations (with and without cartilage exposure) and avulsions (Fig. 1.28).

Figure 1.26

Pinna Hematoma A hematoma has developed, characterized by swelling, discoloration, ecchymosis, and flocculence. Immediate incision and drainage or aspiration is indicated, followed by an ear compression dressing. (Courtesy of C. Bruce MacDonald, MD.)

Figure 1.27

Cauliflower Ear Repeated trauma to the pinna or undrained hematomas can result in cartilage necrosis and subsequent deforming scar formation. (Courtesy of Timothy D. McGuirk, DO.)

Figure 1.28

Avulsed Ear This ear injury, sustained in a fight, resulted when the pinna was bitten off. Plastic repair is needed. The avulsed part was wrapped in sterile gauze soaked with saline and placed in a sterile container on ice. (Courtesy of David W. Munter, MD.)

Differential Diagnosis

These injuries are normally self-evident. Pinna hematomas and contusions can sometimes be difficult to distinguish, but flocculence is the hallmark of the hematoma.

Emergency Department Treatment and Disposition

Pinna hematomas must undergo incision and drainage or large needle aspiration using sterile technique, followed by a pressure dressing to prevent reaccumulation of the hematoma. This procedure may need to be repeated several times; hence, after ED drainage, the patient is treated with antistaphylococcal antibiotics and referred to ENT or plastic surgery for follow-up in 24 h. Lacerations must be carefully examined for cartilage involvement; if this is present, copious irrigation, closure, and postrepair oral antibiotics covering skin flora are indicated. Simple skin lacerations may be repaired primarily with nonabsorbable 6-0 sutures. The dressing after laceration repair is just as important as the primary repair. If a compression dressing is not placed, hematoma formation can occur. Complex lacerations or avulsions normally require ENT or plastic surgery referral.

Clinical Pearls

1. Pinna hematomas may take hours to develop, so give patients with blunt ear trauma careful discharge instructions, with a follow-up in 12 to 24 h to check for hematoma development.

2. Failure to adequately drain a hematoma, reaccumulation of the hematoma owing to a faulty pressure dressing, or inadequate follow-up increases the risk of infection of the pinna (perichondritis) or of a disfiguring cauliflower ear.

3. Copiously irrigate injuries with lacerated cartilage, which can usually be managed by primary closure of the overlying skin. Direct closure of the cartilage is rarely necessary and is indicated only for proper alignment, which helps lessen later distortion. Use a minimal number of absorbable 5-0 or 6-0 sutures through the perichondrium.

4. Lacerations to the lateral aspect of the pinna should be minimally debrided because of the lack of tissue at this site to cover the exposed cartilage.

5. In the case of an avulsion injury, the avulsed part should be cleansed, wrapped in saline-moistened gauze, placed in a sterile container, then placed on ice to await reimplantation by ENT.

Frontal Sinus Fracture

Associated Clinical Features

Blunt trauma to the frontal area may result in a depressed frontal sinus fracture. Often, there is an associated laceration (Fig. 1.29). Isolated frontal fractures (Figs. 1.30, 1.31) normally do not have the associated features of massive blunt facial trauma such as seen in LeFort II and III fractures. Careful nasal speculum examination may reveal blood or CSF leak high in the nasal cavity. Posterior table involvement can lead to mucopyocoele or epidural empyema as late sequelae. Involvement of the posterior wall of the frontal sinus may occur and result in cranial injury or dural tear.

Figure 1.29

Frontal Laceration Any laceration over the frontal sinuses should be explored to rule out a fracture. This laceration was found to have an associated frontal fracture. (Courtesy of David W. Munter, MD.)

Figure 1.30

Frontal Sinus Fracture Fracture defect seen at the base of a laceration over the frontal sinus. (Courtesy of Jeffrey Kuhn, MD.)

Figure 1.31

Frontal Sinus Fracture Fracture of the outer table of the frontal sinus is seen under this forehead laceration. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Simple lacerations or contusions of the frontal area may not involve fractures. Frontal fractures may be part of a complex of facial fractures, as seen in frontonasoethmoid fractures, but generally more extensive facial trauma is required.

Emergency Department Treatment and Disposition

Frontal sinus fractures revealed on plain films of the frontal bones, including posteroanterior (PA), lateral, and Waters views, may be quite subtle. The extent of the frontal injury, especially posterior table involvement, is best investigated with bone windows on CT (Fig. 1.32). Fractures involving only the anterior table of the frontal sinus can be treated conservatively with referral to ENT or plastic surgery in 1 to 2 days. Fractures involving the posterior table require urgent neurosurgical referral. Frontal sinus fractures are usually covered with high-dose antibiotics against both skin and sinus flora (second- or third-generation cephalosporins). ED management also includes control of epistaxis, application of ice packs, and analgesia.

Figure 1.32

Frontal Sinus Fracture CT of the patient in Figure 1.29 demonstrating a fracture of the anterior table of the frontal sinus. (Courtesy of David W. Munter, MD.)

Clinical Pearls

1. Explore every frontal laceration digitally before repair. Digital palpation is sensitive for identifying frontal fractures, although false positives from lacerations extending through the periosteum can occur.

2. Communication of irrigating solutions with the nose or mouth indicates a breach in the frontal sinus.

3. For serious injuries, a CT scan is mandatory to assess the posterior aspect of the sinus and for possible intracranial injury.

Traumatic Exophthalmos

Associated Clinical Features

Normally the result of blunt orbital trauma, the exophthalmos develops as a retrobulbar hematoma pushes the globe outward. Patients present with periorbital edema, ecchymosis (Fig. 1.33), a marked decrease in visual acuity, and an afferent pupillary defect in the involved eye. The exophthalmos, which may be obscured by periorbital edema, can be better appreciated from a superior view (Fig. 1.34). Visual acuity may be affected by the direct trauma to the eye, compression of the retinal artery, or, more rarely, neuropraxia of the optic nerve.

Figure 1.33

Traumatic Exophthalmos Blunt trauma resulting in periorbital edema and ecchymosis, which obscures the exophthalmos in this patient. The exophthalmos is not obvious in the AP view and can therefore be initially unappreciated. Figure 1.34 shows the same patient viewed in the coronal plane from over the forehead. (Courtesy of Frank Birinyi, MD.)

Figure 1.34

Traumatic Exophthalmos Superior view, demonstrating the right-sided exophthalmos. (Courtesy of Frank Birinyi, MD.)

Differential Diagnosis

Periorbital ecchymosis and edema can result from blunt trauma without a retrobulbar hematoma. Traumatic chemosis can present with exophthalmos. Visual impairment can result from retinal detachment, hyphema, globe rupture, or any number of nontraumatic conditions. Nontraumatic exophthalmos can be caused by cavernous sinus thrombosis, a complication of frontal sinusitis, or endocrine (thyrotoxicosis) disorders.

Emergency Department Treatment and Disposition

CT is the best modality to determine the presence and extent of a retrobulbar hematoma and associated facial or orbital fractures (Fig. 1.35). Referral to ENT and ophthalmology is indicated on an urgent basis. An emergent lateral canthotomy decompresses the orbit and can be performed in the ED. Emergency treatment can be sight-saving.

Figure 1.35

Retrobulbar Hematoma CT of the patient in Figs. 1.33 and 1.34 with right retrobulbar hematoma and traumatic exophthalmos. (Courtesy of Frank Birinyi, MD.)

Clinical Pearls

1. The retrobulbar hematoma and resultant exophthalmos may not develop for hours. Give careful discharge instructions to any patient with periorbital trauma.

2. Perform a careful ophthalmic examination including visual acuity, since associated conditions such as hyphema or retinal detachment are common.

3. A subtle exophthalmos may be detected by looking down over the head of the patient and viewing the eye from the coronal plane.

4. Lateral canthotomy is indicated for emergent treatment of patients with traumatic exophthalmos who demonstrate profound ischemic signs and symptoms of an afferent pupillary defect and decreased vision.

5. An afferent pupillary defect in a patient with blunt trauma to the face or eye with normal visual acuity may be pharmacologically induced.