POTD: Le Fort Fractures

Hi everyone,

Welcome to the first of many POTDs this month and what better way to start then to continue Trauma Tuesdays! I decided to focus on Le Fort Fractures because I have noticed these questions come up a lot when going through ROSH Review. So lets dive in! 

Le Fort fractures are broken down into three types (I, II, and III) based on the injury plane. They are caused by blunt trauma to the midface and involve a break in the pterygoid plates. A way to think about it is the higher in #, the worse the injury. 

You have all probably heard of the mnemonic below but if not, here it is: "Speak no evil, see no evil and hear no evil" this should hopefully make sense as you keep reading.

Breakdown of Le Fort Fractures: 

Le Fort I (Horizontal) → Horizontal fracture along the maxilla and usually from lower-velocity trauma

• These fractures separate the maxilla (upper jaw) from the rest of the skull, giving you what’s called a “floating palate.”

Fun tip: gently pulling on the upper incisors might reveal the whole dental arch moving

Exam:  Swelling of the upper lip, dental malocclusion, difficulty biting properly, and mobility of the dental arch when gently manipulated

Pathognomonic Test: Mobility when pulling on upper incisors

Le Fort II (Pyramidal) → Le Fort II is a pyramidal fracture involving the nasal bones, maxilla, and infraorbital rims. These patients often have a widened nasal bridge and flat midface appearance. 

Watch out for CSF rhinorrhea, which suggests the fracture may be deeper than it looks.

Symptoms: Nasal flattening, widened intercanthal distance, periorbital swelling, and potential CSF rhinorrhea. This commonly involves the infraorbital nerve!! 

Buzzword: “Floating maxilla.”

Le Fort III (Transverse) → Le Fort III fractures are the most severe, involving craniofacial disjunction. Look for loss of sensation in the midface from nerve involvement. These are associated with additional complications such as CSF leak and trigeminal nerve damage. 

Injury: Transverse fracture through orbits and zygomatic arches. Craniofacial disjunction is the hallmark.

Symptoms: Flattened face, enophthalmos, mastoid bruising, and severe deformity.

Buzzword: “Floating face” 

So how do we diagnose this? CT Face! 

So our patient has a Le Fort fracture... now what? 

Management: 

• Airway: Be vigilant for airway obstruction from swelling or blood. Intubate early if needed

• C-Spine: Maintain spinal precautions until cleared, may need to obtain a CT C-spine 

• Bleeding: Control with nasal packing or direct pressure.

• Antibiotics may be indicated: Start IV antibiotics to prevent sinus and intracranial infections; these are considered open fractures 

• Tetanus as indicated 

• Maxillofacial Surgery: Essential for surgical repair.

• Neurosurgery: Involvement for CSF leaks or brain injury.

• Pain Control

Key Teaching Points: 

• Always check the airway and C-spine.

• Use the mnemonic “Speak, See, Hear No Evil” for quick recall of fracture types

  • I: transverse fracture separating maxilla from pterygoid and nasal septum

  • II: maxilla and palate fractured

  • III: craniofacial dissociation

  • II and III: CSF rhinorrhea (due to cribriform plate involvement) 

• Involve specialists early for definitive care.

• Remember CT face to help determine the type of fracture 

Resources:

1. UpToDate: Le Fort Fractures (https://www.uptodate.com)

2. Osmosis: Le Fort Overview (https://www.osmosis.org)

3. Radiopaedia: Facial Fracture Imaging (https://radiopaedia.org)

4. WikiEM: Le Fort fractures 

5. ROSH Review 

6. https://www.emrap.org/corependium/chapter/recGrF99hDMuLNdcD/Midfacial-Trauma#h.sfzflara7koe 

Thanks friends and talk to you all soon, 

Caro

POTD: Fishhook Injury

Hi everyone,

Caroline and I have the great privilege of serving as your admin residents for this upcoming block. Throughout the next four weeks, if there are any topics floating in your head that you would like us to dive further into, send it our way!

For today's POTD, I wanted to explore the unfortunate case of a fishhook injury, with a particular focus on fishhook removal techniques if it ever maneuvers its way into your ED. Over the weekend, the south side team successfully removed a fishhook lodged in a patient's pinky finger, and, by the leadership of Dr. Sanjeevan and the grip strength of Dr. Weber, the patient was able to ambulate out of the ED with all digits intact and ready for another day of fishing in Red Hook.

Fishhook Anatomy

A fishhook is composed of the eyelet, shank, belly, barb, and tip. Most fishhooks are J hooks, with one shank and one barb, but occasionally you might see a treble hook, which is essentially multiple J hooks together all sharing a shank. The real troublemaker for fishhook injuries is the barb. Fear the barb. The sharp, reversed nature of the barb makes it so that a simple retrograde removal would be traumatic both to the surrounding tissue and the patient.

Preparation

1) Assess path of fishhook: Your removal technique will in part depend on the depth and location of the needle. Is the distal tip already near the surface? Is it going to hit any important structures on its way in or out? You may need further imaging to better clarify the track it took. If it involves the eye, consult ophtho. If it involves bone or tendon, consult ortho.

2) Local anesthetic/nerve block: Digital blocks work great for these when applicable.

3) Wound cleaning: Chlorhexidine or betadine like wild.

Techniques

1) Advance and Cut Technique: need hemostat, wire cutters/raptors, gauze, eye protection

a. Anesthetize.

b. Advance the fishhook further into the patient until the tip and the barb have both exited the skin.

c. Cut the barb off the fishhook with wire cutters or raptors. If using raptors, you can use the ring cutter function (shown below). Make sure you keep gauze over the barb and have eye protection on before you cut so as to avoid the cut barb from flying off and causing further injuries.

d. Reverse the hook back out of the skin.

2) String Technique: need string or strong suture, eye protection

a. Wrap a string or strong suture around the fishhook.

b. Push down on the shank to dislodge the barb as much as possible.

c. Pull on the string and jerk quickly. Watch out for the fishhook to come flying out of the skin.

3) Needle Technique: need 18 gauge needle

a. Anesthetize.

b. Advance an 18 gauge needle along the fishhook toward the tip and over the barb.

c. Reverse out both the needle and fishhook together as a unit.

4) Scalpel Technique: need scalpel, hemostat

a. Anesthetize.

b. Use #11 blade scalpel to cut down to the barb.

c. Grab barb with hemostat.

c. Pull entire fishhook up and out.

Post-Removal Care

1) Check for foreign bodies: Consider xray if any concern for retained objects.

2) Tetanus: Hit them with that tdap as indicated. 

3) Antibiotics: No trials have been done to study PO antibiotics after fishhook injury. You might consider adding on systemic antibiotics for immunocompromised folks, infection-prone areas, or contaminated hooks. At the very least, topical bacitracin and instructions on local wound care are always a good call.

Happy fishing,

Kelsey

Resources:

1) https://www.aliem.com/trick-fishhook-removal-techniques/

2) https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fish%20hook%20removal&source=search_result&selectedTitle=1%7E1&usage_type=default&display_rank=1#H13

3) https://www.tampaemergencymedicine.org/blog/fish-hook-removal

4) https://www.emra.org/emresident/article/angling-for-success-techniques-for-fishhook-removal-in-the-ed

5) https://www.emrap.org/episode/ucprocedures/ucproceduresfishhookremoval

6) https://www.emrap.org/episode/fishhookremoval1/fishhookremoval1

7) https://www.emrap.org/episode/fishhookremoval/fishhookremoval

POTD: Bringing a needle to a knife fight

Hello friends,

For my final clinical content based POTD, I wanted to summarize the steps for a nightmare event: the pediatric can’t intubate, can’t oxygenate scenario.

Resus residents, do you ever find yourself just glossing over the small bag in the corner of the bottom drawer of the airway cart when you do your daily check? The one labeled with the piece of tape that says “jet insufflation”? Maybe in the back of your head you have a vague idea that it’s supposed to be used for a needle cric in pediatric patients below 8 years old. But that’ll probably never happen right? Well, I’m here to tell you…..you probably are right. But that doesn’t mean that we shouldn’t be prepared for it.

I remember early resus year when I would check that the things on the check list were in that bag, but not actually have the context for how it all pieced together. It wasn't until PGY-2 procedure day when me and my co-residents in our group realized what a blind spot it had been for us. What are these random small syringes with the top off? Why is there the top of an ETT just out and about in here? Well, after reviewing the steps for the procedure, hopefully you can visualize how it all comes together.

Steps

1.     Prep and drape while locating the cricothyroid membrane.

2.     Pierce the membrane with the 14G angiocath directed 30-45 degree caudally.

3.     Advance catheter over needle, hub to skin, and remove needle.

4.     Attach a 7-0 ETT adaptor to top of a 3mL syringe with plunger taken out and attach this apparatus to the catheter.

5.     Attach a BVM to ETT adaptor.

6.     Take a deep breath (but don’t forget to also give your patient one), you did it.

It’s a relatively simple procedure, just with insanely high stakes.

Because I’m very much a visual learner:

Here’s a quick 1:52 min video: https://www.youtube.com/watch?v=F_PV7N2c2pQ. Note how the video does it is probably slightly different than how we would with our own makeshift kit here. Sorry for the potato quality but it’s short and gets the point across.

And lastly, I wanted to summarize a recent article written in June (the First10EM link below) that actually advocates doing a surgical approach with a scalpel and not going down the needle cric route for kids like what is traditionally taught to us. The author was also featured on this week’s episode of EMRAP going over this topic. Basically multiple professional societies have come out with contradictory guidelines over the use of needle vs surgical cric, which is not helpful. Data is super limited because of the rarity of this event in this population. Pediatric case reports seem to demonstrate a lack of success of the needle approach as the first line and that complications are to be expected even when the airway is established. This is seen again and again in adult studies as well.

The author then advocates that having the peds surgical cric approach in your toolbox is the best guarantee of achieving a definitive airway in this scenario with the least complications.

In children less than eight years old, the cricoid membrane may be too small so the horizontal incision step is discarded. There is also a higher risk of transecting the entire trachea with the horizontal incision. Instead in the peds surgical approach, you would just do a vertical cut through the trachea (though no more than 2 tracheal rings as this can make repair afterwards more difficult).

Would love to know what other peds providers think about this stance. It does seem like it is branching a little bit farther than what we’re comfortable with, but this is where the art of medicine comes in because the paucity of data out there.

References

https://www.ncbi.nlm.nih.gov/books/NBK537350/

https://first10em.com/the-pediatric-cant-intubate-cant-oxygenate-scenario-use-a-knife/

https://www.tamingthesru.com/blog/acmc/needle-cricothyrotomy

Breathe easy friends!