Clinical features: Periorbital edema and ecchymosis Hypesthesia of the infraorbital nerve Palpation may reveal step off Concomitant globe injuries are common
Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement. Picture: CT 3-D. The fracture lines involved in a tripod fracture are demonstrated in this 3-D reconstruction.
Maxillofacial consultation Nondisplaced fractures without eye involvement Ice and analgesics Delayed operative consideration 5-7 days Decongestants Broad spectrum antibiotics since the fracture crosses into the maxillary sinus. Tetanus Displaced tripod fractures usually require admission for open reduction and internal fixation
LeFort II: Pyramidal fracture which includes a fracture through: Maxilla Nasal bones Medial aspect of the orbits
Lefort III fractures also known as craniofacial dissociation(separates the face from the cranium) involves fractures through the maxilla, zygoma, nasal bones, ethmoid bones and the bones of the base of the skull.
Emergency care for all these fractures involves airway maintenance, with Intubation or cricothyrotomy if necessary. Airway compromise is possible with any of these fractures but probably more common with LeFort II and III fractures. CSF rhinorrhea is uncommon in LeFort I fracture but is often seen in LeFort II and III fractures. If CSF rhinorrhea is present or intracranial air is seen on X ray or an open skull fracture is present, the patient should be admitted and place in a head elevated position (40-60 degrees) if possible. Prophylactic antibiotics are often given in these patients (Rocephin) though it has not been shown to prevent meningitis or brain abscess. Patients with maxillary fractures also have significant epistaxis which requires nasal packing. Operative intervention may be needed if bleeding doe not resolve with packing alone. Look for associated injuries, especially intracranial, spinal, thoracic and abdominal. Incidence of blindness is high for LeFort II and III fractures so it is important to get opth. consultation. Patients with Complex maxillary fractures require admission for open reduction and internal fixation.
These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth. Patients may have preauricular pain with biting when there is a fracture of the condyle. Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth. Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.
Nondisplaced fractures: Analgesics Soft diet oral surgery referral in 1-2 days Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction. All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1 st generation ceph.
Patients present with the inability to close an open mouth. Other associated symptoms include pain, discomfort and facial swelling near the TMJ. Unilateral dislocation results in deviation of the mandible to the unaffected side. Bilateral dislocation causes the mandible to be displace anteriorly. Picture: TMJ Dislocation Note the asymmetric jaw deviation toward the unaffected side. Always consider the possibility of an associated underlying fracture or cervical spine injury.
The mandible can be dislocated in the anterior, posterior, lateral and superior plane. Anterior dislocation is the most common and occurs when the condyle is forced in front of the articular eminence. Anterior dislocation occurs in up to 70% of the normal individuals but can be spontaneously reduced by the patient. Once the jaw is dislocated, muscular spasm, particularly the temporalis and lateral pterygoid muscles tend to prevent reduction. Dislocations are most frequently bilateral, but they also can be unilateral.
Reduction may be attempted in closed anterior dislocations without fracture. A short acting muscle relaxant (Versed) helps to decrease muscle spasm. An analgesic may also be considered. The patient should be seated. Facing the patient the examiner places his or hers thumbs in the patients mouth, over the mandibular molars as far back as possible. The fingers should curve beneath the angle and the body of the mandible. The examiner applies downward and backward pressure with his or hers thumbs until the condyle slides back into the articular eminence. When the dislocation is bilateral, it may be easier to relocate one side at a time. If reduction is successful, the patient should be able to close his or her mouth immediately. Post reduction films are not usually required unless the procedure was difficult or traumatic. Complications from the reduction are unusual and include iatrogenic fracture or avulsion of the articular cartilage.
Oral surgery should be consulted in patients who are found to have either an open dislocation, superior, posterior or lateral dislocations, non – reducible dislocation or a dislocation associated with a fracture.
A 17-year-old intoxicated unrestrained front seat passenger was thrown from a convertible when it struck a tree. Respirations are agonal, blood pressure is 60 and palpable, glasgow coma scale is 7, blood is present from the right ear canal, the maxilla and nasal bones are freely mobile on both sides, and rhinorrhea is present. Which of the following would be a treatment priority?
Immediate orotracheal intubation or surgical cricothyrotomy.
Nasotracheal intubation with direct laryngoscopy and magill forceps.
Opening the airway with the head-tilt/chin-lift method.
Immediate portable cross-table lateral radiograph of the cervical spine.
Surgical consultation for tracheostomy in the operating room.
10- a 27-year-old woman was unrestrained driver of a car that was rear ended just before arrival at the emergency department. She complains of a sore nose. Examination reveals a large grape-like swelling over the left side the nasal septum. What is the most appropriate action?
Checking prothrombin time and partial thromboplastin time for possible coagulopathy
Closed reduction of the nasal septum with follow-up by an otorhinolaryngologist
Incision and drainage of a septal hematoma with anterior packing
Referral to an otorhinolaryngologist advising the patient to be seen within 1 week
Referral to an otorhinolaryngologist for treatment of her nasal polyps
9- a 32-year-old woman playing tennis sustains a blow to her left eye. She complains of pain in her left eye but denies flashes of light, floaters, diplopia, or decrease in vision. Initial examination reveals 20/20 vision in both eyes, functioning extraocular muscles, and an intact globe. Orbital emphysema is noted surrounding her left eye however, and the patient begins to complain of decreased visual acuity in this eye. What step should be taken next?
Ballottement of the globe started immediately in an attempt to dislodge the clot causing the central retinal artery occlusion
Intra orbital needle aspiration or lateral canathotomy with cantholysis to release pressure under the orbit
Ophthalmologic consult for traumatic retinal tear with vitreous hemorrhage
Topical cycloplegics (5% homatropine) to the affected eye for treatment of traumatic iridocyciltis with an ophthalmologic follow-up
A 32-year-old man was involved in a barroom altercation. He arrived at the emergency department complaining of double vision and right –sided facial numbness after sustaining numerous blows to the head and face. Physical examinations reveals right-sided enophthalmos and inability to gaze upward with the right eye. What would be appropriate emergency department management of this patient’s condition?
Careful follow-up with the ophthalmologist for an orbital blowout fracture
Immediate neurosurgical consultation of traumatic intracranial hemorrhage
Nonsteroidal antiinflammatory agents and reassurance that his vision will improve once the swelling resolves
Blood alcohol level since these symptoms are most likely secondary to ethanol intoxication
Serum Lyme titers and an infectious disease consult
A 25 year old man is punched in the face at a bar and presents to you with dental pain. On examination, his right lower first premolar has a fractrue exposing yellowish surface. No blood is seen on on the tooth. Which of the following is the correct type of fracture and what is the proper management?
A) Ellis I; follow up in dental clinic in one week
B) Ellis I; follow up in dental clinic next day
C) Ellis II; follow up in dental clinic in one week
2- A young male comes to the ED with a stab wound to the neck, resulting in a large hematoma is distorting normal airway anatomy. Vital signs are recorded as follows: heart rate, 94; respiratory rate, 28; and blood pressure, 140/95. there is no evidence of stridor. What would be the proper technique for controlling the airway of this patient?
A wake oral intubation with local anesthesia
Blind nasotracheal intubation
Rapid-sequence induction with endotracheal intubation
Immediate consult of a trauma surgeon for placement of a tracheostomy.
4- paramedics radio in about a 25-year-old female with a stabbing injury to the right side of her neck just under her chin. The patient is awake and is tachypneic to 28 but is maintaining her airway. Her pulse is 115 and blood pressure 93/50. Paramedics report she is bleeding briskly, and they have an 8-minute transport. What should orders include?
Assessment of wound depth and tissue involvement in order to evaluate the extent and nature of hemorrhage
Direct transfer to the operating room on arrival, with early notification of the OR stuff and trauma surgeon
Immediate intubation because the patient is tachypneic and in danger of losing her airway
Placement of two intravenous catheters for volume resuscitation, with frequent assessment of vital sings and placement of MAST trousers should bleeding continue
Placement of two intravenous catheters for volume resuscitation and direct application of external pressure to the site of bleeding
5- A tachycardiac, hypotensive patient with penetrating neck trauma and bleeding into the orophaynx presents to a low-volume, single-coverage emergency department. The nearest appropriate trauma centre is 15 minutes away and is ready to accept the patient. Before transfer, what should the physician do?
Rapidly prepare the patient for transport without further delay and send the patient with a transport nurse certified in ACLS
Secure an airway, place on oropharynx with heavy gauze, and establish intravenous access with fluid and blood product resuscitation
Secure an airway, place an orogastric tube to decompress the stomach of both air and swallowed blood, and establish intravenous access with fluid and blood product resuscitation
Transfer the patient only after completing full primary and secondary surveys, including C-spine, chest and pelvis radiographs
Transfer the patient only if the platysma has been penetrated
6- A patient who was struck in the side of the head and face with a crowbar is experiencing decreasing levels of consciousness, with unilateral limb paresis and Horner’s syndrome. What is the most likely diagnosis?
8- In managing strangulation injuries, which of these is true?
Calcium boluses have been shown to improve the postanoxic cerebral circulation, helping to decrease long-term ischemic sequelae
Because of the high frequency of respiratory complications, prophylactic antibiotics should be routinely given
Intubation is an important adjunct even in the absence of unstable airways
Phenobarbital is the drug of choice of postanoxic seizures
Steroids have been shown to be effective treatment for both cerebral edema and central neurogenic ARDS
Which of the following is true regarding neck trauma
A) Delayed neurologic deficits after blunt neck trauma suggest carotid artery dissection
B) All patients with suspected esphogeal injury should receive barium contrast eshophagram
C) Zone III injuries are most amenable to surgical exploration
D) All neck wounds should be probed to determine the depth of the wound and integrity of vital structures
E) Impaled objects should always be removed in patients presenting neck trauma
A 22 year old woman presents to the ED after a domestic dispute with a boyfriend in which she was stabbed in the neck just lateral to her thyroid cartilage. Which of the following is an indication for mandatory operative exploration?