Tag Archives: fracture

Temporal Bone Fracture

The temporal bone is a very complicated and important piece of bone located at the base of the skull. It houses a number of structures vital to hearing and balance, and is a conduit for several important nerves. Most fractures are due to blunt trauma, and although several classification systems exist, the majority are irregularly shaped and don’t lend themselves to easy categorization.

Clinically, a t-bone fracture should be suspected anytime that blood is seen in the ear canal or behind the eardrum after blunt head trauma. Patients may complain of dizziness or hearing loss. Examination may demonstrate some nystagmus in some cases. Most of the time, the diagnosis will not be made until a head CT is performed. The diagram above shows why this fracture can cause hearing problems (middle ear) or dizziness (inner ear).

There is usually no specific surgical intervention needed for this fracture. However, two important functional exams must be completed once diagnosed: facial nerve function and hearing. The facial nerve exam should document whether only portions of the nerve are affected vs all branches, and whether there is at least partial function. In head injured patients that can’t follow commands, even a grimace can demonstrate some function.

The ideal hearing test is carried out with a tuning fork. However, this is not usually convenient in acute trauma patients. Whispering and rubbing fingers near the patient’s ear can be used as a quick and dirty test. Awake patients will be able to tell you if their hearing is decreased.

Bottom line: Suspect temporal bone injuries in patients with any signs of basilar skull fracture. If the diagnosis is suspected or confirmed by CT scan, document the best facial nerve and hearing exam that you can. Contact your facial surgeon once the diagnosis is confirmed, and call them urgently if there is any loss of facial nerve function. Thin cut CT scans of the temporal bone are generally not necessary, and should not be ordered automatically unless the facial surgeon needs it for a specific reason.

Yes, Smoking is Bad!

Everybody knows that smoking is bad. But how often have you stopped by to see one of your trauma patients and have been told “they’re out smoking?” Well, it turns out it’s bad for their injuries as well.

A German group looked at the effects of smoking on healing of a “simple” tibial fracture. They looked at 103 patients who underwent treatment for an isolated tibial shaft fracture at a trauma center. Patients with more complicated problems like extension into a joint, open fracture (Gustilo III), or significant soft tissue injury were excluded. 

Patients were divided into non-smokers and smokers (including previous smokers). A total of 85 patients were studied, and there were roughly half in each group. The nonsmoking group experienced no delayed or non-unions of their fractures. The smoking group reported 9 delayed unions and 9 non-unions in 46 patients! As expected, time off work and eventual functional outcome was worse as well.

Bottom line: The exact mechanism for impairment of fracture healing by smoking is unclear. It may be due to physiologic effects of inhaled tobacco components on blood flow, blood vessels, transforming growth factor levels or collagen formation. It could also be a secondary effect of socioeconomic variables, patient compliance, or a host of other factors. Regardless, it’s bad. Smoking should be forbidden while in hospital, and should be strongly discouraged after discharge.

Reference: Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 42:1435-1442, 2011.

Dysphagia and Cervical Spine Injury

Cervical spine injury presents a host of problems, but one of the least appreciated ones is dysphagia. Many clinicians don’t even think of it, but it is a relatively common problem, especially in the elderly. Swallowing difficulties may arise for several reasons:

  • Prevertebral soft tissue swelling may occur with high cervical spine injuries, leading to changes in the architecture of the posterior pharynx
  • Rigid cervical collars, such as the Miami J and Aspen, and halo vests all force the neck into a neutral position. Elderly patients may have a natural kyphosis, and this change in positioning may interfere with swallowing. Try extending your neck by about 30 degrees and see how much more difficult it is to swallow.
  • Patients with cervical fractures more commonly need a tracheostomy for ventilatory support and/or have a head injury, and these are well known culprits in dysphagia

A study in the Jan 2011 Journal of Trauma outlines the dysphagia problem seen with placement of a halo vest. They studied a series of 79 of their patients who were treated with a halo. A full 66% had problems with their swallowing evaluation. This problem was associated with a significantly longer ICU stay and a somewhat longer overall hospital stay.

Bottom line: Suspect dysphagia in all patients with cervical fractures, especially the elderly. Carry out a formal swallowing evaluation, and adjust the collar or halo if appropriate. 

Reference: Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation. J Trauma 70(1):46-50, 2011.

Bleeding and Pelvic Fractures

Arterial bleeding from a pelvic fracture is more common than previously thought. The doctor books used to say that 10% of bleeding was arterial and 90% was venous, so angiographic techniques were seldom used unless there was clinical evidence of blood loss. 

It looks like arterial bleeding occurs more frequently than we think. Here are tips that help you identify patients at risk:

  • What type of mechanism caused the fracture? Anterior-posterior compression and vertical shear are the most common.
  • Are the vital signs stable? If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
  • Is the fracture open? Arterial bleeding is very likely.
  • How old is the patient? Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
  • What part of the pelvis is broken? If major sacral fractures, SI joint disruption or separation of the symphysis is present, think arterial bleeding.
  • Are there CT abnormalities? A vascular blush or large hematoma indicates significant bleeding.

The most common bleeding sites are the gluteal and pudendal arteries. The gluteal is in proximity to the SI joint, so this can be torn if the SI joint is damaged or the sacrum is fractured. The pudendal can be injured with ramus fractures, especially when the symphysis is widened.

If the patient can be reasonably stabilized, then a trip to interventional radiology is mandatory. Operative management is not very successful, so patients with blood pressure lability or controllable hypotension should go to IR. All active bleeding and arterial cutoffs should be embolized thoroughly.

Images: On the left is the portable plain image of a vertical shear pelvic fracture. The arrows on the right point to two areas of vascular blush.

Pelvic arterial bleeding