Multiple fractures of the cranial vault and facial skeleton: clinical guidelines

List of Abbreviations

МПМиЛЧ - multiple fractures of the neurocranium and viscerocranium

TMJ - temporomandibular joint

UZF - upper facial zone

ДТП - motor vehicle accident

SSSI - surgical site infections

ПЖК - subcutaneous adipose tissue

MFR — maxillofacial region

ЧЛХ - maxillofacial surgeon

ЧМТ - traumatic brain injury

ЧЛТ - craniomaxillofacial trauma

GIT - gastrointestinal tract

PT – physical therapy

MFZ - middle facial zone

МСКТ - computed tomography of the brain and facial bones

КЛКТ - cone-beam computed tomography

ТРГ - lateral cephalogram

OPG - orthopantomography

МРТ - magnetic resonance imaging of the facial skeleton and brain

LFZ - lower facial zone

ПАП - perioperative antibiotic prophylaxis

Terms and Definitions

Anterograde amnesia – loss of memory for events, experiences, and facts occurring in the period following the acute phase of the illness, often against the background of lingering impaired consciousness from the acute stage.

Congrade amnesia – complete or partial loss of memory for events of the acute phase of the illness (the period of impaired consciousness).

Retrograde amnesia – loss of memory for impressions and events preceding the acute period of the illness or injury.

Anisocoria – a condition characterized by unequal pupil sizes, sometimes accompanied by slight pupillary distortion.

Intraoral approach – a type of surgical approach performed by sequential incision of the oral mucosa, periosteum, and sometimes deeper layers of soft tissue to visualize bone fragments.

Oral hygiene – a set of measures aimed at removing food debris and dental plaque, and reducing dental deposits using hygiene products.

Eye divergence – divergence of the visual axes of the right and left eyes.

Evidence-based medicine – an approach to medical practice in which decisions regarding preventive, diagnostic, and therapeutic interventions are made based on available evidence of their efficacy and safety, and such evidence is searched, compared, synthesized, and widely disseminated for patient care.

Closed fracture of the mandible – a type of fracture in which the fracture line does not communicate with the external environment through a skin wound, a wound (tear) of the oral mucosa, or through the periodontal space of a tooth.

Instrumental diagnostics – diagnostics utilizing various devices, apparatus, and instruments for patient examination.

Laboratory diagnostics — a set of methods aimed at analyzing test material using various specialized equipment.

Medical intervention – kinds of medical examinations and/or medical manipulations, as well as artificial termination of pregnancy, performed by a medical worker or other employee authorized to carry out medical activities in relation to a patient, affecting the physical or mental state of a person, and having a preventive, diagnostic, therapeutic, rehabilitative, or research orientation.

Medical worker – a physical person who has a medical or other education, works in a medical organization, and whose labor (job) duties include the implementation of medical activities, or a physical person who is an individual entrepreneur directly engaged in medical activities.

Fracture line – the representation of the fracture plane on a radiograph.

External approach – a type of surgical approach performed by sequential incision of the skin, subcutaneous adipose tissue, and deeper layers of soft tissue to visualize bone fragments.

Osteosynthesis – the joining of bone fragments in fractures or osteotomies during surgery.

Extra-focal osteosynthesis – osteosynthesis in which the fixation device is located outside the fracture line.

Closed osteosynthesis – osteosynthesis without incision of soft tissues in the fracture area.

Open osteosynthesis – osteosynthesis with incision of soft tissues in the fracture area.

Focal osteosynthesis – osteosynthesis in which the fixation device crosses the fracture line.

Open fracture of the mandible – a type of fracture in which the fracture line communicates with the external environment through a skin wound, a wound (tear) of the oral mucosa, or through the periodontal space of a tooth.

Lumbar puncture – puncture of the subarachnoid space of the spinal cord at the LII-LIV level to obtain cerebrospinal fluid.

Working group – two or more individuals of the same or different professions working together and in coordination to develop clinical guidelines, and bearing joint responsibility for the results of this work.

Reduction of fragments – a procedure aimed at aligning bone fragments in a fracture or following an osteotomy during surgical treatment.

Positive loading test – the appearance of sharp pain in the fracture area due to fragment displacement and irritation of the damaged periosteum when pressure is applied to a knowingly undamaged area of the jaw.

Condition – changes in the body arising due to the impact of pathogenic and/or physiological factors and requiring medical care;

Syndrome – a set of symptoms sharing a common etiology and pathogenesis.

Thesis – a proposition whose truth must be proven by an argument or refuted by an antithesis.

Level of evidence – reflects the degree of certainty that the estimated effect of a medical intervention is true.

Grade of recommendation – reflects not only the degree of certainty in the reliability of the intervention effect, but also the degree of certainty that following the recommendations will bring more benefit than harm in a specific situation.

Surgical intervention – an invasive procedure that may be used for diagnostic purposes and/or as a method of treating diseases.

Surgical treatment is a method of treating diseases by dissecting and/or joining tissues during a surgical operation.

Epiphyseal separation (epiphyseolysis) is a disruption of bone integrity along a line that completely or partially passes through the cartilaginous epiphyseal plate (growth plate).

Greenstick fracture (subperiosteal fracture) is a transverse break of the cortical layer on one side of the jaw without a fracture of the opposite cortical layer.

Jaw immobilization is the fixation of fragments in the correct position for the period necessary for their fusion (consolidation), i.e., until callus formation.

Clear consciousness is the complete preservation of consciousness with adequate reactions to the environment. The main signs are alertness, orientation, and contact with the patient.

Obnubilation (dullness) is a disorder of consciousness characterized by limited verbal contact against the background of an elevated threshold of stimulus perception and decreased intrinsic activity. Obnubilation varies in depth: moderate and deep.

Sopor is the suppression of consciousness with the preservation of coordinated protective reactions and eye-opening in response to stimuli.

Coma is the shutdown of consciousness with the complete loss of perception of the environment and oneself. According to severity, coma is subdivided into moderate, deep, and terminal (apallic).

A child is a human being during childhood (until reaching the age of majority — 18 years).

Polytrauma is a severe or extremely severe associated or multiple trauma accompanied by acute impairment of vital functions, requiring surgical and resuscitation measures.

Associated trauma is the simultaneous damage to tissues or organs of two or more anatomical regions of the body (head, chest, abdomen, spine, limbs, etc.).

Combined trauma refers to injuries caused by different damaging factors.

Standard: generally accepted principles of diagnosis and treatment that can be considered as mandatory therapeutic tactics (efficacy confirmed by multiple randomized trials, meta-analyses, or cohort clinical studies).

Recommendation: therapeutic and diagnostic measures recommended for use by the majority of experts on these issues. Can be considered as treatment options in specific clinical situations (efficacy confirmed by individual randomized trials or cohort clinical studies).

Option: therapeutic or diagnostic measures that may be useful (efficacy confirmed by the opinion of individual experts in specific clinical cases).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Multiple trauma is an injury resulting in two or more soft tissue and/or bone injuries within a single anatomical region [1, 2].

Craniomaxillofacial (craniofacial) trauma is damage to the cranial vault and/or brain combined with trauma to the facial skeleton [3, 12, 21, 47, 69].

Traumatic brain injury (TBI) is damage to the skull, brain, meninges, blood vessels, and/or cranial nerves, accompanied by clinical symptoms and, in most cases, morphological changes. A clear history of trauma is extremely important.

Skull base fracture is damage to the skull base with the development of a symptom complex characterized by a violation of the anatomical integrity of the skull base and functional disorders.

Skull base fractures include fractures of the orbital surface of the frontal bone, the petrous part of the temporal bone, the articular process or squamous part of the occipital bone extending to the foramen magnum, the cribriform plate, and the sphenoid bone.

Depressed skull fracture: a skull fracture in which bone fragments are displaced by more than the thickness of the adjacent bone.

The facial skeleton is formed by six paired bones (maxilla, inferior nasal concha, lacrimal, nasal, zygomatic, and palatine bones) and three unpaired bones (mandible, hyoid bone, vomer).

Maxillofacial injuries are accompanied not only by significant damage to this area with pronounced morphofunctional disorders, but can also be characterized by consequences associated with delayed development and growth of facial and jaw tissues, as well as other facial bone structures, carrying a high risk of post-traumatic deformities.

Associated injuries are generally classified as the most severe type of trauma, causing the onset and development of the "mutual aggravation syndrome," which worsens the course of the injury.

In multiple mandibular fractures, the displacement of fragments appears chaotic. In reality, it follows specific patterns and depends entirely on the pull of the muscles attached to them, the weight of the fragment, the direction of the traumatic force, the localization of the fracture line, and the bevel (angle) of the fracture plane. Intermediate fragments may turn inward, override each other, pull upward, or shift downward. This may be accompanied by a rupture of the mucosal membrane of the alveolar process (part) of the jaw and a marked malocclusion. Concomitant tooth fractures and dislocations may also occur. Bone fragments often become freely displaced due to muscle rupture. Such fractures frequently lead to significant soft tissue injuries of the face and/or associated TBI [5, 16, 38].

Due to anatomical, topographical, and functional features of location and interaction with other parts of the skull, midface injuries are most often multiple and associated, which is an indication for a comprehensive treatment approach for this type of injury [1, 11, 46, 60]. The upper boundary of the middle third of the facial skeleton is an arbitrary line drawn from the frontozygomatic suture on one side to the frontozygomatic suture on the opposite side, passing through the frontonasal and frontomaxillary sutures, while the lower boundary is the occlusal plane of the maxillary dental arch. When the nasal bones, ethmoid bone, and other midface bones are simultaneously damaged, these injuries are grouped under the concept of midface trauma [6, 13, 14, 15, 24, 39].

Associated and multiple maxillofacial injuries belong to the most severe types of trauma, and their clinical manifestations are caused by the development of the mutual aggravation syndrome, which worsens the course of the traumatic disease and leads to a significant increase in complications. In associated trauma, facial bone injuries may be diagnosed untimely. Associated maxillofacial injuries have an especially severe clinical course against the background of traumatic brain injuries [3, 9, 15, 34, 46].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Facial bone fractures account for 3.0–4.0% of the total number of injuries involving bone damage [105, 106].

Severe associated trauma accompanied by multiple facial bone fractures is usually the result of road traffic accidents (7%) and falls from a height. Occupational and sports injuries are significantly less common [105, 106].

Mandibular fractures are the most frequent at 65.1%, followed less frequently by fractures of the zygomatic bone and zygomatic arch at 12.8%; nasal bones at 3.8%; and the maxilla at 2.0% [105, 106].

Facial bone fractures are classified as open and closed. Jaw fractures within the dental arch are considered knowingly open.

The most common causes of skull bone injuries are low- and high-kinetic traumatic impacts resulting from motor vehicle accidents, falls from heights exceeding standing height, blows to the head, direct injury by traumatic objects, and gunshot wounds.

Injuries occurring during various periods of childhood are classified as childhood traumatism [8, 16, 22, 42].

The nature of maxillofacial injuries depends on the child's age. Unlike an adult, a child has a lower body weight, lesser height, well-developed subcutaneous adipose tissue, and, in younger age groups up to 6–7 years, a relatively larger cranial vault compared to older children, which "overhangs" the maxillofacial region, thereby protecting it and mitigating the impact of the traumatic force. Domestic injuries rank first in prevalence among children. Road traffic accidents rank second. As the child grows older, sports, automobile, and bicycle accidents become more common, increasing the incidence of maxillofacial trauma combined with neurotrauma [3, 19, 26, 32, 34, 37].

The risk of maxillofacial soft tissue and bone injuries and dental trauma increases in children in the age group over 6 years. For older children, especially adolescents over 12 years of age, the structure of trauma causes shows an increasing frequency of falls from a height, motor vehicle accidents, falls from scooters and bicycles, as well as violent trauma resulting from assaults. Children in this age group are more likely to experience dental and maxillofacial soft tissue and bone injuries, as well as extensive soft tissue injuries of the face [7, 8, 20, 25, 27]. This is also due to certain anatomical and physiological features of the maxillofacial area at various childhood periods; for example, with age, the amount of subcutaneous adipose tissue on the face decreases, the size of the buccal fat pad decreases, the strength of facial bones decreases due to a relative increase in their mineral component, and the presence of tooth germs also weakens the strength of the jaw bones, etc. [6, 8, 16, 19, 27, 23].

Depressed skull fractures occur as a result of a fall from a height, as well as direct contact impact of a wounding object on the surface of the head.

When the duration of the wounding force exceeds 200 ms, along with damage to the cranial bones, compression of the soft tissues of the head occurs, which can result in the formation of skin necrosis foci. Depressed fractures occur more frequently in areas of thinner bones (the squamous part of the temporal and occipital bones, the outer walls of the paranasal sinuses.

In many victims, depressed skull fractures are accompanied by epidural, subdural, and intracerebral hematomas, and foci of brain contusion.

1.3 Epidemiology of the Disease or Condition

In the overall structure of head injuries, the proportion of all skull bone fractures ranges from 2 to 20%, while fractures of the cranial base are a rarer injury, accounting statistically for 4% of diagnosed severe traumatic brain injuries [2, 12].

In 32-59% of patients, the fracture line extends from the cranial vault to the base. Young, physically active individuals and representatives of socially disadvantaged populations predominate among patients. The male-to-female ratio is approximately 3.5:1 [12, 70].

In children, due to the high plasticity of bone structures, trauma is rarely diagnosed. Craniomaxillofacial trauma is often accompanied by severe brain contusion, increasing mortality, especially in cases of combined skull fractures involving the base and vault [75, 76].

In combined craniomaxillofacial trauma (CMFT), mortality in children, according to various authors, ranges from 7.1 to 22% [3, 48, 49, 51].

In the structure of traumatic brain injury surgery, depressed fractures account for 6-10% of operated patients. In Moscow, 90-110 victims with depressed skull fractures are operated on annually [12].

1.4 Features of Coding the Disease or Condition

S02.0 – Fracture of vault of skull

S02.1 – Fracture of base of skull

S02.2 - Fracture of nasal bones

S02.4 - Fracture of zygomatic bone and maxilla

S02.6 - Fracture of mandible

S02.7 - Multiple fractures of skull and facial bones

S02.70 - Multiple fractures of skull and facial bones, closed

S02.71 - Multiple fractures of skull and facial bones, open

S02.8 - Fractures of other facial and skull bones

S02.80 - Fractures of other facial and skull bones, closed

S02.81 - Fractures of other facial and skull bones, open

S02.9 - Fracture of unspecified part of skull and facial bones

S02.90 - Fracture of unspecified part of skull and facial bones, closed

S02.91 - Fracture of unspecified part of skull and facial bones, open

S07 - Crushing injury of head

1.5 Classification of the disease or condition

I. Mechanical injuries of the upper, middle, lower, and lateral zones of the face

By localization:

A. Soft tissue injuries with damage to:

a) the tongue

b) the salivary glands

c) major vessels

d) major nerves

B. Bone injuries:

a) of the mandible

b) of the maxilla

c) of the zygomatic bones

d) of the nasal bones

e) of two or more bones

II. By wound characteristics:

a) through-and-through,

b) penetrating (blind),

c) tangential,

d) penetrating into the oral cavity, nasal cavity, maxillary sinus

e) non-penetrating into the oral cavity, nasal cavity, maxillary sinus

f) with tissue defect – without tissue defect

g) primary – concomitant

h) single – multiple

i) isolated – combined.

III. By mechanism of injury

A. Firearm injuries:

a) bullet,

b) shrapnel,

c) ball,

d) flechette.

IV. Combined injuries

V. Burns

VI. Frostbite

By type of injury:

• linear (longitudinal, transverse, oblique),

• comminuted,

• depressed.

By location:

• posterior cranial fossa fractures,

• middle cranial fossa fractures,

• anterior cranial fossa fractures.

By the affected bones (eponymous):

• frontal

• parietal

• occipital,

• temporal,

• sphenoid,

• ethmoid.

By the presence or absence of bone displacement:

• non-displaced fracture,

• displaced fracture.

Localization of facial bone fractures:

1. Upper third of the facial skeleton (anterior wall of the frontal sinus, orbital roof (orbital vault)

2. Middle third of the facial skeleton (nasoethmoidal complex fracture, nasal bone fracture (isolated), zygomaticomaxillary complex fracture, high-level maxillary fracture, mid-level maxillary fracture, low-level maxillary fracture, fracture of the maxillary alveolar process.

Comments: Nasal bone fractures are addressed in separate clinical guidelines (otorhinolaryngology), as are orbital fractures (ophthalmology). Separate clinical guidelines in maxillofacial surgery cover fractures of the mandible, maxilla, and zygomatic bone. Therefore, these clinical guidelines will not discuss the treatment of these injuries in detail, but will only mention them in the context of multiple fractures of the middle and upper facial thirds.

Classification of craniomaxillofacial trauma [10].

Subcranial fractures – frontobasal fractures: of the maxilla – fractures of the nasoorbital and nasomaxillary complexes);

central (Le Fort I, II type, Wassmund I, II type, sagittal fracture of the maxilla);

centrolateral (Le Fort III, Wassmund IV type);

lateral (fractures of the zygomatic bone, zygomatic arch, and zygomaticomaxillary complex);

combined midface fractures.

2. Craniofacial fractures – frontobasal fractures – fractures of the upper and middle thirds of the face involving the anterior cranial fossa:

craniofacial (distinguished by predominant involvement of the anterior cranial fossa, frontal bone and sinus, nasoethmoido-orbital complex; and by predominant involvement of the anterior cranial fossa, superior orbital wall, zygomaticomaxillary complex, and temporal bone).

panfacial fractures – traumatic injury involving all regions of the facial skeleton and skull base.

3. Fronto-facial fractures – frontobasal fractures – fractures involving the anterior cranial fossa and the upper facial third, involving the frontal sinus walls, supraorbital margin, superior orbital wall, cribriform plate, posterior ethmoid air cells, and the superior and lateral walls of the sphenoid sinus [9, 10, 47].

Depressed skull fractures (impression fractures) in which bone fragments maintain continuity with adjacent undamaged areas of the cranial vault and are angled relative to the surface of these areas.

Depressed skull fractures, in which bone fragments lose continuity with undamaged cranial bones and lie below their surface.

Comments: Due to the heterogeneous structure of the bones forming the skull base (lack of distinct outer and inner tables with a diploic layer between them; presence of air-filled spaces and numerous foramina for cranial nerves and vessels), discrepancies between their elasticity and resilience in parabasal and basal cranial regions, tight dural attachment, and communication with the external environment, skull base fractures can occur even with minor head trauma as a result of dural tears or damage to the paranasal sinus mucosa [76, 77, 78, 79]. Therefore, most fractures in this group are classified as open penetrating fractures.

In children, isolated skull base fractures are rare; fractures of the anterior cranial fossa in the orbital region are more common. The absence of a pneumatized frontal sinus makes the orbital roof vulnerable, increasing the risk of superior orbital wall injury [78, 80].

Along with a depressed skull fracture, associated linear skull fractures of various shapes (stellate, web-like) may occur.

A specific type of impression occurs in planar splitting of the outer and inner tables, where the thinner inner bone table is depressed.

Depressed skull fractures generally occur with greater traumatic force than impression fractures, causing bone fragments to lose continuity with undamaged bone areas.

Classification:

Closed fractures lack disruption of scalp integrity or present with superficial soft tissue wounds without aponeurosis damage.

Open fractures are injuries involving scalp soft tissue wounds with aponeurosis damage.

«Ping-pong» or greenstick-like fractures are more common in children and represent an indentation of the bone into the cranial cavity. These fractures are of an impression nature, where bone fragments retain continuity with adjacent fragments. The periosteum and outer table are damaged to a greater extent [78, 80].

Growing skull fracture or leptomeningeal cyst – this is a progressive enlargement of a diastatic fracture through which an entrapped arachnoid membrane may herniate, forming a leptomeningeal cyst. As the diastatic fracture widens, brain tissue and ventricles may become involved in the herniation. It occurs exclusively in infants, toddlers, and young children [78, 81].

«Suture diastasis» – separation of cranial sutures resulting from trauma, most commonly affecting the lambdoid suture.

«Diastatic (gaping) fracture» – widening of the fracture line within the first 24 hours after trauma, accompanied by dural tear and formation of a post-traumatic encephalocele. They develop as a result of acute intracranial hypertension against the background of incomplete ossification of the cranial vault and skull base bones.

Comments:

The type of cranial vault and skull base fracture is determined by anatomical and physiological features in specific age groups.

Due to adhesion of the dura mater to the bone in elderly patients, penetrating depressed skull fractures occur more frequently.

The absence of the diploic layer, fusion between cranial sutures, elasticity of the skull bones, and tight adhesions of the skull bones to the dura mater determine the specific features of cranial injuries in infants and young children.

Table 1. Classification of facial bone fractures.

1.6 Clinical presentation of the disease or condition

The clinical course of polytrauma is characterized by a higher rate of complications during the acute trauma period and in the long term compared to isolated injuries of the individual bones involved.

Among focal signs in the clinical presentation of skull base fractures, craniobasal symptoms such as hyposmia or anosmia and basal cerebrospinal fluid leakage occupy a central place. These are followed by extraocular movement disorders (involvement of cranial nerves III, IV, VI), particularly common with bone fractures in the superior orbital fissure region. Optic nerve injuries are observed in one-third of patients, ranging from decreased visual acuity and visual field defects to blindness. A frequent finding in patients with skull base fractures is unilateral or bilateral hearing impairment, spontaneous nystagmus, and less commonly, taste disturbances. Transverse pyramid fractures present with hearing loss, vestibular dysfunction, and facial nerve injury.

The clinical picture of facial bone fractures is determined by the topography of the fracture.

Nasal bone fracture:

External nasal deformity, pain, nasal breathing impairment, edema, ecchymosis of the eyelids and conjunctiva.

Zygomatic bone fracture:

Deformity, edema, ecchymosis of the eyelids, cheek, sclera, and conjunctiva. Numbness of the infraorbital region, half of the nasal dorsum and ala, upper lip, and upper teeth is possible. When the eyeball is displaced into the maxillary sinus, diplopia is observed. Palpation of the infraorbital margin reveals fragment displacement («step-off» sign). Palpation of the zygomaticoalveolar crest on the fractured side reveals fragment displacement. Visual function should be assessed in all patients.

In posterior zygomatic arch fracture – medial displacement of fragments forming an outward-facing angle. A typical sign of the fracture is limitation of mandibular movements («TMJ block»): inability to fully open or close the mouth, with restricted lateral movements. Palpation of the posterior zygomatic arch reveals depression of its fragments.

Mandibular fracture:

Alteration of facial contour, malocclusion, pain, swelling, ecchymosis, abnormal fragment mobility; mastication, swallowing, speech, and sometimes respiratory functions are impaired.

Maxillary fracture:

Characterizing flattening and elongation of the face. Marked hemorrhages into the subcutaneous tissue of the face, periorbital regions, oral mucosa, conjunctiva and sclera, along with edema. Suborbital and subbasal fractures are generally combined with severe traumatic brain injury, the clinical signs of which often predominate. Emphysema, hemorrhage into the retrobulbar tissue, displacement of the eyeballs, impairment of their integrity, and compression or damage of the optic nerve causing severe visual disorders are possible. Intraoral examination reveals various malocclusions, most typically a drooping of the posterior jaws and their posterior displacement, preventing closure of the anterior teeth — resulting in an open bite.

Palpation of the orbital margins, zygomatic processes, and the pterygoid hamulus is painful, with evidence of bone continuity disruption and fragment displacement.

Le Fort fractures of the maxilla are complex fractures of the facial bones resulting from a high kinetic energy trauma directed at the structures of the midface.

Le Fort type III fracture – craniofacial dissociation, which leads to complete separation of the facial bones from the cranial base. This fracture begins at the frontonasal suture and extends laterally along the medial and lateral walls of the orbits and the zygomatic arch; thus, unlike Le Fort types I and II, a Le Fort type III fracture involves the zygomatic bone. The facial buttresses damaged in a Le Fort type III fracture are the upper medial maxillary, lateral maxillary, upper transverse maxillary, and posterior maxillary buttresses. Determining the extension of the fracture to the lateral orbital wall and zygomatic arch on axial or coronal facial scans helps differentiate a type III fracture from a Le Fort type II fracture; involvement of the frontonasal suture and medial orbital walls is common to both.

Multiple fractures of the facial bones:

The symptoms of multiple facial bone fractures are externally inconspicuous, as they are masked by marked soft tissue edema and hemorrhage. Even in the presence of bleeding, CSF leakage, and injuries to the oral cavity and tongue, they are not always diagnosed in a timely manner, especially in severely injured patients with obvious injuries in other locations. At the same time, it is precisely under such conditions that delayed detection of maxillofacial trauma and associated complications can become life-threatening for the victim.

The clinical presentation of a depressed skull fracture is determined by the extent of soft tissue and cranial bone damage, and the severity of the traumatic brain injury. As a rule, focal neurological symptoms correspond to the location of the depressed fracture. Injury to the cerebral cortex results in deficit or irritative symptoms (limb muscle paresis, aphasia, seizure attacks). With a minor depth of depression, focal neurological symptoms do not occur. Fracture in the region of the sagittal sinus may lead to lower monoparesis or paraparesis, while sinus thrombosis can cause tetraparesis. In open fractures, bleeding from damaged skin or from injured cortical vessels or venous sinuses is possible.

A characteristic sign of penetrating depressed fractures is wound CSF leakage and the discharge of detritus from the wound.

Characteristic symptoms of facial region injuries.

Upper facial zone: facial asymmetry, periorbital hematomas, hemorrhage into the periorbital tissue in the first hours after injury against the background of soft tissue edema appearing as the "panda face" sign, true "raccoon eyes" sign appearing a day later, labored nasal breathing, diplopia, sensory disturbance, emphysema, bleeding and/or CSF leakage from the nasal passages, extraocular motility disorders, and the "step-off" sign in fracture areas. Dentognathic disorders are absent or very mild [3, 12, 46].

Middle facial zone: facial asymmetry, "flattening" of the midface, external nose deformity, periorbital hematomas, true "raccoon eyes" sign, labored nasal breathing, diplopia, sensory disturbance, emphysema, bleeding and/or CSF leakage from the nasal passages, extraocular motility disorders, "step-off" sign, pathological mobility of bone fragments, indirect load test positivity, impaired jaw occlusion, restricted mouth opening, and impaired masticatory function [3, 13, 17, 20, 21, 23, 25, 26].

Lower facial zone: facial asymmetry is not mandatory, sensory disturbance is not mandatory, "step-off" sign in displaced mandibular fractures, pathological mobility of jaw fragments in fractures, indirect load test positivity, impaired jaw movements, restricted mouth opening, and impaired jaw occlusion [8, 31, 16, 37, 71].

1.6.1. Indications for hospitalization

If a skull fracture is present or suspected, the patient must be urgently hospitalized in a specialized medical center [81, 82].

Comments: The pre-hospital diagnosis of facial bone fractures is based on the following signs: facial deformity due to depression or edema, malocclusion, sensory disturbances in the innervation zone of the mental and/or infraorbital nerves, restriction of mandibular mobility, pathological mobility and crepitus of fragments, a positive indirect load test, and disruption of facial bone integrity on radiography.

1.6.2. Pre-hospital treatment

1. Restoration and maintenance of respiratory function

• Asphyxia may develop in jaw fractures (Table 2).

• A thorough examination and sanitization of the oral cavity are required – removal of blood clots, tooth fragments, aspirated masses, and foreign bodies.

• In bilateral mandibular fractures, tongue fixation using a tongue holding forceps or a ligature stitched through the tongue is necessary.

• The patient is placed in a lateral recovery position.

• In case of pronounced soft tissue edema causing breathing difficulty, a standard S-shaped airway should be inserted.

Table 2. Classification of asphyxia in maxillofacial injuries (according to G.I. Ivashchenko).

1. Restoration of hemodynamics

Bleeding control: placement of a hemostatic clamp; tight wound packing; tourniquet application (to the neck via an elevated contralateral upper extremity); digital pressure.

Depending on the severity of concomitant TBI, resuscitation measures to restore hemodynamics should be performed in accordance with the Clinical Guidelines "Focal Brain Injury" [78, 79] and "Traumatic Brain Injury in Children" [82].

2. Transport immobilization of fragments

Required to reduce bleeding from the fracture line and decrease pain afferentation by immobilizing the fragments.

Performed using a standard transport bandage or a vertex-chin sling bandage.

3. Emergency transfer of the patient to the hospital

Respiratory function, blood pressure, and heart rate should be monitored, and vital functions maintained (in accordance with general resuscitation principles).

Comments: Depending on the severity of their condition, all patients with facial bone fractures should be divided into 3 main groups:

"PRIORITY ONE" - victims in severe and extremely severe condition, with a high risk of an unfavorable outcome (impaired consciousness; focal neurological symptoms, ongoing bleeding, CSF leakage; marked respiratory dysfunction, tachycardia ≥ 100 bpm; hypotension (BP ≤ 100 mmHg); hemoglobin less than 100 g/L). The presence of these signs requires immediate anti-shock measures

"PRIORITY TWO" - victims in satisfactory and moderate condition (multiple maxillofacial injuries, suspected concussion – with an increased risk of an unfavorable outcome). Criteria for inclusion in the "priority two" group – satisfactory or moderate condition; stable hemodynamics and respiratory function; severe pain syndrome; brief loss of consciousness, nausea, and vomiting; generalized neurological symptoms; age over 60 years; comorbid conditions

"CATEGORY THREE" – (isolated maxillofacial trauma) – low risk of an adverse outcome. Criteria for classification as "Category Three": satisfactory condition; stable hemodynamics and respiratory function; no signs of ongoing bleeding; no neurological symptoms

All patients with suspected fractures of the cranial vault and skull base, or fractures of the facial skeleton, must be immediately referred to specialized hospitals equipped with round-the-clock laboratory diagnostic, intensive care, neurosurgical, maxillofacial, surgical, and traumatological services, as well as ophthalmologists and otolaryngologists.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of facial and cranial bone fractures is established based on complaints from the patient and/or their legal representatives, medical history, laboratory tests, physical examination, and instrumental assessment.

2.1 Complaints and Anamnesis

• When taking the medical history, it is recommended to identify complaints, the mechanism of injury (non-contact acceleration/deceleration, contact impact-counter-impact, non-contact blast injury), the type of traumatic object, the time and location of the injury; the presence of altered consciousness (loss of consciousness, confusion, moderate obtundation) and its duration; the presence of post-traumatic amnesia and its duration. For pediatric patients, question parents/accompanying persons in detail [3, 19, 20, 49].

CGR CLOE 5Level of Clinical Guidance - C (Level of Evidence - 5)

• Obtain information on vaccination history (tetanus), clarify allergy history, medication dependencies, comorbid conditions, and assess the presence of bleeding or fluid discharge from the wound [78, 79].

CGR CLOE 5Level of Clinical Guidance - C (Level of Evidence - 5)

2.2 Physical Examination

When examining patients with soft tissue and facial bone injuries, the principle of maximum informativeness with minimal invasiveness must be observed.

• In all patients with soft tissue and facial bone injuries, it is recommended to perform a mandatory physical examination to clarify the diagnosis and determine the management strategy:

- assessment of the patient's general condition;

- external examination of the maxillofacial region;

- palpation of the maxillofacial region and percussion in case of oral cavity pathology, including the craniomaxillofacial region [8, 17, 18, 58].

CGR CLOE 5Level of Clinical Guidance - C (Level of Evidence - 5)

Comments: The clinical presentation of a skull fracture consists of a combination of 3 groups of symptom complexes: 1) local changes in the scalp and soft tissues at the site of impact; 2) cerebral deficit, irritative, and dislocation symptoms caused by concomitant brain injury; 3) general somatic changes.

Symptoms suggesting the nature of a skull fracture upon external examination:

- periorbital hematoma ("raccoon eyes") appearing 12–48 hours after injury is a sign of an anterior cranial fossa (ACF) fracture;

- hematoma in the mastoid process region (Battle's sign), lagophthalmos, facial asymmetry indicate a temporal bone pyramid fracture and peripheral facial nerve palsy;

- hemotympanum or tympanic membrane rupture may accompany a skull base fracture;

- rhino- or otorrhea is a sign of a skull base fracture (anterior or middle cranial fossa, respectively) and penetrating traumatic brain injury;

- facial emphysema is a sign of facial bone fractures and may indicate concomitant craniofacial trauma and an ACF floor fracture;

- exophthalmos with conjunctival edema may indicate the development of a carotid-cavernous fistula or retrobulbar hematoma formation;

- cranial nerve paresis or paralysis;

- nasal or auricular bleeding of varying intensity;

- hearing impairment, nystagmus, vomiting;

- rather rarely, a fracture may lead to visual impairments if the broken bones compress the optic nerve.

Difficulties in recognizing early CSF leakage arise when it is combined with bleeding. To distinguish bleeding from CSF leakage, a test for a clear ring surrounding a blood spot on a gauze pad has been proposed—it is positive in cases of CSF leakage.

In cases of bleeding and skull base/facial bone fractures with a risk of aspiration, emergency tracheal intubation or the use of an S-shaped airway is indicated. To stop bleeding, mechanical hemostasis (anterior and posterior nasal packing) and pharyngeal packing are performed [106].

CGR CLOE 5Level of Clinical Guidance - C (Level of Evidence - 5)

Comments: Patients with traumatic brain injury accompanied by skull and facial bone fractures are at high risk for severe complications:

- Asphyxia

- Anemia

- Bronchopulmonary purulent-inflammatory diseases

- Sinusitis

- Intracranial purulent-inflammatory complications

- Traumatic osteomyelitis

- Post-traumatic deformity

Comments: the severity of the patient's condition should be assessed in accordance with the Clinical Guidelines "Focal Traumatic Brain Injury" [78, 79] and "Traumatic Brain Injury in Children" [82]

2.3 Laboratory Diagnostics

• Laboratory diagnostic tests are recommended for all patients with soft tissue and facial bone injuries to determine the severity of their condition (complete blood count, urinalysis, etc.) and to determine treatment tactics [1, 17, 18].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: Wounds and soft tissue and facial bone injuries may be infected with pathogenic microflora.

Depending on the severity of the concomitant traumatic brain injury, laboratory diagnostics are recommended to be performed in accordance with the Clinical Guidelines "Focal Traumatic Brain Injury" [78, 79] and "Traumatic Brain Injury in Children" [82].

CGR CLOE 5Level of Clinical Guidance - C (Level of Evidence - 5)

2.4 Instrumental Diagnostics

Instrumental diagnostic methods are used to clarify the clinical diagnosis, evaluate treatment efficacy, and monitor rehabilitation. X-ray examination plays a decisive role in establishing the diagnosis and determining the management strategy for both adult and pediatric patients with combined and multiple craniomaxillofacial trauma.

• In the inpatient setting, MSCT is recommended for patients with soft tissue and bone injuries of the facial skeleton to clarify the diagnosis [3, 10, 26, 49].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: in some cases, patients with fractures of the soft tissue and bone injuries of the facial skeleton may undergo radiography of the entire skull in one or more projections, which allows for the diagnosis of fractures of the maxilla, mandible, zygomatic bones, and cranial vault bones. However, X-ray diagnostics of multiple bone fractures of the middle facial third is difficult due to the complexity of the anatomical structure of this area, as well as the blurriness of the bone structure image caused by overlapping details of adjacent parts of the skull [29, 36, 46].

Comments: radiological examination using plain radiographs is not always sufficient. This is particularly true for multiple fractures in the upper and middle facial thirds. One of the most informative imaging modalities of choice for victims in this group, especially in severe conditions of the child caused by multiple injuries of the soft tissue and bone injuries of the facial skeleton and TBI, is MSCT, which allows obtaining a three-dimensional image of all anatomical structures [3, 36, 27].

The following are evaluated:

- symmetry and position of the orbits;

- measurement of depth, width, and height;

- determination of orbital volume (mL);

- condition of the bony orbital walls;

- presence of intraorbital emphysema, retrobulbar hematoma;

- optic canal;

- position and symmetry of the maxillary sinuses;

- presence of hemosinus, bone damage of all walls;

- evaluation of the ethmoidal labyrinth cells, their bone structures, presence of pathological contents within the cells;

- evaluation of the frontal sinuses, their bone structures, presence of soft tissue pathological contents, hemosinus;

- sphenoid sinus, condition of the body, greater and lesser wings, pterygoid processes of the sphenoid bone, presence of pathological contents;

- symmetry and integrity of the nasal bones;

- integrity of the frontal processes of the maxilla, condition of the frontonasal sutures;

- integrity of the lacrimal bones, condition of the nasal septum, nasal conchae, and vomer.

- integrity of the body of the zygomatic bone and its processes;

- disruption of the integrity of the maxilla and mandible;

- condition of teeth and tooth germs;

- temporomandibular joint.

- presence of osteotramatic injuries of the cranial vault bones;

- pneumocephalus.

- brain: presence of space-occupying lesions, state of CSF pathways, presence of edema, state of the brain ventricles;

- orbit – eyeball (symmetry, position of the lens);

vitreous body, presence of foreign bodies, condition of the retrobulbar adipose tissue, condition of extraocular muscles, optic nerve, lacrimal glands;

- soft tissues of the face: presence of edema, emphysema;

- condition of the major salivary glands.

• All patients with soft tissue and bone injuries of the facial skeleton should recommended, when indicated, undergo magnetic resonance imaging of the brain and facial skull to obtain additional information on the structure of soft tissue damage directly—hemorrhages and emphysema in the orbital tissue, eye muscles, and nerves [3, 36, 27].

GCP CLOE 4Grade of Recommendation — C (Level of Evidence — 4)

• All victims with suspected skull fracture upon admission are recommended to undergo brain computed tomography [87, 102, 103].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

• Cerebral computed tomography angiography, when feasible, is recommended when a depressed fracture is localized in the region of major venous sinuses (sagittal, transverse) to diagnose their compression or thrombosis [83].

GCP CLOE 4Grade of Recommendation — C (Level of Evidence — 4)

Comments: instrumental diagnostics of penetrating TBI and basilar CSF leak (as a consequence of TBI) include: brain computed tomography, facial skull computed tomography, and spiral computed tomography of the paranasal sinuses.

Imaging with a slice thickness of 1–3 mm and subsequent reconstruction in the coronal plane allows visualization of skull base fractures, assessment of their nature (fracture type, presence of fragments and their displacement), and estimation of the CSF fistula location. Axial slices are used to visualize the posterior wall of the frontal sinus, the posterior and lateral walls of the sphenoid sinus, as well as the mastoid air cells of the temporal bone. Coronal slices are necessary to verify fractures of the cribriform plate, the upper and lower walls of the ethmoid cells, the superior wall of the sphenoid sinus, and the roof of the tympanic cavity. Multiplanar reformation in the sagittal projection provides additional information on the topography of anterior cranial fossa base fractures, as well as the superior and inferior orbital walls.

Computed tomography cisternography (with lumbar administration [delivery of medications into the spinal canal] of iodine-containing radiopaque agents) is used for direct visualization of cerebrospinal fluid fistulas [77, 84, 85, 86].

When performing CT, the following should be determined in bone window mode: the location and type of depressed fracture (impression, depression), the presence and arrangement of bone fragments, the condition of the soft tissues of the scalp, and the condition and contents of the paranasal sinuses. In the presence of other intracranial injuries, it is necessary to determine the presence and topographic location of the pathological lesion(s); the volume of each type of lesion (hypo- and hyperdense parts) in cm³; the position of the midline brain structures and the degree of their displacement in mm; the state of the cerebrospinal fluid-containing system of the brain (size, shape, position, ventricular deformation) with determination of ventriculocranial ratios; the state of the perimesencephalic and basal cisterns, and the third ventricle; and the state of the cerebral convexital sulci and fissures.

2.5 Other Procedures

Internal organ injuries

Craniocerebral trauma

• Patients with injuries to the facial bones of the skull, in order to rule out TBI, ENT organ damage, and visual analyzer injury, are recommended to undergo MSCT, an initial consultation (examination) by a neurosurgeon (or, in their absence, an initial consultation by a neurologist), an initial consultation by a maxillofacial surgeon, an initial consultation by an ophthalmologist, an initial consultation by an otorhinolaryngologist, and an initial consultation by a pediatric dentist. If medical indications are identified based on the examination results, the patient is hospitalized in the appropriate specialized department [3, 17, 18, 32].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Radiography

• If spiral CT is not available in the inpatient facility, it is recommended to perform at least skull radiography in one or more projections (in 2 projections) to detect skull and facial skeleton fractures [78, 79].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

• Cerebral angiography, when feasible, is recommended when a depressed fracture is localized in the region of major venous sinuses (sagittal, transverse) to diagnose their compression or thrombosis [78, 79].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

Cerebrospinal fluid examination

• Patients with soft tissue and bone injuries of the facial skeleton are recommended to undergo a lumbar puncture with a general (clinical) analysis of the cerebrospinal fluid when intracranial purulent-inflammatory complications are suspected to be developing [78, 79].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

Comment: Lumbar puncture is performed in the absence of clinical and CT signs of herniation syndrome and with preserved patency of the CSF pathways to avoid the development and progression of brain herniation and dislocation processes [79].

When basilar CSF leak is suspected, it is advisable to collect discharge from the external ear and test the glucose level in the nasal discharge.

When feasible, specific CNS biomarkers should be detected [77].

Comments: It is necessary to differentiate leaking CSF from serous nasal discharge based on glucose content. The method is based on the biochemical composition of cerebrospinal fluid, which contains significantly more glucose (2.3–4.0 mmol/L) and considerably less protein (0.10 to 0.22 g/L) and mucopolysaccharides than serous discharge from the ear or nose and its paranasal sinuses in inflammatory and allergic diseases [93, 94, 95, 96].

The main specific markers investigated to verify CSF leak are beta-2 transferrin, which is present exclusively in CSF [29, 30, 31, 32], or beta-trace protein (normal CSF concentration is 18.4 mg/L, whereas in blood it is only 0.59 mg/L) [95, 97, 98].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The treatment of combined facial injuries has significant differences from isolated maxillofacial trauma. The therapy involves the restoration of impaired functions of both the brain, maxillofacial organs and tissues, and damaged organs of other body areas, as well as the prevention of potential complications. The time elapsed from the moment of injury to the initiation of specialized treatment is a decisive factor determining the outcomes of combined craniomaxillofacial trauma [28, 46, 60, 64, 65, 68, 70].

Emergency care for patients with combined soft tissue and facial bone injuries must be performed as soon as possible and in full. When providing it, the principle of maximum atraumaticity and aesthetic outcomes must be followed.

Since craniomaxillofacial trauma is a collective concept, an approach taking into account the localization of the injury is necessary in each case [3, 37].

The treatment plan is drawn up by a maxillofacial surgeon with the mandatory joint consultative participation of a neurosurgeon. Physicians of other specialties (ophthalmologist, otorhinolaryngologist, orthopedic trauma surgeon) are enlisted for consultation depending on the nature and severity of the polytrauma.

When treating combined maxillofacial injuries, three main tasks come to the fore [28, 46, 61, 63] in order to determine:

• the timeframe for providing specialized care;

• the scope of surgical intervention;

• the method of bone fragment fixation.

In patients with craniomaxillofacial trauma, neurosurgical operations aimed at maintaining the patient's vital functions are often prioritized [21, 60, 65].

Conservative treatment. General recommendations

• In the absence of indications for surgical treatment, conservative treatment of patients with skull fractures is recommended to be carried out in accordance with the severity of the traumatic brain injury (see Clinical Guidelines "Focal Brain Injury" and "Traumatic Brain Injury in Children" [87, 88]).

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

Comments: Conservative treatment is administered to patients with skull fractures not requiring surgical intervention. The decision to perform conservative treatment for a skull fracture is made individually in each case. The clinical presentation of a skull fracture is determined by the degree of damage to the soft tissues of the scalp and skull bones, the severity of the sustained traumatic brain injury, and general somatic disorders [78, 79].

The goal of conservative therapy is to eliminate factors of secondary brain damage: hypoxia, hypoxemia, arterial hypotension, intracranial hypertension, cerebral hypoperfusion, hyperthermia, hypercarbia, hypo- and hyperglycemia, and anemia.

Conservative treatment is initiated in cases of post-traumatic peripheral facial nerve palsy in temporal bone fractures (glucocorticoids, peripheral vasodilators, physical therapy), and basal cerebrospinal fluid leakage (bed rest with a specific position that reduces or completely stops the outflow of cerebrospinal fluid outwardly (usually semi-sitting or with the head of the bed elevated), supplemented by a series of lumbar punctures or the placement of an external lumbar drain (in the absence of contraindications) against the background of dehydration therapy [78, 79, 87, 88].

3.1. Treatment prior to stabilization of vital bodily functions

Surgical treatment of patients with combined soft tissue and facial bone injuries for the purpose of reposition and fixation of bone fragments should be postponed until the period of stabilization of the body's main functions; that is, in the first 2-6 days after injury, it is often performed incompletely. Depending on the severity and condition of the patient, surgical intervention should be performed 2-7 days or more later, and in severe patient conditions, after antishock measures and intensive therapy [3, 62, 63, 70].

Surgical wound debridement is an important medical procedure that facilitates the decontamination of pyogenic flora and mechanical cleansing of the wound; irrigation measures are carried out with weak solutions of potassium permanganate**, nitrofural, chlorhexidine**, hydroxymethylquinoxalindioxide (adults only), proteolytic enzymes, etc.

Primary surgical debridement of maxillofacial wounds is carried out as early as possible. A penetrating wound into the oral cavity is isolated by suturing the oral mucosa. In case of mucosal deficiency, the wound is subsequently managed using a strip dressing. Wounds in the hard palate area are more frequently managed using iodoform gauze strips.

• In patients with combined soft tissue and facial bone injuries, it is recommended to apply primary sutures depending on the time of presentation to the hospital, which can be performed 24-36 hours after the injury [3, 33, 63].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: For the prevention of purulent infection complications, systemic antibacterial drugs are prescribed after 48 hours, less often after 72 hours. When suturing wounds in the area of natural orifices, primary closure is applied regardless of the child's arrival time. For certain types of soft tissue injuries and wound healing conditions, a primary delayed suture may be applied on days 3-4. When reparative processes in the wound are favorable, an early secondary suture can be applied after 2-3 weeks [3, 33, 63].

The maxillofacial surgeon must perform the primary surgical debridement of wounds so that the final result is perfect both functionally and aesthetically [30].In pediatric practice, all deciduous teeth, permanent teeth with periapical foci of infection, compromised root structure, etc., located within the jaw fracture line must be removed. In the absence of damage to the permanent tooth (crown, root), teeth without signs of chronic odontogenic infection should be preserved whenever possible, leaving them under observation and for subsequent endodontic treatment if necessary. Permanent tooth germs located within the fracture line must be preserved, except for rare cases where they interfere with the reposition of jaw fragments. [19, 20].

3.2. Orthopedic treatment

One of the most important signs characterizing a patient with fractures of combined soft tissue and facial bone injuries and determining the indications for choosing the treatment method is age and occlusion status [8, 17, 18, 27, 31].

The orthopedic treatment method for jaw fractures in children is the primary one. It is used in all patients with "subperiosteal" fractures of the mandible, fractures without displacement of fragments of the mandible and maxilla, as well as in a significant portion of patients with mandibular fractures with fragment displacement within the dental arch, the mandibular angle, and the condylar process region [17, 19, 20].

Comments: Reliable immobilization of jaw fragments during a fracture is also important because the mobility of fragments persisting under the action of masticatory muscles promotes the "sucking" of oral fluid containing pathogenic microflora deep into the bone wound and, thereby, its infection [20, 58, 74].

Comments: the danger of jaw fixation in patients, especially children, with urges to vomit, which is often the case in traumatic brain injury, must be taken into account. Some authors believe it is advisable to refrain from applying dental splints and especially maxillofacial elastic traction in them during the first 2-3 days to avoid aspiration of vomit and asphyxia. If necessary, splinting for bone fractures can be performed without maxillofacial fixation. On the other hand, immobilization of patients with combined soft tissue and facial bone injuries is one of the important antishock and pathogenetic elements in the treatment of traumatic disease [46, 69].

3.3. Surgical treatment

Indications for surgical treatment [3, 19, 23, 35]:

1. Inability to reposition displaced bone fragments by orthopedic methods due to their significant displacement or in comminuted fractures

2. Insufficient number of stable teeth for stable fixation of jaw bone fragments by orthopedic methods

3. Interposition of soft tissues in the fracture line

4. Fractures in the angle region of the jaw, outside the dental arch with an insufficient number and stability of teeth for splinting

5. Fractures with significant displacement of bone fragments, including fracture-dislocations of the condylar process

6. Fractures of the zygomaticomaxillary, frontozygomatic, frontonasoorbital complexes in the midface

7. Fractures of the orbital bone walls with fragment displacement

8. Fractures of the frontal sinus walls

9. Penetrating nature of the depressed fracture (wound cerebrospinal fluid leakage, tissue detritus discharge, pneumocephalus)

10. Active bleeding from the wound

11. Cosmetically significant deformation

12. Severe wound contamination

13. Damage or compression of brain structures by intracranial space-occupying lesions;

14. Cerebrospinal fluid leakage through the nose that cannot be stopped by conservative methods;

15. Lack of effect from conservative treatment or delayed onset of peripheral facial nerve palsy.

16. Delayed visual deterioration following trauma, with clinical and radiological signs of optic nerve injury within the canal;

17. Wound infection [78, 79]

18. Expansion of a diastatic fracture with leptomeningeal cyst formation ("growing skull fracture") [81, 82].

Contraindications to surgical treatment:

1. Severe general somatic pathology in the stage of decompensation.

2. Severe or extremely severe acute traumatic brain injury, less frequently moderate severity.

• Patients with maxillofacial fractures and soft tissue injuries are recommended to undergo internal fixation using non-resorbable craniomaxillofacial bone fixation plates*** as the most effective method to achieve fragment stability in all clinical situations, with anatomical bone alignment and bite restoration [18, 26, 32, 43, 44, 59, 67].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

Surgical treatment of patients with skull fractures involves the following types of procedures [76, 77, 78, 79, 100]:

1. Craniotomy with removal of a mass-occupying intracranial traumatic lesion (epidural hematoma, subdural hematoma, intracerebral hematoma, contusion focus);

2. Decompressive craniectomy with duraplasty;

3. Surgical closure of a basal cerebrospinal fluid fistula if conservative therapy fails within 5–7 days. Surgical treatment involves an open transcranial or minimally invasive endonasal endoscopic approach;

4. Surgical neurolysis and decompression of facial nerve branches using a middle cranial fossa approach or translabyrinthine approach in case of conservative treatment failure or delayed peripheral facial nerve palsy;

5. Optic nerve decompression may be performed via a subfrontal or pterional approach in cases of delayed visual deterioration after trauma, given clinical and radiological signs of its injury within the canal. Surgical treatment is impractical in cases of initial and stable amaurosis, as well as when visual functions show positive dynamics during conservative treatment;

6. Endovascular interventions for post-traumatic pseudoaneurysms of major vessels and arteriovenous fistulas, as well as for profuse recurrent epistaxis (endovascular embolization with embolizing agents, stent-graft placement, or ligation/coagulation of the maxillary artery via an endonasal approach).

7. Elevation of a depressed skull fracture in children using an elevator [80].

• Early surgical intervention is recommended for adults and children with skull fractures [78, 79, 87].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: early surgical intervention is necessary to relieve brain compression caused by bone fragments and to reduce the risk of infection in open depressed fractures. Management of open and penetrating fractures should include the use of antibiotics [90].

• In patients with a depressed skull fracture within 24 hours of injury and no wound contamination, it is recommended to preserve and reposition the bone fragments or perform primary cranioplasty using non-absorbable fixation plates for craniofacial surgery*** [76, 78, 79].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: a single-stage procedure—repositioning of bone fragments or primary reconstruction of the skull defect using non-resorbable craniomaxillofacial bone fixation plates***—does not increase the risk of infectious complications and avoids the need for repeat surgery.

If the patient has other intracranial injuries (subdural, epidural, or intracerebral hematomas, brain contusion foci), surgical treatment should follow the Clinical Guidelines on "Focal Brain Injury" [78, 79, 87].

Comments: In 40–60% of patients, the severity of their condition is determined by brain damage resulting from contusion or compression by traumatic intracranial hematomas.

• To stabilize fragments in patients with maxillofacial fractures and soft tissue injuries, it is recommended to use resorbable craniomaxillofacial bone fixation plates***, non-resorbable craniomaxillofacial bone fixation plates***, sterile non-resorbable craniomaxillofacial bone screws***, resorbable craniomaxillofacial bone screws***, moldable cranioplasty plates***, etc. [3, 16, 20].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

Comments: The use of biodegradable materials for osteosynthesis currently has specific indications. It is indicated primarily in areas subject to low functional load due to the potential risk of secondary fragment displacement at the fracture site. Such miniplates are used for osteosynthesis of the inferior orbital rim, the anterior wall of the maxillary sinus, and less frequently the frontozygomatic process and orbital floor. In some cases of multiple midface fractures, resorbable*** and non-resorbable*** craniomaxillofacial bone fixation plates are used simultaneously [3, 16, 20].

Children require mandatory removal of non-resorbable craniomaxillofacial bone fixation plates*** after bone healing at the fracture site to prevent them from eroding through the oral vestibule mucosa, as well as to prevent potential growth retardation of the injured bone and post-traumatic facial deformity.

Comments: it is advisable to use the following surgical approaches: * for upper facial zone surgeries: coronal (mono- and bilateral); * for midfacial zone surgeries: coronal (mono- and bilateral), transconjunctival, subciliary, transpalpebral, transcutaneous (along the lower orbital rim), transoral (via the oral vestibule transitional fold), transantral (maxillary sinusotomy); Limberg's approach in the zygomatic region; * for lower facial zone surgeries: transoral via the oral vestibule transitional fold, transcutaneous (preauricular), parangular, submandibular, submental; * for the intraoral approach to the maxilla, the incision is made at the level of the alveolar process base in the posterior-superior part of the oral vestibule fornix (Keen's method) [3, 19, 46, 60, 61, 65, 71].

3.4. Prevention of surgical site infections

Comments: The choice of PAP regimen and protocol is based on national and international guidelines for SSI prevention.

Comments: in case of a high risk of complications, extending antibiotic prophylaxis for 24–48 hours postoperatively is permitted. Extending antibiotic prophylaxis beyond the end of surgery does not increase its efficacy, but increases the risk of selecting antibiotic-resistant strains and complications, notably C. difficile-associated diarrhea.

Table 3. Systemic antibacterial drugs for PAP in patients with maxillofacial trauma

¹ allergy to beta-lactam antibacterial drugs, penicillins, high risk of MRSA.

² in children over 3 years of age with a patient body weight of up to 80 kg — the dose of Cefazolin** is 1 g; with a weight of 80 kg or more — 2 g. [40, 41, 108]

³ — 120 minutes before incision.

• For type IV wounds ("infected wound") in case of old trauma, prior infection, presence of purulent discharge, non-viable tissues, antibiotic therapy is recommended [30, 46, 68].

LoR CLoE 4Level of Recommendations — C (Level of Evidence — 4).

Comments: Type IV wounds include old traumatic wounds with non-viable tissues, as well as postoperative wounds in the area of which an infection was already present. It is implied that microorganisms capable of causing surgical site infections (SSIs) were present in the surgical intervention area prior to the operation. When prescribing antimicrobial drugs (AMDs) to patients with type IV wounds ("infected"), it is necessary to follow the therapeutic doses specified in the instructions for medical use, and also take into account weight, age, and renal and hepatic function.

Amoxicillin+Clavulanic acid**. For intravenous administration to adults and adolescents over 12 years of age, 1 g (in terms of amoxicillin) is administered 3 times a day. The maximum daily dose is 6 g. The daily dose for children under 12 years of age is 25 mg/kg. The duration of treatment is up to 14 days.

Cefazolin** is contraindicated in children under 1 month of age. The average daily dose for children is calculated at 25 mg/kg/day, in severe cases — up to 100 mg/kg/day. The average duration of treatment is 7–10 days.

Metronidazole** For severe infections, the drug is prescribed as an intravenous infusion at a rate of 5 ml/min. The dose of the drug per administration for children under 12 years of age is 7.5 mg/kg (1.5 ml of 0.5% solution), for children over 12 years of age, the single dose is 500 mg (100 ml of 0.5% solution).

Cefuroxime** for children, including infants, the daily dose is 30–100 mg/kg/day in 3–4 administrations; for newborns and children under 3 months — 30 mg/kg/day in 2–3 injections.

Vancomycin** The drug is administered only by continuous intravenous infusion. Adults and children over 12 years of age with normal renal function should be administered the drug IV at 2 g per day (0.5 g every 6 hours or 1 g every 12 hours). Each dose should be administered at a rate of no more than 10 mg/min and over at least 60 min. The maximum single dose is 1 g, the maximum daily dose is 2 g.

Children from 1 month to 12 years of age should be administered the drug IV at a dose of 10 mg/kg every 6 hours. Each dose should be administered over at least 60 min. The recommended daily dose is 40 mg/kg.

For newborns, the initial dose is 15 mg/kg, followed by 10 mg/kg every 12 hours during the 1st week of life. Starting from the 2nd week of life — every 8 hours until reaching 1 month of age. Each dose should be administered over at least 60 min. When prescribing to newborns, monitoring the serum concentration of vancomycin** is advisable. The concentration of the prepared vancomycin** solution should be no more than 2.5–5 mg/ml. The maximum single dose for newborns is 15 mg/kg of body weight. The daily dose for a child should not exceed the adult daily dose (2 g).

3.5. Pain management

3.6 Other treatment

In children, dental prosthetics during the growth period should be performed using removable laminar dentures; upon completion of jaw bone growth, dental prostheses on dental implants should be used.

• During the post-traumatic rehabilitation period, throughout the patient's growth, orthodontic treatment is recommended as indicated [3, 8, 17].

GSI CLoE 5Grade of Recommendation — C (Level of Evidence — 5)

3.6.1. Medical nutrition therapy

A child with a fracture of the jaw bones cannot consume food of normal consistency or chew it.

Comments: In such cases, administering food into the mouth is not only useless, but also dangerous due to the possibility of aspiration. For children under 3 years of age, the diet is dairy-based. For children aged 3 years and older and adolescents, a jaw diet is prescribed. Feeding is carried out 5 times a day. Special oral care is required. It is necessary to wipe the teeth and oral mucosa with a nitrofural** solution at least 3 times a day until inflammatory phenomena subside [41].

• If tube feeding is ineffective, it is recommended for victims in an unconscious state or with swallowing difficulties to use parenteral nutrition for the purpose of postoperative rehabilitation [7, 45, 63, 73].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

3.6.2. Physical therapy

Comments: as prescribed by a physical therapy physician

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: Full compensation of impaired functions of the central nervous system and other body systems in concomitant maxillofacial trauma occurs more slowly, accompanied by a later recovery of damaged bone structures of the facial skeleton; therefore, the duration of inpatient treatment and subsequent follow-up observation of such patients depends on the regression of neurological symptoms [45, 55, 56, 59, 68].

Medical rehabilitation programs for victims with TBI consist of sequentially performed therapeutic measures in subsequent years and are aimed at eliminating all complications and post-traumatic deformities that arose in the acute period of the traumatic illness, both in the maxillofacial region and in other systems and organs of children [3, 44, 45, 55].

Table 4. Medical rehabilitation program for pediatric patients with facial skull bone injuries.

5. Prevention and Dispensary Observation

Regular clinical check-ups (dispensary monitoring) are necessary for all children throughout childhood, until the completion of facial skull bone growth.

Following any fractures, mandatory long-term follow-up by a maxillofacial surgeon with the involvement of all relevant specialists is required: a neurologist, ophthalmologist, otolaryngologist, orthodontist, and pediatric dentist [3, 8, 45, 19].

Postoperative wound suppuration

Antibiotic prophylaxis is administered 30–60 minutes before the incision (combinations of penicillins, including beta-lactamase inhibitors, first- or second-generation cephalosporins, lincosamides, glycopeptide antibiotics, followed by antibacterial therapy until suture removal).

Postoperative antibiotic therapy is administered to all patients with wound contamination by foreign bodies, depressed fracture plasty with implants, and suppurated head wounds [78, 79, 101].

Comments: in case of wound suppuration, removal of postoperative sutures (ligatures), revision of the postoperative wound, secondary surgical debridement, removal of titanium or other plastic materials, opening and drainage of maxillofacial phlegmon (abscess) via an extraoral approach or opening and drainage of an oral cavity abscess, microbiological (culture) examination of purulent discharge for aerobic and facultatively anaerobic microorganisms, continuation of targeted antimicrobial therapy, and local treatment.

• This group of patients may develop long-term complications following the trauma, such as post-traumatic epilepsy, hydrocephalus, or cerebrospinal fluid leakage. After inpatient treatment is completed, it is recommended to have follow-up visits (examinations, consultations) with a neurologist every 3 months during the first year, and then every 6 months [3, 8].

GCR CLOE 5Grade of Recommendation C (Level of Evidence - 5).

• All patients with midface fractures (Le Fort-type and associated facial fractures) are recommended to undergo a follow-up X-ray imaging 4 weeks postoperatively to confirm bone fragment consolidation in the correct position and to rule out post-traumatic inflammatory processes in the maxillary sinus [3, 58].

GoR CLoE 5Grade of Recommendation - C (Level of Evidence - 5)

Comments: Rehabilitation of patients with maxillofacial bone fractures combined with craniomaxillofacial trauma does not end with discharge from the hospital [3, 20, 22]. Regular specialist check-ups during dispensary monitoring should be performed at 2–4 weeks, 3 months, 6 months, and 1 year.

Comments: Examination at the 1st year of dispensary monitoring:

Brain computed tomography;

Electroencephalography;

Initial appointment (examination, consultation) with a neurologist;

Initial appointment (examination, consultation) with an ophthalmologist.

6. Organization of Medical Care

Indications for emergency hospitalization in the maxillofacial surgery department:

1. suspected or confirmed jaw fracture of any localization

2. presence of soft tissue wounds of the face and oral cavity

3. presence of extensive soft tissue wounds of the maxillofacial region

Comments: For any maxillofacial injuries with suspected traumatic brain injury or damage to other organ systems, if these cannot be ruled out in the emergency department, hospitalization is indicated to clarify the diagnosis. [60].

Comments: in case of suspected midface fractures (Le Fort-type and associated facial fractures) upon hospitalization, temporary jaw immobilization must be provided using a chin-vertex bandage, plaster chin sling, etc. [1, 15, 58, 73].

Hospitalization of casualties with midface fractures (Le Fort-type and associated facial fractures) in a multidisciplinary hospital with neurosurgery and neuro-ICU departments, or, in their absence, in a general intensive care unit within a hospital featuring a neurosurgical (or, in its absence, traumatological) department [78, 79, 87].

Provision of specialized medical care to patients with skull fracture in an inpatient setting.

For the treatment of patients with depressed skull fractures, the hospital must be equipped with a 24/7 spiral computed tomography (SCT) scanner. Neurosurgeons and radiologists must undergo training in the management of casualties with traumatic brain injury. For surgical interventions in patients with depressed skull fractures, the operating room must be equipped with power craniotomy equipment with various attachments, and consumables for bone flap fixation or cranioplasty (craniofixes, titanium plates, etc.) [78, 79, 87].

Indications for planned hospitalization in the Department of Maxillofacial Surgery:

No indications.

Indications for patient discharge from a medical organization

Performance of scheduled diagnostic examinations.

Restoration of the anatomical integrity of the maxillofacial region

No signs of postoperative complications.

7. Additional Information

The prognosis of outcomes in victims with skull fractures is determined by the severity of the sustained traumatic brain injury (TBI). The most significant factors in predicting TBI outcomes are age and damage to the corpus callosum, brainstem, and subcortical structures. (See clinical guidelines "Focal Brain Injury").

Risk factors for unfavorable outcomes of surgical treatment:

Systemic factors

1. Advanced age

2. Immunodeficiency states

3. Vasculitis

4. Cachexia

5. Infection

6. Polyneuropathy

7. Local innervation disorder

8. Oncological process

9. Carbohydrate metabolism disorders

10. Collagenoses and other systemic diseases

Local factors

• Impaired arterial blood inflow

• Impaired venous outflow

• Repeated trauma

• Infection

• Presence of foreign bodies in the wound

• Constant tension of the skin edges

Negative factors affecting treatment outcomes include:

1. Development of infectious complications.

2. Non-compliance with the regimen of local contact hypothermia

3. Poor oral hygiene.

4. Non-compliance by the patient with the diet and masticatory activity restrictions.

5. Non-compliance with exercise therapy recommendations in the postoperative period.

6. Participation in contact sports within 3 months.

7. Failure to attend follow-up examinations.

8. Non-compliance with other recommendations of the attending physician.

Patients with concomitant traumatic brain injury and maxillofacial trauma and soft tissue injuries should be divided into groups depending on the combination of the severity of facial bone fractures and TBI in order to determine the treatment tactics for establishing the timing of temporary immobilization and performing definitive immobilization.

Comments: From a practical standpoint, TBI combined with facial bone fractures is divided into four groups.

1. Group 1 – severe TBI (moderate to severe cerebral contusion, intracranial hematomas) and severe facial bone fractures (Le Fort I and II maxillary fractures, simultaneous fractures of the upper and lower jaws). Half of these patients develop traumatic shock. Temporary immobilization in group 1 patients is possible immediately after resuscitating them from shock. Therapeutic immobilization using orthopedic methods is permitted on days 2–5 from the moment of trauma and recovery from the shock state; osteosynthesis is performed no earlier than the seventh day.

2. Group 2: severe TBI and minor facial bone trauma (Le Fort III maxillary fracture, unilateral fractures of the upper and lower jaws, zygomatic bones, etc.). Therapeutic immobilization in Group 2 patients can be performed within 1–3 days.

3. Group 3: mild TBI (concussion, mild cerebral contusion) and severe facial bone injuries. The severity of the patients' condition is mainly due to concomitant craniomaxillofacial trauma. Therapeutic immobilization, including osteosynthesis, is possible as early as the first day after the injury.

4. Group 4: mild TBI and minor concomitant craniomaxillofacial trauma. Immobilization of fragments can be performed within the first hours after the injury. Early specialized treatment not only does not worsen the patient's condition, but also reduces the risk of intracranial inflammatory complications [1, 3, 46, 73, 74].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Potapov A.A., Academician of the RAS, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

2. Usachev D.Yu., Academician of the RAS, President of the Association of Neurosurgeons of Russia, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

3. Krylov V.V., Academician of the RAS, Chief Freelance Neurosurgeon of the Russian Ministry of Health, Department of Fundamental Neurosurgery, Pirogov Russian National Research Medical University, Moscow

4. Nazarenko A.G., MD, Professor of the RAS, Director of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Moscow

5. Kravchuk A.D., MD, Professor, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

6. Semyonova Zh.B., MD, Neurosurgeon, Research Institute of Emergency Pediatric Surgery and Traumatology of the Healthcare Department, Moscow

7. Okhlopkov V.A., PhD, Neurosurgeon, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

8. Talypov A.E., MD, Neurosurgeon, Sklifosovsky Research Institute of Emergency Care, Moscow

9. Prirodov A.V., MD, Neurosurgeon, Sklifosovsky Research Institute of Emergency Care, Moscow

10. Eolchiyan S.A., MD, Neurosurgeon, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

11. Goryaynov S.A., PhD, Neurosurgeon, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

12. Latyshev Ya.A., PhD, Neurosurgeon, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

13. Alexandrova E.V., PhD, Neurologist, National Medical Research Center for Neurosurgery named after Academician N.N. Burdenko, Moscow

14. Ochkurenko Alexander Alekseevich, MD, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Moscow

15. Kleymenova Elena Borisovna, MD, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Moscow

16. Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.

17. Braylovskaya T.V. – MD, Professor, Executive Secretary of the Association of Maxillofacial Surgery Specialists.

18. Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.

19. Ivanov S.Yu. – Corresponding Member of the RAS, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.

20. Drobyshev A.Yu. – MD, Professor, Vice-President of the Association of Maxillofacial Surgery Specialists.

21. Yaremenko A.I. – MD, Professor, Vice-President of the Association of Maxillofacial Surgery Specialists.

22. Roginsky V.V. – MD, Professor, Member of the Association of Maxillofacial Surgery Specialists.

23. Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".

24. Belchenko V.A. – MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.

25. Topolnitskiy O. Z. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

26. Semyonov Mikhail Georgievich – MD, PhD, Professor, Head of the Department of Maxillofacial Surgery and Surgical Dentistry named after A.A. Limberg, North-Western State Medical University named after I.I. Mechnikov, Board Member of the Association of Maxillofacial Surgeons.

27. Durnovo E. A. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

28. Lepilin A. V. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.

29. Tarasenko S. V. – MD, PhD, Professor, Member of the Association of Maxillofacial Surgeons.

30. Epifanov S. A. – MD, PhD, Associate Professor, Member of the Association of Maxillofacial Surgeons.

Conflict of interest:

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Maxillofacial surgeons

2. Dentists

3. Trauma and orthopedic surgeons

4. Neurosurgeons

5. Otolaryngologists

6. Ophthalmologists

7. Neurologists

8. Mid-level medical personnel

9. Healthcare organizers

10. Medical insurance experts (including conducting medical and economic expertise)

11. Medical students, residents, postgraduate students

Table 1. Levels of Evidence (LE) grading scale for diagnostic methods (diagnostic interventions).

Table 2. Levels of Evidence (LE) grading scale for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions).

Table 3. Grades of Recommendation (GR) scale for methods of prevention, diagnostics, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Article 76 of Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Healthcare Protection in the Russian Federation", regarding the development and approval of clinical guidelines (treatment protocols) for the provision of medical care by medical professional non-profit organizations;

2. Order of the Russian Ministry of Health No. 422n dated June 14, 2019, "On Approval of the Procedure for Providing Medical Care in the Field of 'Maxillofacial Surgery'";

3. Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010 (as amended on July 3, 2016), "On Compulsory Medical Insurance in the Russian Federation";

4. Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care".

5. Order of the Russian Ministry of Health No. 664n dated June 24, 2021, "On Approval of the Procedure for Medical Organizations to Notify Internal Affairs Bodies in Cases Established by Paragraph 5 of Part 4 of Article 13 of the Federal Law 'On the Fundamentals of Healthcare Protection in the Russian Federation'" (Registered with the Ministry of Justice of the Russian Federation on August 19, 2021, No. 64702)

6. Federal Law No. 178-FZ dated July 17, 1990 (as amended by Federal Laws No. 345-FZ of December 8, 2010, No. 345-FZ, No. 169-FZ of July 1, 2011, No. 133-FZ of July 28, 2012, No. 258-FZ of December 25, 2012, No. 99-FZ of May 7, 2013, No. 104-FZ of May 7, 2013, No. 185-FZ of July 2, 2013, No. 317-FZ of November 25, 2013), "On State Social Assistance".

7. Federal Law No. 124-FZ dated July 24, 1998, "On Basic Guarantees of the Rights of the Child in the Russian Federation"

8. Order of the Ministry of Labor of Russia No. 585n dated August 27, 2019 (as amended on October 6, 2021), "On Classifications and Criteria Used in Medical and Social Expertise of Citizens by Federal State Institutions of Medical and Social Expertise" (Registered with the Ministry of Justice of Russia on November 18, 2019, No. 56528)

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Childhood injuries represent a serious issue resulting in various degrees of severity, up to life-threatening conditions. The danger increases with age, especially when the child starts moving independently. Various stabbing and cutting items, when used improperly, cause severe injuries to children of all ages. As children grow older, the pattern of injuries changes: the number of burns decreases, while the number of wounds, contusions, and facial bone fractures increases. The main cause of accidents is adult negligence. Furthermore, maxillofacial trauma leads to severe anatomical, functional, and neurological impairments that may require a series of reconstructive surgeries.

When sustaining a maxillofacial injury accompanied by wounds, tissue defects, or loss of consciousness, immediate medical assistance must be sought by calling an ambulance team.

It should be remembered that a child may not always react adequately, assess symptoms, or report characteristic complaints regarding maxillofacial injuries. Particular attention must be paid to younger children (under 6–7 years of age), in whom clinical manifestations of traumatic brain injuries are masked, and behind the "illusory well-being" of the child's condition after a maxillofacial trauma, brain damage may be missed.

Upon confirmation of the diagnosis of jaw fractures, as well as other facial bone fractures in children, hospitalization is mandatory. Depending on the general condition and the extent of the injury, the appropriate ward and timing for surgical treatment are determined.

Parents should be aware that visible clinical and radiological recovery upon discharge from the hospital or completion of active outpatient treatment does not rule out the possibility of delayed complications. All children who have suffered maxillofacial trauma must be placed on dispensary follow-up.

Maxillofacial trauma leads to impaired chewing, swallowing, and speech articulation.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.