What is the treatment for multiple missed facial skull fractures?

Treatment of Multiple Missed Facial Skull Fractures

The primary treatment for multiple missed facial skull fractures requires immediate surgical intervention, especially when there is evidence of muscle or periorbital tissue entrapment, to prevent permanent functional and cosmetic deficits. 1, 2

Diagnostic Approach

When facial skull fractures have been missed initially, a comprehensive re-evaluation is necessary:

1. CT Maxillofacial: MDCT (Multi-Detector Computed Tomography) is the gold standard for diagnosing maxillofacial injuries, providing superior delineation of osseous and soft-tissue structures 1

   • Look specifically for:
     • Zygomaticomaxillary complex fractures
     • Le Fort pattern fractures (I, II, III)
     • Naso-orbital-ethmoid fractures
     • Orbital wall fractures with potential entrapment

2. Neurological Assessment: Critical due to high association between facial fractures and head injuries

   • 68% of patients with facial fractures have associated head injuries 1
   • A GCS score <8 increases the incidence of cervical spine injury to 7.8% 1

Treatment Algorithm

1. Immediate Surgical Intervention Required For:

• Orbital fractures with muscle entrapment (indicated by restricted ocular motility, diplopia) 2
• Fractures causing oculocardiac reflex (bradycardia, nausea, vomiting) 2
• Displaced zygoma fractures impinging on mandibular movement 1
• Le Fort fractures with malocclusion or airway compromise 1
• Naso-orbital-ethmoid fractures (to prevent telecanthus, enophthalmos) 1

2. Surgical Approach Selection:

• Open Reduction and Internal Fixation (ORIF) with miniplates is the standard treatment for displaced facial bone fractures 3
• Combined Neurosurgical and Maxillofacial Approach for cases with concomitant intracranial injuries (38% of midface fractures) 4
• Primary and Complete Repair of both neurosurgical and maxillofacial injuries should be considered in the same procedure when possible 5

3. Timing of Surgery:

• Immediate surgery for:

  • Muscle entrapment causing oculocardiac reflex
  • "White-eyed" blowout fractures in children 2
  • Compound depressed fractures with intracranial involvement 3

• Early surgery (within 72 hours) for:

  • Most displaced facial fractures without severe brain injury
  • Zygomaticomaxillary complex fractures 1

• Delayed surgery for:

  • Patients with severe traumatic brain injuries requiring stabilization
  • Extensive facial edema requiring resolution before definitive repair

Special Considerations

1. Children and Adolescents: Higher risk of trap-door type fractures with muscle entrapment that may present with minimal external signs ("white-eyed" appearance) 2

2. Associated Injuries: Evaluate for:

   • Ocular injuries (3.9% of facial fracture patients) 6
   • Spinal injuries (0.9% of facial fracture patients) 6
   • Intracranial injuries (5.4% of facial fracture patients) 6

3. Imaging Pitfalls:

   • Head CT alone detects 95% of facial fractures in geriatric patients but often only partially images midface fractures 1
   • Missing the "missing muscle sign" on CT (absence of entrapped muscle in contiguous CT cuts) 2

Complications of Missed or Delayed Treatment

• Permanent diplopia and vision loss 2
• Muscle necrosis in entrapped tissues 2
• Cosmetic deformity and facial asymmetry 1
• Malocclusion and functional impairment 1
• Enophthalmos, telecanthus, and ptosis in naso-orbital-ethmoid fractures 1

Follow-up Care

• Post-surgical CT to confirm adequate reduction and fixation
• Ophthalmologic follow-up for patients with orbital involvement
• Physical therapy for mandibular function if TMJ involvement
• Monitoring for late complications (infection, malunion, hardware issues)

The management of missed facial fractures requires a multidisciplinary approach involving maxillofacial surgeons, neurosurgeons, ophthalmologists, and radiologists to achieve optimal functional and aesthetic outcomes.