OMFS case discussions

[Bifid Uvula]

I think it would be nice if we could (keeping in mind any HIPAA rules/patient privacy rules) discuss a few cases and post some pictures... Any pictures posted must have the eyes and other identifying factors removed/blocked out etc...

I'm thinking this could open up some academic debate and spark a little new life into our posts.

The thing is, for this to be a little meaningful we gotta come to a consensus and try to stick to one or two topics at a time. It be nice to see and compare some cases from the different programs across the country.

I'm thinking we could do it in such a manner to include a couple cases involving the following...

1) Trauma:
Panfacial Fractures
Penetrating Facial Trauma
Extensive/Severe Facial Lacerations
Unusual Trauma Cases

2) Pathology:
Oral Cancer (with neck disections, microvascular recons etc)
Benign Tumors
Skin Cancer

3) Orthognathic Surgery and Facial Cosmetic Surgery
Maxilla
Mandible
Combined Cases
I say Facial Cosmetic surgery in this section, because there is no facial cosmetic surgery more invasive than an orthognathic surgery, and many times there are other cosmetic procedures done in combination.

4) Craniofacial Surgery:
Craniosynostosis
Cleft Lip/Palate
Distraction Osteogenesis

5) Dental Implants:
Extensive Dental Implant Cases involving major bone grafting...

6) 3rd Molars:
U know, funky/hard cases where the 3rd molar is growing somewhere down by the angle of the mandible with the IAN wrapped around it smiling back at you on the panorex....

What do u guys and gals think???

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[aphistis]

Great idea. I'll sticky this thread so it's easy to find.

 

[Bifid Uvula]

Great idea. I'll sticky this thread so it's easy to find.

That just sounds way too wrong... but anyway.

 

[Jaybe]

!

 

[EuroOMFS]

We´re beginning to see a lot of ONJ patients over here. Thought I´d share this case with you.

61 year old lady, with myelomatosis, treated with iv bisphosnoates for 2 years (Zometa). Her dentist refers her to our unit because she spontaniously develops a dehiscence in her left lower jaw. In September 2006 the first premolar is not loosened but the second premolar is. In november 2006, they are both loose. Saw her today. The dehiscence has grown to include the distal aspect of the second premolar. There are currently no signs of infection in the area.

She has been treated with Penicillin V p.o. as well as Metronidazol, with good effect on her symptoms. Currently there are no symptoms, and she isn´t on any medication for her ONJ.

The second premolar will have to be extracted at some point, but we are holding on to it for now.

Any thoughts?

 

[scalpel2008]

We´re beginning to see a lot of ONJ patients over here. Thought I´d share this case with you.

61 year old lady, with myelomatosis, treated with iv bisphosnoates for 2 years (Zometa). Her dentist refers her to our unit because she spontaniously develops a dehiscence in her left lower jaw. In September 2006 the first premolar is not loosened but the second premolar is. In november 2006, they are both loose. Saw her today. The dehiscence has grown to include the distal aspect of the second premolar. There are currently no signs of infection in the area.

She has been treated with Penicillin V p.o. as well as Metronidazol, with good effect on her symptoms. Currently there are no symptoms, and she isn´t on any medication for her ONJ.

The second premolar will have to be extracted at some point, but we are holding on to it for now.

Any thoughts?

nice series of photographs. sounds like this is a stage II BRONJ. I believe the current recommendations (released by the AAOMS task force in September,2006) essentially recommends abx (which you have going), antimicrobial rinses such as chlorohexidene, and conservative superficial debridement extraction if it the tooth is within the area to be debrided (2nd premolar). What's her prognosis with her multiple myeloma now? If it's advanced disease, then I guess one has to just consider pain and local infection control rather than having the last few months of one's life dealing with serial debridements because the mandible starts to slough off because of exacerbating the necrosis with intervention. The fact that she has survived 2 years indicates her MM isn't too advanced, although she is on the most potent bisphosphonate. The last MM pt I saw had an expected survival of about 10-12 months but his Ca was through the roof, had vertebral ds with spinal cord compression, etc etc. Keep us posted. What else are you offering this patient? BRONJ already is and is definitely going to be a bigger issue in the years to come. Also, hyperbaric O2 might be an option but there are no studies yet to prove it's benefit. Have you guys thought of this? I'm curious if the European recommendations are different than the US ones.
Also, you can bet there will be a few questions on the subject on the OMSSAT this year, not that it matters to to you EuroOMFS (do you have a yearly inservice exam in europe?)

 

[Bifid Uvula]

Here is the link to the AAOMS September Position Statement on Bisphosphonate Osteonecrosis of the Jaws...

http://www.aaoms.org/docs/position_papers/osteonecrosis.pdf

 

[EuroOMFS]

nice series of photographs. sounds like this is a stage II BRONJ. I believe the current recommendations (released by the AAOMS task force in September,2006) essentially recommends abx (which you have going), antimicrobial rinses such as chlorohexidene, and conservative superficial debridement extraction if it the tooth is within the area to be debrided (2nd premolar). What's her prognosis with her multiple myeloma now? If it's advanced disease, then I guess one has to just consider pain and local infection control rather than having the last few months of one's life dealing with serial debridements because the mandible starts to slough off because of exacerbating the necrosis with intervention. The fact that she has survived 2 years indicates her MM isn't too advanced, although she is on the most potent bisphosphonate. The last MM pt I saw had an expected survival of about 10-12 months but his Ca was through the roof, had vertebral ds with spinal cord compression, etc etc. Keep us posted. What else are you offering this patient? BRONJ already is and is definitely going to be a bigger issue in the years to come. Also, hyperbaric O2 might be an option but there are no studies yet to prove it's benefit. Have you guys thought of this? I'm curious if the European recommendations are different than the US ones.

Her prognosis is fair, her disease isn´t very advanced, there are no kidney problems and currently no hypercalcemia. We have discussed HBO treatment but since there´s no evidence for it working either way we´ve chosen not to do it for now. The nearest HBO facility is 180 km away from where she lives.

I´m not sure there are any common european guidelines for treatment of BR ONJ. I guess different countries have their own. We have some basic guidelines here in Denmark and there is currently a panel of experts (maxillofacial and hematology) working on refining and expanding them. For now, we follow mostly Woo´s et al recommendations (Ann Intern Med. 2006 May 16;144(10):753-61.)

Also, you can bet there will be a few questions on the subject on the OMSSAT this year, not that it matters to to you EuroOMFS (do you have a yearly inservice exam in europe?)

No we don´t have a yearly exam, but there is a final exam in most european countries.

 

[esclavo]

nice series of photographs. sounds like this is a stage II BRONJ. I believe the current recommendations (released by the AAOMS task force in September,2006) essentially recommends abx (which you have going), antimicrobial rinses such as chlorohexidene, and conservative superficial debridement extraction if it the tooth is within the area to be debrided (2nd premolar). What's her prognosis with her multiple myeloma now? If it's advanced disease, then I guess one has to just consider pain and local infection control rather than having the last few months of one's life dealing with serial debridements because the mandible starts to slough off because of exacerbating the necrosis with intervention. The fact that she has survived 2 years indicates her MM isn't too advanced, although she is on the most potent bisphosphonate. The last MM pt I saw had an expected survival of about 10-12 months but his Ca was through the roof, had vertebral ds with spinal cord compression, etc etc. Keep us posted. What else are you offering this patient? BRONJ already is and is definitely going to be a bigger issue in the years to come. Also, hyperbaric O2 might be an option but there are no studies yet to prove it's benefit. Have you guys thought of this? I'm curious if the European recommendations are different than the US ones.
Also, you can bet there will be a few questions on the subject on the OMSSAT this year, not that it matters to to you EuroOMFS (do you have a yearly inservice exam in europe?)

There have been no reported studies but in my opinion, I'd doubt if HBO will do jack for BRORNJ. The problem is hyperdense bone with no osteoclastic function. I don't know how HBO would help reactivate osteoclasts. HBO supposedly helps macrophages in hypoxic environments to secret angiogenic factors. But according to the "experts" there is no "space" for angiogenesis to occur....once the osteoclasts return to function and create the necessary bone resorption areas (space) then maybe HBO would work, but the key according to the "experts" is return of osteoclast function..... but then again, what do I know.... I thought Ohio State was going to run over Florida in the BCS Bowl (I did predict to many that Boise State was going to beat Oklahoma though, but don't start calling me Nostradamas or anything...)

 

[doncorleone]

i think esclavo is right, HBO won't do anything for BRORNJ, but it would with ORN, since the physiology of ORN has a hypovascular, hypocellular, and hypoxic tissue bed. whereas, like esclavo said, BRORNJ is inhibition in osteoclastic activity.

 

[Bitters]

prediction: in 5 years HBO will no longer be a option for ORN.

as it relates to pre tx extractions.

 

[scalpel2008]

I personally dont believe in HBO for BRONJ, but the thought process of the task force is (and I hate this way of thinking), it can't hurt and we don't have much else. It certainly is on the minds of those who are treating BRONJ until they can prove it does no good (which they haven't done yet)

 

[drhobie7]

From your (all y'all) personal experience with these cases, do any patients get complete resolution of the bone exposure?

 

[esclavo]

From your (all y'all) personal experience with these cases, do any patients get complete resolution of the bone exposure?

I've only seen very small cases when the people were on oral bisphosphonates resolve. My personal treatment algorithm for our bisphosphonate patients is: fasting, prayer, penitence, sweat lodges, seances, witchcraft, wearing my lab coat inside out, and washing myself three times in a row in the Kaskaskia River......oh yeah and antibiotics/peridex

 

[EuroOMFS]

No other cases?

 

[IcedOMFS]

No other cases?

Fine. Here's one for you. 40 something year old dude, was treated non-surgically for his R subcondylar, R body, and L body fractures by plastics using IMF screws. Sat on the ward for 2 weeks before he got to the OR for the MMF. Dude released his own MMF about 2 weeks post reduction, disappeared for 2 months without follow up, but with the screws and wires still there... Came back with a non-union of the left body fracture. Received extraction of all his remaining teeth, debridement, anatomical reduction, and an ex-fix. In case you couldn't guess, he had no dentures, partial or otherwise. No, he did not have any more teeth than this when he was initially placed into the IMF screws. Yes, I broke the root tips off both of the canines when I took them out. Yes, it was because they were kind enough to impale the canines with the IMF screws.

 

[scalpel2008]

Fine. Here's one for you. 40 something year old dude, was treated non-surgically for his R subcondylar, R body, and L body fractures by plastics using IMF screws. Sat on the ward for 2 weeks before he got to the OR for the MMF. Dude released his own MMF about 2 weeks post reduction, disappeared for 2 months without follow up, but with the screws and wires still there... Came back with a non-union of the left body fracture. Received extraction of all his remaining teeth, debridement, anatomical reduction, and an ex-fix. In case you couldn't guess, he had no dentures, partial or otherwise. No, he did not have any more teeth than this when he was initially placed into the IMF screws. Yes, I broke the root tips off both of the canines when I took them out. Yes, it was because they were kind enough to impale the canines with the IMF screws.

malpractice

 

[toofache32]

My program director collects these films. One of the best is a mandible fx referred to him by a local ENT who put a 2.4 recon plate across an isolated body fracture. All 6 screws are through the nerve canal.

 

[EuroOMFS]

Fine. Here's one for you. 40 something year old dude, was treated non-surgically for his R subcondylar, R body, and L body fractures by plastics using IMF screws. Sat on the ward for 2 weeks before he got to the OR for the MMF. Dude released his own MMF about 2 weeks post reduction, disappeared for 2 months without follow up, but with the screws and wires still there... Came back with a non-union of the left body fracture. Received extraction of all his remaining teeth, debridement, anatomical reduction, and an ex-fix. In case you couldn't guess, he had no dentures, partial or otherwise. No, he did not have any more teeth than this when he was initially placed into the IMF screws. Yes, I broke the root tips off both of the canines when I took them out. Yes, it was because they were kind enough to impale the canines with the IMF screws.

Thankfully, the ENT and plastics people here don´t treat facial fractures.

I've just spent a year at another hospital where ENT would regularly treat odontogenic infections, most of the time without ever consulting us. I remember one guy, mid 30s, who had been admitted to ENT for about 10 days on iv antibiotics with a right submandibular abcess. They finally ask for a consult because "he´s got rotten teeth". I go over there only to see he's missing a few teeth, the rest are fine. I order a panoramix and find an impacted 3rd with a huge pericoronitis. At this time the abcess is fluctuating and just screaming for an I and D. The guy has elevated WBC and CRP.

But no. The ENT people have done their ultrasounds every day since he was admitted, and can't really find any abcess. They're not sure it´s really an infection!!!!! And even if it is, they don't think it's a good idea to prick a hole in it, because they're not sure they'd be able to drain any pus. Anyway, I told them the impacted 3rd molar was probably the cause and to cut a long story short, they finally drained the abcess after about three weeks, and of course they empty out large quantities of pus. That the infection didn´t spread more in this time is just dumb luck in my opinion.

 

[esclavo]

Fine. Here's one for you. 40 something year old dude, was treated non-surgically for his R subcondylar, R body, and L body fractures by plastics using IMF screws. Sat on the ward for 2 weeks before he got to the OR for the MMF. Dude released his own MMF about 2 weeks post reduction, disappeared for 2 months without follow up, but with the screws and wires still there... Came back with a non-union of the left body fracture. Received extraction of all his remaining teeth, debridement, anatomical reduction, and an ex-fix. In case you couldn't guess, he had no dentures, partial or otherwise. No, he did not have any more teeth than this when he was initially placed into the IMF screws. Yes, I broke the root tips off both of the canines when I took them out. Yes, it was because they were kind enough to impale the canines with the IMF screws.

In my opinion, IMF screws are crap except for a few isolated situations. The only time I like IMF screws are for people with an excellent full dentition AND a mandible fracture somewhere between the condyle and the angle. For most other fractures the vector of the IMF screws ends up distracting my fractures and frustrating my internal fixation attempts. I've fallen in love with IVY loops. I rarely use arch bars or IMF screws. There are little tricks with IVY loops but they are so versatile and fast. Patients like them so much better if they have to have any time in IMF. The vector of reduction is as close to the axis of the tooth as you can get.....I loved the panorex. Most Plastics working hard tissue is like watching a dermatologist scrub at an OR sink.... it just looks painful.

 

[scalpel2008]

In my opinion, IMF screws are crap except for a few isolated situations. The only time I like IMF screws are for people with an excellent full dentition AND a mandible fracture somewhere between the condyle and the angle. For most other fractures the vector of the IMF screws ends up distracting my fractures and frustrating my internal fixation attempts. I've fallen in love with IVY loops. I rarely use arch bars or IMF screws. There are little tricks with IVY loops but they are so versatile and fast. Patients like them so much better if they have to have any time in IMF. The vector of reduction is as close to the axis of the tooth as you can get.....I loved the panorex. Most Plastics working hard tissue is like watching a dermatologist scrub at an OR sink.... it just looks painful.

we are using MMF screws on a fair # of our mandible fractures to provide MMF for internal fixation, and I must say that I am a fan. The only time we use ivy loops is when we get a mandible that we don't anticipate is going to the OR for a couple of days. We never use ivy loops for MMF for internal fixation, although I can hee how they are an option. We still use arch bars for about 80% of our MMF. We never use MMF screws for a closed treatment of a fracture. We use them only if we know they are coming off at the end of the case.

 

[EuroOMFS]

In my opinion, IMF screws are crap except for a few isolated situations. The only time I like IMF screws are for people with an excellent full dentition AND a mandible fracture somewhere between the condyle and the angle. For most other fractures the vector of the IMF screws ends up distracting my fractures and frustrating my internal fixation attempts. I've fallen in love with IVY loops. I rarely use arch bars or IMF screws. There are little tricks with IVY loops but they are so versatile and fast. Patients like them so much better if they have to have any time in IMF. The vector of reduction is as close to the axis of the tooth as you can get.....I loved the panorex. Most Plastics working hard tissue is like watching a dermatologist scrub at an OR sink.... it just looks painful.

We dont use IMF screws a lot, we use arch bars in most of our cases. I have treated two unilateral subcondylar fractures closed with IMF screws, both in combination with body fractures that were plated. Those cases went well. Both had a perfect dentition and a stable occlusion though.

 

[toofache32]

How about some xrays:

Should this be billed as a surgical extraction? The funny thing is that our department will make almost as much removing that tooth as we will fixing the fractures.



And this is the reason why you take out 3rd molars when the patient is young. This patient is 72, A-Fib, getting ready for a valve replacement for his severe aortic stenosis. All the 3rd molars are palpable.

 

[Doggie]

How about some xrays:

Should this be billed as a surgical extraction? The funny thing is that our department will make almost as much removing that tooth as we will fixing the fractures.



And this is the reason why you take out 3rd molars when the patient is young. This patient is 72, A-Fib, getting ready for a valve replacement for his severe aortic stenosis. All the 3rd molars are palpable.

I love how all these CVTS bitches expect you to clear their patients for CABG just hours before their surgery.

 

[rrc]

I love how all these CVTS bitches expect you to clear their patients for CABG just hours before their surgery.

Just remember that these patients are often acute post-MI or severe unstable angina who have just had an angiography and determined to need bypass surgery. They haven't exactly had time to go to their friendly neighborhood dentist and have the "full court press" restorative work done. The key is to manage these patients as quickly as possible and remove any sources of significant infection so that they can have their heart surgery performed and not drop dead in the next few days. I agree it is frustrating but just remember the circumstances!

 

[scalpel2008]

I love how all these CVTS bitches expect you to clear their patients for CABG just hours before their surgery.

We only do these evaluations/treatments for pre cardiac transplant and pre valve replacement patients. For the pre transplant patients, they are sent over the moment they are identified with needing a transplant so we get it done quickly, even though there's no saying when they will actually get the new heart. The valve replacement patients usually have a specific date they are getting their valve replaced so we get it done before that date. If you are having to do these evaluation prior to CABGs, are you also getting these same requests before fem-pops, AVFs, and other bypass surgeries? Dental extractions prior to a CABG is news to me.

 

[toofache32]

Just remember that these patients are often acute post-MI or severe unstable angina who have just had an angiography and determined to need bypass surgery. They haven't exactly had time to go to their friendly neighborhood dentist and have the "full court press" restorative work done. The key is to manage these patients as quickly as possible and remove any sources of significant infection so that they can have their heart surgery performed and not drop dead in the next few days. I agree it is frustrating but just remember the circumstances!

I used to think that also, but every time I look through their records I find out that they've already been in the hospital for 2 weeks getting their work-up. They've had multiple echos, PFTs, vein mapping of the legs, etc. Then at the last minute someone looks in their mouth and sends them to us "in preparation for CABG tomorrow."

There was a CVTS intern a couple of years ago who just started sending his inpatients to our clinic.....no consult, no note, no recommendations, nothing. For the first couple of patients, I knew what they were there for but I called him to kindly ask him to consult us so we can find the best spot in our schedule for the patients. But he kept on just sending them. So finally one of these patients showed up to clinic on an incredibly busy day, so I just sent him right back to the floor. It was about 7pm that night (after clinic was closed) that the intern realized this guy is back on the floor with all his teeth. He paged me frantically (because the CVTS Fellow was going to eat his ass over this) and asked what happened. I said the patient came to clinic but didn't have an appointment, and that we sent him away because nobody had consulted us. He never did it again.

 

[EuroOMFS]

Dental extractions prior to a CABG is news to me.

Agreed. Over here we only see patients prior to heart valve replacement and transplats (and then usually they're scheduled for surgery in a couple of days!!)

 

[Bifid Uvula]

Here's a nice case...

25 YO Male, driving to work in one morning when an 18 wheeler flips on the icy road and smashes into this unfortunate kid.

The Trauma Team and Ophthalmology got in a nice fight over his right eye and the ruptured globe and transected optic nerve. In the end, Ophthalmology decided to just do a repair, and give him a few days to come to terms with the fact that they would have to enucleate his eye. There was concern regarding antibody destruction that could occur to the intact left eye as a result of the trauma to the right eye. Seems that most trauma surgeons I met just want the eye out ASAP, and that the Ophthalmologists are a little more sensitive to the patient's psychological issues. I guess they have a little more comfort level when it comes to waiting for the enucleation.

The patient was taken to the OR, the globe was repaired and we continued, repairing his "tiny" ZMC fx, and facial lacerations. 2 weeks later I scrubbed in with the Opthalmologist to assist in enucleating this poor guy's eye (which by the way was an awesome review of Eye anatomy).

 

[Bifid Uvula]

These are also a couple I did in the ER last year.... Just goes to show you how important it is to wear your seat-belt! These were treated under local anesthesia with a thorough pulse-vac irrigation (keeping in mind the local anesthetic & epi limits).

Not necessarily anything spectacular, but sure drew lots of "oohs and ahhhhs" from the cute ER nurses.

 

[IcedOMFS]

(keeping in mind the local anesthetic & epi limits).

There's limits to local anesthetic and epi?

 

[toofache32]

My wife put her arm through the window when she was banging on it to get the dogs to shut up. The tendon was partially cut, but she had no deficits. I stole some sutures, irrigation, betadine, lidocaine, and a tetanus dose from the ER and sewed her up on the coffee table at home. My silk suture broke, so I ended up finishing it with some prolene I had laying around.

 

[Doggie]

My wife put her arm through the window when she was banging on it to get the dogs to shut up. The tendon was partially cut, but she had no deficits. I stole some sutures, irrigation, betadine, lidocaine, and a tetanus dose from the ER and sewed her up on the coffee table at home. My silk suture broke, so I ended up finishing it with some prolene I had laying around.

Sure it wasnt a domestic violence issue? I heard people who live in trailer parks are 50x more prone to domestic disputes.

 

[OMFSCardsFan]

My wife put her arm through the window when she was banging on it to get the dogs to shut up. The tendon was partially cut, but she had no deficits. I stole some sutures, irrigation, betadine, lidocaine, and a tetanus dose from the ER and sewed her up on the coffee table at home. My silk suture broke, so I ended up finishing it with some prolene I had laying around.

You planning on taking your kids' thirds out on the coffee table, too?

 

[toofache32]

You planning on taking your kids' thirds out on the coffee table, too?

Hmmm. I haven't thought of that.

 

[esclavo]

Hmmm. I haven't thought of that.

Any guy that would take his kids thirds out on the kitchen table is a man after my own heart.

Here are some pictures of a sweet OMFS case. It is an oldy but a goody. Man! Those Hall Drills sure come in handy but it can be challenging keeping the field cool with enough irrigation. This case happened before my time... Just the thought makes me weak.... Proceed with caution....

 

[IcedOMFS]

Any guy that would take his kids thirds out on the kitchen table is a man after my own heart.

Here are some pictures of a sweet OMFS case. It is an oldy but a goody. Man! Those Hall Drills sure come in handy but it can be challenging keeping the field cool with enough irrigation. This case happened before my time... Just the thought makes me weak.... Proceed with caution....

Man, why you gotta go and post something like that. That's just nasty. I'm scarred for life.

 

[MrVagus]

WTF Holy Crap, but the question I have is what would possess anyone to do such a thing to themselves

 

[WestCoast]

Any guy that would take his kids thirds out on the kitchen table is a man after my own heart.

Here are some pictures of a sweet OMFS case. It is an oldy but a goody. Man! Those Hall Drills sure come in handy but it can be challenging keeping the field cool with enough irrigation. This case happened before my time... Just the thought makes me weak.... Proceed with caution....

i used to see those during urology rotation. some queer people out there.

 

[OMFSCardsFan]

Any guy that would take his kids thirds out on the kitchen table is a man after my own heart.

Here are some pictures of a sweet OMFS case. It is an oldy but a goody. Man! Those Hall Drills sure come in handy but it can be challenging keeping the field cool with enough irrigation. This case happened before my time... Just the thought makes me weak.... Proceed with caution....

Did that happen to you before or after you had kids? Your wife needs to keep a closer eye on you...

 

[flat4]

Kind of looks like this:

 

[toofache32]

Here's a great tat off a guy's leg in the trauma bay. Just before it got amputated. WARNING: PG-13 rated!

 

[IcedOMFS]

Here's a great tat off a guy's leg in the trauma bay. Just before it got amputated. WARNING: PG-13 rated!

Nothing like a golden shower tattoo. Or is it a squirter? Hard to tell...

 

[Drill2Fill]

Here's a great tat off a guy's leg in the trauma bay. Just before it got amputated. WARNING: PG-13 rated!

Let me guess, a motorcycle accident?

 

[esclavo]

I was just trying to emphasize the importance of a finger rest technique when using a hall..... and lots of irigation.... and a good penile block.... when indicated..... heaven help us if you slip on this case....

 

[scalpel2008]

speaking of tattoos, here's one from a pt about to undergo a brow sebaceous cyst excision when i was an intern...now that's what i call porkin' it piggiestyle

 

[Bifid Uvula]

speaking of tattoos, here's one from a pt about to undergo a brow sebaceous cyst excision when i was an intern...now that's what i call porkin' it piggiestyle

I don't have these pics, but i bet esclavo can track them down.

We had a patient in the ICU last year on the vent .... Neo-Nazi dude

He had swastikas and all sorts of tattoos on his body, but most shocking of all was that on his eyelids, he had EYES tattooed on. So when his eyes were closed it looked like his eyes were open!

 

[Doggie]

I don't have these pics, but i bet esclavo can track them down.

We had a patient in the ICU last year on the vent .... Neo-Nazi dude

He had swastikas and all sorts of tattoos on his body, but most shocking of all was that on his eyelids, he had EYES tattooed on. So when his eyes were closed it looked like his eyes were open!

I wonder what hurts more; getting tattoos on your eyelids or having toofache operate on you.

 

[EuroOMFS]

I wonder what hurts more; getting tattoos on your eyelids or having toofache operate on you.

As much as I like the direction this thread has taken, I´m afraid I´m going to have to be a bore and return to the intial topic.

This is not in any way an unusal case, but I´m sure there are very different opinions on when and how to treat.

A 65 yr old, generally healthy male, falls in his home 3 days earlier. Presents at the ER because of persistant diplopia. A CT shows a trapdoor blow-out fracture on the left side. There are no other abnormal findings on the CT, specifically no intracerebral lesions.

His ocular mobility is not impaired, but his diplopia worsens when he looks up and to the sides. His pupils react normally to light and his visual acuity has not changed. There is moderate periorbital swelling and a conjuctival hematoma. There is no enopthalamus.

When would you treat this patient?
Within 24 hrs?
Within a week?
Wait and see?
How would you treat?

View attachment CT1.jpg

View attachment CT2.jpg

View attachment CT3.jpg

 

[scalpel2008]

As much as I like the direction this thread has taken, I´m afraid I´m going to have to be a bore and return to the intial topic.

This is not in any way an unusal case, but I´m sure there are very different opinions on when and how to treat.

A 65 yr old, generally healthy male, falls in his home 3 days earlier. Presents at the ER because of persistant diplopia. A CT shows a trapdoor blow-out fracture on the left side. There are no other abnormal findings on the CT, specifically no intracerebral lesions.

His ocular mobility is not impaired, but his diplopia worsens when he looks up and to the sides. His pupils react normally to light and his visual acuity has not changed. There is moderate periorbital swelling and a conjuctival hematoma. There is no enopthalamus.

When would you treat this patient?
Within 24 hrs?
Within a week?
Wait and see?
How would you treat?

View attachment 7889

View attachment 7890

View attachment 7891

There is no question this fracture requires treatment. I would treat w/i a week to allow edema to subside since there is no evidence of entrapment. I would approach the frature with a subtarsal incision, place a titanium mesh implant, fixate it with a couple of 1.0 screws on the intraorbital aspect of the rim, and do a forced duction. I would get a post op CT to ensure I've managed to place my implant over the posterior ledge given that it's not an uncommon pitfall to miss it in such a posterior fracture. There is no point to wait and see because this will progress to enophthalmos.