Senior Report 8.2

Case Presentation by Andrew Sweeny, MD

History:

The patient is a 79-year-old female with a history of hypertension and atrial fibrillation who presents to the emergency department via EMS after falling at a social event. The patient reports that she fell stepping off the curb hitting her left face. She denies any preceding lightheadedness, shortness of breath, or chest pain. The patient denies any loss of consciousness. She denies using any alcohol, illicit drugs, or sedating medications. Currently, the patient complains of mild occipital headache and pain to her left periorbital region. She denies pain to her neck or extremities. The patient is on warfarin for her atrial fibrillation and has her INR checked regularly.

 

Physical Exam:

Vitals: Blood pressure was 157/95, heart rate 80, respiratory rate 18, temp 36.2, pulse ox 100 on room air

General: awake/alert/no apparent distress

HENT: Normocephalic, no icterus, no cervical midline tenderness, full active range of motion at the neck without pain, large contusion/ecchymosis to left orbit, small abrasion to bridge of nose without gross deformity/crepitus/intranasal hematoma, no facial crepitus, no hemotympanum

Eyes: EOMI, PERRL, large temporal subconjunctival hematoma occupying 40% of conjunctiva of left eye, significant periorbital ecchymosis/edema to L eye, patient unable to open L eyelids due to edema, no hymphema, patient able to read name badge at distance 12” bilaterally, unable to conduct full Snellen eye chart exam as patient requires assistance to hold L eyelid open due to edema

Cardio: Irregularly irregular rhythm, normal rate, no murmurs

Respiratory: clear to auscultation bilaterally

Abdomen: soft/non-tender/non-distended

Neuro: Normal speech, moving all extremities, strength 5 out of 5 and symmetric to hand grip, elbow flexion/extension, knee flexion/extension, hip extension/flexion, dorsi/plantar flexion

Extremities: No contusion/abrasion/ecchymosis/bony tenderness to upper/lower extremities

 

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sr8.21

 

Questions:
1. When performing this patient’s physical exam, what finding would indicate need for an emergent procedure?

a. Inability abduct or adduct the injured eye

b. Hyphema occupying greater than50% of anterior chamber

c. Significant loss of visual acuity of injured eye when compared to uninjured eye

d. Proptosis of injured eye
2. What physical exam finding has the highest incidence of underlying facial fracture in minor head injury?

a. Periorbital ecchymosis

b. Subconjunctival hemorrhage

c. Epistaxis

d. Decreased skin sensation
3. What is the most commonly injured portion of the orbit in a blow-out fracture?

a. Superior

b. Medial

c. Inferior

d. Lateral

 

Answers:

C – This patient has a medial and lateral blow out fracture with proptosis and evidence of orbital edema. If this patient had either increased intraocular pressure or significant loss of vision, a lateral canthotomy is indicated to save patients vision. Ideally, the patient’s vision should be tested using his/her glasses, or if the glasses were broken during the injury, use a pinhole card. (A) Extraocular nerve palsy is not an indication for an emergency department procedure, and rather, requires consultation with ophthomology/ENT for possible intervention in the OR. (B) Hyphema drainage is not an emergency department procedure. Hyphema greater than 50% is associated with formation of synechia (iris adhesions), but an anterior chamber wash out is a procedure that is performed in an OR. (D) Proptosis alone is not an indication for a lateral canthotomy.

A – retrospective study by Buttner et al found that in a cohort of 1676 patients with minor head trauma and black eye had a 68.3 incidence of underlying facial fracture. (B-D) All other physical exam findings where specific for facial fracture in the setting of black eye but had low sensitivity varying from 10-22%. The authors of this study recommend maxillofacial CT for every patient with periorbital ecchymosis in the setting of minor head injury.

C – Inferior blow-out fracture is the most commonly fractured portion of the orbit due to the relatively weak bony structure separating the orbit from the maxillary sinus when compared to the rest of the orbit. Special consideration in an inferior blow out fracture is a trap door fracture where a portion of the inferior rectus muscle becomes entrapped in the fracture leading to reduced ability to look upwards (supraduction). This type of fracture is more common in pediatric populations and is clinically important because of improved outcomes with early surgical intervention. (A) Superior blow out fractures are uncommon. They are associated with CSF leaks and increased risk for meningitis. (B) Medial blow out fractures are second most common and frequently occur in conjunction with inferior blow out fractures. Medial blow out fractures occur commonly due to the weak bony structure of the lamina papyracea. Radiographically, blood in the ethmoid cells is commonly seen. Medial rectus prolapse may occur in these fractures. (D) Lateral blow out fractures are the most uncommon because the bony structure is strongest along the lateral orbit.
References:

1. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years
Büttner, Michael et al.
British Journal of Oral and Maxillofacial Surgery , Volume 52 , Issue 6 , 518 – 522

2. Zilkha A. Computed tomography of blow-out fracture of the medial orbital wall. AJR Am J Roentgenol. 1981;137 (5): 963-5. AJR Am J Roentgenol (citation)[pubmed citation]

3. Curtin HD, Wolfe P, Schramm V. Orbital roof blow-out fractures. AJR Am J Roentgenol. 1982;139 (5): 969-72. AJR Am J Roentgenol (citation) [pubmed citation]

4. Linden JA, Renner GS. Trauma to the globe. Emerg Med Clin North Am 1995;13(3):581-605.

5. Samples JR, Hedges JR. Ophthalmologic procedures. In: Roberts JR, Hedges JR, editors. Clinical procedures in emergency medicine. 3rd ed. Philadelphia: W.B. Saunders Co; 1998. p. 1089-119.

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