11 - Trauma Flashcards
1
Q
Angle Fractures Management
A
- Al-Moraissi 2014
- Less complications with single plate vs two plates
- Infection
- Pain
- Wound dehiscence
- IAN injury
- 3D geometric plate better than linear plate
- 2 plates to one side of bilateral angle fracture
- Less complications with single plate vs two plates
- O’Connor 2015
- Infection rate
- 20% - Intraoral
- 5% - Transbuccal
- Infection rate
2
Q
Neck Trauma Management
A
Zones of the Neck (Monson):
Monson advocated mandatory exploration of neck injuries in Zone 2
This has been challenged by newer studies
- Zone 1 - Clavicle to cricoid
- Zone 2 - Cricoid to Angle of mandible
- Zone 3 - Angle of mandible to Skull base
Nowicki 2018
- Mandatory exploration is not recommended
Exploration based on:- Clinical exam
- CT angio findings (If clinical exam is negative)
- C-Spine collar not routinuely recommended
- C-Spine injury low in penetrating neck injuries
- Clinical Exam
- Airway
- Hoarseness
- Stridor
- Subcut emphysema
- Bubbling from the wound
- Hemoptysis
- Difficulty in pain or swallowing secretions
- Breathing
- Dyspnoea
- Circulation
- Pulsatile bleeding or expanding hematoma
- Audible bruit
- Palpable thrill
- Disability
- Neurological deficits
- Airway
Management
- Vascular Injury
- External compression
- Foley catheter tamponade
- Exploration and Repair
- Carotid - Repair
- Laryngotracheal Injury
- Bronchoscopy
- Undisplaced laryngeal fractures - Conservative Mx
- Stenting
- Oesophageal Injury
- Oesophagoscopy
- Medical
- Antibiotics
- NG Feeds or TPN
- Within 12 hrs - Repair
- Post 12 hrs - Debridement - Consider delayed repair
3
Q
Orbit
Indications and Timing
A
Dubois 2021
- Immediate (within 24 hrs)
- Diplopia with CT evidence of entrapment with oculocardiac reflex
- White eye blowout
- Significant globe displacement with vision threatening injury
- Early (within 2 weeks)
- Early enophthalmos and hypoglobus
- Symptomatic diplopia with positive forced duction, evidence of entrapment
- Delayed (After 2 weeks)
- Symptomatic diplopia without entrapment
- Late onset enophthalmos and hypoglobus
Burnstine 2002
- Form
- Enophthalmos >2mm (1cm2 # = 0.8mm enophthalmos - Whitehouse 1994)
- Orbital floor defect size >50% (Hawes and Dorzbach 1983)
- Obvious diplopia
- Function
- Diplopia within 30 degrees of central gaze
- Entrapment
- Oculocardiac reflex
- Retrobulbar haemorrhage not relieved by lateral canthotomy
- Contraindications
- Hyphema
- Retinal tear or detachment
- Penetrating eye injury
- Blindness in contralateral eye
Key areas of fracture to reconstruct
- Junction between orbital floor and medial wall - Hammer’s area
- Ethmoidal bulge on posteromedial wall - Raskin 1998
- Sigmoidal curve of the floor behind the globe
4
Q
Paediatric Orbital Floor Timing
A
- Orbital Floor Timing
Gerbino 2010
10.1016/j.joms.2009.12.037- Residual diplopia at follow-up
- 8.3% - within 24 hours
- 38% - within 96 hours
- 100% - greater than 96 hours
- Residual diplopia at follow-up
5
Q
Palatal fracture classification
A
- Moss Classification
10.1016/j.joms.2015.09.027- Type I
- Para-alveolar
- Para-sagittal
- Sagittal
- Type II
- Transverse
- Type III
- Comminuted
- Comminuted
- Type I
- Hendrickson Classification
- Type I - Alveolar
- Type II - Sagittal
- Type III - Para-sagittal
- Type IV - Para-alveolar
- Type V - Comminuted
- Type VI - Transverse
6
Q
Mandible fractures Periop Antibiotics
A
Zallen and Curry 1975
- 50% infection rate without antibiotics
Andreasen 2006
- Pre-op and Perioperative antibiotics reduce infection 3 fold
Miles and Ellis 2006
- Post operative antibiotics make no difference
7
Q
Management of teeth in line of angle fracture
A
Indications (Shetty 1989)
- Infected - Periapical or pericoronitis
- Fractured
- Mobile
- Pathology
- Preventing reduction
- Teeth with exposed root apices or entire root surface exposure
- Excessive delay from time of fracture to definite treatment
McNamara 2016
- No increase in rate of infection with retention vs removal
- Statistically increased rates of IAN dysfunction with tooth removal
- 40% - Removal
- 16% - Retention
8
Q
Condylar Fractures Outcomes
A
- Eckelt 2006
10.1016/j.jcms.2006.03.003
RCT - 88 pts; Open vs Closed Treatment- Trial stopped early due to superior results
- Better maximum mouth opening, lateral excursion, pain score, malocclusion
9
Q
Condylar Fracture Complications
A
- Al Moraissi 2018
10.1016/j.jcms.2017.10.024- Temporary Facial nerve injury
- Transoral - 0.72%
- Transbuccal - 2.7%
- Endo Assist - 4.2%
- Low Submand - 15.3%
- High submand/Angle - 0%
-
Retromand Transparotid
- w Facial nerve prep - 14%
- w/o Facial nerve prep - 19%
- Retromand Antparotid Trans Masseteric - 2.3%
- Preauricular
- Deep subfascial dissection - 0%
- Subfascial dissection - 10%
- Retroauricular - 3%
- Permanant Facial nerve injury
- Low Submand - 2.2%
- High Submand/Angle - 0.3%
- Retromand Transparotid - 1.4%
- Preauricular - 0.33%
- Deep Retroparotid - 1.5%
- Temporary Facial nerve injury
10
Q
Condylar Fracture Indications and Contraindications
A
- Zide and Kent 1983
- Absolute
- Inability for closed reduction
- Displacement into middle cranial fossa
- Foreign body
- Dislocation of the head laterally out of the fossa
- Relative
- Bilateral TMJ fracture
- Midface fractures requiring restoration of posterior facial height
- Medical contraindications to IMF
- Seizures
- Intellectually impairment
- Edentulous
- Other Authors
- Loukota 2005
- Angulation - >10 degrees
- Loss of height - 2mm
- Reyneke 2018
Inability for IMF- Angulation - 30 degrees
- Loss of height - 6mm
- Loukota 2005
- Contraindications
- Children <12 yrs old
- No loss of height and not displaced
- Not fit for surgery
- Absolute
11
Q
ZMC Classification
A
- Zing Classification
- A - Isolated fracture at one of the processes
- I - Arch
- II - ZF
- III - Inferior orbital rim
- B - Tripod fracture
- C - Comminuted fracture
- A - Isolated fracture at one of the processes
- Knight and North Classification
- I - Undisplaced
- II - Arch only
- III - Unrotated displaced fractures
- IV - Medially rotated (Based on Waters view)
- In at ZF, Out at Buttress
- V - Laterally rotated
- Out at ZF, In at Buttress
- VI - Comminuted
12
Q
Frontal bone fracture Classification
A
13
Q
Frontal bone fracture Notes
A
- Management considerations, concepts and paradigm shift
- There has been a shift in recent year to treat Posterior table and suspected Nasofrontal outflow tract obstruction conservatively
- Posterior table fracture
- Previous indications for cranialization for comminuted posterior table fractures can be monitored first
- Open comminuted anterior and posterior table fractures still warrants early intervention
- Posterior table fracture does not determine the development of mucocoeles in the future. NFOT obstruction is the main determinant
- Previous indications for cranialization for comminuted posterior table fractures can be monitored first
- CSF leak
- Prolonged CSF leak can lead to infection and meningitis
Meningitis risk in basilar skull fracture is 7% - 7 days is the accepted literature period for observation prior to consideration of operative management
- Prolonged CSF leak can lead to infection and meningitis
- Nasofrontal outflow tract obstruction
- Case series showing NFOT can regain patency spontaneously
- Previous treatment regimes of stenting had a 30% failure rate with obstruction post stent removal
- Obliteration is currently challenged as best practive for NFOT obstruction
- Schultz advocates ORIF of Anterior table fracture with endoscopic Lothrops procedure
14
Q
Frontal bone fracture Assessment
A
- Anterior Table Fracture
- Nasofrontal outflow obstruction
Nasofrontal duct is located on the medial posterior region of the Frontal sinus
25 -50% of Anterior table fractures- Difficult to determine definitively on CT and clinically
- Clinically
- NOE fracture signs
- Supraorbital rim step
- Radiographically if fracture involves the:
- Ethmoids
- Medial Superior orbital rim
- Orbital roof
- Nasofrontal outflow obstruction
- Posterior Table Fracture
- Concomitant neurological injury
- History
- Mechanism of injury
- Amnesia
- Loss of conciousness
- Clinically
- GCS
- CSF leak
- Radiographically
*
- History
- Concomitant neurological injury
15
Q
Frontal bone fracture Complications
A
- Weathers 2013
Frontal bone fracture- Early (<6 months)
- Sinusitis
- CSF Leak
- Meningitis - 7% for basilar fractures
- Late (>6 months)
- Recurrent CSF Leak
- Mucocoeles (Can occur decades after injury)
- Mucopyoceles
- Brain abscess
- Cosmetic deformity
- Early (<6 months)
