Trauma Flashcards
(101 cards)
1
Q
Four articulations of the Zygoma
A
Frontozygomatic, zygomaticomaxillary, zygomaticotemporal, zygomaticosphenoidal
2
Q
ZMC Classification
A
Knight and North. Based on direction of displacement on a Water’s View radiograph
Group 1 - Nondisplaced
Group 2 - Arch fractures
Group 3 - Unrotated
Group 4 - Medially rotated
Group 5 - Lateral rotation outward
Group 6 - Complex fractures
3
Q
Cardinal fields of orbital exam
A
Fields of gaze, integrity of rim, ecchymosis, hyphema, shape of pupil, reactivity of pupil, size of pupil, subconjunctival ecchymosis, periorbital edema, chemosis and position of globe
4
Q
ZMC physical examination
A
Orbital - check pupillary level
Malar eminence flattening
Depression of preauricular region, Antimongoloid slanting -(disruption of frontozygomatic suture and inferior displacement of Whitnalls tubercle)
Neuro disturbances
Step Deformities
Ecchymosis of maxillary vestibule
Trismus - coronoid impingement
5
Q
Approaches for isolated Arch fractures
A
Keen of Gilles
Keen - A 2 cm lateral maxillary vestibular incision (upper gingival buccal incision) is made with a scalpel or a cautery device just at the base of the zygomaticomaxillary buttress. The incision is made through mucosa only. an instrument can easily be placed deep to the fractures to allow elevation of a depressed zygomatic arch
Gilles - temporal incision (2 cm in length), made 2.5 cm superior and anterior to the helix, within the hairline. being careful to avoid superficial temporal artery. dissection continues through the subcutaneous tissue and superficial temporal fascia down to the deep portion of the deep temporal fascia. This fascia is then incised to expose the temporalis muscle. A Rowe zygomatic elevator is inserted just deep to the depressed zygomatic arch and an outward force is applied
6
Q
ZMC fracture order of repair
A
Frontozygomatic to restore facial height
ZM buttress to restore facial projection
Orbital rim to define orbital volume
Orbital floor last
Alignment of sphenozygomatic suture is good indicator of three dimensional position of zygoma
7
Q
Complications of ZMC
A
Malunion/asymmetry
Enopthalmos - eye moves posteriorly in AP position. (Requires placement of space occupying material like bone graft, prosthetic or custom implant)
Blindness - rare, retrobulbar hematoma
Retrobulbar hemorrhage - managed by lateral canthotomy and cantholysis for decompression
Vertical dystopia - reconstruct floor height with autogenous bone or implant/custom plate
8
Q
Volume of an Orbit
A
30 ml, 4 cm horizontal dimension and 3.5 vertical on average
9
Q
Bones of the Orbit
A
Orbital roof (frontal and lesser wings of sphenoid)
Lateral wall (greater wing of sphenoid and zygomatic bone
Orbital floor (maxillary bone, zygomatic bone and palatine bone)
Medial wall (frontal process of maxilla, ethmoid, lacrimal and sphenoid bones)
10
Q
Anatomic Landmarks for Orbit
A
Inferior orbital fissure gives rise to infraorbital groove about 2.5- 30.0 cm posterior to orbital rim. Exits the infraorbital foramen about 5 mm below the infraorbital rim
Superior orbital fissure: CN III, IV, VI, sensory nerve V1, superior opthalmic vein, recurrent and middle meningeal artery
Inferior orbital fissure: Sensory nerve V2, inferior ophthalmic vein
Optic canal : optic nerve, ophthalmic artery
Whitnalls Tubercle - located 10 mm below the Frontozygomatic suture and 3-4 mm inside the lateral orbital rim. Attached to the lateral canthal tendon
Annulis of Zinn: Tendanous ring of fibrous tissue at the apex of the orbit surrounding the optic nerve that is the origin of the rectus muscles of the eye
Safe dissection: All measurements are from an intact anterior lacrimal crest. Anterior ethmoidal foramen 24 mm, posterior ethmoidal foramen 36 mm, optic foramen 42 mm
11
Q
Layers of the Eye
A
Skin, Subcutaneous tissue, orbicularis oclui, septum, tarsal plate, conjunctiva pg 193
12
Q
Orbital Septum
A
Forms the anterior boundary of the orbit
13
Q
Orbicularis Oculi
A
CN VII. Pretarsal and Preseptal: Reflex eyelid closure. Forceful voluntary eyelid closure
14
Q
Levator palpebrae superioris
A
CN III: Main retractor of upper eyelid
15
Q
Muller’s muscle: superior tarsal
A
Tone of upper eyelid that gives 2mm of lift
16
Q
Medial canthal ligament
A
Anteriorly inserts onto maxillary bone, posteriorly onto posterior lacrimal crest, superiorly onto orbital process of frontal bone.
17
Q
Lateral canthal ligament
A
Whitnalls tubercle, 1 cm inferior to the ZF
18
Q
Nasolacrimal duct
A
Opens into the inferior meatus of the nasal cavity 10 mm behind the nasal aperture, reflux of tears is prevented by Hasner’s valve
19
Q
Anisocoria
A
different sizes of pupils
20
Q
Diplopia
A
double vision
21
Q
Enophthalmos
A
inward position of globe
22
Q
Exophthalmos
A
Outward position of the globe
23
Q
Hyperglobus
A
Superior positioning of the globe
24
Q
Hypoglobus
A
Inferior positioning of the globe
25
Hypertropia
misalignment of eyes
26
Proptosis
Same as exophthalmos
27
Ptosis
drooping of the eyelid
28
Orbital physical exam
pupils, extraocular muscle function, visual acuity, ocular pressure, edema, ecchymosis, subconjunctival hemorrhage, proptosis, infraorbital nerve sensation, intercanthal distance
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Visual acuity chart
Snellen Chart
30
Visual fields
Goldman Chart
31
Afferent pupillary defect
pupils respond differently to light stimuli shone in one eye at a time due to unilateral or asymmetrical disease of the retina or optic nerve
32
Tonometry
to test for ocular pressures (normal is 10-20 mmHg)
33
Indication for Orbital fracture repair
Large orbital fractures >50% orbital floor
Enophthalmos >2 mm
Diplopia in primary gaze
Muscle incarceration - entrapped muscles will become ischemic
Signs of oculocardiac reflex - emergent surgery
34
Surgical approaches to Orbit (Transconjunctival)
Transconjunctival -
-Corneal shield with ophthalmic- grade bacitracin/ocular lubricant placed.
Local with vasoconstrictor injected under the conjunctiva to aid in hemostasis and around the lateral canthus if lateral canthotomy planned.
-15 blade incision made through lateral canthus, iris scissor used to cut through lateral palpebral fissure (lateral extension should not exceed 7 mm for safe distance from temporal branch of facial nerve. Layers are skin, orbicularis oris, orbital septum, lateral canthal tendon, conjunctiva.
-Lateral orbital rim is a stop, inferior cantholysis performed.
- Conjunctiva approached with blunt dissection. Conjunctiva undermined over the orbital septum and extended medially.
-Scissor used to incise conjunctiva below curvature of the tarsal plate. Sutures placed for retracttion and to hold corneal shield in place
- Inferior bony orbit located, dissect down to orbital rim staying lateral to lacrimal sac.
- Elevators used to strip periosteam over orbital rim, anterior surface of maxilla, zygoma and orbital floor
- 4-0 vicryl used to reattach lateral canthal tendon, subcutaneous 6-0 sutures placed along the canthotomy.
35
Surgical approaches to Orbit (Subciliary)
Corneal shield with ophthalmic bacitracin/ocular lubricant placed on globe.
Skin incision made 2 mm below gray line
Dissection deep to orbicularis oculi muscles includes pretarsal orbicularis muscle in the levated skin muscle flap
Incision through periosteum for entry into the floor of orbit made beneach the infraorbital rim (3mm)
Subperiosteal dissection is accomplished posteriorly exposing orbital walls
Periosteal elevators used to expose orbital floor.
Broad retractor placed to protect the orbit and confine herniating periorbital fat
36
Orbital repair complications
Infection
Ectropion - shortening of anterior lamellae. May require tarsal strip
Entropion - shorting of posterior lamellae
Persistent enophthalmos
Sympathetic ophthalmia - injury induced antibodies. Enucleation, evisceration, exenteration
Retrobulbar hemorrhage - IV infusion 20% mannitol 2g/kg to shrink vitreous humor and steroids. Manage surgically with lateral canthotomy.
37
Nasolacrimal duct test
Jones Test
Jones I Test - few drops of fluorescence dye or propofol in the lower conjunctival sac, observe for fluorescein/propofol in the nose. If not, then go to test II
Jones II Test - Irrigate the punctum and inject fluorescein in the SAC puncta/canaliculi. If fluorescen is seen then the blockage is after the lacrimal sac, if not, then the blockage is near the punctum or canaliculus
38
Repair of nasolacrimal duct
Primary Repair: Dilate with bowman probe, place stent (Crawford or Jackson Tube) through puncta and nasolacrimal duct opening in the nose, suture both ends with 8-0 PDS sutures and leave the stent for 3 months
Secondary Repair: Dacryocystorhinostomy; the goal is to create a bony window between the lacrimal sac and nose. Incision placed 6 mm from medial canthal angle and dissection carried to lacrimal sac. An H incision made in teh nasal soft tissue and lacrimal sac. Posterior flaps sutured together. Puncta intubated with Crawford tube and passed through the openings of the nose. Ends of tube are tied and anterior flaps of the nasal mucosa and lacrimal sac are sutured together. Orbicularis muscle and skin are closed. Stent left in place for 3-6 months
39
Hyphema treatment
1% ophthalmic drops (Dilates pupil and immobilizes iris to prevent bleeding)
Timolol ophthalmic drops (beta blocker to decrease intraocular pressure
Acetazolamide
Steroids
40
Horner's Syndrome
Injury to sympathetic nerves supplying the globe.
Triad of signs: Miosis, ptosis, anhidrosis
41
Superior Orbital fissure syndrome
Ophthalmoplegia (CN III, IV, VI),
lid ptosis (CN III)
Mydriasis and loss of direct pupillary light reflex (CN III parasympathetic fibers)
42
What bones make up the NOE
Nasal, frontal processes of the maxilla, nasal process of the frontal bone, medial orbital wall including (lacrimal bone and ethmoid bone)
43
Telecanthus for NOE
intercanthal distance should be coincident with width of alar bases. Normal (28-35). If greater than 40 then high liklihood for telecanthus.
Use bow-string test to confirm disruption of the medial canthal tendon.
44
Anosmia
damage to cribriform plate
45
Epiphora
Obstruction of nasolacrimal duct. Jones I and II tests.
46
Rhinorrhea
CSF leak noted as thin blood tinged discharge from nose.
Test for beta-2 transferrin.
May also send sample for glucose and chloride level. CSF will show high chloride, low potassium, and low glucose concentration.
Halo test - straw colored halo on filter paper
47
Nasal dorsal reconstruction
Cortex of calvarium to correct Saddle nose deformity
48
Avulsed medial canthal tendon via canthopexy
-Transnasal wiring technique. Vector of fixation is posterior and superior to lacrimal fossa
-Suturing tendon to miniplate technique.
-Mitek anchor procedure
49
Nasal bones attachment
Frontal bone and frontal processes of the maxilla. Inferior attachment is upper lateral cartilage
50
Kisselbach plexus
Most common site of epistaxis.
Confluence of anterior ethmoidal artery, posterior ethmoidal artery, nasopalatine artery, septal branch of superior labial artery
51
Nasal fracture repair
first 10-14 days can predictably be reduced with closed reduction.
Vasoconstrictor to nasal cavity, then Boise elevator and digital manipulation
If older than 14 days, open reduction may be done. Incision within the nose to perform lateral endonasal osteotomies.
Nasal packing and intranasal splints (use antibiotics if internal packing is done). Removed in first 7 days
External splint along dorsum. Removed in first 7 days.
Wait until 1 year after initial surgery before considering septorhinoplasty if needed.
52
Septal hematoma
Drain immediately at time of initial evaluation. If not drained then can cause necrosis of cartilage and saddle nose deformity
53
Frontal sinus fluid drainage
Mucosal fluid exits the frontal sinus through the ostium on the posteriomedial portion of the sinus floor.
15% of population has true nasofrontal duct facilitating frontal sinus drainage into middle meatus of nose. Remaining population drains via the hiatus semilunaris to the nasal frontal tract
54
Frontal sinus fracture classification
Gonty's Classification
Type 1- isolated anterior
Type 2 - anterior and posterior table fractures
Type 3 - posterior table fracture
Type 4 - comminuted fracture
55
Reasons to involve Neurosurg with Frontal sinus fracture
Pneumocephalus - the presence of air in the intracranial space
Extradural hematoma
Subarachnoid hemorrhage
56
How do you manage a CSF Leak of the Frontal Sinus
Consult neurosurgery
Results from posterior table and associated dural tear. CSF can be managed conservatively with observation
If CSF leak does not resolve in 7 days, NSG may place a lumbar drain to decrease ICP or direct repair of dural tear
57
Nasofrontal duct involvement test
Injection of fluorescen into duct/tract with a large bore catheter and observation for passage into the nasal sill. If there is obstruction, then a sinus obliteration procedure is recommended.
58
Cranialization of sinus
Frontal crainotomy, repair of dura, debridement of the damaged brain segment, repair of dural lacs, removal of posterior wall, removal of mucosal lining of sinus, plugging the nasofrontal ducts, pericranial flap.
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Conservative treatment for CSF Leak from frontal sinus fracture
Non displaced fracture with small CSF leak may be observed up to 7 days. Bed rest, stool softeners, elevation of the head of bed between 35-45 degrees, sinus precautions.
60
When can you obliterate and not cranialize
If posterior table fracture is displaced but involves less than 25% of the table and has minimal to no comminution and doesnt have a CSF leak
61
Bicoronal approach technique
Local anesthetic for hemostasis and insufflation of planned dissection.
Incision curves anterior at the vertex 5 cm behind the hairline. Incision through skin, subq, galea between temporal lines exposing loose areolar plane.
Blunt dissection is used to elevate in all directions, primarily anterior
Extension below the temporal line using subgaleal plane to bluntly dissect down the anterior helix. Incision made down to the instrument
Raney clips used for hemostasis
Incision of pericranium 2-3 cm superior to supraorbital rims. Blunt dissection of pericranium.
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Complications follow frontal sinus repair
-Meningitis - inflammation of arachnoid membrane and pia mater. (Acute fever, headache, stiff neck, confusion)Kernig sign (can flex leg), Brudzinski sign (flexion of hips and knees when neck is flexed). Antibiotics used
-Mucocele and Mucopyocele - retained sinus mucosa leading to mucous filled lesions. Infection creates a mucopyocele. Obliteration of sinus required
-Intracranial abscess (mental status changes, focal neurologic deficits, fever, nausea/vomiting, seizures. NSG consultation, third generation cephalosporins with possible craniotomy for aspiration and drain placement
-Cavernous Sinus Thrombosis - headache, ptosis, ophthalmoplegia, paresthesia of ophthalmic and maxillary branch of CNV, papilledema, periorbital edema. Antibiotics, anticoagulation with heparin, sinus drainage, steroids.
-20% are associated with spinal fractures, take spine films!
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Vertical buttresses of skull
Nasomaxillary, zygomaticomaxillary, pterygomaxillary, posterior mandibular
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Horizontal Buttresses of skull
Mandibular, maxillary, zygomatic, frontal
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Surgical sequence for Panfacial trauma.
Bottom up, inside out
MMF - consider prefabricated splints from stone models
Mandible
Condyle
ZMC
NOE
Frontal Sinus
Implants/augmentation
Soft tissue repair
66
Tetanus
Neuromuscular disease caused by Clostridium Tetani
Neurotoxin carried to nerve terminals blocking spinal cord inhibitory neurons
DTap immunization. Tetanus toxoid if has not had vaccination over 10 years.
67
Soft tissue management
Pulsatile irrigation requires 7 IB PSI to remove adherent bacteria
Tension free closure if possible
68
Bite/Rabies
Single stranded RNA virus
Penicillin
Doxycycline and metronidazole
69
Stensen Duct Repair
Avoid sympathlolytics or short acting agents
Encourage ketamine use for salivary flow
Identify distal and proximal ends with 20-22g silastic tube
Repair duct with 6-0 nylon
Stent kept in place 5 days up to 3 weeks and given lemon drops to prevent scarring
70
Facial nerve transection/damage
Repair in first 72 hours prior to Wallerian degeneration. Repair epinurium with 9-0 nylon using 3 sutures.
House Brackmann scale
I - Normal
II Mild dysfunction
III moderate dysfunction noticeable weakness with complete eye closure
IV moderately severe dysfunction obvious weakness, incomplete eye closure with maximum effort
V Severe dysfunction only perceptible movement and asymmetry at rest
VI Total paralysis
71
Laceration of submandibular gland
Repair of duct normally unnecessary, fistula will form in floor of mouth. Serial aspirations and pressure bandages will resolve this. If not then gland excision
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Nasolacrimal injury
Epiphora may be present
Anesthetize medial canthus, dilate punctum with dilator, pass silicone intubation stent (Crawford tube); pigtail probe passed through intact punctum and canaliculus to identify the transected portion
Cannulate upper and lower punctum and thread stent into nose, cut steel rods and tie a knot. Allow 3 months to heal, remove tube through segment visible in corner of eye.
May also perform Dacryocystorhinostomy
73
Hypertrophic scars and keloids
Intralesional steroids started 1 month post-op.
Traimcinolone 40 mg/ml, 0.2 ml given every 3 weeks for 3 months.
74
Ear injury
Antibiotics - Fluoroquinolones for cartilage to cover Pseudomonas aeruginosa. Toxic to developing cartilage and should not be give under 18 yrs.
Mladick technique (retroauricular pocket) for partial avulsion
- de-epithelialize amputated auricle, perform anatomic cartilage reattachment, bury into retroauricular pocket.
-Second stage is cartilage elevation and split thickness skin graft
Baudet technique
- amputated auricles posterior surface is de-epithelialized, cartilage fenestrated, retroauricular pocket raised, and anterior pinna skin sutures placed.
- Second stage: ear elevation and split thickness skin graft
Temporoparietal fascia flap used to cover denuded cartilage and a split thickness skin graft
Auricular hematoma - can lead to cartilage destruction and replacement with fibrous tissue. Needle evacuation and bolster dressing for 7 days
75
Nasal Hemorrhage
Anesthesia and vasoconstriction for exam can be achieved with 4-10% cocaine topical solution (max 1 mg/kg for infant or 2-3mg/kg for adult). Another option is using local anesthesia with oxymetazoline (Afrin- topical decongestant and vasoconstrictor) soaked neuro sponges.
Septal hematomas drained with small mucosal incision or needle drainage. Nasal pack or septal stent secured with multiple pass 4-0 suture technique to prevent recurrence.
Anterior bleeds from Kiesselbach, posterior bleeds sphenopalatine artery and posterior pharyngeal artery (Woodruffs plexus)
Anterior bleeds - finger compression 10 min, topical vasoconstrictors, silver nitrate, nasal sponge with petroleum jelly, balloon tamponade (Rhino rocket)
Posterior bleeds- 14 French foley catheter with 30 ml balloon filled with 10-15 ml saline. Retract foley so balloon is wedged and add 3-5 ml of more saline. Removed in 3 days.
If unable to control bleeding posteriorly, then nasal endoscopic artery ligation.
76
Lip laceration
Defects up to 25% of the width of the upper lip closed primarily, 30% of lower lip closed primarily
Misalignment of 1 mm of vermillion border detected by human eye
Defects up to 2/3 of upper or lower lip can be reconstructed with Abbe Flap or Estlander Flap
Large defects require Karapandzic flap, Gilles Flap, Webster-Bernard flap
77
Plating for pediatric trauma
SonicWeld - resorbable plating to not cause premature ossification
Resorbable mesh or Gelfilm for reconstruction of orbital floor/wall fractures
If using titanium plates/screws plan for secondary surgery for removal in 2-3 months. Concern for migrating titanium plates and inhibition or alteration of growth
78
Pediatric Ocular trauma
Ecchymosis, diplopia, entrapment, enopthalmos, hypoglobus, loss of globe support, loss of orbital volume
"White eyed" orbital floor fractures where muscle necrosis of inferior rectus due to entrapment.
Oculocardiac reflex may be seen (nausea/vomiting, bradycardia, syncope)
79
Pediatric ZMC concern
Maxillary tooth buds still present in children under 6, must be careful when fixating a fracture from the maxillary vestibule approach
80
Pediatric dentition development
6 months first deciduous incisors erupt
2.5 yrs children have full complement of deciduous teeth
Root resorption of primary teeth occurs between 5-9
Mixed dentition between 9-12 yrs
81
Pediatric mandible fracture repair
High vascular supply to periosteum by IAN and high osteogenic potential causes early fracture healing 2-3 weeks
Infants <1 yr should be observed. Diet modification not required
Young children with non displaced and stable occlusion - conservative management, soft/liquid diet
Displaced fractured need stabilization and immobilization (MMF 2-3 weeks if less than 12 yrs and 1-2 weeks if condylar fracture involved), lingual occlusal splint)
In patients without adequate dentition - circum-mandibular, circum-piriform, circum-orbital, circum zygomatic.
ORIF only for significantly displaced or comminuted fractures
82
Ellis Fracture Classification
Class I - confined to enamel
Class I - Enamel and dentin involved
Class III - Enamel, dentin, and exposed pulp involved
Class IV - Root fracture
83
Intrusion of teeth from trauma
Orthodontic assisted eruption is favored. Must be done slowly over 3-4 weeks and once in position must be stabilized for 2-3 months
Endodontic treatment is based on follow up findings
If deciduous tooth intruded may extracted it to not impede erupting permanents
84
Extrusion of teeth from trauma
Usually can be repositioned and splinted for 1-3 weeks
Endodontic treatment usually needed
85
Displacement of teeth from trauma
Reposition of tooth and alveolus and splint
Repair lacs
86
Avulsion
Rinse tooth immediately with patients saliva or saline and replant immediately
Limit contact with root surface
If unable to replace, put in HANKS solution or milk
Semi-rigid splint 7-10 days
Follow up often for root resorption and ankylosis. May need endodontic treatment
87
Guerins Sign
ecchymosis in maxillary vestibule denoting a zygoma fracture
88
What comprises the lateral retinaculum
Lateral aponeurosis, lateral check ligament, Lockwoods ligament, lateral canthus
89
How would you check patency of the nasofrontal duct
Fluorescein into the duct and check to see if empties at the middle meatus in the nare
90
Nasofrontal duct is obstructed. What to do?
Obliteration and cover duct with bone. Can use pericranium, temporalis fascia, fat, bone, or alloplastic material like glass ionomer cement or hydroxyapetite
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Initial examination of a trauma
HPI from individual if alert and oriented and family if not, trauma team members, any witnesses of the accident, and perform a physical examination from head to toe.
Ensure stable airway
C-spine clearance
Consult proper services
Maxillofacial CT with 3d reconstruction for trauma
Head and Neck Trauma exam
-Neurological status
-Facial lacerations
-Cranial nerve damage
-Orbital involvement
92
GCS and stages of hemorrhagic shock
Look up charts
93
What is Rigid Fixation
Fixation that prevents interfragmentary movement when load is applied
94
Primary Bone Healing
No callus forms
Haversian remodeling (contact healing)
Deposition of lamellar bone if small gaps exist
Requires absolute rigid fixation with minimal gaps
95
Secondary Bone Healing
Bony callus forms
Subperiosteal hematoma forms, then granulation tissue, thin layer of bone by membranous ossification
Hyaline cartilage deposited, woven bone, lamellar bone.
96
What is the classification of a atrophic mandible fracture?
Luhr's classification of mandibular fracture
Classification of fractures in edentulous atrophic mandible
Class I - height 16-20 mm
Class II - height 11-15 mm
Class III - height <10 mm
97
Condylar Process fracture classification
AO
98
When do you perform Open reduction of a condylar fracture?
Zides Absolute and relative indications
Absolute
-Middle cranial fossa involvement with disability
-Inabilty to achieve occlusion with closed reduction
-Invasion of joint space with foreign body
-Lateral capsule violation and displacement
Relative
-Bilateral condylar fractures where vertical facial height needs to be restored
-Delayed treatment with misalignment of segments
99
Battle Sign
ecchymosis in mastoid region, base of skull fracture
100
Intraoral exam
Evaluate dentition for mobility, tooth loss, and fractures.
Lacerations or ecchymosis in the vestibules
Occlusion
Pathology
Evaluate airway
101
Airway assessment
General appearance, dental exam, Mallampati score, maximum incisal opening, thyromental distance, mandibular protrusion, BMI, Neck circumference
