Trauma Flashcards
What are conditions that can affect airway in the trauma patient (even after initial ATLS is preformed)?
-Facial lacerations
-EAC lacerations
-C-spine injuries
-Facial nerve injuries
-Intracranial injuries
-Carotid artery injuries
What types of fractures can be treated with closed reduction?
-Simple, favorable fractures
What are situations that favor open reduction?
-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)
What are overall principals of rigid fixations?
-Extraoral approach and no MMF
-Large plates and bicortical screws
-Concerns about stress shielding (plate prevents transmission of force to mandible, causing bone atrophy)
What are overall principals of semi-rigid fixation?
-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
What are MMF options?
-Arch bars
-IMF screws
-Bonded orthodontic brackets
-Wires only
-Consider impressions, models and splints for complex cases
What are absolute indications for open treatment of condylar fractures?
-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
What are relative indications for open treatment of condylar fractures?
-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)
What are your approach options for a condylar fracture?
-Retromandibular
-Transoral
-Submandibular
-Preauricular (high fractures only)
-Endoscopic
What are characteristics of pediatric mandible fractures?
-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
What are the risk factors for ankylosis in pediatric condylar fracture considerations.
-<3 years old
-Prolonged MMF
-High intracapsular fractures
-Consider soft diet or elastic MMF
-May require costochondral graft to reconstruct
What are considerations in management of an atrophic edentulous mandible?
-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)
What are the fixation principals of edentulous atrophic mandibles?
-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
What is the technique in management of Lefort I/II fractures?
-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
What is the technique in management of Lefort III fractures?
-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
What is the key reduction area in a zygomatic fracture?
Zygomatico-sphenoid suture
What are the indications for reduction of zygomatic fractures?
-Functional (trismus, orbital)
-Cosmetic (facial contour)
-Must avoid facial widening post-op
What are the approaches to a zygomatic fracture?
-Giles (temporal arch)
-Keen (buccal sulcus for arch)
-Dingman (eye brow)
-Percutaneous (bone hook, towel clamp, Carroll-Girard Screw)
What is the approach for an orbital floor/wall fracture?
-Tranconjunctival (posterior septal vs preseptal)
What is the sequence of fixation in a ZMC with orbital floor fracture?
-Reduce ZMC after freeing trapped periorbital tissue
-FIxate ZMC
-Reconstruct orbital floor
What are principals in orbital floor reconstruction?
-Coated vs noncoated plates
-Try to identify all bony ledges
-Stabilize material for large defect
-Excellent hemostasis to prevent retrobulbar hematoma
How are lid lacerations managed?
-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
What is a corneal abrasion and how is it managed?
-Pain, foreign body sensation, excessive tearing
-Exam: Slit lamp, tetracaine, fluorescein dye
-Treat with patch
Describe hyphema
-Blood in anterior chamber of eye
-10-30% rebleed first 5 days
-Treat w/ bed rest, atropine, consider amicar x5 days
Describe retinal hemorrhage/detachment.
-Monocular diplopia
-Window shade over eye
-Grey elevation of retina containing vessels
Describe a ruptured globe.
-Soft globe
-Vision often affected
-Oblong, irregular pupil
-Treat with cyclopegia, steroids, surgical repair if possible
Describe superior orbital fissure syndrome.
-Ophthalmoplegia, ptosis, dilation of pupil, V1 numbness
Describe orbital apex syndrome.
-Ophthalmoplegia, ptosis, dilation of pupil, V1 numbness
-And Blindness!
What are the consequence of failure to treat/inadequate treatment of a NOE fracture
-Nasal deformity
-Telecanthus
How is an NOE fracture treated?
-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
How are NOE fractures categorized?
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
What are the indications for treatment of a frontal sinus injury?
-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
How are frontal sinus fractures approached?
-Coronal flap or use of previous laceration
Describe your post-op care for a frontal sinus fracture patient?
-Antibiotics
-Dependent drainage (may require lumbar drain for CSF leak)
-Avoid blowing nose (intracranial air)
What are complications with a frontal sinus fracture?
-Early: Meningitis
-Late: Mucocele, mucopyocele
