Resident Manual of Trauma to the Face, Head and Neck

CHAPTER 3: Upper Facial Trauma

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.

Figure 3.3 Mucosa and bone are removed from the margins of the fracture fragments.

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

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