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