Chapter 68- Facial Trauma Flashcards
best time to reduce nasal fx
immediately after (1-2 hr) OR 5-10d later once swelling has subsided
how edentulous mandible affects repair
no cross-sectional stability
too weak to load share site w/ small bone plate
needs load-bearing reconstruction
color of vision lost earliest with orbital injury
red
Feature of all LeFort fxs
traverse pterygomaxillary fissure
interrupt pterygoid plates, mobile palate
two most common mandible fx sites
angle
condyle
Aspects of PE important with facial trauma
ABC Cerv spine/brain CN Eye Ear (hearing, hemotymp, fx) Skull/midface/mandible Throat: occlusion, TMJ fxn, bleed, hematoma, airway, speech, swallow
which areas of h/n difficult to evaluate w/o sagittal/coronal recons?
orbital floor
mandibular condyle
frontal sinus outflow tract
Radiographic signs of fx
Non-anatomic linear lucency, cortical defect, suture diastasis, overlapping bone fragment, facial asymm
soft tissue swell, periorbital/IC air, fluid in sinus (indirect)
High vs low impact forces
Low are <50g (<50 times force of gravity)
g’s that different facial bones can withstand
nasal- 30 zygoma- 50 mandible angle- 70 frontal-glabella- 80 midline maxilla/mandible- 100 supraorbital rim- 200
Indications for surgery for A/P table fxs of frontal sinus
Ant: bony displacement causing deformity, FSOT impairment
Post: displace post table >1 table width, dural injury, CSF rhinorrhea, FSOT impairment, severely comminuted
Approaches to frontal sinus
trephination, elevate anterior wall frontoethmoidectomy using lynch incision ORIF through laceration or coronal flap obliteration cranialization
How to avoid vessel/nerve injury when raising coronal flap
avoid CN VII frontal branch injury by incising superficial layer of deep temporal fascia at temporal line of fusion, so elevation can be deep to this layer
osteotome to inferior lip of supraorbital/trochlear nerve foramen to allow nerve to move inferiorly
How to treat nasal fx that occurred 10d ago
may not be amenable to closed reduction
may need complete healing (3-6mo) then septorhinoplasty
3 types of medial canthal tendon injuries
I- single noncomminuted central fragment, MCT attach
2- central fragment comminuted
3- MCT detached
Types 2/3 need transnasal wiring
where orbital contents leak into sinuses in blowout fracture
floor (0.5mm)
less often the lamina (0.25mm)
When to perform surgery with blowout fx of orbital floor
enophthalmos >2mm
double vision primary or inferior gaze
EOM entrap (forced duction)
>50% floor on CT
white eye blowout fracture
greenstick (child)
contents leak out floor, then bone closes, inferior rectus trapped/ischemic
white sclera, usually with nausea
Surgical approaches to orbit
Floor: infraorb, subciliary, transconj (pre/post septal)
Med: transcaruncular, endoscopic, lynch (external ethmoidectomy)
Lat: infrabrow, upper lid skin crease (bleph), extended lower lid transconj with lateral canthotomy
Roof: lynch, transbrow, coronal
risks of lynch incision
between medial canthus and bridge
skin scar, disinsert medial canthal tendon, damage lacrimal sac, diplopia from trauma to trochlea of sup oblique, scar
How does transcaruncular approach compare to lynch for medial orbit access
rapid, less dabmage to skin/muscle layers, better cosmesis, less manipulation of lacrimal sac, MCT
absolute indications for lateral canthotomy
retrobulbar hemorrhageg acute loss of visual acuity, increased IOP, proptosis
If unconscious: IOP >40 (NL is 10-21)
Optic nerve injury manifestations
First: lose red color vision
Later: other colors, decreased central vision, APD, visual field defect
Tx: steroids (high dose) or surgical decomp
traction test
with NOE fx, pull laterally on lower eyelid to see if MCT disrupted
