Facial Fractures and Soft Tissue Injuries Flashcards
the early examination of the optic nerve is through…..
is through the red desaturation
What are the surgical emergencies in facial trauma?
Entrapment of the extraocular muscles and septa) hematoma
the percentage of patients whom have intracranial injury&cervical spine injuries
Over 45% of patients with facial fractures have a concomitant intracranial injury and nearly 10% have cervical spine injuries
Vertical
facial buttresses are divided into coronal and sagittal types
F Horizontal
facial buttresses are divided into coronal and sagittal types
the frontal bone lacks sagittal support
F Whereas the frontal bone and mandible display
stability in each plane, the midface lacks sagittal support
What are the vertical Buttress?
Orbital
Naso&ontal
Zygomatic
Pterygomaxillary
Mandible
What is the Coronal buttress?
Supraorbital
lnfraorbital rim
Transverse maxillary
Mandible
What is the Sagittal buttress?
Frontal bone
Zygomatic arch
Lefort I segment
Mandibular body
Zygomatic arch present in vertical and sagittal buttress T F
T
Zygomatic arch present in coronal butress T F
F
Prompt recognition of both auricular and septal hematomas is critical
T
The swinging flashlight test distinguishes afferent pupillary defects from an oculomotor nerve injury
T
red desaturation is one of the earliest signs of visual loss
T
swelling usually masks enophthalmos in the acute
setting.
T
In an unresponsive patient, forced
duction testing rules out entrapment without anesthesia
T
The normal position of temporomandibular joint
The temporomandibular joint (TMJ), positioned directly anterior
to the tragus and under the zygomatic arch
the success of maxillomandibular fixation depend on dental hygiene
T
Loss of lip depression while smiling can result from injury to the ipsilateral marginal mandibular only
F result from injury to the ipsilateral marginal mandibular nerve or cervical branch as the platysma (cervical branch innervation) can cofunction with the depressor anguli oris (marginal mandibular
innervation) to display a full denture smile.
How we can distinguish between marginal mandibular and cervical branch injury?
These can be distinguished
by asking the patient to evert her lower lip: with a cervical branch injury,
eversion is preserved because of intact mentalis function
Thin-slice CT scan should be obtained for patients whose mechanism
of injury or examination suggests facial fractures (1mm slice)
T
For optimal access to correct
bony injuries, edema should be allowed to subside for 7 to 10 days
T
minimizing buried dissolvable sutures that may incite inflammatory and infectious responses in a contaminated field
T
Accurate tissue reapproximation is the most important step after
wound debridement
T
Neurologic deficits from
zygomatic and buccal branch injuries are less common
T
Neurologic deficits from
zygomatic and buccal branch injuries are less common, particularly
when lacerations occur medial to the lateral canthus, Why?
because of the
arborization that occurs medially, with multiple nerve endings innervating a muscle.
What is the most common nerve injury with the parotid duct?
Buccal branch injuries are most likely to occur with
large, mid-cheek lacerations. Concomitant parotid duct injuries are
common
Cervical branch injuries are less common
T. and
also exhibit crossover from multiple sub-branches
the most common site form marginal mandibular nerve injury?
most commonly injured as it crosses the inferior border of the
mid-mandibular body
Penetrating auricular injuries should
receive 7 to IO days of antibiotic prophylaxis, typically with ciprofloxacin, to prevent chondritis.
T
no immediate signs ofparotid
duct injury exist
T
If the duct is lacerated,
repair should be conducted over a small-caliber pediatric feeding tube.
The tube should be left in place as a stent for 7 days
F for 14 days
A subcutaneous
drain left in place for I week and facial wrap providing external pressure for the first 48 hours may also help prevent sialocele
T
frontal sinus fractures are commonly seen in children
F Pneumatization of the frontal sinus begins around the age of
2 years and is completed by 12 years. Because the bone is thicker
in childhood, frontal sinus fractures are not commonly seen
Management of frontal sinus depends on what?
the fracture extends through the anterior or posterior table or both,
the degree of displacement, and the likelihood of nasofrontal outflow
tract obstruction
Fractures of the anterior table may lead t contour irregularities or instability of the supraorbital
bar
T
The nasofrontal outflow tract exit in the middle nasal meatus at the hiatus semilunaris
T
Nasofrontal outflow tract involvement with obstruction is strongly
correlated with a higher degree of fracture displacement
T
How you can Obliterate the frontal sinus?
- surgical curettage of the sinus mucosa
- burring of the sinus bone to remove any invaginations of mucosa
- surgical occlusion of the nasofrontal ducts.
- Placement of bone, muscle, fat, pericranial, or galeal
flaps.
Cranialization
removing the posterior table so the sinus and the anterior cranial fossa are contiguous.
The sinus mucosa must be carefully curetted,
the inner portion of the anterior table bone burred away, and the nasofrontal duct occluded with bone graft.
The brain is allowed to fill what was formerly the frontal sinus
Displaced fractures of only the anterior table
generally require operative reduction and fixation with low-profile
miniplates to restore forehead contour
T
In posterior table fractures, surgical intervention is a most
F In posterior table fractures, the degree of displacement and
presence of a cerebrospinal fuild (CSF) leak dictate management
Displaced fractures carry a higher risk of dural tear, CSF leak, and
meningitis. These complications are minimized with cranialization
F Displaced fractures carry a higher risk of dural tear, CSF leak, and
meningitis. These complications are minimized with obliteration for
less severe fractures or cranialization for more displaced or comminuted fractures
With obstruction of the nasofrontal outflow tract can be treated with observation
F With obstruction of the nasofrontal outflow tract in either anterior or posterior table fractures, the sinus must be obliterated or cranialized regardless degree of fracture displacement
The most common complication after frontal sinus fracture?
Abscesses and Mucoceles
Mucoceles are easy to treat
Mucoceles are difficult to
treat; therefore, prevention is ofprimary importance
Mucoceles
Mucoceles result
from the indolent overgrowth of residual basilar sinus mucosa from
the diploic veins of Breschet, which are small mucosa! crypts that
invaginate into the bone
Mucoceles typically present in a delayed
fashion with chronic headaches, mass effect, visual disturbance, nasal
obstruction, or erosion of the frontal bone
T
The orbit designed to support the vertical and sagittal position of the globe
T
Fractures often increase orbital volume
T
Consequence of Retrobulbar hematoma
if not promptly diagnosed.
Superior orbital fissure and orbital apex syndromes
Facial CT is the only method of ensuring
accurate diagnosis of orbital fracture
T
however, the only way to accurately diagnose of orbital muscle
entrapment is by physical exam.
T
Diplopia is the primary surgical indication in orbital floor and
medial wall fractures
T
indications for a reduction of orbital roof fractures in adult
In adults, indications for reduction of orbital roof fractures are limited to patients with dural tears or orbital apex syndrome
that does not respond to medical therapy
Risk of ectropion and scleral show increases with use of
a transcutaneous incision
T
Frost stitch can prevent acute globe exposure
from chemosis, it has been shown to prevent ectropion
F it has not been shown to prevent ectropion
What is the tripod fractures?
zygomaticomaxillary complex (ZMC)
The zygomatic bone sets the width
and projection of the midface
T
Superior orbital fissure (SOF) syndrome VS Orbital apex syndrome
Same as SOF syndrome, with the addition of blindness
zygomaticomaxillary buttress is most important in verifying accurate realignment
of the zygoma
F the zygomaticosphenoid buttress is most important in verifying accurate realignment
of the zygoma
In many cases, ZMC fractures are associated with fractures of
the orbital floor
T
ZMC fracture with orbital fracture need to address the orbital floor before
F The ZMC must be reduced first
For depressed fractures with the inherent stability of ZMC which surgical approach can be employed
Gillies approach or 2-centimeter upper buccal sulcus incision (Keen incision)
most commonly fractured facial bones
Nasal Bone
The cartilage should repair Even after closed reduction
of the nasal bones, in the presence of an incomplete septum! fracture why>?
the bones will tend to deviate toward the displaced portion of the
septum during the healing process
Closed nasal
reduction under general anesthesia givee superior
outcomes to that under local anesthetic
F Closed nasal
reduction under general anesthesia has not been shown to have superior
outcomes to that under local anesthetic
severely displaced fractures nasal fracture is better to reduce it ander general anasthesia
T
The borders of the NOE ?
superiorly: by the frontal sinus, cribriform plate, and anterior skull base
anteriorly: by the nasal bones, the bifrontal process of the maxilla, and the nasal process of the frontal bone.
laterally: by the lacrimal bone and lamina papyracea of the ethmoid
bone
medially: by the septum and the perpendicular plate of the
ethmoid
Why NOE fractures particularly susceptible to CSP leak
The thin bones ofthe anterior cranial fossa at the fovea ethmoidalis and the tight dural adhesion at the cribriform plate
The medial canthal tendon sets the intercanthal distance and
the angle of the palpebral fissure
T
Classification of NOE fracture depends on what?
based upon the involvement of the central fragment, or the fragment of bone to which the medial canthal tendon attaches
trans canthal wiring. A 3-0 stainless steel wire is
passed from a point anterior to the medial canthal
attachment in NOE III
F superior and posterior to the medial canthal
attachment.
Placed anterior to the medial canthal attachment site will not prevent lateral migration of the canthus, thus
leading to permanent telecanthus and a broad nasal base
Management of soft tissue edema is of equal importance as bony
reduction
T
Fracture patterns may differ on each side of the face
T In these cases,
the term hemi-LeFort is often used.
A key component of each fracture type is the disruption of
the ipsilateral pterygoid plates, which are a major source ofmidfacial
stability
T
Lefort fractures are typically
the result of high-energy trauma and are rarely isolated fractures
T
Which type of lefort fracture termed craniofacial disjunction
Lefort III
Lefort I fractures may be treated through an upper
buccal sulcus incision
T
Lefort II and III fractures benefit from the
Buccal sulcus
F Lefort II and III fractures benefit from the
exposure ofa coronal approach
What is the primary objective of lefort surgery?
Restoring normal occlusion is the primary goal of reduction; normal facial width, height, and projection
should follow secondarily.
Palatal fractures usually occur in the coronal plane
F Palatal fractures usually occur in the sagittal plane
Palatal
fractures often occur in conjunction with Lefort IIIfractures
F Palatal
fractures often occur in conjunction with Lefort I fractures
How we can achieve the stability of the palatal fracture?
After
reduction, stability can be restored anteriorly with a miniplate in the
area of the piriform, and posteriorly with a plate across the palatal
concavity for maintenance of palatal width
Tooth extraction is also
recommended whenever the tooth roots are fractured in mandibular farcture
T
Type of mandibular fixation
rigid and functionally
stable
In functionally stable fixation
(load-sharing), micromotion is allowed at the fracture site
T
Non-locking screws are typically only used in oblique
mandibular fractures,
T
lag screws are usually only used at the
symphysis.
T
Fractures of the angle have the highest incidence of
complications
T
Fractures of the condylar head and sub condylar region are less common,
Fractures of the condylar head and subcondylar region are common,
accounting for 25% to 35% of mandibular fractures in adults
condylar and
subcondylar fractures are often treated in a closed fashion
T
the percentage of mandibular parts fracture?
condyle/ subcondylar region
Symphysis,parasymphysis
Angel
body
Hardware infection in mandibular fracture
may be managed with a period of observation and antibiotics with or
without surgical irrigation; ideally, hardware removal is delayed until
union occurs
T
Cranialnerve (CN) functionis examined by testing sensation to light
touch in the Vl, V2, and V3 distributions, comparing sensitivity with
the contralateral side and with baseline
t
X-rays are rarely useful
t
the ear should be bolstered
for 5 to 7 days to prevent hematoma formation or recurrence
t
Abscesses can occur in acute or delayed fashion and can range from
subcutaneous to intracranial. These are managed with repeat surgical debridement and obliteration or cranialization
t
This muscular entrapment
is a surgical emergency because the prolapsed portion of the muscle
quickly becomes ischemic. If the muscle is not released within 6 to 8 hours, it will become fibrotic with a high risk of permanent diplopia
T
Alignment of the orbital floor should be evaluated
on coronal and sagittal cuts
T
Diplopia is the primary surgical indication in orbital floor and
medial wall fractures. Diplopia is more likely to occur with larger
fractures exceeding I to 2 cm
T
The optic nerve is located approximately 32
to 42 mm posterior to the infraorbital rim
T
The ZMC can be approached through transconjunctival and
upper buccal sulcus incisions
T
Nasal Bone Fractures accounting for over 55% of facial fractures
T
Class I
NOE fractures involve a single central fragment with relative stability
T
In class II NOE fractures comminution is present,
but the medial canthal tendon remains attached to a central fragment
that is large enough for stabilization with a miniplate or microplate
T
Class III fractures are characterized by detachment of the medial canthal tendon from bone, extensive bony loss,
or a high degree of bony comminution such that fixation cannot be
accomplished with traditional measures
T
Adequate
restoration ofthe tendon attachment is critically important to avoid
alteration of the palpebral fissure or telecanthus. Vertical asymmetry of as little as 2 mm is noticeable at conversational distance
T
The
medial canthi should be positioned no more than 25 mm apart
T
Splinting with a padded metal
bolster is recommended. The splint is fixated with transcanthal wires
designed for soft tissue support alone
T
key component of each maxillary fracture type is the disruption of
the ipsilateral pterygoid plates, which are a major source of midfacial
stability
T
Lefort II fractures are
pyramidal, extending from the pterygomaxillary junction through
the zygomaticomaxillary buttress and orbital floor obliquely to the
nasofrontal junction
T
Lefort I fractures occur transversely across the maxilla
T
rigid and functionally
stable. In rigid fixation (load-bearing)
T
Because of the curved nature of the mandible, locking plates are
often desirable
T
