Bicoronal Approach Open Reduction and Internal Fixation of Midfacial Fractures
The bicoronal approach to an open reduction and internal fixation of multiple midfacial fractures is a method done to avoid incisional scars that may be visible on the face (AOCMF, 2018). The incision is made several centimeters posterior to the patient’s hairline. The placement of the incision depends on factors of patient’s hairline such as hair loss, receding hairlines, or specifically-shaped hairlines. The surgeon will incise from one ear to the other across the scalp, dividing the scalp into anterior and posterior planes (AOCMF, 2018). With multiple midfacial fractures, the bicoronal incision will allow exposure of the anterior cranial vault, forehead, and upper-middle sections of the facial skeleton. This procedure will require a surgeon who specializes in oral and maxillofacial surgery (OMFS). Usually, a representative from a surgical instrument manufacturer company, such as KLS, Biomet, Depuy Synthes, or Stryker, will be present in the operating room to help the surgical technologist, first assist, and surgeon use the manufacturer’s equipment. A bicoronal approach to an open reduction and internal fixation of multiple midfacial fractures is an invasive and lengthy OMFS procedure.
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Anatomy and Physiology of the Cranial and Facial Bones
There are 22 skull bones: 14 facial and 8 cranial. In table 1, the cranial and facial bones are listed. Some bones exist as pairs (listed in table 1). The skull functions as protection for the brain and structure for the face. The cranial bones house the brain while the facial bones lie under the facial structures to help maintain shape and support the facial structures (BCcampus, 2018).
|Cranial (8)||Facial (14)|
– Parietal (2)
– Temporal (2)
|– Nasal (2)
– Maxillary (2)
– Lacrimal (2)
– Zygomatic (2)
– Palatine (2)
– Inferior nasal turbinate (2)
Note. From SJVC STT33 Oral and Maxillofacial Procedures PowerPoint Slides
The facial structures supported by facial bones are the eyes, nose, mouth, and cheeks. The eyeballs and eye muscles are structured by the orbit (BCcampus, 2018). The nasal cavity in the interior of the nose and all the components that make it up. There is a bony portion called the nasal septum that divides the nasal cavity into halves. The nasal septum is composed of the ethmoid bone and vomer bone (BCcampus, 2018). The mouth portion of the face is formed by a series of bones. The roof of the mouth is a combination of the palatine bone and maxilla bone. The mandible is the only skull bone that is movable. The cheeks are characterized by the zygomatic bone (BCcampus, 2018). The zygomatic bone is also referred to as the malar bone. This bone is categorized as an irregular bone due to its shape. The main function of the zygomatic bone is to articulate with the maxilla, temporal, sphenoid, and frontal bone (BCcampus, 2018).
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The space where the brain inhabits is referred to as the cranial cavity. The cranial bones (frontal, occipital, sphenoid, ethmoid, parietal, and temporal) protect the brain, nerves, vessels, and other interior tissues in the cranial cavity (BCcampus, 2018). The cranial bones are made of two types of bones: irregular bones and flat bones (Seladi-Schulman, 2018). Irregular bones are exactly what they sound like. They are bones that are shaped in random, unorganized ways that do not fall under any other bone types. Flat bones are also exactly what they sound like. They are flat, thin, and sometimes slightly curved (Seladi-Schulman, 2018). The frontal bone is a flat bone that gives structure to the eye socket and forehead (Seladi-Schulman, 2018). The parietal bones are flat bones that are located bilaterally on the sides. The temporal bones are irregular and inferior to the parietal bones. The occipital bone is flat and found posteriorly. The sphenoid bone is irregular and found inferior to the frontal bone. The ethmoid bone is irregular and is part of the bone that makes up the nose bridge.
The primary cause of the patient having surgical intervention is multiple fractures of the facial and cranial bones. The patient has a variety of fractures present in his condition. He has a combination of linear, depressed, simple, and compound fractures. A linear fracture reflects a line that divides the bone without altering the bone itself (A.D.A.M. Inc., 2018). A depressed fracture is breakage of the bones that look as if the head is sunken in. Bones that are fractured in this way are typically caused by blunt forced trauma. The bones have been broken into multiple pieces and shattered, losing their shape and structure (A.D.A.M. Inc., 2018). A simple fracture is a complete break in the bone with the skin intact (A.D.A.M. Inc., 2018). A compound fracture is a breakage of the bone and damage to the skin which causes an opening of the skin (A.D.A.M. Inc., 2018).
Fractures to the cranial and facial bones can also easily cause head trauma to the deeper, soft tissue organs and parts of the head. There can be bruising from internal bleeding. Brain damage can also be expected due to physical impact, torn tissue, perforation from broken cranial bones, and/or internal bleeding (A.D.A.M. Inc., 2018). Some symptoms to head trauma are apparent and obvious to the eye. There may be bleeding from the ears and eyes (A.D.A.M. Inc., 2018). Bruising is a sign of internal bleeding. Pupil size may change from the normal size and become insensitive to light (A.D.A.M. Inc., 2018). Clear or bloody fluid may drip from the nose and ears (A.D.A.M. Inc., 2018). There may be vomiting, dizziness, and nausea (A.D.A.M. Inc., 2018). Redness and swelling are true signs of inflammation, infection, and damage (A.D.A.M. Inc., 2018). Other symptoms cannot be seen and must be professionally diagnosed by a medical provider. These symptoms may be more complicated to catch and realize. Confusion, convulsions, unbalanced body movements, headache, migraines, unconsciousness, abnormal speech, and restlessness are all symptoms of head injury that may be overlooked or mistaken (A.D.A.M. Inc., 2018). These symptoms may occur instantaneously or days after the injury. The patient may feel pain and discomfort right when the injury occurs or not feel anything until the damage is extremely severe and fatal (A.D.A.M. Inc., 2018).
Head Trauma First Aid
Head injuries and damage are very risky, and improper care may further injure the patient. Firstly, make sure the patient has a clear airway for breathing (A.D.A.M. Inc., 2018). Do not move or shift the patient until the head and neck are stabilized (A.D.A.M. Inc., 2018). Moving the head requires placing both hands on the sides of the head and beneath the shoulders (A.D.A.M. Inc., 2018). Adequate pressure may be applied to any sites of bleeding (A.D.A.M. Inc., 2018). Blood loss control is very crucial. If blood bleeds through the cloth or gauze being applied to bleeding sites, then do not remove that cloth or gauze. Place a new cloth or gauze over the old, soaked cloth or gauze and apply pressure (A.D.A.M. Inc., 2018). If there is vomiting, then arrange the patient to his or her side after head and neck stabilization. This prevents him or her from choking on his or her own vomit and keeps his or her airway clear for breathing and circulation (A.D.A.M. Inc., 2018). With any injury, one of the most critical things to do is to transport the patient to a medical facility for critical care. The patient’s chances of surviving his or her trauma significantly depends on how quickly he or she arrives at a trauma center once the injury has occurred. The optimal timing is for the patient to arrive within one hour. This is referred to as the golden hour. The golden hour is the first hour after a traumatic injury and is extremely vital to treating the patient’s life. The longer it takes to transport a patient to receive critical care, the lower the chances are for the patient surviving the traumatic injuries.
Safety Tips and Prevention of Cranial/Facial Bone Injuries
Most head injuries are caused by trauma such as motor vehicle collisions, falls, physical blunt forces, fights, and accidental events. Although not all injuries can be prevented, there are ways to prevent damage and safety precautions. Safety equipment such as hard hats, helmets, eye protection, and face guards can help prevent fractures and injury to the cranial and facial area. Wearing seatbelts and the usage of proper car seats may aid in motor vehicle collisions. Safe practice of driving also saves lives. Driving under the influence of drugs or alcohol threatens the life of the driver, passenger(s), and other people on the road. Even driving sober while sleepy or tired is dangerous. Walking on the sidewalk and using crosswalks may also save someone from getting hit by a car. Bicycle riding requires safety precautions too. Proper helmets and light-reflective clothing may stop a driver from hitting the biker. Following the bike lane and safe riding is very important. Not all head injuries are from fast moving vehicles or modes of transportation. A simple fall can cause major damage. Always make sure ladders are leveled and stable. Loose cords must be secured flat to the ground so that no one trips. Had rails for stairs and showers must be present if applicable. For babies and infants, head injuries are more easily done due to their cranial and facial bones not being fully developed. Their bones are softer. Rotating the baby’s sleeping position affects the baby’s head health. Sleeping on the same side of the head for a long period of time can lead to misshaped head and bruising (Seladi-Schulman, 2018). Switching arms when breastfeeding or bottle-feeding so that the baby’s head changes pressure points is also key (Seladi-Schulman, 2018). Tummy time is a specified time for babies to strengthen their core and neck muscles. This helps them be able to stabilize the weight of their heads and prevents whiplashing (Seladi-Schulman, 2018). Sport injuries are also very common causes. Always make sure to follow all safety precautions with any recreational activities.
The patient will initially come into the emergency department conscious or unconscious due to their head injury. If the patient is conscious, then the physician will examine him or her and ask about his or her symptoms. The physician will also ask about his or her medical history and how, where, when the injury occurred (Boston Children’s Hospital, 2018). The patient may also be asked about his or her name, the date, where he or she is, and if he or she remembers anything. This is to check for memory loss and cognitive abilities because of the head injury. If the patient is unconscious then these questions may be directed to family members, friends, or whoever comes in with the patient.
Computed tomography scans will be done to create detailed images of the patient’s brain and head (Boston Children’s Hospital, 2018). The beneficial factor of a computed tomography scan is that it provides visualization for bruised soft tissues, bleeding, and other soft tissue damages (Boston Children’s Hospital, 2018). This imaging test may help to rapidly point to the cause of bleeding, fracture sites, blood clots, contusions, and tissue inflammation (Boston Children’s Hospital, 2018).
Another x-ray diagnostic test is the magnetic resonance imaging test. This test is also a depiction of the brain and head. Magnetic resonance imaging uses radio waves, a computer, and extremely strong magnetic forces to create a comprehensive image of whatever body part the physician may want to diagnose (Boston Children’s Hospital, 2018). There is no radiation usage with a magnetic resonance imaging test.
The intracranial pressure may also be monitored via placement of a probe in the skull (Boston Children’s Hospital, 2018). Because of swelling and extra fluids that may be present during the trauma, the pressure inside the skull may be too high (Boston Children’s Hospital, 2018). This can be fatal to the brain’s condition. If the pressure is high, then a drain or shunt may be placed to lower the intracranial pressure (Boston Children’s Hospital, 2018).
There will be blood tests done for complete blood count, blood sugar tests, and blood type and screen (Mayo Clinic, 2018). It is important to know the patient’s blood type and levels for surgery. If there is a high level of blood loss during the trauma and/or during the surgical procedure, then the patient will receive blood from the blood bank. For this to go well, the correct blood must be given to the patient. The patient’s blood can tell the physician many things without direct verbal communication. For example, a high white blood cell count translates as presence of infection, inflammation, trauma, stress, allergies, or an immune system disorder (Mayo Clinic, 2018).
Another common test done is a chest x-ray to check the patient’s lungs and heart. This allows the physician to see medical problems related to the cardiopulmonary system. Chest x-rays may portray an abnormally large heart (Mayo Clinic, 2018). Fluid surrounding the lungs can also be visible through this diagnostic imaging test (Mayo Clinic, 2018). Congestive heart failure and disease may be identified at this time (Mayo Clinic, 2018).
An electrocardiogram may also be done to test the electrical activity of the heart (Mayo Clinic, 2018). This test uses soundwaves or ultrasound to create a dynamic image of the heart’s activity (Mayo Clinic, 2018). Cardiologists are able to read an electrocardiogram and distinguish heart problems and conditions. These heart specialists can also read the electrocardiogram and determine the signs for a heart attack. They know the wave patterns that lead to heart attacks. There is no radiation exposure with this test (Mayo Clinic, 2018). Electrocardiograms are considered noninvasive diagnostic tests (Mayo Clinic, 2018).
The possibilities of medications are massive, but some common ones that may be administered to control and prevent secondary injuries will be mentioned. Diuretics are drugs that may be given to decrease the level of fluid in the patient’s body (Mayo Clinic, 2018). This type of drug will make the patient urinate. The excreted fluids will help lower the patient’s brain pressure (Mayo Clinic, 2018). Anti-seizure drugs can also be administered to prevent seizures (Mayo Clinic, 2018). A seizure occurs when there is an unrestrained electrical disturbance in the brain. Seizures can cause permanent brain damage (Mayo Clinic, 2018). Anti-seizure drugs are to keep the brain safe and healthy. The physician does not want the patient to have any more brain damage than he or she may already have from the trauma. Another possible drug that may be given to the patient is a coma-inducing drug. The reason this type of drug may be administered is because brains in comas use less oxygen to operate (Mayo Clinic, 2018). This state may immensely help out the patient if his or her blood vessels cannot supply the brain with adequate levels of oxygen and nutrients. Increase intracranial pressure from the trauma may be the cause of suppressed blood vessels (Mayo Clinic, 2018).
- A.D.A.M.Inc. (2018). Skull Fracture. Retrieved December 5, 2018, from https://medlineplus.gov/ency/article/000060.htm
- AOCMF. (2018). Coronal Approach. Retrieved December 5, 2018, from https://www2.aofoundation.org/wps/portal/!ut/p/a1/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAwCTYEKIvEocDQnTr8BDuBoQEi_l35Uek5EtipkY55ScYW6fpRRalpqUWpRXqlRUDhjJKSgmIrVQNVg_Lycr30_Pz0nFS95PxcVQNsWjLyi0v0I1BV6hfkhkZUaSGAwBJYqzy/dl5/d5/L2dJQSEvUUt3QS80SmlFL1o2XzJPMDBHSVMwS09PVDEwQVNFMUdWRjAwMFE1/?approach=Coronal approach&bone=CMF&classification=&contentUrl=/srg/92/04Approaches/A70_Coronalapproach.jsp&implantstype=&method=&redfix_url=&segment=Midface&showPage=approach&treatment=
- BCcampus. (2018). The Skull. Retrieved December 5, 2018, from https://opentextbc.ca/anatomyandphysiology/chapter/7-1-the-skull/
- Boston Children’s Hospital. (2018). Head or Brain Injury | Testing & Diagnosis. Retrieved December 5, 2018, from http://www.childrenshospital.org/conditions-and-treatments/conditions/h/head-or-brain-injury/testing-and-diagnosis
- Mayo Clinic. (2018). Traumatic Brain Injury. Retrieved December 5, 2018, from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/diagnosis-treatment/drc-20378561
- Seladi-Schulman, J., PhD. (2018, May 24). Cranial Bones Overview. Retrieved December 5, 2018, from https://www.healthline.com/health/cranial-bones
- SJVC STT33. (2018). Oral and Maxillofacial Procedures [PowerPoint Slides].