A 15 yo male presents with a complaint of facial laceration after a boating injury. The injury occurred 3 – 4 hours ago. He was on a boat and a line from another boat came across and clothes-lined him, as well as demolishing a good portion of the boat. Patient was “knocked out on the seat in the back of the boat”.
+Brief LOC
No nausea headache, vomiting, chest pain, dizziness, difficulty breathing or talking
Exam
GCS of 15, appropriate, interactive VS normal
Exam significant for normal strength in all extremities, no sensory deficits. Mild tenderness to right shoulder and right side of neck. No C, T, or L spine tenderness. TMs clear. Dried blood is noted over the right auricle lacerations on the right side of the face and intra-orally on the right side, pain with palpation of neck. He describes it as being sensitive. Erythema/rope burn on the right side of his neck from under his chin to the clavicle and towards the right shoulder with mild swelling. Multiple lacerations of lip, skin above lip and intraoral mucosa on right.
The right upper jaw is mobile compared with the left, and he does not have a normal bite. His left front incisor ( #9) is partially intruded, his right central incisor ( #8) is tender, and an avulsion of tooth #6.
Questions for you:
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Alright. Here's my 2 cents----
ReplyDeleteWhenever there's facial trauma I love to trot out the LeFort Fractures as some potential real live serious pathology. In this case, I'm worried about that with the right upper jaw mobility and dental trauma. Remember the classification? Here it is, courtesy of good old Wikipedia:
Le Fort I fractures (horizontal) may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. It is also known as a Guerin fracture or 'floating palate', and usually involves the inferior nasal aperture. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates.
LeFort II fracture
Le Fort II fractures (pyramidal) may result from a blow to the lower or mid maxilla and usually involve the inferior orbital rim. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.
LeFort III fracture
Le Fort III fractures (transverse) are otherwise known as craniofacial dissociation and involve the zygomatic arch. These may follow impact to the nasal bridge or upper maxilla. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid. This type of fracture predisposes the patient to CSF rhinorrhea more commonly than the other types.
When I assess the face, in addition to checking for malocclusion I like to use a 2 hand exam where the finger of one hand is on the glabella and the other hand grabs hold of the maxillary dentition to check for instability. If there is any, my index of suspicion is heightened and I'm fairly quickly involving OMFS.
I'm wondering if this patient got any C-spine imaging, and I would really want to be careful about my cranial nerve exam too.
The other thing that bothers me is the neck swelling and "sensitivity." It's a little unusual and gets me started thinking about the different Zones in neck trauma-- there are a lot of structures that can be officially classified as "make me nervous" and although the zones really refer to penetrating trauma I think you would have to consider pseudo aneurysm of one of the vessels as well. I'll think more about this, but there's a lot that gets my attention here and early surgical involvement and consultation would be my inclination.