EM Trauma 2 (Facial trauma) Flashcards
descending order of causes of facial fractures
- assault
- MVC (severe injury)
- falls
- sports
- GSW (severe injury)
descending order of facial fractures
- nasal bone
- orbital floor
- sygomaticomaxillary
- maxillary sinuses
- mandibular ramus
“Mandibular fratures anre the second most common facial fracture after nasal fracture”
3 screening questions in secondary survey of facial trauma
- HOW IS YOUR VISION?
- IS YOUR FACE NUMB?
-check for anesthesia of the
»forehead
»lower eyelid
»cheek and upper lip
»chin
-suggests injury to the
»supraorbital nerve
»infraorbital nerve
» mental nerves - DO YOUR TEETH FIT TOGETHER NORMALLY?
-mandibular or maxillary fractures
remarks on abnormal vision in facial trauma
“Loss of vision implies injury to the optic nerve or globe”
Binocular double vision suggests entrapment of the extraocular muscles
Monocular double vision suggests lens dislocation
This indicates globe injury
Teardrop-shaped pupil
Telecanthus
Widening of the distance betweel medial canthi with normal interpupillary distance
occurs with naso-orbito-ethmoid injuries
Widening of the interpupillary distance
“hypertelorism”
-results from a “Blow-out” injury to the orbits, often resulting in Blindness
blow-out fracture
-limitation in or diplopia when looking up
These suggest corneal abrasions
foreign body sensation and photophobia
features of retrobulbar hematoma
exophthalmos
afferent nerve defects
inc IOP
dish face deformity on lateral view
classic for Le Fort III
“craniofacial dysfunction”
-entire face is separated from the skull
-from fracutres of the Frontozygomatic suture line, across the Orbit and through the base of the Nose and Ethmoids
-the entire face shifts with the globes held in place only by the optic nerve
remarks on CSF leak
in trauma, presence of rhinorrhea or otorrhea* is CSF leak until proven otherwise
*rhinorrhea -> temporal bone or middle cranial fossa injury
double ring or halo sign occurs when clear CSF diffuses past blood when dropped on a paper towel
not specific or sensitive
serum BETA-2 TRANSFERRIN
-highly sensitiv and specific
Battle’s sign
bruising over the mastoid process
suggests basilar skull fracture
I&D of auricular hematoma is required to prevent
destruction of cartilage resulting in a cauliflower deformity
malocclusion occurs in
mandibular fractures
Le Fort fractures
zygomatic fractures
test to indentify clinically significant mandibular fracture injuries
tongue blade test
diagnostic for forntal bone fracture
low suspicion
-head CT
if with significant clinical findings
-head CT with skull windows
if with involvement of the supraorbital ridge
-include a facial CT with axial and coronal section
Diagnostic for midface fractures
low suspicion
-Water’s view
if with significant clinical findings
-face CT with coronal and axial sections
(this is also the imaging study of choice for patients with an abnormal Water’s view”
Head CT may replace an additional Water’s view
*multiplanar computer reconstructions increase the effectiveness of visualization of fractures, especially in the case of fractures in the INFERIOR ORBITAL WALL
imaging for mandibular fractures
low suspicion
-Panorex (orthopantomogram) (initial)
if with significant clinical findings
-Mandible CT (gold standard)
remarks on intubation in facial trauma
To prevent the “can’t intubate/ can’t oxygenate” failred airway, do not administer paralytics unless a patient can be bagged effectively or alternative airway devices of plans are in place
etomidate and ketamine both provide sedation with preservation of respiratory drive
remarks on blood supply of the face
face: primarily from the sphenopalatine and greater palatine branches of the ECA
nasal: anterior and posterior ethmoidal branches of the ICA
Most common finding in ocular injuries in patients with frontal bone fractures
afferent pupillary defect
remarks on sinus fractures
oral antibiotics, such as first-gen cephalosporins or amoxicillin clavulanate, are recommended with any sinus fracture
features of naso-orbito-ethmoid fractures
”PTEC”
pain on eye movement
traumatic telecanthus
epiphora (tears spilling over the lower lid)
CSF leak
requires admission for specialty consultation with facial surgery and neurosurgery*PTEC
remarks on ocular injuries in facial trauma
emergent ophthalmology consultation is required for associated ocular injury
retrobulbar hematoma or malignant orbital emphysema may create an ocular compartment syndrome, resulting in an acute ischemic optic neuropathy
PE:
exophthalmos
dec VA
inc IOP
tx:
emergency lateral canthotomy
orbital fissure syndrome
fracture involving the superior orbital fissure
injury to the oculomotor and ophthalmic nerve
PE:
abn EOM
ptosis
periorbital anesthesia
obital apex syndrome
orbital fissure syndrome + involvement of optic nerve
abn EOM
ptosis
periorbital anesthesia
DIMINISED VISUAL ACUITY
Tripod fracture location
- zygomatic arch practure
- lateral orbital rim fracture
- inferior orbital rim fracture
- lateral wall of maxillary sinus fracture
Le Fort I
“alveolar fracture”
transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum
only the hard palate and teeth move, similar to a loose upper denture
Le Fort II
“fracutre of zygomatic maxillary complex)
a pyramidal fracture through the central maxilla and hard palate
movement of the hard palate and nose occurs, but not the eyes
Le Fort IV
includes characteristics of the Le Fort III and also involves the Frontal bone (4tal bone)
remarks on mandibular fractures
a mandibular fracture should be considered BILATERAL until proven otherwise
comminuted mandibular fractures could result in upper airway obstruction due to the tongue being unsupported anteriorly
presume an OPEN fracture until a thorough intraoral exam determines otherwise
remarks on mgt of mandibular fracture
in the patient with a stable airway, placement of a Barton’s bandage, an ace wrap over the top of the head and underneath the mandible, will stabilize the fracture and help relieve pain
administer pain control and clindamycin 600-900mg IV
open fractures require admission for operative repair
remarks on facial fractures in children
cricothyrotomy is contraindicated in patients <8 y/o bec the cricothyroid membrane is not developed until age 8 and should be avoided bet 9 and 12 years of age
the *maxillary sinuses do not begin developing until age 6y, which reduces the incidence of midfacial fractures compared with adults
