Trauma

Question 1

A patient provides a history of having recent blunt trauma to the left zygoma. Regarding the clinical condition exhibited:
(A) recurrent hemorrhage may occur in 0-38% of the cases.
(B) there may be decreased intraocular pressure and optic ischemia.
(C) topical cycloplegics are contraindicated for this condition.
(D) topical steroids may result in scaring of the cornea.

Answer 1

A

Question 2

The child shown in the photograph suffered a dog bite with soft-tissue involvement. Twenty-four hours after primary closure the patient develops a wound infection. Which of the following is the most likely primary cause of the infection?
(A) Pasteurella multocida
(B) Streptococcus viridians
(C) Staphylococcus aureus
(D) Eikenella corrodens

Answer 2

A

Question 3

An avulsive upper lip injury involving approximately one fourth of the transverse length of the lip should be treatment planned for a/an:
(A) Abbe-Estlander flap.
(B) Gilles fan flap.
(C) full-thickness wedge resection and primary closure.
(D) Karapandzic flap.

Answer 3

C

Question 4

he most specific reliable marker of perfusion in a multiple trauma patient is:
(A) urine output.
(B) Doppler blood pressure.
(C) capillary refill time.
(D) tachycardia.

Answer 4

A

Question 5

Diffuse axonal injuries are thought to arise from which of the following mechanism?
A) Acceleration and deceleration
(B) Blunt object trauma
(C) High velocity missle penetration
(D) Low velocity missle penetration

Answer 5

A

Question 6

Severe ocular pain, decreased vision, increased intraocular pressure and proptosis after facial injury most likely is due to:
(A) retrobulbar hematoma.
(B) fracture of the optic canal.
(C) hemorrhage from the maxillary sinus.
(D) superior orbital fissure syndrome.

Answer 6

A

Question 7

Traumatic telecanthus is caused by:
(A) lateral displacement of a zygomatic fracture.
(B) orbital rim fracture.
(C) orbital roof “blow-in” fracture.
(D) medial orbital wall “blow-out” fracture.

Answer 7

D

Question 8

With respect to mandibular fractures, a “favorable” fracture is one in which:
(A) there are teeth on each side of the fracture.
(B) there is no displacement of the fragments.
(C) the displacing muscles are countered by the interlocking of fragments.
(D) a repeatable occlusion is present without treatment.

Answer 8

C

Question 9

The site of mandibular fracture associated with the highest incidence of complication, whether treated open or closed, is the:
(A) condylar process.
(B) angle.
(C) body.
(D) symphysis.

Answer 9

B

Question 10

Which of the following is the best image for assessing the orbit for fractures?
(A) Axial CT
(B) Direct Coronal CT
(C) 3-D CT Reconstructions
(D) MRI

Answer 10

B

Question 11

An elderly patient presents with bilateral fractures of the posterior mandibular body. The height of bone at the fracture is 9 mm. The patient’s dentures are available. The best method of treatment is:
(A) closed reduction using the dentures wired to the maxilla and mandible, and maxillomandibular fixation for 6 weeks.
(B) closed reduction and external pin fixation.
(C) transoral open reduction and bone plate fixation. (D) extraoral open reduction and bone plate fixation.

Answer 11

D

Question 12

What is the most important factor in re-establishment of the vertical facial height in the management of pan-facial fractures?
(A) Reduction of mandibular condyle fractures
(B) Reduction of fronto-zygomatic sutures
(C) Establishing proper zygomatic projection
(D) Establishing proper dental occlusion

Answer 12

A

Question 13

The most common reason for posttraumatic enophthalmos that develops after a ZMC fracture is:
(A) orbital floor fracture.
(B) increase in orbital volume.
(C) necrosis of orbital fat.
(D) loss of medial canthal attachment.

Answer 13

B

Question 14

Which of the following is the most useful point of fixation for ZMC fractures?
(A) Fronto-zygomatic suture
(B) Infra-orbital rim
(C) Zygomatic arch
(D) Zygomatico-maxillary buttress

Answer 14

D

Question 15

Rigid fixation hardware that is present in a fracture that becomes infected after treatment should be:
(A) removed.
(B) irrigated with penicillin solution 4 times/day.
(C) left in place if providing stability.
(D) removed, autoclaved, and replaced.

Answer 15

C

Question 16

Severe ocular pain, decreased vision, increased intraocular pressure and proptosis after facial injury most likely is due to:
(A) retrobulbar hematoma.
(B) fracture of the optic canal.
(C) hemorrhage from the maxillary sinus.
(D) superior orbital fissure syndrome.

Answer 16

A

Question 17

Traumatic telecanthus is caused by:
(A) lateral displacement of a zygomatic fracture.
(B) orbital rim fracture.
(C) orbital roof “blow-in” fracture.
(D) medial orbital wall “blow-out” fracture.

Answer 17

D

Question 18

With respect to mandibular fractures, a “favorable” fracture is one in which:
(A) there are teeth on each side of the fracture.
(B) there is no displacement of the fragments.
(C) the displacing muscles are countered by the interlocking of fragments.
(D) a repeatable occlusion is present without treatment.

Answer 18

C

Question 19

The site of mandibular fracture associated with the highest incidence of complication, whether treated open or closed, is the:
(A) condylar process.
(B) angle.
(C) body.
(D) symphysis.

Answer 19

B

Question 20

Which of the following is the best image for assessing the orbit for fractures?
(A) Axial CT
(B) Direct Coronal CT
(C) 3-D CT Reconstructions
(D) MRI

Answer 20

B

Question 21

The clinical sign differentiating superior orbital fissure syndrome from orbital apex syndrome is:
A. absence of superior palpebral fold
B. proptosis
C. dilated and fixed pupil
D. decreased visual acuity

Answer 21

ANSWER: D
RATIONALE:
Symptoms of superior orbital fissure syndrome include:
1. Pupillary dilation via alteration in cranial nerve III function in it’s innervation of the
pupillary constrictors.
2. Paresis of cranial nerves III, IV, and IV causing ophthalmoplegia.
3. Cranial nerve III involvement causes paresis of the levator palpebrae superiorus muscle,
leading to ptosis and loss of the superior palpebral fold.
4. Neurosensory disturbance to the first division of cranial nerve V with hypesthesia of the
supraorbital and supratrochlear nerves and loss of the corneal reflex.
5. Proptosis from engorgement of the ophthalmic vein and lymphatics.
The orbital apex syndrome includes all of the above plus optic nerve involvement, leading to changes in visual acuity.
REFERENCE:
Zacharides et al, The superior orbital fissure syndrome. J Maxillofac Surg 13: 125-8, 1985 Zacharides et al, Orbital apex syndrome. Int J Oral Maxillofac Surg 16:352-4, 1987

Question 22

Post auricular ecchymosis in cases of high velocity trauma is usually indicative of:
A. fracture of the vertex of the skull
B. mandibular fracture
C. basilar skull fracture
D. LeFort III fracture

Answer 22

ANSWER: C
RATIONALE:
A fracture of the skull base results in the extrusion of blood subperiosteally. This hematoma or ecchymosis may be exhibited at the thin skinned mastoid region (post- auricular), as hemotympanum, as bilateral periorbital ecchymosis, or as a posterior pharyngeal ecchymosis or hematoma.
REFERENCE:
Wong, M.E.K., and Johnson, J.V.; in Fonseca, R.J.: Oral and Maxillfacial Surgery. W.B. Saunders, Co. 2000: 254, 255
Stedman’s Medical Dictionary; 27th Ed. 2000 Lippincott Williams & Wilkins, Philadelphia, PA

Question 23

Alignment of which of the following is the most reliable for proper reduction of the zygomaticomaxillary complex fracture?
A. Frontozygomatic suture
B. Sphenozygomatic suture
C. Infraorbital rim
D. Medial orbital rim

Answer 23

ANSWER: B
RATIONALE:
The sphenozygomatic suture area has been previously analyzed and shown to be an area for confirmation of alignment of the zygomatic arch and the zygomatic complex (ZMC). This has also been shown to key point for fixation thru biomechanical studies.
The sphenozygomatic suture is a broad area along the greater wing of the sphenoid and can be approached along the internal aspect of the lateral orbit. Even in severe midface fractures the greater wing of the sphenoid is intact thus acting as a key landmark for proper reduction of the ZMC fracture.
Reduction of the frontozygomatic suture or the infraorbital rim alone can result in errors due to the small surface area. The medial orbit is generally not involved in a ZMC fracture.
REFERENCE:
Rohner D, Tay A, Meny CS, Hutmacker DW, Hammer B.: The sphenozygomatic suture as a key site for osteosynthesis of the orbitozygomatic complex in panfacial fractures: A biomechanical study in human cadavers based on clinical practice. Plast Reconstr Surg 110: 1463, 2002.
Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft tissue reductions and sequencing treatments of segmental fractures. Plast Reconstr Surg 103: 1287, 1999.

Question 24

Which of the following is the least cosmetic surgical approach for an adolescent with an orbital floor fracture?
A. Subciliary incision
B. Post septal transconjunctival incision
C. Infraorbital incision
D. Preseptal transconjunctival incision.

Answer 24

ANSWER: C
RATIONALE:
Although the infraorbital incision provides direct and excellent exposure of the orbital rim and floor with a low incidence of complications, it frequently produces a noticeable scar. In younger people, this scar increases in size with growth. The subciliary incision is more cosmetic. Whether pre- or post-septal, the transconjunctival incisions do not involve the skin and are cosmetically hidden.
REFERENCE:
Fonseca, R.J. and Walker, R.V.: Oral & Maxillofacial Trauma. Philadelphia, PA: W.B. Saunders, Co; 1991: 463, 1184.
Haug, R.H. and Buchbinder, D.: Incisions for access to Craniomaxillofacial Fractures. Atlas of Oral & Maxillofacial Clinics of North America. 1993; 1:1-29.

Question 25

The first step in the general order of treatment of panfacial fractures is:
A. Establish soft and hard tissue reduction
B. Expose all fracture sites
C. Alleviate soft tissue entrapments
D. Apply internal fixation

Answer 25

ANSWER: B
RATIONALE:
The first issue in the order of treatment of panfacial fractures is to ascertain the sites and conditions of the disrupted anatomical structures. This can only be accomplished by exposure of the entire injured facial skeleton. Soft tissue entrapments are next alleviated, the osseous fractures are then reduced, and rigid fixation is applied followed by soft tissue approximation.
REFERENCE:
Assael, Leon A.: Atlas of Facial Fractures. Oral & Maxillofacial Surgery Clinics of North America. Vol. 11, No. 2, May 1999, 320-321

Question 26

Acute dacryocystitis following trauma is treated by all of the following except:
A. warm compresses
B. intubation of the canaliculi and injection of dye
C. systemic or topical nasal decongestants
D. incision and drainage

Answer 26

ANSWER: B
RATIONALE:
Dilation, intubation and dye injection are diagnostic, not therapeutic measures. Moreover, these maneuvers should not be attempted in the face of an acute dacryocystitis. Incision and drainage of the lacrimal sac, administration of medicaments (systemic or topical decongestants,) or palliative care(warm compresses) are acceptable treatment modalities..
REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic Clinics of North America 1991; 24: 59-78

Question 27

Epiphora can be caused by all of the following except:
A. Telecanthus with rounding of the medial canthus
B. Entropion of the lower lid
C. Ectropion of the lower lid
D. A soft tissue laceration of the lateral aspect of the upper eyelid

Answer 27

ANSWER: D
RATIONALE:
Ectropion and entropion can affect the contact of the inferior lacrimal punctum with the tear fluid decreasing lacrimal fluid flow through the punctum and leadin to epiphora. Traumatic telecanthus can also lead to alterations in tear flow and drainage in the medial aspect of the inferior palpebral area and decrease lacrimal drainage through the inferior canilculus. The codnition affect lacrimal fluid drainage but not lacrimal fluid delivery to the palpebral fissure. Although a laceration through the laterial aspect of the upper eyelid can disrupt tear flow from the lacrimal gland, such a decrease in tear production would not lead to epiphora.
REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic Clinics of North America 1991; 24: 59-78

Question 28

Disruption of the nasolacrimal apparatus with subsequent epiphora occurs most commonly after which facial fracture:
A. Nasal
B. LeFort III
C. Nasoethmoidal
D. Zygomaticomaxillary

Answer 28

ANSWER: C
RATIONALE:
The incidence of nasolacrimal disruption is 0.2% following nasal fracture, 3-4% following midface fractures, 17-21 % following naso-ethmoidal fractures, almost non existent following zygomatic-maxillary fractures. The location of the zygoma is so far removed from the lacrimal apparatus so as to make it a concomitant injury.
REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic Clinics of North America 1991; 24: 59-78

Question 29

Confirmation of a CSF leak following a fontal sinus fracture is best done with which of the following imaging studies?
A. A high resolution computed tomography cisternogram after administration of intrathecal fluorescein
B. A facial series of radiographs to include a Caldwell and lateral view
C. A non contrast computed tomography study of the brain
D. Magnetic resonance imaging of the base of the skull

Answer 29

ANSWER: A
RATIONALE:
Plane radiography is incapable of confirming a CSF leak. While magnetic resonance is helpful with soft tissues, without dye, this diagnostic aid is useless. A similar rationale exists for non- contrast CT. An intrathecal injection of dye, and confirmation of the dye at distant sites is diagnostic.
REFERENCE:
Manolidis, S.: Management of frontal sinus trauma. Seminars in Plastic Surgery 2002; 16:261-271

Question 30

The most likely diagnosis in a patient with painful proptosis, progressive visual loss, restricted extraocular movement, and increased intraocular pressure following surgery to reduce a zygomatic fracture is:
A. Horner’s syndrome
B. Movement of an alloplastic implant
C. Injury to the infraorbital nerve
D. Retrobulbar hematoma

Answer 30

ANSWER: D
RATIONALE:
Movement of an alloplastic implant is generally asymptomatic. Injury to the infraorbital nerve produces anesthesia or paresthesia over it’s cutaneous distribution (the lower eyelid area). Horner’s syndrome, caused by a disruption in the sympathetic innervation to the upsilateral maxillofacial region, is characterized by: a constricted pupil (by unopposed parasympathetic constriction), ptosis (by loss of smpathetic inneration to Mueller’s muscle), and anhidrosis (by interruption of sympathetic innervation to cutaneous sweat glands). The symptoms described are most consistent with retrobulbar hematoma, and require prompt diagnosis and intervention.
REFERENCE:
Korinth MC, Ince A, Banghard W, Huffmann BC, Gilsbach JM: Pterional orbita decompression in orbital hemorrhage and trauma. Trauma 2002; 53:73-
78

Question 31

Suspension wires utilized to stabilize a LeFort I fracture resists forces in which direction?
A. Superior
B. Inferior
C. Anterior
D. Posterior

Answer 31

ANSWER: B
RATIONALE:
The recent development and improvements in miniaturized bone plate systems has greatly enhanced treatment of midface fractures and diminished but not obviated the need for wire suspension with direct wiring techniques. While wires may provide minor resistance to deformation in an anterior and posterior direction, they offer no resistance superiorly. The best answer is that the resist deformation in an inferior direction and thereby resist facial elongation.
REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

Question 32

When evaluating visual acuity in the orbital trauma patient:
A. The pupils should be dilated.
B. Eyeglasses should not be worn by the patient, even if available.
C. Viewing through a pinhole can compensate for some refractory errors.
D. Topical tetracaine can aid acuity evaluation.

Answer 32

ANSWER: C
RATIONALE:
Dilation may mask signs and symptoms of neurologic injury. Pupillary dilation does not aid in a visual acuity examination but is utilized to fully visualize the retina, vessels and the optic disc. Pre-existing visual acuity defecits (such as myopia and presbyopia) can mimic traumatic visual acuity loss; and therefore the use of prescription eyeglasses can facilitate the distinction of pretaumatic from traumatic visual defecits. Topical tetracaine is a local anesthetic and is of no value in the evaluation of visual acuity. If pretraumatic myopia is prsent, acuity evaluation while looking through a pinhole can substitute somewhat for corrective lenses if such lenses are not available.
REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA6. Classification D - Trauma - Soft tissue

Question 33

Which of the following is true when treating eyelid lacerations:
A. Eyelid and ocular mobility should be evaluated before injecting local anesthetic.
B. Fat herniation is not an indication of orbital septum violation.
C. Fat herniation is not an indication of possible globe penetrating injury.
D. Iridocyclitis describes an irregularly shaped pupil which “points” away from the area of
globe injury.

Answer 33

ANSWER: A
RATIONALE:
Iridocyclitis is a traumatic anisocoria and many times points towards the injury. Fat herniation occurs with aging and of itself is not necessarily indicative of traumatic septum violation. Herniated fat without lid laceration is therefore of no consequence; however, fat herniation through a lid laceration indicates septum violation and mandates the need for careful evaluation for penetrating globe injury. Penetrating globe injury is diagnosed by visualization of the globe surface. The lid should be examined prior to the administration of local anesthesia because edema and local anesthesia may limit motility.
REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA 7-8. Classification D - Trauma - Soft tissue

Question 34

Which of the following is true when treating injuries of the external ear:
A. Cartilage should never be sutured, thereby avoiding necrosis.
B. Loose or macerated skin should be extensively débrided.
C. Cartilage lacerations should be sutured with conventional, interrupted chronic gut sutures
to encourage overlapping.
D. Cartilage should be sutured with slowly resorbable figure-of-eight sutures.

Answer 34

ANSWER: D
RATIONALE:
Cartilagenous lacerations should be approximated to reconstruct anatomy and prevent chronic chondritic inflammation. Interrupted sutures may promote cartilage margin overlap; the use of figure of eight sutures prevents overlap of lacerated cartilage margins. Cartilage has a limited vascurlar supply, originating from overlying soft tissue; therfore extensive debridement of overlying soft tissue should be discourage.
REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA 18-19. Classification D - Trauma - Soft tissue

Question 35

When the medial canthal ligament is attached to a bony segment in naso-orbito-ethmoidal(NOE) fracture repair the transcanthal wire is best placed:
A. after all soft tissue injuries have been addressed.
B. anterior to the original insertion of the canthal ligament.
C. posterior and inferior to the original insertion.
D. posterior and superior to the original insertion.

Answer 35

ANSWER: D
RATIONALE:
The purpose of the trans-canthal wire is to secure the canthal ligament and boney segment in the pretraumatic position. Pull of the soft tissues displaces the bone and canthal ligament in an anterior and inferior direction. Therefore a wire placed posterior and superior to the original insertion provides a vector whose resistance to displacement is most ideal and provides the best alignment.
REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA 75-76. Classification D - Trauma - Soft tissue Oral and Maxillofacial Surgery In-Training Examination (OMSITE) questions for the Trauma Section.

Question 36

An 18-year-old man is stabbed to the left upper chest. You record a blood pressure of 75/60. He is gasping for air, breath sounds are diminished on the left, and his trachea is deviated to the right. The initial treatment should be:
A. Perform tracheal intubation.
B. Obtain a chest x-ray to verify the pneumothorax.
C. Place a chest tube between the anterior and midaxillary line in the fifth intercostal space.
D. Perform needle decompression of the left chest.

Answer 36

ANSWER: D
RATIONALE:
This is a classic tension pneumothorax and treatment is a clinical diagnosis with immediate needle decompression of the second intercostal space, midclavicular line The time involved in waiting for a chest x-ray might prove lethal. Insertion of a chest tube in a controlled fashion to facillitate lung re-expansion normally follows needle deompression of the tension pneumothroax. Endotracheal intumbation with positive pressure ventilation often worsen a tension pneumothrorax, but may be indicated for other types of chest injuries.
REFERENCE:
1997 ATLS for Doctors, Sixth Edition.

Question 37

A 21-year-old female is an unrestrained driver involved in a MVA. She suffers a scalp laceration and is noted to have lost 1000mL of blood at the scene. You would expect her vital signs to be consistent with:
A. Pulse rate >100, normal systolic blood pressure, decreased pulse pressure, respiratory rate of 20-30, urinary output of 20-30mL/hr.
B. Pulse rate <100, normal systolic blood pressure, normal or increased pulse pressure, respiratory rate of 14-20, urinary output of >30mL/hr.
C. Pulse rate >120, decreased systolic blood pressure, decreased pulse pressure, respiratory rate of 30-40, urinary output of 5-15mL/hr.
D. Pulse rate >140, decreased systolic blood pressure, decreased pulse pressure, respiratory rate of >35, urinary output that’s negligible.

Answer 37

ANSWER: A
RATIONALE:
These findings are consistent with a Class II hemorrhage, 750-1500ml, The vitals signs or such a blood loss are consistent with those in response A. Response D reflects the vital signs of a Type IV blood loss, Response C a Type III and Response B a Type I.
REFERENCE:
1997 ATLS for Doctors, Sixth Edition.

Question 38

A 65-year-old man fell down the stairs. Upon examination of him, you notice that he opens his eyes to speech, localizes pain, and mutters inappropriate words. You assess his Glasgow coma scale (GCS) to be:
A. 13
B. 11
C. 9 D. 7

Answer 38

ANSWER: B
RATIONALE:
According to the Glascow Coma Scale, the patient can open his eyes in response to commands speech, (3 out of 4); localizes pain, (5 out of 5); yet produces inappropriate words, (3 out of 6); for a Glascow coma score of 11.
REFERENCE:
1997 ATLS for Doctors, Sixth Edition

Question 39

The most frequent location of internal orbital injury in children seven years old and under is the?
A. floor
B. medial wall
C. lateral wall
D. roof

Answer 39

ANSWER: D
RATIONALE:
Fronto-orbital injuries are the most frequent in this age group. Because the antrum, sphenoid, ethmoid and frontal sinuses are not yet pneumatized in this age group, fronto-basilar (or roof) injuries most commonly occur. Wall or floor injuries occur in young children.
REFERENCE:
Koltai PJ, Amjad I, Meyer D, et al. Orbital fractures in children. Arch Otol Head Neck Surg 121:1375, 1995

Question 40

After nasal injuries in children, growth disturbance are most associated with premature ossification of which suture?
A. Nasofrontal
B. Septovomerine
C. Nasomaxillary
D. Nasoethmoidal

Answer 40

ANSWER: B
RATIONALE:
The septovomerine suture determines growth in this area. If this suture is involved in trauma growth consequences are a concern since neither of the other sutures, if involved, provides as deforming a growth consequence.
REFERENCE:
Precious DS, Delaire J, Hoffman CD. The effects of nasomaxillary injury on future growth. Oral Surg, Oral Med, Oral Pathol, 66:525, 1983.

Question 41

When reconstructing an orbital floor injury, the safe distance for dissection from the infraorbital rim to the anulus of Zinn is up to how many millimeters?
A. 20
B. 25
C. 35
D. 40

Answer 41

ANSWER: D
RATIONALE:
According to a recent cadaveric study involving specimens with intact soft tissue, the mean distance from the inferior orbital rims to the annulus of Zinn is 39.4 mm +/- 2/9 mm. Previously cited studies on dry skulls, using bony landmarks only with no soft tissue references at the orbital apex provide clinically less useful information.
REFERENCE:
Danko I, Haug RH. An Experimental investigation of the safe distance for internal orbital dissection. J Oral Maxillofac Surg 56:749, 1998.

Question 42

The most common chronic problem associated with the surgical treatment of frontal sinus fractures is?
A. The development of mucoceles
B. Chronic pain
C. Osteomyelitis
D. Contour deficits and irregularities

Answer 42

ANSWER: B
RATIONALE:
With the advent of rigid internal fixation, contour deficits and irregularities are infrequent. Using modern aseptic protocols, osteomyelitis is very uncommon. While mucoceles do occur in rare instances when sinus membrane regenerates, pain remains the most frequent of chronic problems.
REFERENCE:
Haug RH, Cunningham LL Management of Fractures of the Frontal Bone and Frontal Sinus. Selected Readings in Oral and Maxillofacial Surgery. 10:6, 1-32, 2002.

Question 43

Patients who survive facial fractures are most likely to have suffered what forms of facial injury?
A. Upper only
B. Mid only
C. Lower only
D. Combinations of lower, mid and upper

Answer 43

ANSWER: C
RATIONALE:
Mandibular injury is associated with c-spine injury, but mid- and upper are associated with death. Mid- and upper-facial third injuries initially act as shock absorbers until a particular magnitude of impact, after which they transmit force to the neurocranium. The more commonly results in fatality than does trauma to the lower 1/3 of the facial skeleton.
REFERENCE:
Plaiser BR, Punjabi AP, Super DM, et al: The relationship between facial fractures and death from neurologic injury. J Oral Maxillofac Surg 58:708, 2000

Question 44

The intercanthal distance in the uninjured adult patient is approximately:
A. 25-30 mm
B. 31-35 mm
C. 36-40 mm
D. 41-45 mm

Answer 44

ANSWER: B
RATIONALE:
The inter-canthal distance in adult Caucasians is 33 + mm. This varies minimally with gender and race. The other answers are outside of this range.
REFERENCE:
Murphy WK, Laskin DM: Intercanthal and interpupillary distance in the black population. Oral Surg Oral Med Oral Pathol 69:676, 1990

Question 45

Which of the following is true of the annulus of Zinn?
A. It is attached to the lacrimal, ethmoid and sphenoid bones.
B. It contains the ophthalmic artery and its branches.
C. It is the origin of the rectus and oblique muscles.
D. It contains the maxillary and ophthalmic divisions of the trigeminal nerve.

Answer 45

ANSWER: B
RATIONALE:
The annulus of Zinn contains the ophthalmic artery and its branches. The oblique muscles originate outside of the annulus. The annulus is distant from the lacrimal bone, and does not contain the maxillary division of the trigeminal nerve.
REFERENCE:
Dutton JJ: Atlas of clinical and surgical orbital anatomy. WB Saunders Co. Philadelphia PA, 1994 pgs 1-80.
Rowe NL. Fractures of the zygomatic complex and orbit. In:Rowe NL, Williams JL. Maxillofacial Injuries. Churchill Livingstone. New York, New York, 1985 p 450.

Question 46

Which of the following is the best definition in the Markowitz and Manson classification system of a Type II nasoethmoidal injury?
A. a single large fragment, with the canthal ligament attached. B. minor comminution, with the canthal ligament attached.
C. comminution beneath the canthal ligament.
D. comminution with the canthal ligament detached.

Answer 46

ANSWER: B
RATIONALE:
Below are figures adapted from the original article on nasoethoidmal fractures published by Markowitz and Manson in 1991. Choice B is the correct answer. Choice A represents a Type I fracture. Choice C doesn’t fit into any classification scheme since it doesn’t address the region of the canthal ligaments. Choice D represents a Type III fracture.
This figure depicts the nasoethmoidal region. The region shaded is the central fragment. The inset figure represents a Type I fracture, where the canthal ligament is attached to a large central fragment and there is no comminution of the fractured nasoethmoidal region.
27
This figure represents a Type II fracture. There is some comminution of the nasoethmoidal region but the canthal ligament is attached to a substantial fragment of bone.
This figure represents a Type III fracture. The canthal ligament is detached or there is severe comminution with the canthal ligament attached to a small fragment of bone.
REFERENCE:
Markowitz BL, Manson PN, Sargent L, et al: Management of the medial canthal tendon in nasoethmoid orbitae fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg 87: 843 1991.

Question 47

When repairing cranial bone trauma utilizing a coronal approach, the temporal branches of the facial nerve can best be preserved by:
A. avoid extending the incision into the preauricular areas
B. confining the surgical dissection between the superficial temporal fascia and the deep
temporal fascia
C. insuring the surgical dissection is deep to the superficial layer of the deep temporal fascia
D. avoid reflecting the periosteum of the zygomatic arch

Answer 47

ANSWER: C
RATIONALE:
The temporal branches lie immediately beneath the superficial layer of the temporal fascia, just above the superficial layer of the deep temoral (temporalis) fascial. Dissection below the superficial temporal fascia this layer may injure the nerve. Dissection beneath the superficial layer of the deep temporal fascia preserves the temporal facial nerve branches.
REFERENCE:
Abubaker AO, Sotereanos G, Patterson GT. Use of the coronal surgical incision for reconstruction of severe craniomaxillofacial injuries. JOMS 48:579-586, 1990.

Question 48

Which of the following surgical approaches for repair of orbital trauma has the highest incidence of post operative scleral show?
A. Transconjunctival without lateral cantholysis B. Infraorbital (orbital rim)
C. Upper eyelid blepharoplasty
D. Subciliary

Answer 48

ANSWER: D
RATIONALE:
Several studies have shown that the subciliary approach has the highest rate of post operative scleral show. The scar contracture associated with the infraorbital approach does no affect the orbicularis to the same degree as for other incisions. The transconjunctival incision is associated with minimal scleral show. The design of the upper blepharoplasty incision is associated with the least percentage of this complication.
REFERENCE:
Patel PC, Sobota BT, Patel NM, et al. Comparision of Transconjunctival versus subciliary approaches for orbital fractures. J Cranio-maxillofacial trauma 4(1):17-21, 1998.

Question 49

The most sensitive clinical laboratory indicator able to confirm cerebrospinal fluid leakage is:
A. Comparison of suspected fluid glucose to patient’s serum glucose
B. Dipstick test utilizing glucose oxidase
C. Beta 2 transferrin level of suspected fluid
D. Comparison of protein and potassium levels of suspected fluid to nasal secretions and
serum levels

Answer 49

ANSWER: C
RATIONALE:
Beta 2 transferrin is found only in the brain and eyes. The patient’s CSF may be contaminated with blood and therefore mimic serum. The dipstick test is colorimetric and if contaminated with red blood, may alter the results. Again, CSF may be contaminated with nasal secretions or blood and thus mimic those fluids rather than CSF.
REFERENCE:
Brandt MY, Jenkins WS, Fattahi TT, Haug RH. Cerebrospinal fluid: Implications in oral and maxillofacial surgery. JOMS 60:1049-1056, 2002

Question 50

The end metabolic degradation byproducts of bioresorbable osseous fixaton devices (plates and screws) are:
A. glycolic acid
B. lactic acid
C. carbon dioxide and water
D. Acetic acid

Answer 50

ANSWER: C
RATIONALE:
Both homopolymer and copolymer products follow the same metabolic degradation pathway culminating in the citric acid cycle, ultimately ending with the production of carbon dioxide and water.
REFERENCE:
Peltoniemi H, Ashammakhi N, Kontio R, et al. The use of bioabsorbable osteofixation devices in craniomaxillofacial surgery. Oral Surg Oral Med Oral Path, 94(1):5-14, 2002

Question 51

An adult patient, with a normal dentition, has a closed right mandibular subcondylar fracture with 90 degree medial displacement of the condylar head. Secondary to this fracture, the patient could be expected to demonstrate which of the following clinical findings?
A. Deviation of the mandible to the left with opening
B. Reduced right lateral excursion
C. Right posterior apertognathia
D. Reduced left lateral excursion

Answer 51

ANSWER: D
RATIONALE:
With a right subcondylar fracture, the action of the right lateral pterygoid muscle would be reduced and the patient would deviate to the right upon opening, and would experience diminished left lateral excursion. Lastly, decreased right ramus height would cause an occlusal prematurity on the right side.
REFERENCE:
Hlawitschka M, Eckelt U. Assessment of patients treated for intracapsular fractures of the mandibular condyle by closed techniques. JOMS 60:784-791, 2002

Question 52

In the case of an isolated lesion of the right oculomotor nerve:
A. The right globe rotates upward and outward.
A. The left eye consensual light reflex is preserved.
B. Motor nerves alone are affected resulting in ptosis and miosis.
C. Light stimulation of the left eye results in a consensual reflex in the right eye.

Answer 52

ANSWER: B
RATIONALE:
Motor and sensory nerves are affected. Light stimulation in the left eye produces no consensual reflex in the right eye, since the oculomotor nerve carries parasympathetic branches that allow consensual pupillary constriction. The left eye consensual light reflex is preserved. Only abduction (via cranial nerve VI) and adduction (via cranial nerve IV) of the right globe are possible.
REFERENCE:
Rowe NL, Williams J Ll: Maxillofacial Injuries, London, Churchill Livingstone, 1985

Question 53

Low velocity missile wounds are characterized by:
A. small entry wounds and larger exit wounds.
B. bullet speed over 2000 ft per second
C. minimal tissue avulsion
D. soft tissue cavitation injury

Answer 53

ANSWER: C
RATIONALE:
Low velocity wounds are characterized by a small and clean cut or ragged entrance wound but no exit wound. When hard tissue is struck fracture, comminution and displacement occurs, but external avulsion is rare. The soft tissue cavitation is minimal. Low velocity missiles travel at less than 2000 ft/sec.
REFERENCE:
Shelton DW, Albright CR: Study in wound ballistics. J Oral Surg 1967; 25: 341

Question 54

Which of the following best describes the most appropriate initial fluid bolus during the fluid resuscitation of a pediatric patient.
A. 1 liter lactated Ringer’s solution
B. 500 cc normal saline
C. 20 cc/kg body weight crystalloid solution
D. 10 – 15 cc/kg body weight colloid solution

Answer 54

ANSWER: C
RATIONALE:
Initial resuscitation for pediatric patients is done with crystalloid solution, and the volume administered is determined by body weight. Fluid resuscitation is not accomplished with set amounts of fluid., nor is colloid an appropriate medium for initial intravascular resuscitation.
REFERENCE:
Advanced trauma life support for doctors student course manual. Sixth edition. Page 97

Question 55

Along which wall of the orbit is there a normal bony prominence just behind the equator of the globe?
A. Superior and lateral
B. Lateral and inferior
C. Inferior and superior
D. Inferior and medial

Answer 55

ANSWER: D
RATIONALE:
The bone anatomy of the orbital walls has been well defined. Often forgotten in
clinical practice, however is the elevation of the infero-medial orbital wall behind the equator
of the globe. In addition, significant alteration of the bony anatomy along the medial wall is sometimes not appreciated because displacement can result in a straight medial wall that to the uninitiated appears normal.
REFERENCE:
Manson PN, Clifford CM, Iliff NT, Morgan R: Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconstr Surg 77(2): 193-202, 1986.

Question 56

In the setting of traumatic blindness, which of the following is an acceptable indication for surgical decompression of the optic nerve?
A. failure to respond to high-dose steroid therapy
B. visual loss immediately following the trauma event
C. penetrating trauma
D. delayed visual loss following blunt trauma

Answer 56

ANSWER: D
RATIONALE:
Following blunt trauma visual recovery after decompression is not likely whenever there was immediate blindness, penetrating ocular injury, or failure to respond to the initiation of high-dose steroids.
REFERENCE:
Anderson RL, Panje WR, Gross CE: Optic nerve blindness following blunt forehead trauma. Ophthalmology 89:445-455, 1982.

Question 57

ailure to re-suspend the periosteum overlying the zygoma after fracture repair most commonly results in which of the following deformities?
A. ectropion of the lower eyelid
B. sagging of the facial soft-tissues
C. thinning of the upper lip
D. inward rotation of the vermillion

Answer 57

ANSWER: B
RATIONALE:
Ectropion results from overzealous dissection, tissue injury or pexing of the periorbita. Thinning of the lip and inward rotation of the vermillion should only be a consideration if the periosteum was dissected from the anterior maxilla. Following coronal or hemicoronal flap elevation and exposure of the zygomatic bone and malar eminence, posterio-superior resuspension of the periosteum is indicated to prevent tissue sagging.
REFERENCE:
Yaremchuk MJ: Orbital deformity after craniofacial fracture repair: avoidance and treatment. J Craniomaxillofac Trauma 5(2):7-16, 1999.

Question 58

Which of the following is the appropriate amount of time for the arch bar fixation of a dentoalveolar fracture:
A. 3-5 days
B. 7-10 days
C. 14-17 days
D. 21-25 days

Answer 58

ANSWER: D
RATIONALE:
Isolated tooth avulsion is treated by splinting for seven tot en days with isolation from occlusal function and endodontic therapy on theeth with fully developed apices. In the case of a true alveolar fracture, three to four weeks, or twenty one to twenty eight days is an appropriate duration of arch bar fixation.
REFERENCE:
Peterson, L. DDS, MS, et. al. Oral and Maxillofacial Surgery, 3rd Ed., 1998, pp. 577 & 580.

Question 59

The initial antibiotic coverage for a cat, dog, or human bite is:
A. penicillin
B. clindamycin
C. cephalexin
D. amoxicillin with clavulanate

Answer 59

ANSWER: D
RATIONALE:
Augmentin. This antibiotic is bacteriocidal for the range and spectrum of human and animal bite pathogens including Staphylococcus species and Pasteurella multocida.
REFERENCE:
Fonseca, RJ. Oral & Maxillofacial Surgery 2000. p.385

Question 60

A patient seen in the emergency department presents with: elevated venous pressure, muffled heart sounds, and decreased arterial pressure. What is the most likely diagnosis?
A. Dissecting aortic aneurism
B. Cardiac tamponade
C. Acute myocardial infarction
D. Pneumothorax

Answer 60

ANSWER: B
RATIONALE:
The patient presents with the classic Beck’s triad of increased venous pressure, decreased arterial pressure, and muffled heart sounds indicating cardiac tamponade. dissecting aortic aneurysm may cause a drop systolic pressure in Class III or IV shock, but would not exhibit increased venous pressure or muffled hear sounds. Acute myocardial infarction can present with a number of different blood pressure changes, but usually does not exhibit heart sounds. Tension pneumothorax can cause decreases in pulse pressure and muffled heart sounds, but also is accompanied by ipsilateral chest resonance and decreased breath sounds, and often with tracheal shift to the contralateral side.

Question 61

Traumatic disruption of the adult nasolacrimal system is best handled acutely by:
A. Silicone nasolacrimal duct intubation x 3-4 months
B. Cannulation with Bowman probe of the inferior canaliculus
C. Cannulation with Bowman probe of the superior canaliculus
D. Dacryocystorhinostomy

Answer 61

ANSWER: A
RATIONALE:
Nasolacrimal duct intubation may bypass a disrupted nasolacrimal apparatus and avoid the morbidity associated with a dacryocystorhinostomy. Dacryocystorhinostomy is reserved for a chronic condition. Cannulation should be instituted for both inferior and superior canaliculi.
REFERENCE:
Fonseca and Walker. Oral and Maxillofacial Trauma, p.533-534.

Question 62

A 22 year old male status post two gun shot wounds to the face and abdomen presents with a blood pressure of 80/40 and a pulse of 160 after 2 liters of Ringers lactate. There is no significant facial hemorrhage or expanding hematoma. Proper immediate management is:
A. four vessel angiography of the neck
B. CT scan of the abdomen
C. diagnostic peritoneal lavage
D. emergency celiotomy

Answer 62

ANSWER: D
RATIONALE:
This patient exhibits no symptoms of massive hemorrhage from the facial gunshot wounds, and is hemodynamically unstable with a penetrating abdominal injury. This is a clssic indication for an emergency celiotomy for intra-abdominal hemorrhage control. CT abdominal scans or diagnostic peritoneal lavage may be indicated in blunt tauma with evidence of intra- abdominal hemerrhage; but these procedures are time-consuming and are indicated if there is greater hemodynamic control. From the clinical presentation, although eventual head and neck angiography may be indicated, the more emergent problem is shock from abdominal blood loss and must be addressed first by cleotomy.
REFERENCE:
ATLS Student Course Manual 1997, pp 165-6

Question 63

Which of the following signs and/or symptoms are associated with venous thrombosis?
A. Homans sign
B. Levine’s sign
C. Quinke’s sign
D. Psoas sign

Answer 63

ANSWER: A
RATIONALE:
Homan’s sign: calf pain with forcible dorsiflexion of the foot, associated with lower extremity deep venous thrombosis. Levine’s sign: clenched fist over the chest while describing chest pain: associated with angina and acute myocardial infarction. Quinke’s sign: alternating blushing and blanching of the fingernail following light compression: seen in aortic regurgitation. Psoas sign (iliopsoas test): extension and elevation of the right leg produces pain in cases of inflammation of the psoas muscle: indicative of appendicitis.
REFERENCE:
Stedman’s Medical Dictionary 23rd ed., Williams & Wilkins, 1976 Bates B: A Guide To Physical Examination, 2nd ed. Lippincott, 1979

Question 64

When repairing eyelid lacerations or avulsive injuries:
A. The eyelid skin should be aggressively débrided.
B. The lid margin is initially approximated with a suture at the “gray line”.
C. Repair must be completed within 24 hours.
D. Split thickness skin grafts are best for replacing avulsed eyelid skin.

Answer 64

ANSWER: B
RATIONALE:
The best answer is to re-approximate landmarks by suturing the lid at the gray line. A lid may be repaired by a number of techniques, each of which has a specific time limitation, therefore 24 hours may vary. Aggressive debridement should be avoided. Split thickness skin grafts are not the most desirable modality as they may have texture and color differences.
REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA 9-10. Classification D – Trauma - Soft tissue

Question 65

Which of the following is not seen in cases of fracture of the larynx with acute airway obstruction.
A. Hoarseness
B. Palpable fracture
C. Dysphasia
D. Dyspnea

Answer 65

ANSWER: C
RATIONALE:
Dysphagia, pain on swallowing, is not part of the classic triad described by the other answers: a palpable fracture, . hoarseness (if the vocal chords are compromised); and comprised breathing.
REFERENCE:
1997 ATLS for Doctors, Sixth Edition

Question 66

Which of the following is a common finding in patients with bilateral displaced fractures of the condylar processes treated by closed reduction that is not commonly seen following proper open reduction?
A. Temporomandibular joint ankylosis
B. Loss of posterior facial height
C. Temporomandibular disc displacement
D. Facial muscle weakness

Answer 66

ANSWER: B
RATIONALE:
Disc displacement may occur from the injury or the treatment, but has not been shown to be significantly different for the two different types of treatment. Likewise, the incidence of ankylosis has not been shown to be statistically different with either treatment. Facial weakness via cranial nerve V damage is only possible in the setting of open reduction.
REFERENCE:
Ellis E, Throckmorton G: Facial symmetry after closed aand open treatment of fractures of the mandibular condylar process. J Oral Maxilofac Surg 58:719-728, 2000.

Question 67

A mandibular angle fracture with comminution, infection, or loss of bone buttressing is best treated with which type of fixation:
A. miniplate
B. dynamic compression plate (DCP)
C. reconstruction plate
D. wire osteosynthesis

Answer 67

ANSWER: C
RATIONALE:
The need for absolute stability for these types of fractures negates wire or miniplate fixation. DCP causes interfragmentary compression with possible bone devitalization and necrosis. The reconstruction plate is specifically indicated in these instances.
REFERENCE:
Ellis- Treatment of mandible angle fractures using AO reconstruction plates.JOMS- 1993;51(3):250-254.

Question 68

When considering instituting total parenteral nutrition, which of the following statements is true?
A. Peripheral venous access is appropriate if a large bore vein is present.
B. Bolus administration can precipitate a hypo-osmotic state.
C. Intrinsic protein stores are exhausted prior to carbohydrate and fat.
D. Acute pancreatitis is an indication for this therapy

Answer 68

ANSWER: D
RATIONALE:
Total parenteral nutrition is indicated for many conditions which may cause malabsorption of nutrients from the gastrointestinal tract such as acute pancreatitis. Central venous access is necessary, as peripheral access cannot accommodate the volumes of concentrated fluid necessary for total parenteral support of nutrition. Injudicious bolus administration of TPN fluid (which often has a concentration greater than 1000 mosm/L) can cause a hyperosmotic state. When calculating a particular TPN prescription, one must consider that intrinsic carbohydrate stores are exhausted in less than 24 hours, while
the body’s protein and fat stores may be available for weeks.
REFERENCE:
Condon R, Nyhus L: Manual of Surgical Therapeutics 9th ed., Little Brown, 1996. pp. 203-7

Question 69

Which of the following medications may trigger asthmatic symptoms?
A. Atropine
B. Ipatropium
C. Valdecoxib
D. Isoetharine

Answer 69

ANSWER: C
RATIONALE:
Valdecoxib (Bextra) is a cyclo-oxygenase-2 inhibitor. Any inhibitor of prostaglandin synthesis (such as nonsteroidal anti-inflammatory drugs) can cause an increase in leukotrienes which cause bronchoconstriction.
Atropine, being an anticholinergic, was formerly used to decrease bronchoconstriction in asthma but is no longer used because of its systemic side effects. Ipatropium bromide(Atrovent) is an inhaled anticholinergic used in chronic refractory asthma and in chronic obstructive pulmonary disease. Isoetharine (Bronkosol) is an inhaled B2 agonist used for bronchodilation as a nebulized solution.
REFERENCE:
Washington Manual of Medical Therapeutics 28th ed., Little Brown, 1995 pp. 238-242