Theme 13 - Max Fax trauma Flashcards
From a legal perspective, what should you write down when examining an injured patient?
- Mode of attack
- By whom
- Where they were
- What time
- Witnesses
- Have they got the police involved
What type of injury is bilateral periorbital ecchymosis (racoon eyes) a sign of?
Base of skull fracture
or Localised trauma
Why might pupil reaction time be affected when examining in injured patient?
On high dose opiates
Head injury/ increase intracranial pressure
Retrobulbar haemorrhage
As age increases where does the site of injury change to in the face?
As age increases site moves from upper face to lower face
What could be the possible causes of airway obstruction in an injured patient?
- Foreign body
- Broken tooth/denture
- Blood clot
- Tongue (remember to do head tilt chin lift or jaw thrust)
- Fracture displacement
What are the steps in advanced trauma life support (ATLS)?
Airway
Breathing
Circulation
Disability
Exposure
Secondary survey ie inspection and palpation, CSF leaks, eyes, paraesthesia, occlusion
What types of fractures can cause an airway obstruction?
Bilateral parasymphyseal mandibular fracture - genioglossus displaces anterior mandible lingually, no support to tongue which then occludes airway
Posterior displacement maxilla
Mid-facial fracture - directly occludes airway
As part of circulation assessment:
a) How can you stop a bleed
b) What should you be wary of and how is this managed
a) Pressure, ties for arterial bleeds, diathermy (electrocauterize), fracture reduction if bleeding from cancellous bone
b) Hypovolaemic shock - from external or internal bleeding. Major haemorrhage protocol. Volume replacement with fluid while blood is ordered.
What are the 5 Ps for retrobulbar haemorrhage?
Pain
Proptosis
Paralysis
Pupil
Poor vision
Why is a retrobulbar haemorrhage concerning and what is the treatment?
Sight threatening as bleed behind eye causes compartment syndrome and puts pressure on optic nerve
Pressure released through lateral canthotomy
If teeth are missing why is a chest xray good to get?
Risk of aspiration pneumonia
In what window of time should facial fractures be treated?
2 week window - else will need osteotomising to achieve reduction
If there is a foreign body in the neck, how should this be managed?
Do not remove as any wound deep to platysma has risk of involving major neck vessels and weapon may tamponade vessels
CT angiogram to assess vascular damage
Remove under GA so bleed controlled in optimum environment
(lateral ST xray or US if small)
How is a soft tissue wound decontaminated?
Washout, copious irrigation with saline (not CHX as kills fibroblasts and inhibits wound repair)
Surgical scrub under GA to remove ingrained dirt
What is primary closure?
Where edges of wound can be brought together tension free with sutures, glue or staples. Ensure wound edges well opposed and slightly everted to counteract contraction from fibroblast and collagen maturation
When should sutures be removed from the a) face b) scalp?
a) 5 days
b) 7 days
What are the methods used for healing when there is soft tissue loss?
- Secondary intention - allow granulation
- Split thickness skin graft
- Full thickness graft
- Local flaps
- Regional flap
- Free flap
If a patient presents with a bite (animal or human) how should this be treated?
Thorough decontamination
Always give antibiotic prophylaxis: flucloxacillin and/or co-amoxicalav
What are the complications of soft tissue injuries?
Scarring - poor technique or keloid
Loss of function 0 nerve injury or structural involvement
Infection - dehiscence/breakdown
What are the 4 principles of treatment of fractures?
Reduction (ends back in position)
Fixation (help in place)
Immobilisation
Restoration of function (gradually reintroduce)
Why are flexible splints used for root fractures and alveolar fractures?
To prevent ankylosis
What are the most common places for fractures to occur (most to least)
Nasal
Mandible
Zygoma
Maxilla
Where are the sites of weakness in the mandible?
Third molar
Socket of canine tooth (parasymphysis)
Condylar neck
Mental foramen
What are 5 extraoral signs of a mandibular fracturs?
Bruising extending into neck
Sublingual haematoma
Displaced teeth/marked step in occlusion
Gingival haemorrhage
Anterior open bite (guardsman fracture - bilateral condyles)
What are the actions of these muscles that govern the placement of fixation plates
a) Digastric
b) Temporalis
c) Masseter
d) lateral pterygoid
a) back/down
b) up
c) up
d) forwards
All fractures involving the tooth bearing area are considered open fractures. What is required because of this?
Antibiotic cover
What are the 2 ways fractures of the jaws are managed?
Mandibulomaxillary fixation - teeth wired together
Miniplate fixation - ORIF, pt sticks to soft diet
How are the following fractures managed with miniplates i.e. where are they fixed?
a) body of mandible fracture
b) angle of mandible fracture
c) symphysis/parasymphysis fracture
a) Single fixation plate above IAN
b) single plate on external oblique ridge as muscle compression of lower border
c) single fixation plate in midline, 2 plates around mental nerve
What guidelines are there for the management of condylar fractures?
SORG guidelines
What are the considerations when managing condylar fractures?
- Location
- Amount of vertical reduction of ramus
- Degree of angulation
- Degree of luxation out of fossa
- Fragmentation pattern (simple v complex)
- Other mandibular injuries
- Dental occlusion
- Foreign body in TMJ
When are condylar fractures manage by ORIF and what incisions should be done to access the condyle?
If there is a shortening of the process by more than 2mm or an angulation of the fracture fragment by more than 10 degrees then better long term outcome if managed by ORIF.
If bilateral fracture at least one should be internally fixated to prevent late onset anterior open bite
E/O incision - facelift approach, submandibular, preauricular, retromandibular - small risk of facial nerve damage
What are the indications for a reconstruction plate/load bearing osteosynthesis?
Atrophic/edentulous fracture
Communited fracture
Defect fracture i.e. piece of mandible missing
When is the conservative management of alveolar fractures the best method of treatment?
-Non-displaced, non-mobile fracture with normal occlusion in a compliant pt with close follow up
- If pt refuses treatment
- Angle or condylear fracture ususally
- Conditions making ORIF difficult e.g. medically unstable
What are the techniques for mandibulomaxillary fixation?
- Arch bars
- Ernst ligature
- IMF screws (avoid roots and nerves)
- Hager plates
- Interarch miniplates
What are the complications of alveolar fractures?
Malunion - from fracture instability, infection or inaccurate reduction
Failure of fixation - fracture of plate, loosening of screws, devitalisation of bone around screws
Ankylosis - prolonged mandibulomaxillary fixation, condylar head
Necrosis - inferior alveolar artery narrows with age so much leave periosteal supply intact if possible
Infection
What are the treatment options for nasal fractures?
Manipulation under anaesthesia (MUA)
Septal repositioning
Septoplasty
Rhinoplasty
How are the occipitomental views interpretted?
Campbells lines
How are zygomatic arch fractures diagnosed i.e. clinical features?
Pain in cheeks
Facial flattening and lack of symmetry
Restriction on opening/lateral excursion
Radiography with OM10/30, SMV
Conjunctival haemorrhage
What is the management of zygomatic arch fractures?
Operate within 2 weeks or around 5 days when swelling reduced
Gillies approach (shave hair) and rowe’s elevator inserted under arch
Fracture stable when reduced so doesn’t require fixation
What is a zygoma tripod fracture?
Detaches across all three sutures: infraorbital margin, Z-F suture, zygomatic arch (can have orbital and antral involvement)
What is the diagnosis/ signs of a zygoma tripod fracture?
- Pain
- Periorbital ecchymosis/ oedema
- Unbordered subconjunctival haemorrhage
- Step deformities at infraorbital rim, ZF and arch
- Paraesthesia
- Diplopia/enopthalmus
- Telecanthus
What is the management of a zygoma tripod fracture?
ORIF - poswillo hook (unfavourable scarring), gillies apprach or I/O approach, rowes elevator
If bones well aligned then conservative management
Don’t blow nose as risk of surgical emhyseme by forcing air into maxillary sinus
Describe the following and what would happen if you manipulate the maxillary teeth and alveolar ridge whilst stabilising the forehead:
a) LeFort 1 fracture
b) Lefort 2 fracture
c) LeFort 3 fracture
a) maxillary suture, movement of entire maxilla
b) pyrimidal fracture of maxilla and naso-ethmoidal complex, maxilla and nasal complex move
c) Transverse fracture - detachement of face at ZF, zygoma and naso-ethmoidal complex
What are the clinical signs of a LeFort fracture
- Facial flattening/elongation
- Bilateral facial and periorbital oedema
- Epistaxis (nose bleed)
- Anterior or lateral open bite
- Paraesthesia of midface - damage to V2
- Ecchymosis in maxillary vestibule
What is the management of a LeFort fracture?
ORIF
Traditional with halo frames in extreme comminuted fractures
What is an orbital floor fracture/’blow out’ fracture and what are the signs?
Blunt trauma. Orbital contents herniate into maxillary sinus. Restriction of upward gaze, bioccular diplopia and periorbital bruising
How is an orbital floor fracture repaired?
Lower lid incision, orbital contents elevated, orbital floor plate to give eye something to rest on. Can’t repair damage to muscles/nerves - pt will have persistant diplopia
