Supraorbital wall fracture exploration, debridement and dural repair

Eyelid fractures are more common in war injuries, and are more common in traffic accidents and industrial accidents. Some of them must have early surgery, some can have advanced surgery, and some do not require surgery. Regardless of the type of surgery, the purpose is to: 1 protect life. 2 maintain the function. 3 restore the appearance. Treatment of diseases: pediatric epidural abscess acute subdural hematoma Indication Exploration, debridement and dural repair of the superior wall fracture are applicable to: The upper edge of the iliac crest and the upper wall of the iliac crest may involve the anterior cranial fossa and frontal sinus. Contraindications The wounded are in a state of shock and coma, and the brain has serious injuries. When life is dying, life-saving is the mainstay, and surgery is not suitable for the time being. Preoperative preparation 1, eye examination There is a history of frontal trauma, and there is a depression in the early injury, which can be covered later due to edema and bleeding depression. The degree of depression in the upper part of the sputum varies from person to person, depending on the size of the frontal sinus. The sinus of the frontal sinus is obvious, and the depression of the bone is obvious. The small frontal sinus is not obvious. When the fracture involves the attachment of the trochlear and superior oblique muscles, the casualty may have a temporary diplopia. If the frontal muscle is involved and the diaphragm is lifted, the injured person may have ptosis. When there is a hemorrhage or other mechanical disorder in the eyelid, which makes the eyeball difficult to look up, it is easy to be misdiagnosed as a popliteal burst fracture. Separate the eyelids with a sputum hook, and the eyeball can be rotated upwards to make a differential diagnosis. 2, nasal examination Check nasal fractures, nasal mucosal injury, nosebleeds (bleeding when nasal mucosa tears), and check the frontal sinus and paranasal sinus injury, pay attention to the presence or absence of cerebrospinal fluid rhinorrhea. 3, neurosurgical examination The fracture of the dome should be treated with neurosurgery, regardless of whether the frontal bone is damaged or damaged. Severe fractures, brain tissue can be prolapsed, causing traumatic brain swelling; light dural rupture, causing cerebrospinal fluid leakage. If the injury affects the supracondylar sacral fissure, there may be supracondylar fissure syndrome, eye movement disorder, sensation diminished, and good vision; if the apex of the sac is affected, the optic nerve is damaged, the apical syndrome may occur, vision loss, combined with supracondylar fissure Syndrome. 4, imaging examination Including X-ray, CT, magnetic resonance examination, etc. X-ray plain film, whether it is normal or lateral, is difficult to detect bone destruction, because these fractures are often accompanied by local edema and hematoma; three-dimensional CT or magnetic resonance imaging is valuable, can clearly show bone and soft tissue The condition of the injury, whether the frontal sinus is involved, whether the fracture piece affects the anterior cranial fossa. Surgical procedure 1. Upper wall fracture debridement (1) Under the eyebrow arch, make a skin incision along the entire length of the upper edge of the iliac crest, cut the muscle and tendon fascia, cut the septum and separate it, find the fracture site, or make a coronal incision in the forehead. After opening the flap and the bone flap, the anterior horn of the lateral ventricle was puncture (2 cm in front of the 2 cm midline of the coronal suture), and 20 ml of cerebrospinal fluid was released, and the brain collapsed, which was conducive to operation. (2) Slowly lift the dura mater along the base of the skull to expose the dome. (3) If there is broken bone from the periosteum, take it out with a flat file. (4) Carefully lift the broken bone piece that has not been detached from the periosteum and use a blunt-head separator or a bone opener to reset it. (5) The fracture piece of the reduction can generally be stored in place. For those who can not maintain the in situ, a 5-0 chrome gut can be taken, and the periosteum covering the broken bone piece can be sutured with the adjacent periosteum to repair the tidy (can also use stainless steel wire). (6) If it is observed that the optic nerve is swollen, it is feasible to cut the fascia at the optic nerve hole to reduce the pressure. (7) After repairing the upper wall of the iliac crest, suture the septum, orbicularis oculi and frontal fascia with 5-0 chrome gut layer, suture the skin with 3-0 black silk thread, and suture intermittently. The distance between each line is 3 mm. (8) Place a rubber drainage strip at the top of the temporal side to reach the fracture. Especially for wounds that have oozing and infection. If the condition is good, the drainage strips should be taken 24 hours after surgery. 2. Dural repair In severe cases, the frontal bone fragments tear the dura mater, which can cause cerebrospinal fluid leakage. In the fresh case, after finding the dural wound in the debridement process, a large fascia 1cm larger than the wound was taken, and a semicircular blunt-arc needle was used to sew on the dura mater. Thereafter, the broken bones were resected, and the layers were sutured separately or transplanted with a pedicled aponeurosis. 3. Repair of dura mater and bone defect in the temporal margin The dome and the margin of the iliac crest, bone loss, brain swelling, cerebrospinal fluid leakage, repair method is to take Tantalum tablets as a substitute. There is no cytotoxic reaction, but it does not tolerate any infection, either low or low. The surgical procedure is as follows: (1) A craniotomy incision in the forehead. (2) Find the dura mater with rupture and defect in the anterior cranial fossa. (3) Take the defect model, and cut the bracts according to their size and shape. The bracts are 0.25cm thick, and the holes are punched around the clams. Holes are also drilled in the corresponding parts of the meningeal defect area, using stainless steel wire and nylon. The thread or the first thread is passed through and ligated one by one, and then the layers of tissue and skin are layered. (4) For the defect margin, take the appropriate bone tissue, cartilage or silica gel as the graft, smooth it with a bone chisel, use a round head to chisel the transplant bed and transplant the hole, and use a stainless steel wire to ligation one by one. fixed. complication 1. Due to the injury, the anterior lobes of the brain have a foreign body piercing leading to brain abscess, which must be treated with craniotomy, otherwise it can cause serious consequences. The diagnosis of cerebrospinal fluid rhinorrhea is difficult, and the X-ray is difficult to display. A reliable method is to take cerebrospinal fluid drainage for glucose test. The content per 100ml exceeds 30mg. It has been thought to be complicated by meningitis in the past. It has been rare in recent years, so it is generally followed by conservative treatment. The patient is in bed, the head is raised 60°, the patient is not allowed to sneeze, the neurosurgery consultation is required, the antibiotic treatment is strengthened, the fracture is reset, but the nasal cavity is not filled. If necessary, the damaged dura mater can be repaired with various materials such as fascia lata, sclera, etc., without craniotomy. 2. The posterior hematoma of the ball can oppress the optic nerve and produce posterior optic neuritis, resulting in loss of vision. 3. Local infection can seriously affect the survival of the graft bone, and special attention must be paid to prevent infection.