Regarding zygomatic fractures due to blunt facial trauma, which ONE of the following statements is TRUE?
Answer: A: The prominence of the zygoma (malar eminence) makes this fracture common with blunt injury but the true ‘tripod’ fracture is less common. The injuries in tripod fracture are:
The other associated features are:
Although a patient with an uncomplicated fracture of the zygomatic arch can be discharged from the ED with outpatient maxillofacial follow up, patients with tripod fractures require admission for intravenous antibiotics and surgical repair.
References:
Regarding the diagnosis and ED management of midfacial fractures in a patient involved in severe blunt trauma, which ONE of the following interventions is LEAST appropriate?
Answer: C: Although rare, the danger of midfacial fractures in a multitrauma patient is the loss of mechanical support it provides to the oral cavity and the severe haemorrhage, causing obstruction to the airway. In a patient with facial trauma the early identification of this injury is important to consider interventions. Midfacial instability, and in fact the type of Le Fort fracture, can be identified by gentle rocking of the midface and hard palate during primary and secondary surveys. Types of Le Fort fractures are:
In the management of unstable midfacial fractures with significant bleeding, airway control and haemorrhage control should be achieved during primary survey. Early control of posterior and anterior epistaxis with balloon devices can be attempted, with care not to place the balloon device intracranially through the fracture. For very severe oral bleeding the use of two suction devices are often needed. Twoperson bag–valve–mask (BVM) ventilation is often required in the airway management. This should be done with skilled expertise and a definitive plan in hand to manage a difficult airway. Oral packing to control bleeding should be done after intubation. In an awake patient who is maintaining the airway the sitting position is more suitable to protect the airway and for better control of bleeding.
Regarding the management of injuries in the face, which ONE of the following statements is CORRECT?
Answer: C: An avulsed primary tooth should not be replaced due to possible ankylosis and failure of secondary dentition to emerge. However, a permanent tooth should be replaced as soon as possible (none will survive > 6 hours post-injury). A perforated tympanic membrane of > 50% will require tympanoplasty but smaller perforation takes 6 weeks to heal when treated conservatively. The tongue being a muscular structure does not require repairing, but large lacerations, particularly those involving the edge of the tongue, or bleeding may do so. Often the patient/parents need to be advised that if complications occur and the tongue is deformed, then revision will be required. Nasal septal haematoma with superadded infection can cause septal cartilage necrosis in 24 hours.
Reference:
A 25-year-old male presents to the ED with a stab wound to the neck. During the primary survey, the emergency medicine registrar searches for the presence of any hard signs.
Which ONE of the following is LEAST likely to be a hard sign in this patient?
Answer: C: In a patient presenting with a penetrating injury to the neck such as a stab wound or a gunshot wound, the presence of any hard signs should be promptly identified during the primary survey. These hard signs are well described in literature. Hard signs are signs of significant injury that indicate the need for immediate surgical exploration in operating theatre. In the presence of one or more hard signs the patient should be transferred to the operating theatre (OT) without further extensive diagnostic testing such as CT and the injuries should be managed in the OT. Hard signs are identified by physical examination. Hard signs detected on physical examination have a reasonably high specificity for the presence of significant injury that requires surgical intervention. Hard signs of significant injury include:
Patients with soft signs alone without any hard signs are suitable to have further diagnostic imaging while staying in the ED. Significant subcutaneous emphysema with a normal CXR is described as the most common soft sign. Air can originate from the airway, oesophagus, a pneumothorax or from outside through the wound.
The neck is divided into three zones to aide clinical assessment and management of penetrating neck injuries.
Compared with zone II stab wounds, all of the following statements are true regarding zone I and III stab wounds EXCEPT:
Answer: D: The neck is horizontally divided into three zones to aid the clinical assessment and management of penetrating neck injuries. The surgically significant penetrating neck injuries are the injuries that penetrate platysma. Such injuries, although they may look trivial at times, should not be explored in the ED. The neck zones are:
In zone ll, most structures are readily accessible for both physical examination as well as surgical exploration when necessary. In zone I and III, assessment of the injuries is difficult and unreliable especially when physical examination alone is used. This is due to the transition of zone I into the thoracic cavity and zone III into the base of skull as well as the fact that the structures in these areas are not readily visible.
External and internal jugular veins are the most commonly injured vascular structures, but injury to the carotid arteries cause most devastating effects. Occult vascular injuries are more likely to occur in zones I and III than in zone II. However, CT angiography is still reliable in detecting both vascular and aerodigestive injuries in these zones. The rate of significant cervical spine injury (cervical fracture or cord injury) is very low in stab wounds to the neck. Patients with cord injury usually present with neurological deficits.
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