Week 26: Trauma Part 1/4: Above the Clavicles

This xray shows a Jefferson fracture, or a C1 burst fracture. These fractures occur with axial loading with vertical compression, an injury pattern that is common when a football player spears another player. When looking at the odontoid view of a c-spine film, the lateral masses of C1 shoulder align with the lateral parts of the C2 vertebral body. A Hangman’s fracture, or bilateral C2 pedicle fracture is best seen on a lateral view and shows C2 displaced anteriorly on C3. Odontoid fractures involve the odontoid process and are graded type I through type III depending on position.  Type II and III are both unstable fractures. Bilateral facet dislocation fractures are seen on lateral xrays of the c-spine and is characterized by anterior displacement greater than 50% diameter of vertebral body.

The correct answer is that this injury is associated with anterior cord syndrome. This patient has a flexion teardrop injury at C5 (note the wedge shaped fracture at the base of the vertebral body).  This is generally caused by extreme flexion and axial load, classically a diving injury. There is failure of the anterior column, often middle column, and disruption of the posterior ligamentous complex and the significant potential for cord injury from retropulsion of a fragment as a result.

The patient has an epidural hematoma. Epidural hematomas result from blunt trauma to the temporal or temporoparietal area with skull fracture and disruption of the middle meningeal artery. Blood pools in the potential space between the skull and dura mater, leading to a classic biconvex-appearing hematoma. Patients classically present with an initial loss of consciousness followed by a “lucid interval” and subsequent rapid neurologic decline as mass effect and herniation develops. Treatment is surgical evacuation of the hematoma.

The patient presents with minor head trauma and complaints consistent with a concussion and should have neurology follow up arranged. A concussion is a minor traumatic brain injury (TBI) that is often seen in MVCs and collision sports (football, hockey). It is typically caused by a rotational injury or an acceleration-deceleration injury. Patients will present with a number of non-specific symptoms including headaches, dizziness, confusion, amnesia, difficulty concentrating, and blurry vision but do not have focal neurologic findings. Despite the absence of severe intracranial injury, patients can have chronic and debilitating symptoms from concussions. Neurology referral is recommended, as patients should have functional testing and tracking of their symptoms for resolution. It is vital to council patients to avoid contact sports or activities that increased the risk of recurrent injury as these patients are at risk for more severe injury with second impact.

Odontoid (dens) fractures are classified as Type I, II and III. Type I fractures are stable avulsion injuries to the tip of the odontoid. This patient has a Type II fracture, which is a fracture at the junction of the odontoid and body of C2. A Type III fracture is a fracture at the base of the the dens. Both Type II and III fractures are unstable because of ligamentous attachments. A bilateral C2 pedicle fracture is also known as a Hangman’s fracture and is seen on lateral xray as C2 being displaced anteriorly on C3. A teardrop fracture is an avulsion fracture of the anteroinferior portion of the vertebral body. Both of the former fractures patterns are unstable c-spine injuries.

This patient has sustained a Zone II neck injury. He is demonstrating signs of impending airway obstruction with an expanding anterior neck hematoma, dysphagia, and dysphonia. The primary focus in the care of this patient and any other patient presenting following a traumatic injury should be the ABCs. This particular patient should be intubated right away: he is at risk for rapid deterioration and respiratory failure. Indications for establishing a definitive airway in the setting of penetrating neck trauma include respiratory distress, altered mental status, bloody secretions in the oropharynx, subcutaneous emphysema, expanding hematoma, and tracheal shift. Other signs of potential airway compromise include dysphagia and dysphonia. Orotracheal intubation is preferred in penetrating neck injury, but backup airway techniques should be available. If quickly available, awake fiberoptic intubation may be considered.

The patient’s presentation is critical. As soon as the airway is established, he should be transported immediately to the OR. Performing angiography would inappropriately delay management. All symptomatic patients with penetrating injuries to Zone II require surgical exploration.

Again, sending the patient for a CT scan would delay appropriate management. Additionally, CT is more appropriate in the evaluation of blunt trauma.

Cricothyrotomy should be avoided when an anterior neck hematoma is present. If the patient were more stable on arrival, intubation could be delayed until the patient reached the OR.

The treatment and amelioration of increased intracranial pressure (ICP) is one of the most important steps in the management of the multiple trauma patient. Mannitol is very effective, with a slightly delayed effect on the oncotic forces at work within the cranial cavity. Indicated in patients with impending herniation or evidence of increased ICP from trauma, mannitol is given as a bolus to lower ICP via osmotic diuresis and increase plasma expansion. A continuous mannitol drip can increase the chance of hypovolemia and is thus not recommended.

Hyperventilation after intubation has been used as a rapid intervention to lower ICP. It can be used for impending herniation or as a lifesaving therapeutic measure. But more recent studies indicate that patients with traumatic brain injury have a worse prognosis if hyperventilation is used in any prolonged manner, and that it should be avoided especially in the first 24 hours.

Neuromuscular paralysis is part of the process of rapid sequence intubation, but it does not in itself contribute to reduction of ICP. Successful intubation to manually control the patient’s respiratory rate and ventilation volume is made more successful with the use of neuromuscular blockers. Complete paralysis allows mechanical hyperventilation while the patient is on the ventilator.

The value of steroids in the care of patients with increased ICP from other processes, including cancer, is debatable. Several large studies have shown that steroids are not effective in treating patients with traumatic brain injury.

A. Admission to the hospital
This patient is presenting with a basilar skull fracture, evidenced by the CSF fluid coming from his ear. Recommendations are that all of these patients should be admitted to the hospital for monitoring. A recent cochrane review found no evidence that routine antibiotics were indicated for CSF leaks in these patients however. Source: Ratilal BO, Costa J, Pappamikail L, Sampaio C, Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015;4:CD004884. PMID: 25918919

B. Admission and systemic antibiotic therapy
While this patient should be admitted for his basilar skull fracture, antibiotics are not indicated. A recent cochrane review found no evidence that routine antibiotics were indicated for CSF leaks in these patients however. Source: Ratilal BO, Costa J, Pappamikail L, Sampaio C, Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev. 2015;4:CD004884. PMID: 25918919

C. Admission and systemic steroids
While this patient should be admitted for his basilar skull fracture, steroids are not indicated

D. Discharge with oral antibiotics
This has a basilar skull fracture and CSF leak, and should be admitted for monitoring.

Complex facial fractures may be classified into the Le Fort system of fracture patterns. Three types exist. Type I Le Fort fractures are transverse fractures through the base of the maxilla and often involve the roots of the teeth. It may be unilateral and bilateral. The upper teeth may be grasped and rocked independent of the midface, indicating discontinuity with the maxilla. Type II Le Fort fractures are often bilateral and are characterized by pyramidal fractures that extend through the body of maxilla, orbital floor, nasal bones, hard palate, and lacrimal bones. The nasal unit and maxilla may be grasped and move as a unit relative to the orbital complexes and lower face. Type III Le Fort fractures are considered complete craniofacial disjunction as the fracture extends from the nasal bridge traveling posteriorly along the ethmoid bone, which comprises the medial orbital wall, and continues through the inferior and lateral orbital walls and frontozygomatic suture. The sphenoid bone is often involved with type III fractures, and cerebrospinal fluid (CSF) leak may occur. CSF may also leak from involvement of the cribriform plate of the ethmoid bones. Le Fort fractures are best seen with computed tomography. Depending on the extent of the injury, Le Fort fractures often require management of a multidisciplinary team and may necessitate consultation to otolaryngology, plastic and reconstructive surgery, dentistry and neurosurgery if a CSF leak is present.

A type II Le Fort fracture involves the central maxilla (A), nasal bridge, lacrimal bones, hard palate (C), and orbital floor. It often occurs bilaterally and in a pyramidal pattern. Fractures of the mandibular condyle (D) are not included in the Le Fort classification of midface fractures.

Bedside intraocular ultrasound performed by an emergency physician is a very useful tool for rapidly diagnosing many intraocular conditions. Dislocated lens, foreign body, and detached retina can be identified by ultrasound. It has not been demonstrated as useful in the diagnosis of orbital compartment syndrome caused by a retrobulbar hemorrhage.