The Tripod Fracture

The tripod fracture (officially known as the zygomaticomaxillary complex fracture, and sometimes called a malar fracture) is the most common one seen after trauma. Fundamentally, the zygoma is separated from the rest of the face in a tripod fracture.

As you might imagine (tripod fracture), there are three components to this fracture. The first is a fracture through the zygomatic arch (1). Next, the fracture extends across the floor of the orbit and includes the maxillary sinus (2). Finally, the fracture includes the lateral orbital rim and wall (3). 

Extraocular muscles may become trapped in the fracture line, leading to diplopia. It is very important to do a good eye exam to try to detect entrapment. The infraorbital nerve also passes through the orbital floor and may be injured, leading to numbness along the lower eyelid and upper lip.

Nondisplaced fractures are treated symptomatically and reevaluated after a week or so to see if surgery would be beneficial. Displaced or symptomatic fractures require early open reduction. The pictures below show the anatomy of these fractures. They are derived from teaching materials provided by the Radiology Department at the University of Washington.



Up In The Air: Tree Stand Injuries

Deer hunting season is upon us again, so it’s time for emergency departments to start seeing an increase in hunting injuries. Although you would think this would mean accidental gunshot wounds, that is not the case. The most common hunting injury in deer season is a fall from a tree stand.

Tree stands typically allow a hunter to perch 10 to 30 feet above the ground and wait for game to wander by. They are more frequently used in the South and Midwest, usually for deer hunting. A recent descriptive study by the Ohio State University Medical Center looked at hunting related injury patterns at two trauma centers.

Half of the patients with hunting-related injuries fell, and 92% of these were tree stand falls. 29% were gunshots. The authors found only 3% were related to alcohol, although this seem very low compared to our experience in Minnesota.

Most newer commercial tree stands are equipped with a safety harness. The problem is that many hunters do not use it. And don’t look for comparative statistics anytime soon. There are no national reporting standards.

The image on the left is a commercial tree stand. The image on the right is a do-it-yourself tree stand (not recommended). Remember: gravity always wins!

Commercial tree stand Do-it-yourself tree stand

Helicopter EMS: The Final Word??

One of my readers left a lengthy comment on the helicopter EMS guidelines from the ACS-COT and NAEMSP on Wednesday. For those of you who don’t dig into the comments, I’m publishing it in its entirety today. It’s that good. Thanks to Mike Abernathy for the time he took to write it! BTW, he is a co-author on several papers with Brian Bledsoe, whose data I quoted. See references below. 

“Great recommendations –they make perfect sense. But..with the current structure of the US HEMS system, they are largely unenforceable . Due to multiple factors, there is a HUGE disparity among the aviation and medical abilities of HEMS programs –yet they are treated and paid as a uniform entity.

An ever growing, profit driven sector of the industry is run by large corporations ( Air Medical Holdings, PHI, AMC) who operate independently and have little connection with health care/hospitals as we know them.

Due to loophole in the the Airline Deregulation act of 1978, there is little meaningful state or federal regulation over the HEMS industry. Several states have tried to create and enforce regulations but have been defeated in court every time. Medical standards, equipment and training are essentially determined by individual programs. The classic fox guarding the henhouse. One program mayfly with almost minimum wage paramedic team with minimal training/experience while another down the street may use a highly trained EM physician- nurse team ( and everything in between) One program may fly a 25 y/o single engine aircraft worth $800k and another program invests in $8M state of the art helicopters. Does the program want to put profits into the pockets of shareholders or back into improving the quality of the program? Right now –there is zero incentive for quality. Everyone gets paid the same per patient mile. There is absolutely no reason why these programs would not want to fly every pt they can –because they get paid very well for it.

Anyone can put a helicopter anywhere and due to lack of real Medicare/Medicaid requirements (currently so vague, any transport can be justified) and get paid damn well for it. Interestingly – the ground EMS industry is highly regulated by comparison.

But – there are many good programs out there who do the right thing – use well trained, experienced medical personnel and pilots along with state of the art equipment but they are slowly being overtaken by the “darkside” of the industry.

BTW – the standard of care for HEMS in almost every other developed country in the world is a physician-medic team using larger dual engine aircraft. Considering these patients should be the most critically ill of all those transported –not a bad idea. The bar in the US has been grossly lowered in the name of profit.

The only way to fix the whole system is that reimbursement must be tied to quality measures and appropriate utilization criteria based on medical research. When Medicare requires precertification and other quality measures, insurance companies will follow. Like every other aspect of medicine quality must be incentivized ( = $$$) When this happens the low end / low quality, profit driven subsection of the HEMS industry will disappear –and so will many of the problems that you have appropriately outlined.”

Related posts:


  • Helicopter Scene Transport of Trauma Patients with Nonlife-Threatening Injuries: A Meta-Analysis. J Trauma 60:1254-1266, 2006.
  • Helicopter Accidents in the United States: A 10-Year Review. J Trauma 56:1325-1329, 2004.

When Can Your Trauma Patient Stop Taking Warfarin?

The number of elderly patients needing care at trauma centers is skyrocketing. Many are on anticoagulants for medical conditions, most commonly atrial fibrillation. When one of these patients is seriously injured, anticoagulation can cause serious and life-threatening complications that might otherwise not occur. 

Reflexively, many trauma professionals decide to just stop the medication, especially if they believe that the patient may injure themselves again (and again, sometimes). However, this may not always be a good idea. Remember the good old juice to squeeze ratio. Look a the risks (reinjury) vs the potential benefits (stroke prevention). The easiest way to assess this is to use CHADS2.

CHADS2 is a validated scoring system for predicting stroke risk in people with atrial fibrillation. There are 5 components as follows:

  • C – congestive heart failure – 1 point
  • H – hypertension (treated or untreated) – 1 point
  • A – age >= 75 – 1 point
  • D – diabetes mellitus – 1 point
  • S2 – history of stroke or TIA – 2 points

Stroke risk is directly correlated to the number of points scored. So based on that the recommendations are:

  • Score = 0: low risk, no therapy needed or just take aspirin
  • Score = 1: moderate risk, aspirin or oral anticoagulant
  • Score >= 2: moderate to high risk, take oral anticoagulant

Bottom line: Evaluate every trauma patient on anticoagulation to see if they really need to keep taking it. If it’s for a one-time episode of DVT or PE that happened years ago, they should be able to stop. If it’s for a-fib, check their CHADS2 score and work with their primary care provider to see if they could take aspirin or nothing. Factor in a history of frequent falls or car crashes as well.

Related posts: 

Reference: Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin. Circulation 110 (16): 2287–92, 2004.

Helicopter EMS: The Recommendations

So after two days of pros and cons about helicopter EMS (HEMS), we lead up to this. The American College of Surgeons Committee on Trauma, Emergency Medical System subcommittee, has released a set of guidelines on appropriate use of HEMS. It’s been endorsed by the National Association of EMS Physicians and looks like a lot of thought has gone into it.

Here are the factoids about the HEMS guidelines:

  • Must be integrated with your trauma system
  • Must utilize standardized field triage guidelines that should be applied consistently throughout your trauma system
  • Is blind to the insurance status of the patient
  • Uses a regional dispatch system. Self-launch should never happen.
  • Referring physician to receiving physician conversations must occur when considering transportation mode (air vs ground) for interfacility transfers
  • There must be good online medical direction from a physician
  • Offline medical direction must be based on protocols and policies developed by the trauma system
  • There must be regular PI review of all HEMS transports to ensure compliance
  • HEMS crews must have regular training opportunities
  • A culture of safety must be maintained

Bottom line: We absolutely must take a critical look at our patient transport practices and procedures. To ensure even-handed application of best practices, our state trauma systems are going to have to step up and address this issue so the right patient will get to the right hospital at the right time, safely and cost effectively.

Related posts:

Reference: Appropriate use of Helicopter Emergency Medical Services for transport of trauma patients: Guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma 75(4):734-741, 2013.