Maxillofacial Trauma Flashcards
Proper reduction of a zygomaxillary complex (ZMC) fracture requires reduction and realignment of which of the following?
A) Zygomatic arch, infraorbital rim, alveolus
B) Zygomaticofrontal suture, infraorbital rim, alveolus
C) Zygomaticofrontal suture, zygomaticomaxillary buttress, infraorbital rim
D) Zygomaticofrontal suture, zygomaticomaxillary buttress, orbital floor
E) Zygomaticomaxillary buttress, infraorbital rim, alveolus
The correct response is Option C.
A zygoma fracture involves displacement of the zygoma that articulates with the frontal bone, maxilla, and sphenoid. In order to stabilize the fracture after adequate reduction, the zygomaticofrontal, zygomaticomaxillary buttress, and infraorbital rim need to be fixated. If there is a large (>2 cm2) defect in the orbital floor after reduction, reconstruction of the orbital floor is also necessary to prevent enophthalmos.
While the nasomaxillary buttress is one of the vertical buttresses of the face, the zygoma does not articulate with the nasal bones.
2018
A 7-year-old boy is brought to the emergency department after being injured in a domestic violence incident. Physical examination shows bruising around the right eye. The patient reports pain and nausea when looking upward. A CT scan shows an entrapped inferior rectus muscle. Three weeks later, the floor of the orbit is repaired with an orbital floor implant. One year later, he continues to have diplopia. Which of the following is the most likely reason for the persistent diplopia?
A) Exophthalmos
B) Location of prosthesis
C) Nerve damage
D) Persistent swelling
E) Timing of surgery
The correct response is Option E.
Timing of pediatric orbital floor fractures is well studied. Unlike adult fractures, significant delays for surgery in children, especially more than 7 days after injury, is associated with varying degrees of diplopia. Many consider this pathology an emergency and should be treated within 24 hours. Assuming a typical, standard of care approach is performed well from a technical standpoint, only delays in time to treat were shown to predict such a poor outcome.
2018
A patient underwent open reduction and internal fixation of naso-orbital-ethmoid fractures 12 months ago, and epiphora was noted on follow-up examination. After 6 months of observation and persistent epiphora, which of the following is the most appropriate next step to evaluate the function of the patient’s nasolacrimal system?
A) Conjunctivorhinostomy tube placement
B) Continued observation, as function is likely to return
C) Jones tests
D) Lacrimal system flushing
E) Schirmer tests
The correct response is Option C.
The Jones test is used to evaluate lacrimal drainage. Divided into two parts, the Jones I test investigates lacrimal outflow under normal physiologic conditions. A drop of sterile 2% fluorescein solution or a moistened fluorescein strip is placed into the conjunctival fornix and a cotton-tipped wire applicator is placed into the inferior nasal meatus in the region of the ostium of the nasolacrimal duct at 2 and 5 minutes to check for fluorescein. As this test occasionally yields abnormal results in normal patients, it is not uniformly performed. The Jones II test determines the presence or absence of fluorescein when the residual fluorescein is flushed from the conjunctival sac with clear saline to determine whether there is reflux of fluorescein.
Naso-orbital-ethmoid (NOE) fractures can be challenging fractures, and either through direct instrumentation with transcanthal wiring or from the fractures themselves, the lacrimal drainage system can be affected. Postoperative epiphora can be very common and is present in at least 50% of patients who have undergone open reduction and internal fixation (ORIF) of an NOE fracture. After 3 to 6 months approximately half of this epiphora resolves, with the other half of patients (25%) requiring consideration for other investigations to evaluate lacrimal drainage. Schirmer test is used to evaluate dry eyes and is not appropriate in this patient.
2018
A 22-year-old man is evaluated for multiple facial fractures after he was assaulted. Which of the following fractures is most likely associated with an increased risk of temporomandibular joint dysfunction?
A) Bilateral parasymphyseal mandible
B) Comminuted unilateral condylar mandible
C) Complete Le Fort I maxillary
D) Displaced unilateral subcondylar mandible
E) Unilateral zygomaticomaxillary
The correct response is Option B.
Temporomandibular joint (TMJ) dysfunction symptoms are serious, often overlooked complications of facial fractures and their treatments. They can range from clicking and pain to locking, malocclusion, and trismus. Overt ankylosis can occur in rare circumstances. Fractures that result in significant disruption of the condylar/glenoid apparatus are more likely to result in TMJ dysfunction symptoms than more anatomically remote fractures. Condylar fractures are most susceptible to post-fracture TMJ dysfunction. This is especially true in comminuted condylar head fractures. One recent study demonstrated an increase in TMJ dysfunction symptoms in patients with condylar fractures and concomitant contralateral mandibular body/angle fractures. Le Fort I and zygomaticomaxillary complex (ZMC) fractures are unlikely to be associated with TMJ symptoms.
2018
A 10-year-old boy is brought to the physician after sustaining a nondisplaced fracture of the mandibular body in a fall. Soft diet is recommended. Two days later, he is brought back to the office and reports pain in the right mandibular lateral incisor when drinking cold liquid. The base of the defect appears yellow and is tender when probed. Examination shows a lingual fracture of the tooth crown. On the basis of these findings, which of the following is the deepest layer of exposed tooth?
A) Cementum
B) Dentin
C) Enamel
D) Pulp cavity
E) Root canal
The correct response is Option B.
This patient has a fracture of the tooth crown that extends through the dental enamel into the deeper parts of the tooth. This is evidenced by the sensitivity to touch and cold, a finding not characteristic of a fracture limited to the enamel. The yellow color to the base of the fracture indicates exposed dentin, which resides just under the hard outer enamel layer of the tooth. If the fracture had extended deeper into the pulp cavity, the area where the vessels and nerves reside, the base of the fracture would appear as a blood-filled cavity. These injuries often challenge the viability of the tooth and often require drilling and packing of the pulp space (root canal). The fracture described is of the crown and there is no indication that it involves the root of the tooth or the surrounding structures. Cementum is a bone-like covering of the tooth root and would not be affected by this injury.
The Ellis classification provides a useful system of categorizing these injuries. There are 9 categories:
Ellis I: enamel fracture. The tooth is non tender and treatment is smoothing of the rough surfaces and, possibly, application of a filling or amalgam.
Ellis II: fracture of the enamel and dentin. Tooth is tender to air, cold, and probing and the base of the defect often appears yellow.
Ellis III: involves the enamel, dentin, and the pulp space. The tooth is sensitive as in Ellis II, but the base of the defect appears red or bloody.
Ellis IV: a nonviable tooth.
Ellis V: luxation of the tooth.
Ellis VI: tooth avulsion.
Ellis VII: displacement without fracture.
Ellis VIII: fracture of entire crown.
Ellis IX: fracture of deciduous teeth.
2017
Which of the following is the most common complication of a fracture to the temporal bone?
A) Cerebrospinal fluid leak
B) Facial nerve injury
C) Hearing loss
D) Meningitis
E) Temporomandibular joint ankylosis
The correct response is Option A.
Cerebrospinal fluid leak is the most common complication of a temporal bone injury. The majority of these will resolve spontaneously within a week. If they persist longer, then there is higher risk for meningitis, but this is not common. Facial nerve injury is the second most common injury and prognosis is dependent on the severity and delay of onset. Incomplete nerve loss or delayed onset is associated with a better prognosis for recovery. Hearing loss is the third most common complication seen with this fracture. Temporomandibular joint ankylosis is an unlikely sequela of this type of injury.
2017
In adults, which of the following bones is most commonly fractured in isolated orbital floor fractures?
A) Ethmoid
B) Frontal
C) Lacrimal
D) Maxillary
E) Zygomatic
The correct response is Option D.
Most isolated orbital fractures involve the orbital floor made up of the maxillary bone. The maxillary bone is quite thin behind the infraorbital rim and is perforated by the infraorbital nerve passing in a canal below it. Most pure blow-out fractures involve the orbital floor with the maxillary bone making the majority of the orbital floor.
A retrospective study by Hwang et al. evaluated 391 patients with orbital bone fractures from a variety of accidents that were treated at the department of Plastic and Reconstructive Surgery, Inha University Hospital, Incheon, South Korea, between February 1996 and April 2008. The medical records of these patients were reviewed and analyzed to determine the clinical characteristics and treatment of the orbital bone fractures. The following results were obtained. The mean age of the patients was 31.1 years, and the age range was 4 to 78 years. The most common age group was the third decade of life (32.5%). There was a significant male predominance in all age groups, with a ratio of 4.43:1. The most common etiology was violent (assault) or nonviolent traumatic injury (57.5%) followed by traffic accidents (15.6%) and sports injuries (10.7%). The most common isolated orbital bone fracture site was the orbital floor (26.9%). The largest group of complex fractures included the inferior region of the orbital floor and zygomaticomaxilla (18.9%). Open reduction was performed in 63.2% of the cases, and the most common fracture reconstruction material was MEDPOR (56.4%) followed by a resorbable sheet (41.1%). The postoperative complication rate was 17.9%, and there were no statistically significant differences among the reconstruction materials with regard to complications. During follow-up, diplopia, hypoesthesia, and enophthalmos occurred as complications; however, there was no significant difference between porous polyethylene sheet (MEDPOR) and resorbable sheet groups.
Long-term epidemiologic data regarding the natural history of orbital bone fractures are important for the evaluation of existing preventative measures and for the development of new methods of injury prevention and treatment.
2017
A patient underwent open reduction and internal fixation of naso-orbital-ethmoid fractures 12 months ago, and epiphora was noted on follow-up examination. After 6 months of observation and persistent epiphora, which of the following is the most appropriate next step in management of the patient’s nasolacrimal system?
A) Conjunctivorhinostomy tube placement
B) Continued observation
C) Dacryocystorhinostomy
D) Jones tests
E) Lacrimal system flushing
The correct response is Option D.
Naso-orbital-ethmoid (NOE) fractures can be challenging fractures, and either through direct instrumentation with transcanthal wiring or from the fractures themselves, the lacrimal drainage system can be affected. Postoperative epiphora can be very common and is present in at least 50% of patients who have undergone open reduction and internal fixation (ORIF) of an NOE fracture. After 3 to 6 months approximately half of this epiphora resolves, with the other half of patients (25%) requiring consideration for other investigations to evaluate lacrimal drainage.
2017
A 22-year-old man comes to the office because of a history of nasal trauma with resultant nasal deformity, C-shaped septal fracture, and nasal obstruction. Two weeks after injury, he undergoes closed reduction of the nasal fractures, but significant nasal obstruction persists. Which of the following is the most likely reason for his residual nasal deformity and nasal obstruction?
A) Inadequate time of nasal casting
B) Nonunion of the nasal bones
C) Presence of a septal fracture
D) Turbinate hypertrophy
E) Unidentified septal hematoma
The correct response is Option C.
One of the most important causes of failure of closed reduction to address the nasal fracture is simultaneous nasoseptal fracture. Murray, et al. found 30 to 40% residual nasal deformity after closed reduction. The cadaver study showed failure consistently associated with a C-shaped nasoseptal deviation and fracture when the external nose deviated at least 1/2 of the nasal bridge width. The theory is that the interlocking of the septal fracture creates tension causing the nasal bone to displace.
Untreated septal hematoma results in thickening of the cartilage and nasal obstruction, but not with inadequate reduction. Nasal casting for 7 to 10 days is sufficient to allow the reduction to set. Nonunion is a rare cause of inadequate reduction, usually in comminuted or open nasal fractures. Turbinate hypertrophy can cause nasal obstruction but does not interfere with nasal bone reduction.
2017
A 26-year-old woman who is at 32 weeks’ gestation sustains a traumatic head injury during a boating collision. CT scan shows subarachnoid hemorrhage and pan-facial fractures. The patient is cleared by the neurosurgeon for facial fracture repair. In the ICU, blood pressure is 112/70 mmHg and heart rate is 95 bpm. Fetal monitoring shows no distress. The patient is taken to the operating room and placed in supine position. On the operating table, blood pressure is 80/50 mmHg and heart rate is 130 bpm. Which of the following is the most appropriate next step in management?
A) Administer fluid bolus intravenously
B) Logroll the patient to the left
C) Obtain immediate chest x-ray study
D) Prepare and drape the patient for the planned procedure
E) Start vasopressors
The correct response is Option B.
The most appropriate next step in this scenario is to logroll the patient 4 to 6 inches (or 15 degrees) to the left, decompressing the inferior vena cava (IVC). Women in the second half of pregnancy may become hypotensive when placed in the supine position, caused by compression of the inferior vena cava by the enlarged uterus, reducing venous return to the heart by up to 30%. Spinal precautions should be maintained for any patient whose spine has not been appropriately cleared.
Vasopressors should be used as a last resort in restoring the blood pressure of pregnant trauma patients, as these drugs further reduce uterine blood flow, resulting in fetal hypoxia. The placental vasculature is exquisitely sensitive to catecholamine stimulation.
Crystalloid fluid resuscitation would be indicated if the patient’s vital signs did not return to baseline after repositioning and IVC decompression. Similarly, a chest X-ray could be obtained as part of the workup for unresponsive hypotension.
Ignoring this patient’s hemodynamic changes and proceeding with surgery would be a mistake, as the placenta would most likely be deprived of vital perfusion, resulting in fetal distress.
2017
A 25-year-old man is brought to the emergency department after sustaining injury during a roll-over motor vehicle collision. CT scan shows multiple facial fractures and systemic injuries. Which of the following is a CONTRAINDICATION to nasotracheal intubation in a trauma patient?
A) Base of skull fracture
B) Bilateral mandibular condyle fractures
C) Cervical spine fracture
D) Depressed mental status
E) Fracture of the maxilla
The correct response is Option A.
Of the options listed, base of skull fracture is the only contraindication to nasal intubation. In these patients, there is a risk of the nasotracheal tube passing through the cribriform plate into the frontal lobes of the brain. Other absolute contraindications include mid face instability, suspected epiglottitis, coagulopathy, or apnea/impending respiratory arrest. Relative contraindications to nasotracheal intubation include nasal polyps, suspected nasal foreign bodies, recent nasal surgery, upper-neck hematoma or infection, and a history of frequent epistaxis. Depressed mental status, suspected cervical spine fracture, hypotension, and bilateral mandibular condyle fractures are not contraindications to nasotracheal intubation.
The options for intubating a trauma patient include nasal, oral, and surgical airways. The indications for nasotracheal intubation include intraoral and oropharyngeal surgery, complex intraoral procedures involving the mandible (e.g., segmental mandibulectomy, osteotomy, mandibular reconstructive procedures), and dental surgery.
The advantages of nasotracheal intubation include uninhibited access to the mouth as well as an enlarged surgical field. Despite these advantages, one must be cognizant of the contraindications and when in doubt (e.g., during initial advanced trauma life support management), the airway should be secured using either oral intubation or tracheostomy. Other drawbacks to nasotracheal intubation are that it often requires multiple attempts, there can be an abrupt rise in intracranial pressure, and it is difficult to attempt in an uncooperative patient.
In the presence of an isolated maxillary fracture nasal intubation may be preferred so that premorbid occlusion can be established.
The method of insertion of a nasotracheal tube includes using a well-lubricated tube with the cuff fully deflated. The tube should be inserted into either naris at a right angle to the face. Once the tube is beyond the nasopharynx, a laryngoscope is placed in the oral cavity and the tube is advanced under direct vision.
2017
A 21-year-old man undergoes repair of the parotid gland and Stensen duct after sustaining an injury while being assaulted with a glass bottle. Ten days later, salivary leakage from the wound is noted. Which of the following is the most appropriate next step in management?
A) Pressure dressings and limited oral intake
B) Radiation therapy
C) Re-exploration of the wound and repair of the duct injury
D) Tympanic neurectomy
E) Observation only
The correct response is Option A.
Sialocele and cutaneous fistula may occur as a complication of a major salivary gland injury or after attempted parotid gland or duct repair. Prior to intervention, the surgeon should confirm the presence of salivary fluid in the aspirate by evaluating for amylase (>1000 U/L). This helps to rule out hematoma vs. infection. At this time, the accepted initial treatment of sialocele and cutaneous fistula is conservative management. This includes pressure dressings, repeated aspirations, limited intake by mouth, and the use of antisialagogues to decrease salivary flow. Most studies have shown that most sialoceles and fistulas will resolve within 2 to 3 weeks with this approach.
Secondary repair of the duct is generally difficult because of granulation and scar tissue. This runs the risk for delayed or poor wound healing as well as facial nerve injury. Radiation therapy has been used in the past but has been found to have a high failure rate in ductal injuries. More than 6 weeks is needed for gland atrophy to occur after radiation. There is also the risk of inducing malignancy, which has led to the abandonment of radiation for the treatment of sialoceles and cutaneous fistulas. Antisialagogues primarily have a role as an adjunct therapy to decrease salivary flow. Alone, they have had mixed reviews in the literature and have been found generally ineffective in major salivary duct injuries. Tympanic neurectomy has a high failure rate and does not speed recovery. Internalization of salivary flow could be considered for failures of conservative management. It has lower surgical risk than wound exploration and duct repair.
2016
A 40-year-old man is evaluated for orbital fractures from a direct blow to the right eye. A swinging flashlight test is performed to evaluate a suspected afferent pupillary defect. Which of the following is the most appropriate description of this procedure?
A) The flashlight shone into the left eye causes both eyes to constrict; then when the light is shone in the right eye, the right eye constricts but the left eye does not
B) The flashlight shone into the left eye causes consensual constriction, and then both eyes dilate when the light is shone in the right eye
C) The flashlight shone into the left eye causes consensual constriction; then when the light is shone in the right eye, the right eye dilates while the left eye constricts
D) The flashlight shone into the left eye causes consensual dilation followed by paradoxical constriction when swung to the right eye
E) The flashlight shone into the left eye causes the left eye to constrict while the right eye remains dilated; both eyes are constricted when the light is shone in the right eye
The correct response is Option B.
A relative afferent pupillary defect, or Marcus Gunn pupil, results from an optic nerve dysfunction. The physical examination maneuver used to evaluate the optic nerve for a relative afferent pupillary defect is the swinging flashlight test described above. The most common cause of Marcus Gunn pupil is a lesion on the optic nerve, optic neuritis, or severe retinal disease but can also be caused by trauma. The normal response to light in one eye is constriction of both pupils and when the light is taken away both eyes dilate (consensual light reflex). In an abnormal exam the normal eye/optic nerve will cause a normal constriction of both pupils but the light shone in the affected eye will not have normal light perception (minimal pupillary constriction). The afferent pathway refers to the nerve impulse sent from the pupil to the brain via the optic nerve of one eye. The efferent pathway is the impulse sent back to both pupils via CN III and ciliary ganglia, causing both pupils to constrict.
2016
A 21-year-old man is evaluated because of pain and double vision 2 weeks after being punched in the face. An orbital fracture is suspected. Which of the following characteristics of an orbital floor fracture is the most common indication for surgical repair?
A) Concomitant naso-orbito-ethmoid fracture
B) Contralateral zygomaticomaxillary complex fracture
C) Herniation of orbital contents with diplopia
D) Medial wall fracture without additional symptoms
E) Nondisplacement
The correct response is Option C.
The facial skeleton acts as a buffer and barrier against injury to the brain and deep structures. Reconstruction of the buttress system is integral to reforming the form and function of the facial skeleton.
Zygomaticomaxillary complex (ZMC) fractures, sometimes referred to as tripod fractures, may involve fractures of the following: zygomaticotemporal suture, maxillary sinus, and occasionally sphenoid bone. Correction involves reduction of the fracture, commonly with miniplate fixation or with 2-point wire fixation. These fractures can also involve the orbital floor and maxillary wall.
Symptoms may include numbness in the maxillary nerve (V2 of trigeminal (V) nerve), subconjunctival hemorrhage, diplopia, and enophthalmos. Orbital floor fractures can be isolated, as in a blowout, or involve other structures (e.g., orbital rim, orbital medial/lateral walls, orbital apex). Additional fractures are typically associated with higher-force injury and may require more extensive surgical repair.
Diagnostic study typically includes CT scan of the facial bones to assess the fractures and to delineate the extent of the facial trauma.
There are three main indications to treat isolated orbital fractures:
Entrapment of the extraocular muscles: this may cause injury and permanent dysfunction of the globe if not reduced.
Prevention of globe malposition: malposition of the globe may occur leading to diplopia or enophthalmos. This may not be apparent immediately after the injury because of soft-tissue edema. Reduction is indicated if there are signs of early enophthalmos, displacement of more than 50% of the orbital floor, or significant soft-tissue displacement.
Lateral orbital wall displacement: when the injury is more severe, the lateral orbital bone (sphenoid bone) may impact the orbital apex or even the mid-cranial fossa.
The CT scan should be examined for muscle entrapment, herniation of orbital contents, and associated fractures (naso-orbito-ethmoid, zygomaticomaxillary, Le Fort). Open reduction and internal fixation can be performed emergently or after edema has subsided, and usually after the orbit has been examined by an ophthalmologist for ocular injury.
Repair of the orbital floor can be done using several different types of materials—alloplastic and autologous. This is usually dictated by the surgeon’s preference and the extent of the injury.
2016
A 50-year-old man is evaluated for facial trauma sustained after falling off a bicycle 5 days ago. The patient reports mid-facial pain and resolved swelling. Physical examination of the face shows no signs of trauma. Intraoral examination shows traumatic loss of tooth No. 8. He has no cervical spine tenderness or pain to active range motion. Which of the following is the most appropriate next step in management?
A) Obtain cervical spine MRI
B) Obtain maxillofacial CT scan to evaluate for facial fracture
C) Recommend elevation of the head of the bed and ice pack to the face
D) Recommend soft diet and referral to a dentist
E) No further management is necessary
The correct response is Option B.
The patient described most likely has a facial fracture and, thus, the most appropriate next step in management is to obtain a maxillofacial CT scan. A retrospective analysis of patients with facial trauma who had maxillofacial CT scan for the evaluation of facial fractures identified five independent criteria highly predictive of facial fracture. Any of the following five physical examination criteria – the Wisconsin criteria – were predictive of facial fracture: bony step-off or instability, periorbital swelling or contusion, Glasgow Coma Scale score less than 14, malocclusion, or tooth absence (sensitivity, 98.2%). Because the patient has a missing tooth, he should be evaluated with a maxillofacial CT scan. Although soft diet and eventual referral to a dentist as well as elevation of the head of bed with cool compress are reasonable recommendations, the first important step is obtaining a diagnosis.
Because the patient does not have tenderness of the cervical spine, there is no indication for obtaining cervical spine x-ray studies.
Systematic and efficient decision instruments in the management of multisystem trauma patients are critical in identifying all injuries including those of the maxillofacial skeleton and the cervical spine. The accurate use of systematic decision instruments could potentially result in a dramatic decrease in the number of CT scans and x-ray studies performed annually in the United States.
2016
An 18-year-old woman is evaluated for persistent fullness of the left cheek 3 months after undergoing open reduction and internal fixation of a left zygomaticomaxillary complex fracture. She has no pain. The fracture was fixated at the inferior orbital rim (1.3-mm-thick titanium plate), the frontozygomatic suture (1.3-mm-thick titanium plate), and the lateral buttress (2.4-mm-thick titanium plate). On physical examination, the incisions are well healed. Which of the following is the most likely cause of this patient’s cheek fullness?
A) Excessive profile of the lateral buttress and orbital rim plate fixation
B) Malreduction of the fracture
C) Mucocele from the maxillary sinus
D) Residual soft-tissue edema
E) Subclinical hardware infection
The correct response is Option D.
Fullness of the soft-tissue envelope is expected after any severe trauma, regardless of location. This is further compounded by operative dissection to effect open reduction and internal fixation. Although most soft-tissue swelling around a fracture site dissipates in several weeks, there will be persistent thickening of the soft tissue in the area for many months after the trauma.
It is nearly impossible to “over-reduce” a zygomaticomaxillary (ZMC) fracture in the sagittal plane. Malreduction of these injuries characteristically results in flattening of the cheek (not fullness), vertical dystopia, or enophthalmos. Prominent hardware can create contour irregularities, but this would be localized and would not lead to global cheek fullness. Furthermore, the plate choices in areas where they could potentially be visible (i.e., the orbital rims) here are quite low profile and would be very unlikely to create excessive soft-tissue fullness. Hardware infection can rarely occur and lead to fullness of the cheek. Nevertheless, the absence of pain and the presence of healed wounds make this improbable. Mucocele from the maxillary sinus after repair of ZMC fracture is a rare but described entity and can result in localized soft-tissue fullness. These often occur in the context of a concurrent sinus infection and present many months to years after the injury. Soft-tissue swelling is usually accompanied by pressure and/or pain, and the symptoms can wax and wane. External drainage is not uncommon.
2016
A 23-year-old man is brought to the emergency department 30 minutes after sustaining a self-inflicted shotgun wound to the face. Physical examination shows loss of soft tissue of the mid face with exposed mandible and maxilla, sonorous respiration, and periods of apnea. Heart rate is 100 bpm and blood pressure is 65/30 mmHg. Which of the following is the most appropriate course of management?
A) Assess and establish airway, control bleeding, perform secondary survey, stabilize cervical spine
B) Assess and establish airway, stabilize cervical spine, control bleeding, perform secondary survey
C) Assess and establish airway, stabilize cervical spine, perform secondary survey, control bleeding
D) Stabilize cervical spine, control bleeding, assess and establish airway, perform secondary survey
E) Take the patient to the operating room for debridement of facial wound with reconstruction
The correct response is Option B.
The appropriate management sequence in this patient is to assess and establish the airway, stabilize the cervical spine, control bleeding, and perform a secondary survey. Only after the patient’s condition has been stabilized using standard Advanced Trauma Life Support (ATLS) protocol would he be taken to the operating room for debridement and eventual facial reconstruction. While the deformity is obvious, and will require near-immediate attention in the operating theater, it can easily distract the evaluator from executing the ATLS management protocol.
The ATLS protocol was developed by the American College of Surgeons (ACS) Committee on Trauma (COT) in 1980 and is the standard of care for all trauma patients. The steps of the primary survey are remembered by the mnemonic ABCDE (Airway, Breathing, Circulation, Disability, Environment/exposure). The airway is the first priority and is assessed by determining the ability of air to pass unobstructed into the lungs. Treatment may require endotracheal intubation or establishment of a surgical airway. Breathing should then be evaluated to determine the patient’s ability to ventilate and oxygenate. Circulation is evaluated by identifying hypovolemia and external sources of hemorrhage. Disability is determined by performing gross mental status and motor examinations. The final step includes patient exposure and control of the immediate environment. The secondary survey should only be completed after following the fundamental steps of the ATLS protocol.
Cervical spine injury should be assumed in all trauma patients and should be managed as such until it can be definitively excluded. This patient with a gunshot wound to the face should have the cervical spine stabilized immediately and strict cervical spine precautions should be maintained during the assessment of the patient’s airway and breathing. During assessment of the airway, the cervical spine should not be flexed, extended, or rotated. If the external neck support must be removed, a member of the trauma team should maintain control of the head and neck using the in-line immobilization technique.
2016
A 21-year-old man is evaluated after being struck in the chin with a lead pipe during a bar fight. Physical examination shows a 6-mm displaced bicortical right parasymphyseal fracture and left nondisplaced subcondylar fracture with open crossbite. A full trauma evaluation is performed; no injury to the cervical spine or intracranial injury is noted. Which of the following is the most appropriate treatment in this patient?
A) Liquid diet for 3 weeks, followed by mechanical soft diet for 3 weeks
B) Maxillomandibular fixation followed by open reduction and internal fixation (ORIF) in 4 weeks
C) Maxillomandibular fixation alone for 4 to 6 weeks
D) ORIF of the parasymphyseal fracture followed by immediate maxillomandibular fixation
E) Maxillomandibular fixation followed by immediate ORIF of the parasymphyseal fracture
The correct response is Option E.
The proper surgical repair is rigid maxillomandibular fixation, followed by open reduction and internal fixation (ORIF) of the parasymphyseal fracture. Patients with mandibular fractures sustain significant blunt force trauma and require a full trauma assessment. Closed head injury and cervical spine trauma must be excluded. Additionally, a thorough assessment of the facial skeleton for other fractures is necessary.
Mandibular fracture repair is based on the paramount principle of restoring proper dental occlusion. As such it is necessary to place the patient into maxillomandibular fixation (MMF), rigidly with arch bar technique prior to addressing the parasymphyseal fracture. MMF will effectively reduce the subcondylar fracture and realign the bicortical anterior fracture, allowing plate and screw fixation to be done anatomically. Rigid fixation is needed in this particular case due to the need for full immobilization of several weeks while the subcondylar fracture sets and heals.
Mandibular fracture rigid fixation with plates and screws without proper restoration of dental occlusion can potentially lead to severe consequences. Patients will have temporomandibular joint pain due to the malalignment of the maxilla and mandible. They can develop associated painful trismus. Nonunion with or without osteomyelitis can also occur due to the force of the muscles of mastication and the abnormal mandibular forces created by the malocclusion.
Starting the surgical repair with ORIF of the parasymphyseal fracture followed by MMF is inappropriate since proper dental occlusion is not assured prior to the rigid fixation. With the presence of the subcondylar fracture, the MMF placed after plating the parasymphyseal fracture can still achieve dental occlusion by further displacement of the subcondylar fracture, rather than reducing it.
MMF with elastics followed by open repair of the parasymphyseal fracture in 4 weeks is inappropriate. Because of displacement of both fractures, rigid MMF is needed. Furthermore, waiting 4 weeks to reduce and fixate the parasymphyseal fracture will likely lead to fibrous non-union or malunion. Facial fractures in adults should be repaired within 10 to 14 days so as to readily manipulate the fracture elements for anatomical reduction.
MMF with elastics as the only treatment is also inappropriate for the treatment as indicated above. Similarly liquid and soft mechanical diets without fixation is inappropriate and will lead to nonunion or malunion with subsequent malocclusion and pain.
2016
A 52-year-old man is evaluated 7 months after sustaining an isolated left-sided orbital blowout fracture for which no surgical intervention was performed. Physical examination shows extraocular movements are intact. He reports gradual and progressive episodes of double vision over the past 3 months. Which of the following physical findings is most likely associated with this condition?
A) Ectropion
B) Muscle entrapment
C) Exophthalmos
D) Vertical dystopia
E) Orbital proptosis
The correct response is Option D.
The physical finding that would most likely be associated with the finding of double vision 7 months after having sustained an orbital blowout fracture is enophthalmos. The position of the globe is altered in enophthalmos. Because of increased orbital volume, the globe is situated deeper or more inferiorly, such that the direct line of vision of the affected eye no longer matches that of the unaffected eye. The two eyes no longer track appropriately, causing double vision or diplopia by virtue of not having the same visual field.
Orbital fractures frequently occur in conjunction with other facial fractures, most commonly the zygomaticomaxillary complex fracture. Often the orbital floor or sidewall can be fractured without concomitant fractures. This occurs from a direct blow to the orbit/eye, most often by a punch or elbow/ball in sports. The absolute indication for operative repair acutely is the presence of entrapment, most often of the inferior rectus muscle. The belly of the muscle herniates into and remains within the fracture site in the orbital floor. The finding of diplopia on upward, lateral gaze with the affected eye having reduced movement in that upward direction indicates entrapment. The forced duction test further documents this condition. Surgical repair is indicated acutely to avoid permanent damage and fibrosis to the inferior rectus muscle and consequent visual difficulties.
In the absence of entrapment or orbital hematoma, surgical repair is a judgment call based on the location and extent of the fractures. If the fracture is deemed sizable enough to increase the orbital volume, then the risk of subsequent enophthalmos and diplopia is considered high and surgical repair is indicated. The repair involves reduction of orbital contents and restoration of the orbital floor, most often with titanium mesh. Large fractures may require primary bone grafting.
The conventional means of correcting post-traumatic enophthalmos is bone grafting. However, it is often difficult to accurately judge the correction needed due to multimodal increase in orbital volume from the combination of increase orbital volume and potential reduction in periorbital fat from traumatic atrophy. New techniques of alloplastic floor restoration and periorbital fat grafting have shown encouraging results.
Exophthalmos, ectropion, and proptosis are not conditions typically associated with isolated orbital blowout fractures. Furthermore, these conditions frequently occur without diplopia.
Entrapment of the periorbital muscles, most usually the inferior oblique, can cause entrapment by limiting proper movement of the involved globe. However, this is usually an acute symptom and would not present initially several months after the trauma.
2016
In patients without loss of posterior vertical height, which of the following is the most appropriate duration of maxillomandibular fixation (MMF) for treatment of minimally displaced bilateral subcondylar fractures of the mandible?
A) 1 week
B) 4 weeks
C) 8 weeks
D) None; stabilize mandible with gunning splint for 8 weeks
E) None; treat patient with soft diet
The correct response is Option B.
Closed reduction has historically been the standard treatment for subcondylar fractures of the mandible. Its widespread use is attributed to the idea that closed reduction results in fewer complications with similar functional and aesthetic outcomes compared with open reduction and internal fixation (ORIF). For instance, complications such as facial nerve damage and excessive scarring are significantly decreased because of the noninvasive nature of this approach. However, as highlighted by ongoing debate, a consensus regarding outcomes between open and closed reduction is not evident in the literature. In short, some studies conclude that both approaches produce roughly similar results, while other studies have associated an array of unfavorable outcomes with closed reduction. These outcomes include facial asymmetry, deviation upon mouth opening, skeletal malocclusion, and chronic pain of the temporomandibular joint (TMJ). The fact that many of these parameters lack standardization in the duration of the treatment further obscures the debate. Larger studies with consistent parameters are needed to reassess outcomes with the surgical techniques and technology present today. However, it is unlikely that a large enough trial will deliver granular evidence to conclusively quell this debate.
Another controversial point regarding closed reduction is the length of time a patient should spend in maxillomandibular fixation (MMF). Many surgeons choose to apply fixation for a very short period (i.e., 2 weeks) to avoid ankylosis of the TMJ secondary to forced immobilization during MMF. While the etiology of ankylosis is not completely understood, it is hypothesized that trauma leading to intracapsular hematoma results in fibrosis and excessive bone formation, ultimately causing hypomobility of the affected side.
Given the current hypothesis, ankylosis of the TMJ is most likely a manifestation of direct injury within the joint capsule or condylar head itself. It is imperative to point out that as a result, there should be a lower risk of ankylosis in subcondylar fractures compared with fractures of the condylar head. Therefore, the position of the fracture line relative to the joint capsule should be closely examined, and a longer period of MMF should be employed if there is no involvement of the condylar head, disc, or capsule. A longer period of MMF commonly results in better union of the fractured segments with no increase in the incidence of ankylosis. In a nondisplaced fracture or minimally displaced fracture with a functional occlusion, 4 to 6 weeks of MMF is recommended, followed by 2 to 3 weeks of guiding elastics. The same treatment applies in the case of a nondisplaced bilateral fracture. However, this scenario is less common because the force parameters to cause the bilateral fracture are often greater and tend to displace the fracture fragments significantly, necessitating ORIF. The patient will most likely develop shortening of the masseter muscle and stiffness with prolonged immobilization during 8 to 10 weeks. With bilateral instability, the fracture pattern is unstable and soft diet alone would likely lead to malocclusion. A gunning splint is often used in edentulous mandible only and is not functional MMF
2015
A 30-year-old woman presents with the dental findings shown in the diagram. Which of the following best describes the dental relationship?
A) Angle class I
B) Angle class II
C) Angle class III
D) Negative overjet
E) Overbite
The correct response is Option B.
The images show an Angle class II relationship. The Angle classification system describes the relative positions between the mesial buccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. Angle class I molar relationship implies that the mesiobuccal cusp is in line with the buccal groove. In an Angle class II molar relationship, the maxillary mesiobuccal cusp is anterior to the mandibular buccal groove. Class II is subdivided into two divisions. In class II, division 1, patients have minimal crowding of the maxillary teeth and proclination of the upper central incisors, and a significantly increased overjet. In a class II, division 2 relationship, the central incisors are retroclined. An Angle class III molar relationship exists when the maxillary mesiobuccal cusp lies posterior to the mandibular buccal groove.
An overbite refers to a vertical overlap between the incisal surfaces of the central maxillary and mandibular incisors. An overjet refers to a horizontal discrepancy in the position of the maxillary and mandibular central incisal surfaces.
2021
An 18-year-old man presents with right periorbital edema and ecchymosis after an all-terrain vehicle collision. Physical examination shows enophthalmos, diplopia, and pain with eye movements. When asked to look upward from forward gaze, there is upward gaze restriction. A photograph is shown. Which of the following locations is most likely fractured?
A) Greater wing of sphenoid bone
B) Lamina papyracea of ethmoid bone
C) Orbital plate of frontal bone
D) Orbital process of maxillary bone
E) Posterior crest of lacrimal bone
The correct response is Option D.
Limitation with vertical gaze, as described in the vignette, is indicative of extraocular muscle (EOM) entrapment.
The lamina papyracea of the ethmoid bone contributes to the medial orbital wall. Fractures of the medial wall may result in medial rectus entrapment and restriction with lateral gaze. Such injuries can involve the ethmoidal/sphenoidal sinuses.
The greater wing of the sphenoid bone contributes to the lateral orbital wall. Fractures of the lateral wall are less common due to its increased strength, but at the wings of the sphenoid, bone can have serious effects on contents of the superior orbital fissure and may even involve the intraorbital portion of the optic (II) nerve.
The orbital plate of the frontal bone contributes to the superior orbital roof. Fractures of the superior roof may result in superior rectus and/or oblique entrapment. Such injuries can involve the frontal sinus, frontal lobe, supraorbital nerve, and/or supratrochlear nerve (resulting in loss of sensation of the forehead and upper eyelid).
The orbital process of the maxillary bone contributes to the inferior orbital floor. Fractures of the inferior floor may result in inferior rectus/oblique entrapment and restriction with upward gaze. Such injuries can involve the maxillary sinus and/or infraorbital nerve (resulting in malar and superior alveolar numbness).
The posterior crest of the lacrimal bone contributes to the medial orbital wall. Fractures of the medial wall may result in medial rectus entrapment and restriction with lateral gaze. Such injuries can involve the ethmoidal/sphenoidal sinuses.
2022
A 29-year-old woman presents after sustaining a traumatic avulsion of the scalp. A photograph is shown. She undergoes replantation after 5.5 hours of warm ischemia time. Which of the following cytokines is most likely to foster reperfusion injury?
A) Fibroblast growth factor 3
B) Interleukin-2
C) Transforming growth factor beta
D) Tumor necrosis factor alpha
E) Vascular endothelial growth factor
The correct response is Option D.
Tumor necrosis factor alpha is a key cytokine in reperfusion injury. This cytokine is proinflammatory and plays a role in mediating vasodilation, edema, and oxidative stress after restoration of perfusion.
Interleukin-2 is also proinflammatory, but it is not central to reperfusion injury. The other cytokines are growth-mediating cytokines.
Transforming growth factor beta and vascular endothelial growth factor are involved with vascular growth. Fibroblast growth factor 3 is involved with cellular growth and wound healing.
2023
A 7-year-old girl is brought to the emergency department following a motor vehicle collision. The CT scan shown demonstrates fractures of the right orbital roof, inferior orbital rim, nasal bone, and left naso-orbital-ethmoid segment. There is no laxity of the medial canthal tendon with lateral traction on the upper eyelid (negative bowstring test). Surgical treatment is most strongly indicated for which of the following fractures?
A) Frontal bone
B) Inferior orbital rim
C) Nasal
D) Naso-orbital-ethmoid
E) None; surgery is not indicated
The correct response is Option E.
Serious facial trauma in the pediatric population is uncommon, and the need for operative intervention is rare. Very young patients, like the 7-year-old in this scenario, heal quickly, and subsequent facial growth lends to rapid bone remodeling. Consequently, the requirement of anatomic or near anatomic reduction of all bony fractures is far less stringent than in adults, who have very limited bone remodeling potential. Moreover, surgical intervention, especially through open incisions and with the application of fixation, risks altering normal facial growth and should be reserved for injuries with significant bone displacement. All of these fractures are minimally displaced, and, in light of the patient’s age, surgical intervention is not indicated.
2023
