trauma Flashcards
frontal sinus fracture classification system
Gonty -
type 1 - isolated anterior table
type 2 - anterior table and posterior table fracture
type 3 - posterior table fracture
type 4 - comminuted fracture
CSF leak tests
and management of csf leak
if you see clear fluid
Halo test- a clear ring around the blood on some filter paper (coffee filter paper, white)
beta 2 transferrin
and testing of
chloride - higher than blood
low potassium and
low glucose compared to blood.
beta trace protein - not diagnostic in the setting of renal deficiency or bacterial meningitis.
csf leak management -
1) conservative with antibiotics, HOB elevated, sinus precautions.
2) if no resolution in 72 hours then place a lumbar drain and direct repair if not successful after 7 days.
Posterior table fractures observation vs indications to interviene surgically
posterior table fractures without csf leaks and are non displaced can be observed
posterior table fractures that are displaced can be treated with cranialization or frontal sinus obliteration.
cranialization should be performed when the frontal sinus posterior table is highly comminuted - and cranialization is 1) repair of the dura if needed, 2) removal of the posterior table, removal of the mucosa 3) obliteration of the nasofrontal duct 4) the anterior table is reconstructed.
anterior table fracture indications:
cosmetic
displaced 1-2 mm
nasofrontal duct management
if the nasofrontal duct is involved then the frontal sinus needs to be obliterated, by removing all the mucosa, putting temporals fascia in the nasofrontal duct and then doing autogenous grafting (fascia, bone, fat) to the frontal sinus.
where does the nasofrontal duct drain to?
the middle meatus
if frontal sinus fracture make sure no:
c spine injuries
head injuries like head bleeds, pneumocephalus, etc.
bicoronal approach to the frontal sinus, zmc, orbit, etc. one-liner
5 cm behind the hairline making an incision from ear to ear through skin, subcutaneous layer and galea to the loos areolar plan, dissecting anteriorly to an area 3 cm superior to the supraorbital rim and incising down to paracranium and developing a subperiosteal plane and can use this flap as a vascularized flap later if desired.
follow up for frontal sinus fractures
weekly follow up for 4 weeks, then every 3 mo for one year and then every year for 5 years, ct scans at 1,2,5 years
NOE fracture classification, tests, tx, complication
NOE fracture classification
Manson and Markowitz Classification
* Type I – no comminution and the medial canthal tendon intact.
* Type II – comminution of the central fragment and the medial canthal tendon is intact.
* Type III – severe comminution of the central fragment and the medial canthal tendon is avulsed.
tests -
- telecanthus present - greater than 35 -40 mm in caucasians
bowstring test - place finger on medial canthal area and pull laterally to feel if the bone fragment moves
secure fragments of bone and if medial canthal tendon is involved then will secure the tendon in a posterior, superior vector with transnasal wiring/suturing (can also do miniplate, or mitek anchor. use prolene non resorbable suture
complication, permanent telecanthus
what if the nasal dorsum needs to be reconstructed? one liner
if the nasal dorsum needs to be reconstructed, you can do a calvarial bone graft fixated with a miniplate making sure to extend the calvarial bone graft
nasolacrimal injury testing, if laceration overlying the area
tx:
nasolacrimal testing - jones 1,2 test -
1) propofol in the eye
2) in the sac
look for in the nose, if fail jones 1 - go to jones 2 - if fail jones 1 then the level of obstruction is in the canaliculi
dilate with woman probe and place a Crawford tube through canaliculi into the nasolacrimal duct and into the nose (inferior meatus) and securing both ends of the Crawford tube
zones of the neck for penetrating trauma and workup/tx
zones of the neck for penetrating trauma
Zone 1 – thoracic inlet to cricoid cartilage.
* Zone 2 – cricoid cartilage to angle of the
mandible.
* Zone 3 – angle of the mandible to the base of
the skull.
*
Zones 1 and 3 are usually worked up using
conventional or, more commonly now, CT
angiography due to difficulty in access.
surgical exploration: zone 2 AND
* Patients who are unstable or present with hard
signs such as bruits, thrills, large/pulsatile hematomas require immediate exploration.
Physical exam trauma patient
explore lacerations, Cranial nerve 2-12, palpate the face for bone stepoffs in the orbits, zygoma, maxilla and mandible
Eye: EOMs, Pupillary light reflex, afferent pupillary defect, proptosis, enopthalmos, visual changes, diplopia, raccoon eyes (Base of skull fracture, along with battle sign below), bowstring test if needed, telecanthus
Ear: TM, battle sign, hearing. can do rinne and weber exam if needed.
Maxilla/mandible: mobility of the maxilla, loose or avulsed teeth, bleeding gingiva, dental stepoffs, occlusion looking for good intercuspation, MIO, deviation on opening, FOM swelling.
concerning lacerations -
- cheek - posterior to a line drawn from the lateral tragus to the mental nerve. (increased risk for parotid duct injury, eyelid lacerations, ear hematoma, neck lacerations
- consider using lacs for approaches
edentulous mandible considerations
ask Desa
considerations: greater than 20mm height treat like normal mandible, digastric pull greater, minimize periosteal stripping because IAN has atrophied, and can treat with:
gunning splints/dentures with IMF screws?, recon, load bearing plate, and external fixation (cold cure acrylic with pins).
Fonseca short in mandible fx
