INFORMATION FOR CANDIDATE: You

are working in an emergency department when

the ambulance brings in a 25 year old, James
Way, a driver of a car who was not restrained by
a seat belt and hit a tree at medium speed. He
injured his face by hitting the steering wheel.
There was no LOC, his right eye became quite
swollen and he could hardly open it and he was
bleeding from his nose but had no other injuries.
YOUR TASK IS TO:
1.take a focused history
2.examine the patient
3.Explain your findings and management plan
to the patient
4.answer questions from the patient and the
examiner
HOPC: as above, the crash happened about 90 minutes ago. The patient remembers all
details of the crash. His face hurts with his right eye having swollen up so that he can
hardly open it and he had some nose bleeding which now has stopped. The ambulance
officers placed a cervical collar and transported the patient to the hospital.
PHx + FHx.: unremarkable
SHx: married sales man, no children, non smoker, drinks about 2 standard drinks every
day, NKA, no medication

EXAMINATION: Beeing trauma, you have to go through DRABC!!!

D = danger none
R = response the patient is fully conscious, no need to call for help
A = airway is open
B = breathing is normal
C = circulation not compromised with BP of 125/80 and pulse of 76/ min.
General Inspection:
Except for facial injuries the patient looks quite well, no pallor.
There is a periorbital haematoma on the right side and swelling over the right cheek bone
with marked bruising and a small amount of blood from his nostrils.
HEAD: no deformity, swelling, no depressed bone, no bruising
EYES: obvious periorbital haematoma on right side, but can open his eyes with effort, has
slight double vision, although the visual acuity seems to be intact in both eyes separately.
Limitation of upward gaze on right side due to inferior rectus entrapment. Normal
conjunctiva and anterior chamber, fundoscopy, and reflexes. The globe should be
evaluated carefully for rupture, hyphema, inflammation, iridodialysis, and retinal or
choroidal injury.
EARS: no external blood or CFS, ear canal normal, drums normal, hearing o.k., no battles
sign.
NOSE: obvious deformity of his nose with deviation of the lower nose to the left, crepitus
and some small epistaxis.
MOUTH: good bite, no obvious deformity, normal inspection.
FACE: obvious swelling over the right maxilla with superficial abrasions over the cheek
bone.
NECK: no tenderness in midline or paravertabrally, normal range of motion
CRANIAL NERVES: all intact except for diplopia.
The rest of the physical examination is normal.
SPINE: NAD

INVESTIGATIONS:
Facial bones X-ray, incl. Caldwell view to assess the orbital floor (tear drop)
and orthopantamogram (OPG, dentation)
Facial CT:
Coronal Images show extensive orbital emphysema with air-fluid level in the right
maxillary sinus. The fluid in the maxillary sinus as attenuation value of 71
consistent with blood. Orbital floor is fractured in multiple places and the patient
has also suffered a comminuted fracture of the nasal bone.
DIAGNOSIS: facial trauma with:
1. orbital floor blow out fracture with entrapment of inferior rectus
2. nasal fracture
3. abrasions

Blowout fracture = isolated fracture of orbital floor presents with pain that increases upon
vertical eye movement
Cause: sudden direct blow to globe with increase in intraorbital pressure transmitted to the
weak orbital floor, often associated with fracture of the thin lamina papyracea
diplopia on upward gaze (entrapment of inferior rectus + inferior oblique muscles)
crepitus after nose blowing
Epistaxis and ecchymosis may also be present (mainly lower eyelid)
Enophthalmus
Orbital emphysema
facial anesthesia, hypaesthesia of the ipsilateral cheek and upper lid, resulting
from disruption of the infraorbital nerve as it traverses the orbital floor!
soft-tissue mass extending into maxillary sinus
complete opacification of maxillary sinus (edema + hemorrhage)
depression of orbital floor
posttraumatic atrophy of orbital fat leads to enophthalmus

MANAGEMENT:
analgesia, nasal decongestant sprays, broad-spectrum oral antibiotics, and ice
packs should all be administered.
urgent referral to facio-maxillary surgeon for exploration and elevation of orbital
floor within 24 h if CT shows entrapped muscle or tissue with signs of diplopia
and gastrointestinal (nausea/vomiting) or cardiovascular symptoms (heart block,
bradycardia or syncope). If no entrapped muscle is suspected, surgical repair of the
orbital fracture can be delayed for 1-2 weeks, and is indicated in cases of cosmetic
deformity or diplopia.
D/W ENT regarding nasal fracture and need of reduction