Skull and Face Fractures

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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1 Skull and Face Fractures

Anatomy of the Skull and Facial Skeleton

image

Anterior and Lateral Aspects

Skull and Facial Bones

• Neurocranium (cranial vault): frontal, ethmoid, sphenoid, temporal, parietal, occipital bones
• Viscerocranium (facial skeleton): maxilla, nasal, lacrimal, zygomatic, vomer, palatine, mandible bones
• Base of skull: occipital, sphenoid, temporal, palatine, maxilla bones
• Most of the bones of the skull are flat (type), with inner and outer “tables” (layers) of compact (cortical) bone surrounding trabecular bone and marrow space (diploë).
• Emissary veins connect diploic spaces with cerebral veins/sinuses (intracranial) and scalp and superficial veins: potential route for intracranial spread of infection.
• Sutures

image Thin fibrous joints found only between skull and facial bones
image Produced by intramembranous ossification
image May be indented (e.g., coronal suture), planar, or squamous

• Most cranial and facial bones are pharyngeal arch derivatives.
• Occipital, sphenoid, and ethmoid bones modified vertebrae and developed around notochord.

Scalp Layers

• Skin: thin (thicker in occipital region); well supplied with arteries, veins, lymphatic drainage
• Connective tissue: dense subcutaneous layer with rich neurovascular supply
• Aponeurosis of occipitofrontalis muscle, with lateral attachments of temporoparietalis and posterior auricular muscles (collectively the epicranius)
• Loose areolar tissue: allows aponeurosis movement; danger space for infections owing to emissary vein drainage into diploic spaces of cranium
• Pericranium: external periosteum, fibrously fused to sutures

Neurovascular Supply

image

Superficial Arteries and Veins of Face and Scalp

Arteries of Face and Cranium

External Carotid (Proximal to Distal)

• Lingual: to tongue and floor of mouth, may have common origin with facial
• Facial: superior, inferior labial, lateral nasal, angular branches; to anteromedial face
• Posterior auricular: posterior to ear and mastoid regions
• Occipital: lateral aspect of head behind ear
• Maxillary: deep auricular, anterior tympanic, deep temporal, middle meningeal, inferior alveolar, posterior alveolar, infraorbital branches; to deep face
• Transverse facial: lateral face, parallel to parotid duct
• Superficial temporal: anterior, lateral aspect of crania

Internal Carotid

• Anterior cerebral

image Ophthalmic artery: supraorbital, supratrochlear, anterior and posterior ethmoid branches

• Middle cerebral

Other

• Vertebral: basilar, pontine, posterior and inferior cerebellar, posterior cerebral, posterior communicating branches
• Facial: face richly perfused, with anastomoses across midline, anterior to posterior, and between intra- and extracranial branches
• Kiesselbach’s area/plexus: anterior inferior nasal septal region, anastomoses between superior labial (facial), sphenopalatine, palatine (maxillary), and anterior ethmoid (anterior cerebral via ophthalmic) branches; frequent site of epistaxis

Venous Drainage

Internal Jugular Vein

Common Facial Vein

• Tributaries

image Facial: superior, inferior labial, deep facial, external nasal, angular ← orbital, inferior and superior palpebral
image Submental
image Retromandibular: superficial temporal, middle temporal, maxillary

• Pterygoid venous plexus of deep face connects with deep facial and maxillary veins and with cavernous sinus via connections through foramen ovale.
• Facial veins have no valves: potential route for spread of infection from face and deep venous sinuses to intracranial sinuses (e.g., cavernous sinus via angular and orbital veins)
• Common facial connects to external jugular vein

External Jugular Vein

• Drains posterior auricular
image

Cutaneous Nerves of Head and Neck

Innervation of the Head and Neck

• Cranial nerve deficits may be associated with specific regional fractures, trauma
• Olfactory (I): special somatic sensory to superior nasal cavity; foramina: cribriform plate of ethmoid; intranasal CSF leakage, anosmia with ethmoid fracture
• Optic (II): foramen–optic canal (sphenoid)
• Oculomotor (III), trochlear (IV): motor to extraocular muscles, travel through cavernous sinus, superior orbital fissure (sphenoid bone), and orbit
• Trigeminal nerve (V): sensory to most of face and head, superficial and deep, including sinuses and supratentorial dura; motor to muscles of mastication, tensor palati, and tensor tympani

image Ophthalmic division: foramen—superior orbital fissure (sphenoid bone)
image Maxillary division: foramen rotundum (sphenoid bone)
image Mandibular division: foramen ovale (sphenoid bone)

• Abducens (VI): runs along clivus and through cavernous sinus and superior orbital fissure to lateral rectus; clival fracture can cause lateral gaze paralysis
• Facial (VII)

image Supplies muscles of facial expression and stapedius
image Carries visceromotor fibers to lacrimal and submandibular and sublingual salivary glands
image Taste afferents for anterior 2/3 of tongue
image Exits stylomastoid foramen (temporal bone)

• Acousticovestibular (vestibuloacoustic, auditory) (VIII): from cochlea and vestibular apparatus (labyrinth) in temporal bone; nerve enters internal acoustic meatus (temporal bone)
• Glossopharyngeal (IX): taste and common sensation from posterior third of tongue and tonsillar fossa; exits jugular foramen (between temporal and occipital bones)
• Vagus (X): motor to palate, pharynx and larynx, thoracoabdominal viscera; exits jugular foramen (between temporal and occipital bones)
• (Spinal) accessory (XI): motor to sternomastoid and trapezius muscles; exits jugular foramen (between temporal and occipital bones)
• Hypoglossal (XII): motor to tongue muscles except for palatoglossus (X); exits hypoglossal canal (anterior supracondylar occipital bone)
• Cervical nerves

image No C1 dermatome exists.
image C2 spinal nerve: sensory to skull, skin from vertex down, infratentorial dura, parotid (auriculotemporal nerve), and infratemporal skin
image C3 spinal nerve: sensory to suboccipital region

Clinical Correlates

image

Compound Depressed Skull Fractures

Skull Fractures

Classification

• Linear: fracture line is distinct
• Comminuted: multiple fragments, may be depressed with compression of dura and brain (image)
• Basilar: in skull base
• Diastasis: fracture along a suture

Compound

• A compound fracture is any fracture communicating with scalp laceration, sinuses, or middle ear.
• Depressed compound fractures require surgical treatment.

Middle Meningeal Artery

• Underlies sphenoid, parietal, temporal bones
• May be lacerated with fractures at pterion, resulting in epidural hematoma

Facial Fractures

• Nasal fractures are most common (3rd most common fracture overall).
• Blowout fracture of orbit

image Pressure of direct blunt trauma to eye fractures superior maxilla.
image Entraps orbital fat, inferior rectus or inferior oblique in antrum
image Impairs upward gaze

image

Mid-face Fractures

Mid-face Fractures

• Consequence of high-energy impact with mid-face (e.g., motor vehicle accident)

Le Fort Classification

• I: horizontal detachment of maxilla along nasal floor
• II: pyramidal fracture of maxilla, including nasal bones, antra, infraorbital rims, orbital floors
• III: pyramidal fractures as in II, with both zygomatic bones; may be accompanied by airway problems, nasolacrimal obstruction, CSF leakage
image

Zygomatic Fractures

Zygomatic Fractures

• Trauma to cheek can disrupt zygomatic articulations with frontal, maxilla, sphenoid, and temporal bones.
• Frontal and maxillary suture line fractures are common, with displacement inferiorly, medially, or posteriorly.
• Displacement of canthic ligament with lower margin of orbit may be associated with ipsilateral ocular and visual changes and diplopia.
• Hyphema (anterior chamber blood from hemorrhage) from associated eye impact
image

Mandibular Fractures

Mandible Fractures

• Second most commonly fractured facial bone (after nasal)
• Multiple fractures are common (50%), favored by U shape and bilateral articulations
• Most common sites are cuspid (canine) and 3rd molar regions.
• Ecchymosis (blood leakage) is common in loose tissues of floor of mouth.

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