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CHAPTER 3: Upper Facial Trauma

Resident Manual of Trauma to the Face, Head, and Neck

Figure 3.3

Mucosa and bone are

removed from the

margins of the fracture

fragments.

removed, and a thin layer of the underlying bone is resected with a

diamond bur (Figure 3.3). The fracture fragments are fixed in place with

a series of miniplates and square plates.

2. Posterior Wall Fractures

Management of posterior wall fractures is the most controversial of all

the fracture sites. The major issue is whether the fragments are dis-

placed. With the advent of fine-cut CT scanning, this dilemma is more

easily resolved.

Linear fractures can be safely observed. The detection of displacement

as well as an idea of the patency of the frontonasal duct can be deter-

mined by making a small trephine hole in the sinus floor through the

upper lid and passing an angled telescope through the trephine hole.

Posterior wall displacement as well as the presence of a CSF leak can be

determined.

If any doubt concerning posterior wall displacement exists, frontal sinus

exploration is indicated. This is usually done through a coronal scalp

incision, then creating an osteoplastic bone flap of the anterior wall of

the frontal sinus. A clear view of the interior of the sinus is obtained,

and any disruption of the posterior wall is identified. If a CSF leak is

seen, the limits of the anterior fossa dural rent are exposed by removing

posterior wall bone. The dural tear is closed with interrupted sutures,

and the area is reinforced with a patch of fascia lata or temporalis fascia

(Figures 3.4 and 3.5).

If an area of bone greater than 2 centimeters in diameter is removed,

the anticipated sinus drillout and obliteration with fat are abandoned,

and a frontal sinus cranialization procedure is performed. If fat grafting