ATLS Ocular and Facial Trauma 2 — Questions and Answers
Question 1: A patient has periorbital swelling and ecchymosis after trauma. On exam, there is enophthalmos and limitation of upward gaze. What injury does this suggest?
- Orbital floor (blowout) fracture with inferior rectus entrapment (Correct answer)
- Open globe injury
- Retrobulbar hematoma
- Zygomaticomaxillary complex fracture only
Correct answer: Orbital floor (blowout) fracture with inferior rectus entrapment
Blowout fractures of the orbital floor can trap the inferior rectus muscle, causing restricted upward gaze and enophthalmos from loss of orbital volume support.
Question 2: Retrobulbar hematoma after orbital trauma is a true emergency because it can cause what serious complication?
- Ischemic optic neuropathy and permanent vision loss from elevated orbital pressure (Correct answer)
- Corneal laceration
- Hyphema
- Traumatic iritis
Correct answer: Ischemic optic neuropathy and permanent vision loss from elevated orbital pressure
Rapidly expanding retrobulbar hematoma increases orbital compartment pressure, compressing the optic nerve and central retinal artery, causing permanent blindness if untreated.
Question 3: What is the emergency bedside treatment for retrobulbar hematoma with impending vision loss?
- Lateral canthotomy and cantholysis (Correct answer)
- Immediate surgical decompression in the OR only
- Ice packs and head elevation
- IV mannitol alone
Correct answer: Lateral canthotomy and cantholysis
Lateral canthotomy and inferior cantholysis releases orbital compartment pressure rapidly and is a time-critical bedside procedure to save vision.
Question 4: A patient with a nasal fracture has complete obstruction of both nostrils after manipulation. What immediate concern must be addressed?
- Septal hematoma requiring drainage to prevent avascular necrosis (Correct answer)
- Bilateral choanal atresia
- Le Fort I fracture
- Nasal bone osteomyelitis
Correct answer: Septal hematoma requiring drainage to prevent avascular necrosis
Septal hematomas must be drained promptly because the elevated perichondrium disrupts cartilage blood supply, causing avascular necrosis and saddle-nose deformity.
Question 5: Le Fort I fractures involve which anatomical level?
- Horizontal fracture at the base of the maxilla above the tooth apices, separating the palate from the upper face (Correct answer)
- Fracture through the nasal bones and orbital floors
- Fracture through the zygomatic arches and lateral orbital walls
- Fracture of the frontal sinus only
Correct answer: Horizontal fracture at the base of the maxilla above the tooth apices, separating the palate from the upper face
Le Fort I is a horizontal fracture separating the tooth-bearing maxilla (hard palate and alveolar ridge) from the rest of the facial skeleton.
Question 6: In chemical eye burns, what is the immediate first-line treatment before any other assessment?
- Copious irrigation with normal saline or water for at least 30 minutes (Correct answer)
- Apply topical antibiotic ointment
- Measure visual acuity first, then irrigate
- Patch both eyes and transfer to ophthalmology
Correct answer: Copious irrigation with normal saline or water for at least 30 minutes
Immediate and prolonged irrigation dilutes and removes the chemical agent, minimizing ongoing corneal and conjunctival damage — time to irrigation is the key determinant of outcome.
ATLS Ocular and Facial Trauma 2
A patient has periorbital swelling and ecchymosis after trauma.
On exam, there is enophthalmos and limitation of upward gaze.
What injury does this suggest?