Facial Trauma — MCQs

10 questions

An adult patient sustained a subcondylar fracture on the left side. Clinically it is seen that there is :

Patient with history of blunt trauma to face presents with enophthalmos, diplopia on upward gaze and loss of sensitivity over cheek. True statement about this is:

In an accident case, after the arrival of medical team, all should be done in early management except;

Le Fort II facial fracture implies:

Which of the following is NOT a characteristic of a blowout fracture of the orbit?

Le Forte II is fracture of?

What is to be addressed first in case of polytrauma -

Paresthesia is seen with which of the following types of fractures:

After an accident, a patient is unable to close her mouth completely due to certain facial injuries. Which muscle is paralyzed most commonly?

Q10

What causes Frey's syndrome?

Facial Trauma Indian Medical PG Practice Questions and MCQs

Question 1: An adult patient sustained a subcondylar fracture on the left side. Clinically it is seen that there is :

A. Deviation of the mandible to the left on protrusion (Correct Answer)
B. Inability to deviate the mandible to the right
C. Moderate intraoral bleeding
D. Trismus and bilateral crepitus

Explanation: ***Deviation of the mandible to the left on protrusion*** - A **subcondylar fracture on the left side** disrupts the normal function of the left lateral pterygoid muscle and the biomechanics of mandibular movement. - During protrusion or mouth opening, the **intact muscles on the right side** pull normally while the fractured left side cannot, causing the mandible to deviate **toward the fractured side (left)**. - This is the **classic clinical sign** of unilateral subcondylar fracture - deviation toward the affected side during protrusion and opening. *Inability to deviate the mandible to the right* - This is **not correct** for a left subcondylar fracture. - The patient would have difficulty deviating to the **left side** (fractured side), not to the right. - Lateral deviation to the contralateral (right) side would still be possible. *Moderate intraoral bleeding* - While some **intraoral bleeding** can occur with mandibular fractures due to soft tissue injury, **moderate bleeding** is not a specific or primary clinical sign of an isolated subcondylar fracture. - Subcondylar fractures are typically **extracapsular** and often present without significant intraoral hemorrhage. *Trismus and bilateral crepitus* - **Trismus** (limited mouth opening) is common with subcondylar fractures due to muscle spasm and pain. - However, **bilateral crepitus** is unlikely with a **unilateral** subcondylar fracture. - Crepitus would typically be localized to the **left side only**, and bilateral crepitus suggests bilateral fractures or more extensive trauma.

Question 2: Patient with history of blunt trauma to face presents with enophthalmos, diplopia on upward gaze and loss of sensitivity over cheek. True statement about this is:

A. Maxillary fracture
B. Zygomatic bone is most likely injured
C. It is a blow out fracture (Correct Answer)
D. Frontal bone fracture

Explanation: ***It is a blow out fracture*** - The combination of **enophthalmos** (sunken eye), **diplopia on upward gaze** (due to **inferior rectus muscle entrapment**), and **loss of sensitivity over the cheek** (indicating infraorbital nerve involvement) are classic signs of an **orbital blowout fracture**. - These fractures typically involve the **orbital floor** or medial wall, caused by a direct impact to the orbit, which transmits force to the thin bony walls causing them to fracture while the orbital rim remains intact. *Maxillary fracture* - While the **infraorbital nerve** passes through the maxilla, a general maxillary fracture typically presents with broader symptoms such as **midfacial pain**, **swelling**, and **malocclusion**, which are not specified here. - Maxillary fractures often involve the **zygomaticomaxillary complex** or Le Fort patterns, which usually lead to more extensive facial abnormalities. *Zygomatic bone is most likely injured* - A **zygomatic arch fracture** would primarily cause **flattening of the cheek** and pain upon opening the mouth, not enophthalmos or diplopia on upward gaze. - While the zygoma forms part of the orbit, isolated zygomatic fractures rarely cause these specific orbital findings. *Frontal bone fracture* - **Frontal bone fractures** typically result from **high-impact trauma** and can involve the **frontal sinus**, leading to **forehead swelling**, **CSF rhinorrhea**, or **periorbital ecchymosis** (raccoon eyes). - The symptoms described are not characteristic of a frontal bone fracture.

Question 3: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 4: Le Fort II facial fracture implies:

A. Fracture running through alveolar ridge
B. Fracture running through midline of the palate and zygomatico-maxillary suture
C. Fracture running through zygomatic process of the maxilla, floor of orbit, and root of nose bilaterally (Correct Answer)
D. Bilateral fracture involving multiple facial bones with midface mobility

Explanation: ***Fracture running through zygomatic process of the maxilla, floor of orbit, and root of nose bilaterally*** - A **Le Fort II fracture**, also known as a **pyramidal fracture**, involves the separation of the midface from the cranium. - The fracture line typically extends bilaterally from the **nasal bones** through the **lacrimal bones**, **orbital floors**, and **zygomaticomaxillary sutures**, involving the **zygomatic process of the maxilla**. *Fracture running through alveolar ridge* - This description is characteristic of a **Le Fort I fracture**, which is also known as a **transverse maxillary fracture**. - A **Le Fort I fracture** involves separation of the palate and alveolar processes from the rest of the maxilla at the level of the nasal floor. *Fracture running through midline of the palate and zygomatico-maxillary suture* - While Le Fort fractures can involve the **zygomaticomaxillary suture**, a fracture specifically through the **midline of the palate** is more indicative of a **palatal fracture** or can be a component of a **Le Fort I fracture** if it extends transversely. - The unique combination described (midline palate and zygomatico-maxillary suture) does not perfectly fit the established Le Fort classifications on its own. *Bilateral fracture involving multiple facial bones with midface mobility* - While there is **midface mobility** in most Le Fort fractures, this description is too generic and could apply to **Le Fort II** or **Le Fort III fractures**. - It does not specify the precise anatomical path of the fracture, which is crucial for distinguishing between the different Le Fort types.

Question 5: Which of the following is NOT a characteristic of a blowout fracture of the orbit?

A. Orbital floor and medial wall involvement are common
B. Exophthalmos (Correct Answer)
C. Tear drop sign on CT scan
D. Diplopia due to muscle entrapment

Explanation: ***Exophthalmos*** - A **blowout fracture** typically causes the orbital contents to herniate into adjacent sinuses (maxillary or ethmoid), leading to an **increase in orbital volume**. - This increased orbital volume, combined with swelling and potential hemorrhage, usually results in **enophthalmos** (recession of the eyeball), not exophthalmos (protrusion of the eyeball). *Orbital floor and medial wall involvement are common* - The **orbital floor** (paper-thin bone separating the orbit from the maxillary sinus) and **medial wall** (separating the orbit from the ethmoid sinus) are the weakest structures of the orbit and are most commonly fractured in a blowout injury. - These areas are susceptible to fracture due to the force transmitted to the orbital contents, causing a sudden increase in intraorbital pressure. *Tear drop sign on CT scan* - The **tear drop sign** on a CT scan is a classic finding in orbital blowout fractures, representing the **herniation of orbital fat** or inferior rectus muscle into the maxillary sinus. - This sign indicates the displacement of soft tissue through the fractured orbital floor. *Diplopia due to muscle entrapment* - **Diplopia** (double vision) is a common symptom in blowout fractures, often caused by the **entrapment of extraocular muscles** (most commonly the inferior rectus or medial rectus) within the fracture site. - Muscle entrapment restricts ocular motility, particularly on upward or sideways gaze, leading to double vision.

Question 6: Le Forte II is fracture of?

A. Fracture involving midline of the palate and zygomatico-maxillary suture
B. Fracture involving alveolar ridge
C. Fracture involving lateral side of hard palate
D. Fracture involving zygomatic process of the maxilla, floor of orbit, root of nose (Correct Answer)

Explanation: ***Fracture involving zygomatic process of the maxilla, floor of orbit, root of nose*** - A **Le Fort II fracture**, also known as a **pyramidal fracture**, involves the **nasal bones**, **frontal processes of the maxilla**, **lacrimal bones**, and the **zygomaticomaxillary suture**. - This fracture pattern creates a pyramid-shaped detached segment of the midface, including the **floor of the orbit** and the **zygomatic process of the maxilla**. *Fracture involving midline of the palate and zygomatico-maxillary suture* - This description is characteristic of a **Le Fort I fracture**, which involves the **maxilla separating from the pterygoid plates** and nasal septum, producing a floating palate. - A **Le Fort I fracture** typically involves the **midline of the palate** and may extend to the zygomaticomaxillary suture but often inferiorly. *Fracture involving alveolar ridge* - This describes a **dentoalveolar fracture**, which is a localized fracture of the **alveolar process** containing teeth, without involving the major midfacial structures. - These fractures are typically confined to the tooth-bearing part of the maxilla or mandible and are not classified as a Le Fort fracture. *Fracture involving lateral side of hard palate* - While a fracture extending to the lateral side of the hard palate can occur with various midfacial traumas, this specific description is not the defining characteristic of any of the Le Fort fracture classifications. - Le Fort fractures involve comprehensive patterns of maxillary and midfacial separation, rather than isolated fractures of the lateral hard palate.

Question 7: What is to be addressed first in case of polytrauma -

A. Circulation
B. Neurology
C. Blood Pressure
D. Airway (Correct Answer)

Explanation: ***Airway*** - Maintaining a **patent airway** is the absolute first priority in polytrauma management according to the **ATLS (Advanced Trauma Life Support)** protocol. - Failure to secure an airway can lead to **hypoxia** and **brain damage** within minutes, regardless of other injuries. *Circulation* - While critical, addressing **circulation** (C in ABCDE) comes after establishing a secure airway and adequate breathing (A and B). - Uncontrolled hemorrhage would be the focus of circulation management, but only after guaranteeing proper oxygenation. *Neurology* - Neurological assessment (D in ABCDE for Disability) follows the primary survey of airway, breathing, and circulation. - Initial neurological evaluation focuses on **level of consciousness** using the **GCS (Glasgow Coma Scale)**. *Blood Pressure* - **Blood pressure** is an indicator of circulatory status but is not the first thing to be addressed. - It falls under the "C" for circulation in the ATLS protocol, which is secondary to airway and breathing.

Question 8: Paresthesia is seen with which of the following types of fractures:

A. Zygomatico maxillary (Correct Answer)
B. Coronoid process
C. Subcondylar
D. Symphyseal

Explanation: ***Zygomatico maxillary*** - Fractures involving the **zygomatico maxillary complex** (ZMC) can damage the **infraorbital nerve**, which passes through the infraorbital canal within the maxilla part of the ZMC. - Damage to the infraorbital nerve results in **paresthesia** (numbness or tingling) in the distribution of this nerve, affecting the cheek, upper lip, and anterior maxillary teeth on the affected side. *Coronoid process* - Fractures of the **coronoid process** are generally stable and typically do not involve nerves that would cause paresthesia. - The primary symptoms are usually pain, swelling, and an inability to open the mouth fully. *Subcondylar* - **Subcondylar fractures** primarily affect the **mandibular condyle**, leading to issues with occlusion, pain, and limited mouth opening. - While branches of the **trigeminal nerve** are nearby, significant nerve damage leading to paresthesia is uncommon with this type of fracture, unless there's an associated extensive injury. *Symphyseal* - **Symphyseal fractures** involve the midline of the mandible. - Although the **inferior alveolar nerve** passes through the mandible, paresthesia due to a symphyseal fracture is less common as the nerve is typically not transected at this site.

Question 9: After an accident, a patient is unable to close her mouth completely due to certain facial injuries. Which muscle is paralyzed most commonly?

A. Orbicularis oris (Correct Answer)
B. Zygomaticus major
C. Levator anguli oris
D. Buccinators

Explanation: ***Orbicularis oris*** - The **orbicularis oris** muscle forms a ring around the mouth and is primarily responsible for **closing and protruding the lips**, as well as other facial expressions involving the mouth. - Injury leading to paralysis of this muscle would directly impair the ability to **close the mouth completely** and **seal the lips**. *Zygomaticus major* - The **zygomaticus major** muscle acts to pull the corners of the mouth **upward and laterally**, contributing to smiling. - Its paralysis would affect the ability to smile effectively, but not directly impede the ability to close the mouth. *Levator anguli oris* - The **levator anguli oris** muscle elevates the corner of the mouth (angle of the mouth). - Its dysfunction would impair the ability to raise the corner of the mouth, not the ability to completely close the mouth. *Buccinators* - The **buccinator** muscle is involved in pressing the cheek against the teeth, which helps in chewing, whistling, and sucking. - Paralysis of the buccinator would primarily affect these actions, potentially causing food to pocket in the cheeks, but would not directly prevent mouth closure.

Question 10: What causes Frey's syndrome?

A. Facial nerve damage.
B. Greater auricular nerve involvement.
C. Aberrant regeneration of parasympathetic fibers from the auriculotemporal nerve to sweat glands. (Correct Answer)
D. None of the options

Explanation: ***Aberrant regeneration of parasympathetic fibers from the auriculotemporal nerve to sweat glands.*** - Frey's syndrome, or **gustatory sweating**, occurs due to aberrant regeneration after parotid surgery or trauma where parasympathetic secretomotor fibers meant for the **parotid gland** (carried by the auriculotemporal nerve) incorrectly reinnervate **sweat glands and blood vessels** in the overlying skin. - This misdirection leads to **sweating and flushing** over the parotid region in response to gustatory stimuli (eating, thinking about food). - The auriculotemporal nerve is a branch of the **mandibular division of the trigeminal nerve (V3)** that carries parasympathetic fibers to the parotid gland. *Greater auricular nerve involvement.* - The greater auricular nerve is a sensory nerve (from C2-C3) that provides sensation to the **external ear** and skin over the parotid region. - Damage to this nerve causes **numbness** in its distribution, not gustatory sweating. *Facial nerve damage.* - The facial nerve (CN VII) primarily controls **muscles of facial expression** and provides taste sensation from the anterior two-thirds of the tongue. - Damage leads to **facial paralysis**, not Frey's syndrome. *None of the options* - Incorrect, as the first option accurately describes the underlying cause of Frey's syndrome.

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