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ABOMS Trauma

Terms in this set (100)

Emergencies

Retrobulbar hematoma - Signs/Symptoms
Collection of blood posterior to globe
Proptosis
Chemosis
Change or loss of vision
Increase IOP
Ophthalmoplegia
Severe pain
Emergencies

Retrobulbar hematoma - Diagnosis
Presentation of superior orbital fissure syndrome or orbital apex syndrome, ophthalmic tonometry

Irreversible blindness may occur if not treated within 2 hours
Intraocular pressure (IOP) is measured how?
Tonometry

IOP ranges between 10 and 21 mm Hg with a mean of about 15 or 16 mm Hg
Emergencies

Retrobulbar hematoma - Treatment
Lateral canthotomy with local anesthesia
Sharp scissors laterally between upper and lower lids and dissecting carefully to orbital rim/lateral fornix to avoid traumatizing the globe.

ID and subsequent disinsertion of the inferior crus of the lateral canthal tendon using blunt scissors vertically.
Emergencies

Septal hematoma - Signs/Symptoms
Bulging of nasal tissue over septum, painful often obstructing airflow.

Will lose septum if hematoma is not evacuated
Emergencies

Septal hematoma - Treatment
Evacuate hematoma.

Anesthetize
Attempt evacuation with large bore needle
Enlarge opening with surgical blade
Compress septum with packing, Doyle splints or quilting suture to prevent accumilation
Describe the signs and symptoms of Superior Orbital Fissure Syndrome
Loss of forehead sensation (V1-frontal n.)
Loss of corneal reflex (V1-nasociliary n.)
Ptosis
Ophthalmoplegia
Fixed dilated pupil (mydriasis)
What are the contents of the superior orbital fissure?
L-F-(V1)T(4)

V1 (nc), 2, 3-s-i, 6 (within annulus)
Distance of Vital Orbital Structures from Bony Landmarks
Describe the signs and symptoms of Orbital Apex Syndrome
SOFS + visual changes from optic nerve inolvement
Cavernous sinus syndrome is defined by its resultant signs and symptoms:
ophthalmoplegia
chemosis
proptosis
Horner syndrome
trigeminal sensory loss (V1/V2)
What are the prinicple causes of Cavernous sinus syndrome?

Specific examples include?
Infectious or noninfectious inflammatory, vascular, traumatic, and neoplastic processes are the principal causes.

-Carotid artery aneurysms
-Carotid-cavernous fistulas (C-C fistulas)
-Tumors
Carotid-cavernous fistulas (CCF) signs & symptoms?
bruit (a humming sound within the skull due to high blood flow through the arteriovenous fistula)

progressive visual loss

pulsatile proptosis or progressive bulging of the eye due to dilatation of the veins draining the eye.
How do you diagnose a CCF?
A cerebral digital subtraction angiography (DSA) enhances visualization of the fistula.
Branches of the External Carotid Artery can be described through
SALFO-PSM
Frontal Sinus Fractures:

What are the concerns for anterior table fractures?
...
Internal fixation can be classified as Rigid fixation and Non-regid fixation. What is the definition of each?
Rigid: "any form of fixation applied directly to the bones which is strong enough to prevent interfragmentary motion across the fracture when actively using the skeletal structure."

Rigid fixation permits primary bone healing without callus formation and immediate return to full function.

Non-Rigid: mobility of the osseous fragments during active use of the skeletal structure after application of internal fixation devices
What type of healing occurs with rigid fixation?
Primary or direct bone healing

A: Contact healing= osteoclasts "drill" their way across the fracture line, osteoblasts follow making haversion canals

B: Gap healing= small gap, lamellar bone laid down and then the same process above is followed.
What are examples of rigid fixation?
2 lag screws or bone plates across a fracture

the use of a reconstruction bone plate with at least 3 screws on each side of the fracture

Examples of this type of fixation include large commercially available locking and nonlocking reconstruction bone plates, the application of multiple plates at a fracture site, or lag screw fixation
What are examples of nonrigid fixation?
transosseous wire placed across a mandibular fracture
What is the definition of functionally stable fixation? What is an example?
Form of nonrigid fixation strong enough to allow active use of the skeleton during the healing phase but not of sufficient strength to prevent interfragmentary mobility.

Example: single miniplate technique of treating mandibular angle or body fractures (Champy)
Intramembranous ossification through bone healing
A: Hematoma formation
B: Hyaline cartilage (callus) is formed
C: Cartilage is replaced with woven bone
D: Remodeling and replacement of woven bone continues until a lamellar pattern
Functional forces acting across the intact mandibular angle or body region
zone of tension (separation)
zone of compression (inferior border)
LOAD-BEARING vs LOAD-SHARING FIXATION
Load-bearing fixation (reconstruction plate) is a device that is of sufficient strength and rigidity that it can bear the entire load applied to the mandible during functional activities.

Load-sharing fixation (2.0-mm miniplating systems) = functional load is shared between the hardware and the bone along the fracture site
The indications for providing load-bearing fixation are those fractures with
comminuted segments, atrophic mandibular fractures,
and fractures with avulsed or missing segments.
LOCKING PLATE-SCREW SYSTEMS

Advantages
The most significant advantage may be that it becomes unnecessary for the plate to intimately contact the underlying bone in all areas
PLATE FATIGUE
One of the undesirable properties of titanium is its brittleness (or lack of ductility) when compared with bone.

Under function, the mandible "wishbones" in
and out = plates being fractured over time
What is Stress Shielding?
Rigid fixation of fractures results in osteopenia (atrophy) beneath the plate because of the stress-shielding effect.

Not a problem in the mandible
Tooth fractures are classified via
Ellis classification:
I = fracture within enamel;
II = fracture of enamel-dentin;
III = fracture involving pulp;
IV = fractures involving the roots
Treatment Summary for Avulsed Teeth (<2 hours)
Treatment Summary for Teeth Avulsed (> 2 Hours) - open or closed
Treatment of Pediatric Injuries involving primary dentition
Anatomic distribution of mandibular fractures.
1. Body
2. Angle
3. Condyle
Teeth in the Line of Mandible Fractures - extract or leave?
Although there are no universally agreed upon criteria, many surgeons retain all teeth in the line of fracture unless they are grossly mobile, infected, or inhibit fracture reduction
Indications for Open Reduction of Fractures of the Mandibular Condyle
Retromandibular (Transparotid) Approach

STEP 1: Surgical Site Preparation
1. A sterile marking pen is used to mark the proposed incision site.

2. A vertical 3- to 4-cm mark, beginning 0.5 cm below the earlobe, is placed at the posterior mandibular border
Retromandibular (Transparotid) Approach

STEP 2: Local Anesthesia and Incision
1. Incise through the skin and subcutaneous tissue to expose the platysma, which is scant in this region.

2. Undermining the skin in a subcutaneous plane with Metzenbaum scissors at this point is critical to tensionless skin closure.
Retromandibular (Transparotid) Approach

STEP 3: Dissection to the Parotid Capsule
1. Vertical incision through SMAS and parotid capsule until you encounter parotid substance.
Retromandibular (Transparotid) Approach

STEP 4: Dissection Through the Parotid Gland and
Pterygomasseteric Sling
1. Hemostats are used to bluntly dissect through the parotid, paralleling the direction of the major facial nerves branches.
2. Use nerve monitor
3. The dissection is continued to the pterygomasseteric sling, where the periosteum is sharply incised directly over the posterior mandibular border
4. Retromandibular vein is encountered and ligated
5. A sigmoid notch retractor, Dingman clamp, or 24-gauge wire through the distal segment's inferior border can facilitate fracture site manipulation and reduction
Retromandibular (Transparotid) Approach

STEP 5: Paralysis of the Patient and Fracture Reduction
1. nondepolarizing agent to facilitate manipulation and reduction of the fracture segments
2. most common displacement of the condylar fragment is medial, by pull of the lateral pterygoid
muscle.
3. Distal segment is reduced with help of IMF
4. Proximal segment with hemostats or by securing a plate
Retromandibular (Transparotid) Approach

STEP 6: Hardware Selection and Fixation
STEP 7: Closure of the Incision
1. Use of 2 plates (if enough room) or a single heavier plate can be used if limited bone is available for plating.
2. Reapproximation of the pterygomasseteric sling is carried out with a slow-resorbing suture (e.g., 3-0 polyglactin) in an interrupted fashion.
3. The same suture is then used in a running fashion to close the platysma, superficial musculoaponeurotic system (SMAS), and parotid capsule in a single watertight layer to prevent parotid fistula formation.
4. Skin is then closed
Ellis and associates reported that _______of open reduction patients had temporary facial nerve weakness with the use of a retromandibular approach
17.2%
Pediatric Mandibular Fractures (open vs closed treatment)
Non-displaced fractures--> no-chew diet & observation

Displaced fractures--> primary dentition, IMF using interdental wires or arch bars, lingual splints, 2 weeks MMF

Displaced fractures-->mixed dentition, IMF using interdental wires or arch bars, lingual splints, 2 weeks MMF

Use resorbable fixation when you have severely displaced fractures (inferiormost aspect of the mandible to avoid the developing tooth buds)
Pediatric condylar fractures
Normal ROM with stable, reproducible, age-appropriate occlusion and minimal pain, close observation and limiting the child to a blenderized diet

Unstable occlusions or significant malocclusions = arch bars, risdon cables, closed treatment with guiding elastics
Patients with primary or mixed dentition who have unilateral subcondylar fractures can be treated with
with analgesics and a blenderized diet for 7 to 10 days. Minor malocclusions in this group are generally self-limited.

Midline opening exercises are helpful for correction of deviation on opening.
Children with primary or mixed dentition who have bilateral subcondylar fractures with normal opening and stable occlusion can usually be treated with
analgesics and a blenderized diet
The diet can be advanced to soft foods after 10 days if tolerated by the patient.

Any minor malocclusions resulting from such treatment resolve with growth and eruption of the permanent dentition.
Children with primary or mixed dentition with bilateral subcondylar fractures, with or without dislocation, who have an open bite malocclusion due to ramus height shortening should have
maxillomandibular fixation for 7 to 10 days.
When the fixation is released, the patient should be placed in guiding elastics for 10 days and then reevaluated.
Children with permanent dentition who have unilateral or bilateral subcondylar fractures with stable and reproducible occlusion can be treated effectively with
analgesics and a blenderized diet
+/- guiding elastics with some malocclusion
Edentulous / Atrophic mandible fracture
Extraoral surgical approach
o Very difficult to reduce and fixate intraorally
o Nerve may be on top of crest
o Contamination of site, bone grafting is often needed

Subperiosteal dissection
o No evidence that supraperiosteal dissection maintains blood supply
o Advantages of open reduction lost such as visualization of fracture segments
o Can not bone graft if needed, as graft must be subperiosteal

Expose all fractures
Edentulous / Atrophic mandible fracture (Plate?)
• Reconstruction plate locking with minimal 3 screws on each side if possible
o Consider smaller plates for temporary stabilization if needed to contour larger plate, then remove
o The smaller the mandible the bigger the plate needed
• Immediate cancellous bone grafting to add osteogenic potential and height
Techniques for Maxillomandibular Fixation
Erich Arch Bars
Ivy Loops
Intermaxillary Fixation (IMF) Screws
The Risdon cable
Gunning splints
Midfacial Fractures

Lefort Fractures
• Lefort I - horizontal fracture
• Lefort II - pyramidal fracture
• Lefort III - complete craniofacial dysjunction
LeFort I
Traverse the lateral antral wall, the lateral nasal wall, and the lower third of the septum, and they separate at the pterygoid plates.
Lefort II
Le Fort II level involve most of the nasal bones, the maxillary bones, the palatine bones, the lower 2/3'ds of the nasal septum, the dentoalveolus, and the pterygoid plates.
Lefort III
Le Fort III level involve the nasal bones, the zygomas, the maxillae, the palatine bones, and the pterygoid plates
Waters' view and lateral facial radiographs were used for visualizing
maxillary fractures and may still be used today in remote areas without access to a computed tomography (CT) scanner
Technique - Lefort I / II
o Transoral approach
o Complete mobilization - beware of subtle, greenstick fracture that is nonmobile as this may have occlusal discrepancy - need to complete fracture
o Place into MMF
o Plate stabilization
o Check occlusion
o Nasal reduction open / closed as needed

Reduction should be achieved at the nasofrontal region, inferior orbital rim, and ZM buttress in Le Fort
II fractures
Technique - Lefort III
o Transoral, lower lid, coronal approaches (expose all fractures)
o Good mobilization
o Place into MMF
o Fixate starting at FZ junction (top-down)
o Check occlusion
o Reconstruction of orbit floor / medial wall
o Nasal reduction open / closed

Reduction should be achieved at the nasofrontal region, lateral orbital rim (FZ), and zygomatic arch in Le Fort III fractures
Zygomatic Fractures - Key reduction area
sphenozygomatic suture

• Need for Reduction
o Functional - trismus, orbital
o Cosmetic - facial contour
- Must avoid facial widening post operatively
Physical Examination for Zygomatic Fractures
Depression of the malar eminence and infraorbital rim produce flattening of the cheek.

Subconjunctival hemorrhage is often noted.

Downward displacement of the zygoma produces an antimongoloid slant to the lateral canthus, enophthalmos, and accentuation of the supratarsal fold of the upper eyelid
Knight and North14 classified zygomatic fractures
by the direction of displacement on a Waters view
radiograph.
In 1990, Manson and colleagues proposed a method
of classification based on the pattern of segmentation and displacement.
Low-Energy Zygomatic Complex Fractures
-nondisplaced or minimally displaced

Middle-Energy Zygomatic Complex Fractures
-displaced requires reduction and internal fixation.

High-Energy Zygomatic Complex Fractures
-significant comminution
A zygomatic complex fracture includes disruption of the 4 articulating sutures:
zygomaticofrontal
zygomaticotemporal
zygomaticomaxillary,
zygomaticosphenoid sutures
Multiple approaches
Transoral
o Gilles - temporal for arch
o Keen - buccal sulcus for arch
o Dingman - eye brow
o Percutaneous - bone hook, towel clamp, Carroll-Girard Screw
Determine if ZMC is reduced at what regions?
- Sphenozygomatic suture
- ZM buttress
- Arch
- Orbital rim

o Determine if fixation is necessary
- Simple fractures may only need fixation at buttress
- High energy fractures may require multiple points of fixation

o Determine need for orbital reconstruction
For ZMC fracture reduction, if fixation needed?
Open Reduction and Internal Fixation of the Zygomaticofrontal Buttress (what techniques can be used)
Supratarsal fold
-The 2cm incision is placed in a skinfold parallel
to the superior palpebral sulcus above the tarsal plate. It is placed approximately 10 to 14 mm above the margin of the upper eyelid.

Lateral eyebrow incision
-A 2.0-cm incision is made within the confines of the lateral eyebrow parallel to the superior lateral orbital rim
Open Reduction and Internal Fixation of the Infraorbital Rim and Orbit (what techniques can be used)
Transcutaneous
-Subciliary (A, synonym: lower blepharoplasty)
-Subtarsal (B, synonym: lower or mideyelid)
-Infraorbital (C, synonym: inferior orbital rim)

Transconjunctival incision
Subciliary (aka lower blepharoplasty) technique
1. The initial incision is carried through the skin layer only (2-3mm below grey line).
2. Obicularis oculi is intact
3. The orbicularis oculi layer is undermined and a dissection plane between the muscle and the septum orbitale is created.
4. Dissection is taken down to periosteum
5. Incision at the orbital rim with subperiosteal dissection and exposure of rim
Transconjunctival incision technique
1. The incision is placed in the depth of the fornix.
2. Conjunctiva
3. Lower lid retractors
4. Fat
5. Periosteum
A temporary tarsorrhaphy is recommended to help protect the cornea. This is done by employing a mattress suture.
Frost sutures is used for
Transcutaneous lower eyelid approaches may be complicated by vertical scar contraction during the healing period with an ectropion.

Skin and septal scaring may be counteracted by so called Frost sutures.

This is a mattress suture through the Gray line of the lower lid and is applied at the end of the operation. It lengthens the lower eyelid when it is taped to the forehead. This creates traction for several days until the wound healing has passed its first critical phase.
Appling and colleagues found a ______ rate of transient ectropion and rate of ______permanent scleral show with a subciliary approach.
12%

28%

In comparison, the transconjunctival approach had no transient ectropion and a 3% rate of permanent scleral show.
Specific indications for surgical repair of orbital fracture
restrictive strabismus
enophtalmus >2 mm
CT evidence of muscle entrapment
Oculocardiac reflex
Hypo-ophtalmos
Large floor fracture >50%, based on CT estimate of fracture size
In reconstructing the orbital floor, what plates will you use and why?
Fan-shaped titanium plate (A)
Fan-shaped with porous polyethylene coating (B)
a titanium orbital reconstruction plate (C), preformed titanium orbital plates (D).
Orbital plates with Porous polyethylene coating

Complications?
Because the average pore diameter of polyethylene is > 150 μm, which is above the standard limit (100 μm), this material allows the ingrowth of host orbital vasculature and soft tissue, which integrates the implant with the host's body.

Pyogenic granuloma
Exposure
Migration of implant
Infection (open to the sinus)
Foreign body reactions
Sympathetic Ophthalmia
Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis that occurs after either surgical or accidental trauma to one eye. It occurs in less than 0.2% of penetrating globe injuries

Treatment of sympathetic ophthalmia consists of systemic anti-inflammatory agents or immunosuppression. The role of enucleation after the diagnosis of sympathetic ophthalmia remains controversial.
Lid lacerations
o Always close primary - no secondary healing
o 1/3 lid loss - close with direct advancement
o ½ lid loss - lateral canthotomy and advancement
o > ½ lid loss - require local flap
Corneal abrasion
o Pain, foreign body sensation, excessive tearing
o Exam - slit lamp, tetracaine, fluorescein dye
o Treat with patch
Hyphema
blood in anterior chamber of eye

o ~ 10 - 30 % rebleed first 5 days
o Treat with bed rest, atropine (Cycloplegics maintain a dilated pupil and thus immobilization of the iris, which discourages further rebleeding.), consider Amicar 50mg/kg q 4h x 5 days

carbonic anhydrase inhibitors (acetazolamide, which limits aqueous humor production)
Retinal hemorrhage / detachment
Characteristic symptoms include flashing lights and a field loss best described as a "curtain" or "window shade" coming over the eye

Monocular diplopia

Retinal detachments require surgery
Lens dislocation
Symptoms include monocular diplopia and
blurred vision
Acute binocular diplopia, secondary to trauma, derives
from one of 3 basic mechanisms:
edema or hematoma,
restricted motility
neurogenic injury.

The most common cause of binocular diplopia after trauma is orbital edema and hematoma.
Ruptured Globe
o Soft globe
o Vision often affected
o Oblong, irregular pupil
o Treatment - Cyclopegia, steroids, surgical repair if possible
The Jones dye test is used to assess the functioning of the lacrimal drainage system.
Primary: 2% fluorescein dye is placed in the medial conjunctival fold area, and a cotton-tipped applicator is placed under the inferior turbinate. If positive = no obstruction.

If negative --> 2ndary Jones test is done.

Recovery of dye from the secondary test, after a negative primary test result, is consistent with gross patency but relative dysfunction or incomplete obstruction.

If no dye is recovered in the 2ndary Jones test - punctual or canalicular obstruction.
NOE fracture classification according to Markowitz et al.
A type I fracture maintains the attachment of the MCT to a large single NOE fracture segment. Repairing this type of fracture is straightforward.

A type II fracture shows more comminution yet maintains the attachment of the medial canthus to a sizable bony segment.

Type III fractures display severe comminution with possible avulsion of the MCT from its bony attachment
Examination to distinguish between a nasal fracture and unstable NOE fracture?
Telecanthus:
The normal distance is between 28.6 and 33.0 mm for adult women and is between 28.9 and 34.5 mm for adult men

2 tests:
1. Bowstring test
2. Bimanual examination
Indications for the Use of the Procedure (NOE treatment)
-Instability of canthal-bearing bone or avulsion of medial canthal tendon
-Loss of nasal projection and support
-Comminution of medial orbital wall component
-Interruption of lacrimal drainage
-Concomitant facial fractures undergoing repair
Limitations and Contraindications to NOE treatment
Contraindications that may apply specifically to a NOE fracture include an open globe injury and traumatic hyphema.
A sequential approach to the repair of a NOE fracture is
important so that all elements of the injury are addressed.

The following sequential approach,
1. Expose fractures completely
2. Identify canthal-bearing bone or MCTs
3. Reduce or stabilize medial orbital rim, inferior orbital rim and piriform aperture
4. Reconstruct internal orbit
5. Perform transnasal canthopexy as required
6. Reduce septal fractures
7. Reconstruct bony dorsum
8. Perform soft tissue reduction
Type I NOE fractures with minimal displacment requires what type of incision?

Type II and III NOE fractures?
Type I NOE fracture: Vestibular incision alone

Type II/III NOE fractures: Coronal exposure + vestibular incision

Commonly, a minimum of 3 points of fixation will be needed. This will include plating at the NOE/frontal bone (1), a plate along the orbital rim (2), and a plate along the piriform aperture (3)
Coronal incision technique
1. Mayfield headrest
2. "Lazy S" incision (post op camouflage of incision)
3. Subgaleal plane (ear to ear)
4. 3-4cm posterior to supraorbital rims - subperiosteal dissection
5. Supraorbital nerves identified (released)
6. Laterally incision must be deep to superficial layer of the temporalis fascia(fat between this layer and deep layer of TF)
7. Subperiosteal exposure of periorbital structures
Transnasal canthopexy
The point of fixation of the wires should be directed posterior and superior to the lacrimal fossa so that the medial canthal distance is decreased and widening of the nasal bones and blunting of the medial canthal area can be avoided.

Drill from the contralateral side with use of an awl or spinal needle.

Securing transnasal wire
The transnasal wire is secured to a screw placed in the frontal bone, and tightened with the appropriate tension needed to secure the medial canthus into its proper position.
Reconstructing the Nasal Dorsum/Bone Grafting for NOE
The calvarium is a preferred harvest site because it is commonly exposed for surgical access to the NOE region. The outer cortex can be harvested in block form from the parietal bone.

Preferred method is to use a 1.5-mm Y-plate. The straight limb of the plate is fixated on the deep surface of the graft to prevent a palpable plate in a region
where the skin is quite thin
Frontal Sinus - Indications for treatment
o Anterior table displacement with esthetic deformity
o Nasofrontal duct obstruction / destruction
o Displaced posterior table fractures - greater than one cortex - cranialization with pericranial flap
o Persistent CSF rhinorrhea (Dura injury)
o Concomitant orbital or facial fractures
Cranialization Procedure
Posterior wall of sinus is removed
Sinus mucosa removed
Brain and dura evaluated by Neurosurgeon for dura closure
Pericranium is mobilized and inset under the brain separating it from frontal sinus
Brain, dura mater rest against a reconstructed anterior frontal table (frontal sinus no longer exists)
Complications of frontal sinus fractures
• Early - meningitis
• Late - mucocele, mucopyocele
Parotid duct laceration - how would you treat it?
The distal portion of the duct is entered from the intraoral orifice and stented with silastic tubing until continuity is reached with the lumen of the proximal duct.

The edges of the duct are reapproximated and closed over the stent using microsurgical instrumentation. The silastic tubing is left in position for a period of up to 3 weeks.
Subcondylar classification
Lindahl classification
Hemarthrosis in the joint, what vessel?
Pterygoid artery
Synovium/retrodiskal tissue
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