Treatment depends on the pattern of the fracture. Dislocations or displaced fractures of the nasal bones need to be repositioned accurately. If a deformity is to be avoided, treatment is best carried out by facial, ENT or plastic surgeons.

Once diagnosed, the fragment needs repositioning and sometimes fixation with wires or external fixation.

Faciomaxillary surgeons are usually responsible for treating these fractures, which may require internal fixation, interdental wiring (Fig. 10.5) or dental treatment.

Maxillary fractures were divided into three main types by Le Fort, a French surgeon of the early 20th century who broke the faces of corpses with a cudgel to study the fracture lines. His classification is as follows (Fig. 10.6):

All maxillary fractures require urgent attention because the middle third of the face may be unstable and can fall backwards to obstruct the airway. Tracheostomy may be needed.

Because facial injuries are, by definition, head injuries, they are often seen in unconscious patients with brain damage. Always look at the maxillary antrum on the skull radiograph of patients with head injuries; if it is opaque, it is probably full of blood and there is a maxillary fracture.

A more accurate assessment is possible with the Glasgow coma scale (Table 10.1).

Eye signs. Raised intracranial pressure impairs the function of the iris on the side of the lesion. The size of the pupil and its reaction to light is recorded as a sign of intracranial bleeding. A fixed dilated pupil indicates an urgent problem.

Cerebral oedema follows any major head injury and can be reduced with diuretics, such as a mannitol infusion, or by controlled hyperventilation with the patient paralysed and ventilated. This treatment is best conducted in a dedicated neurosurgical unit.

The classic story of an extradural haematoma is the patient who walks into hospital after a minor head injury and gives a clear, sensible history. The radiograph shows a small temporal fracture. The patient is discharged home, lapses into unconsciousness and is found dead the following morning. This is a constant nightmare for those who treat head injuries. Extradural haemorrhage can be caused by damage to the middle meningeal artery. As the artery bleeds, a haematoma develops and the brain is gradually compressed. The level of consciousness slowly deteroriates until the patient becomes unrousable. If the diagnosis is made soon enough, the haematoma should be evacuated through a burr hole and the artery tied.

In days gone by, it was safer to drill burr holes than risk missing an extradural bleed but with the advent of CT scanning this complication should not take the surgeon by surprise. CT scanning is now an essential part of the management of head injuries and will show areas of brain damage as well as extradural haematomas and the position of the falx (Fig. 10.10).

Although these investigations are reliable, ligation of the middle meningeal artery can be life saving and the correct site for the burr hole should be memorized by everyone who may be exposed to the treatment of patients with an extradural haematoma. The middle meningeal artery crosses the pterion, which lies two fingers above the zygoma and three fingers behind the orbit (also see Fig. 10.11). The artery can be found either by exposing the fracture and nibbling away the edges of the skull, or by making a burr hole at the pterion itself.

Acute subdural haematomas usually accumulate slowly and cause more gradual loss of consciousness than an extradural haematoma. The cause is the gradual enlargement of a blood clot beneath the dura. As the clot liquefies, serum is drawn into its centre and it gradually increases in size. A chronic subdural haematoma is not a clinical emergency but any patient whose level of consciousness deteriorates in the weeks following a head injury should have a CT scan.

The fact that a patient appears alert and oriented does not exclude brain damage. It is by no means uncommon to find that patients who have been unconscious for only a few minutes are unable to recall events for several days after their accident.

The period of post-traumatic amnesia is a reliable guide to the severity of the head injury:

Cerebrospinal fluid (CSF) can leak from nose or ears if the fracture enters the subdural space. The leak usually ceases spontaneously but if it is profuse or persists for more than 2 weeks the defect in the dura may need to be patched with fascia.

The long-term results of brain damage include continued neurological deficits, personality change, epilepsy, and serious physical disabilities requiring long-term care and rehabilitation.