Trauma

Question 1

What are conditions that can affect airway in the trauma patient (even after initial ATLS is preformed)?

Answer 1

-Facial lacerations
-EAC lacerations
-C-spine injuries
-Facial nerve injuries
-Intracranial injuries
-Carotid artery injuries

Question 2

What types of fractures can be treated with closed reduction?

Answer 2

-Simple, favorable fractures

Question 3

What are situations that favor open reduction?

Answer 3

-Unstable with closed reduction alone
-Need or desire to avoid MMF
-Patient would benefit from early return to function (seizure, difficult airway, need for rehab, elderly)

Question 4

What are overall principals of rigid fixations?

Answer 4

-Extraoral approach and no MMF
-Large plates and bicortical screws
-Concerns about stress shielding (plate prevents transmission of force to mandible, causing bone atrophy)

Question 5

What are overall principals of semi-rigid fixation?

Answer 5

-Intraoral approach and MMF
-Functionally stable fixation (smaller plate, monocortical screws)
-Placed along mandibular lines of tension or ideal lines of fixation (Champy palte)
-Intraoral placement along angle is now easier with right angled instrumentation
-Contraindicated in comminuted fractures

Question 6

What are MMF options?

Answer 6

-Arch bars
-IMF screws
-Bonded orthodontic brackets
-Wires only

-Consider impressions, models and splints for complex cases

Question 7

What are absolute indications for open treatment of condylar fractures?

Answer 7

-Inability to achieve closed reduction
-Fractures in the middle cranial fossa
-Lateral extra capsular dislocation of the condylar head
-Foreign body within the joint capsule

Question 8

What are relative indications for open treatment of condylar fractures?

Answer 8

-Bilateral condylar fracture with comminuted midface fracture in which rigid internal fixation of midface is not possible

-Medical restrictions (uncontrolled seizures, psychiatric disorders, severe mental retardation, dentures/splitns not feasible)

Question 9

What are your approach options for a condylar fracture?

Answer 9

-Retromandibular
-Transoral
-Submandibular
-Preauricular (high fractures only)
-Endoscopic

Question 10

What are characteristics of pediatric mandible fractures?

Answer 10

-Bones are flexible
-Mandible heals quickly 2-3 weeks
-Non-union is very rare
-MMF usually for 2 weeks
-Usually treated with CR, consider splints
-Resorbable fixation

Question 11

What are the risk factors for ankylosis in pediatric condylar fracture considerations.

Answer 11

-<3 years old
-Prolonged MMF
-High intracapsular fractures
-Consider soft diet or elastic MMF
-May require costochondral graft to reconstruct

Question 12

What are considerations in management of an atrophic edentulous mandible?

Answer 12

-Very difficult to reduce and fixate intraorally
-Nerve may be on top of crest
-Contamination of site, bone grafting often needed

-Do a subperiosteal dissection (No evidence that supraperiosteal dissection maintains blood supply, harder visualization, can’t graft)

Question 13

What are the fixation principals of edentulous atrophic mandibles?

Answer 13

-Non-compression bone fixation with 3 screws on each side
-Consider smaller plates to temporary stabilization
-Consider locking plate system (acts as an internal ex-fix)

-Immediate cancellous bone graft to add osteogenic potential and height

Question 14

What is the technique in management of Lefort I/II fractures?

Answer 14

-Transoral approach
-Complete mobilization (beware of greenstick fracture that is nonmobile but has malocclusion)
-Place in MMF
-Plate stabilization
-Check occlusion
-Nasal reduction open/closed prn

Question 15

What is the technique in management of Lefort III fractures?

Answer 15

-Transoral, lower lid, coronal approaches
-Good mobilization
-Place in MMF
-Fixate starting at FZ junction
-Check occlusion
-Reduce/reconstruct orbital floor/medial wall
-Nasal bone open/closed

Question 16

What is the key reduction area in a zygomatic fracture?

Answer 16

Zygomatico-sphenoid suture

Question 17

What are the indications for reduction of zygomatic fractures?

Answer 17

-Functional (trismus, orbital)
-Cosmetic (facial contour)

-Must avoid facial widening post-op

Question 18

What are the approaches to a zygomatic fracture?

Answer 18

-Giles (temporal arch)
-Keen (buccal sulcus for arch)
-Dingman (eye brow)
-Percutaneous (bone hook, towel clamp, Carroll-Girard Screw)

Question 19

What is the approach for an orbital floor/wall fracture?

Answer 19

-Tranconjunctival (posterior septal vs preseptal)

Question 20

What is the sequence of fixation in a ZMC with orbital floor fracture?

Answer 20

-Reduce ZMC after freeing trapped periorbital tissue
-FIxate ZMC
-Reconstruct orbital floor

Question 21

What are principals in orbital floor reconstruction?

Answer 21

-Coated vs noncoated plates
-Try to identify all bony ledges
-Stabilize material for large defect
-Excellent hemostasis to prevent retrobulbar hematoma

Question 22

How are lid lacerations managed?

Answer 22

-Close primary (no secondary healing
-1/3 lid loss: Close with direct advancement
-1/2 lid loss: Lateral canthotomy and advancement
->1/2 lid loss: Require local flap

Question 23

What is a corneal abrasion and how is it managed?

Answer 23

-Pain, foreign body sensation, excessive tearing

-Exam: Slit lamp, tetracaine, fluorescein dye

-Treat with patch

Question 24

Describe hyphema

Answer 24

-Blood in anterior chamber of eye
-10-30% rebleed first 5 days
-Treat w/ bed rest, atropine, consider amicar x5 days

Question 25

Describe retinal hemorrhage/detachment.

Answer 25

-Monocular diplopia
-Window shade over eye
-Grey elevation of retina containing vessels

Question 26

Describe a ruptured globe.

Answer 26

-Soft globe
-Vision often affected
-Oblong, irregular pupil
-Treat with cyclopegia, steroids, surgical repair if possible

Question 27

Describe superior orbital fissure syndrome.

Answer 27

-Ophthalmoplegia, ptosis, dilation of pupil, V1 numbness

Question 28

Describe orbital apex syndrome.

Answer 28

-Ophthalmoplegia, ptosis, dilation of pupil, V1 numbness
-And Blindness!

Question 29

What are the consequence of failure to treat/inadequate treatment of a NOE fracture

Answer 29

-Nasal deformity
-Telecanthus

Question 30

How is an NOE fracture treated?

Answer 30

-Expose all fractures completely
-Identify fanthal bearing bone/medial canthal ligament
-Reconstruct internal orbit and orbital rims
-Transnasal canthopexy (wire, attach to screws/plate, direction posterior/superior)
-Reconstruct bony dorsum with graft if needed

Question 31

How are NOE fractures categorized?

Answer 31

Markewitz classification:
Type I: Maintains attachment of MCL to large, single fracture segment
Type II: More comminution, but maintains attachment to a sizable piece of bone
-Type III- Severe comminution with possible avulsion of ligament from bone

Question 32

What are the indications for treatment of a frontal sinus injury?

Answer 32

-Anterior table displacement with esthetic deformity
-Nasofrontal duct obstruction/destruction (most ppl drain through frontal recess and not a true duct)
-Displaced posterior table fractures, greater than one cortex-cranialization with pericranial flap

Question 33

How are frontal sinus fractures approached?

Answer 33

-Coronal flap or use of previous laceration

Question 34

Describe your post-op care for a frontal sinus fracture patient?

Answer 34

-Antibiotics
-Dependent drainage (may require lumbar drain for CSF leak)
-Avoid blowing nose (intracranial air)

Question 35

What are complications with a frontal sinus fracture?

Answer 35

-Early: Meningitis
-Late: Mucocele, mucopyocele