Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature.

We present our experience following a unique case of coincident intracranial hemorrhage and comminuted fractures of both the squamous temporal bone and zygomaticofrontal orbit. Surgical techniques and outcome for this presentation have yet to be sufficiently described. A 55-year-old male presented following trauma with Glasgow Coma Scale score of 7. Radiographic evaluation revealed comminuted fractures of the squamous temporal bone with extension into the lateral orbit, along with zygomatic process fracture extending 2.5 cm medially into the orbital roof. Zygomaticofrontal orbital roof fragments reached superiorly into the middle cranial fossa and inferiorly into the orbit. Surgical intervention was deemed necessary to address underlying epidural hematoma, subarachnoid hemorrhage, correction of cranial bone defects, and decompression of the optic nerve and other intraorbital nerves. A frontotemporal approach was employed. Repair of temporal and orbital fractures was accomplished using a combination of wire mesh screws and titanium miniplates. Postoperative imaging demonstrated bony approximation and successful evacuation of traumatic hemorrhage. The patient remains functionally and neurologically intact apart from a sluggishly responsive left eye presumed to result from a left optic nerve or ciliary ganglion lesion. Although rapid reconstruction of complex cranial-orbital trauma and hematoma evacuation can permit acceptable gross functional neurological outcome following massive trauma, orbital fracture and subsequent hemorrhagic processes may be the nidus of neurological sequelae in this complex traumatic constellation. Thus, alterations in surgical approach and reconstruction are appropriate in order to maximize neurological function while supporting restoration of cosmetic space.