Trauma

Take a Knee…

Case:

An otherwise healthy 17-year-old male presents to the ED after an ATV accident. He was riding at a low speed when he swerved to avoid a branch, lost control, forcing him to bail forward over the handlebars. He sustains a laceration to his knee during the fall, but suffers no other injuries. Exam of the right knee is notable for a 2.5 cm deep, jagged laceration (Figure 1), tenderness to the patella and a joint effusion, no palpable bony deformities, stable ligamentous exam, with the distal extremity neurovascularly intact. Radiographs of the knee are obtained:

Figure 1: Right knee laceration

Figure 1: Right knee laceration

Figure 2: Lateral and AP right knee radiographs

Figure 2: Lateral and AP right knee radiographs

Now what?

The above radiographs demonstrate no evidence of fracture or dislocation; however, subcutaneous gas is visible in the region of the laceration. Given the depth and location of the injury, there is concern for traumatic arthrotomy. Orthopedics is consulted.

 

Overview:

Knee injuries are a common reason for patient presentation to the emergency department, often with concomitant wounds adjacent to the joint. These injuries typically occur in young adult males, with common mechanisms including gunshot wounds, motor vehicle accidents, motorcycle accidents, or injury due to sharp objects[1]. When there is concern for wounds entering the joint space, the saline load test (SLT) is used for further evaluation.

 

Technique:

The knee contains the largest synovial joint cavity in the body. To perform arthrocentesis, the knee should be placed in approximately 15-20 degrees of flexion (often helpful to place a folded blanket or pillow in the popliteal fossa to aid in positioning); a medial or lateral approach may be used, but should enter at the superior third of the patella, with the needle aimed towards the intercondylar notch[2].

A systematic review by Daley, et al, in 2011 of needle entry location showed that the superolateral approach had the overall greatest success of 91%[9]. In difficult cases, use of ultrasound has been shown to improve accuracy of intra-articular needle placement, a modality readily used and available in the ED[10].

Figure 3: Anatomic overview and appropriate targets for arthrocentesis, from Thomsen, et al, 2006[2].

Figure 3: Anatomic overview and appropriate targets for arthrocentesis, from Thomsen, et al, 2006[2].

Video: 

https://www.emrap.org/episode/knee/knee

How much is enough?

 In examination of the saline load test, varying sensitivities have been reported using a range of infused volumes. Using an arthroscopy model with a 1 cm incision, Nord et al, showed that 95% sensitivity could be achieved using a volume of 155 cc, if tolerated by the patient[3]. In the ED setting, potentially lower volumes may be used due to generally larger arthrotomy sizes. Konda, et al, demonstrated 94% sensitivity with a dynamic (moving the knee through flexion and extension) saline load test using a volume of 74.9 cc +/- 28.2 cc, but had a 9% false positive rate[4].

But don’t I need to inject that blue stuff?

A single study comparing injection of normal saline alone vs. methylene blue in patients undergoing routine knee arthroscopy showed instillation of methylene blue did not improve sensitivity in diagnosis of arthrotomy[5].

 

Is a picture alone worth a thousand words?

A retrospective study in 2013 compared the traditional SLT to CT scan identification of intra-articular air in evaluation of a traumatic arthrotomy. This study revealed that CT scan was more sensitive in detection of traumatic arthrotomy over the traditional SLT (100% vs. 92%)[6]. The additional benefit of performing a CT scan is detection of periarticular fractures, and in the study group, findings on CT scan in evaluation of traumatic arthrotomy altered management in 43% of patients[8].

Figure 4: Intra-articular air visualized on CT scan on bone and lung windows (A and B respectively), from Konda, et al, 2014[1].

Figure 4: Intra-articular air visualized on CT scan on bone and lung windows (A and B respectively), from Konda, et al, 2014[1].

What about pediatrics?

A prospective study of 87 pediatric patients with mean age 13.4 years +/- 3.0 years undergoing elective knee arthroscopy were studied. After a 5-mm superolateral arthrotomy site was made, the authors concluded that a minimum of 47 mL was required to detect 90% of the arthrotomies in this population[7]. A limitation, however, is that all patients were anesthetized during joint injection, preventing assessment of patient comfort with this infused volume.

  

Case Conclusion:

The patient undergoes saline load testing of the affected knee in the ED using 155 cc of intra-articular saline, with noted extravasation from the wound. He is placed in a splint, IV antibiotics are started, and he is taken to the operating room for irrigation and debridement. Intra-operatively, he is noted to have a 1 cm traumatic arthrotomy to the lateral joint capsule. The joint is thoroughly irrigated, he is continued on antibiotics, and was discharged home the following day without complication.  

A great post by our EM colleagues at the Las Vegas Emergency Medicine Residency also reviewing this topic can be found here: http://www.lasvegasemr.com/foam-blog/knee-capsule-violation-bedside-rule-out-test

 

Take Home Points:

  • Knee injuries are common: when there is concern for joint violation, the saline load test can be used for further evaluation

  • If using anatomic landmarks, the superolateral approach may be the most successful, and in difficult cases, ultrasound can help improve success

  • Methylene blue does not add additional sensitivity over normal saline alone

  • CT scan can be used to identify traumatic arthrotomy, may have better sensitivity than the SLT, and adds evaluation of potential periarticular fractures not seen on plain radiographs

  • In general, wounds seen in the ED may require less overall volume due to larger arthrotomy size, but optimal volume is still unclear

Faculty Reviewer: Dr. Dina Gozman

References:

  1. Konda, SR., Davidovitch, RI., Egol, KA; “Open knee joint injuries: an evidenced-based approach to management”, Bulletin of the Hospital for Joint Diseases, Vol 72 No. 1, 2014

  2. Thomsen, TW., Shen, S., Shaffer, RW., Setnik, GS; “Arthrocentesis of the knee”, New England Journal of Medicine, Vol 354 No. 19, May 2006

  3. Nord, RM., Quach, T., Walsh, M., et al; “Detection of traumatic arthrotomy of the knee using saline solution load test”, Journal of Bone and Joint Surgery American Volume, Vol 91 No. 1, January 2009

  4. Konda, SR., Howard, D., Davidovitch, RI., Egol, KA; “The saline load test of the knee redefined: a test to detect traumatic arthrotomies and rule out periarticular wounds not requiring surgical intervention”, Journal of Orthopedic Trauma, Vol 27 No. 9, September 2013

  5. Metzger, P., Carney, J., Kuhn, K., Booher, K., Mazurek, M; “Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies”, Journal of Orthopedic Trauma, Vol 26 No. 6, June 2012

  6. Konda, SR., Davidovitch, RI., Egol, KA; “Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test” Journal of Orthopedic Trauma, Volume 27 No. 9, September 2014

  7. Haller, JM., Beckmann, JT., Kapron, AL., Aoki, SK; “Detection of a traumatic arthrotomy in the pediatric knee using the saline solution load test”, The Journal of Bone and Joint Surgery, Vol 97 No. 10, May 2015

  8. Konda, SR., Howard, D., Davidovitch, RI., Egol, KA; “The role of computed tomography in the assessment of open periarticular fractures associated with deep knee wounds”, Journal of Orthopedic Trauma, Vol 27 No. 9, September 2013

  9. Daley, EL., Bajaj, S., Bisson, LJ., Cole, BJ; “Improving injection accuracy of the elbow, knee, and shoulder: does injection site and imaging make a difference? A systematic review” The American Journal of Sports Medicine, Vol 39 No. 3, March 2011

  10. Daniels, EW., Cole, D., Phillips, SF.; “Existing evidence on ultrasound-guided injections in sports medicine”, Orthopaedic Journal of Sports Medicine, Vol 6 No. 2, February 2018

Subtalar Dislocations

Case

A 24 year-old male presents with right foot pain after falling off of a 12 foot ladder, his foot locked in supination, with obvious deformed (Figure 1). Pulses, sensation, and motor function intact distally. X-rays are ordered (Figure 2).

Figure 1: Right foot physical examination findings.  Pictures: http://westjem.com/articles/subtalar-dislocation.html

Figure 1: Right foot physical examination findings.

Pictures: http://westjem.com/articles/subtalar-dislocation.html

Figure 2: Plain films of right foot.  http://westjem.com/articles/subtalar-dislocation.html

Figure 2: Plain films of right foot.

http://westjem.com/articles/subtalar-dislocation.html

Diagnosis

Subtalar dislocation

Background

This is a rare injury; it accounts for approximately 1 – 2% of all dislocations. This can look similar to an ankle dislocation on examination, but the tibiotalar joint and mortise are intact.

These injuries typically from a high energy mechanism such as a fall from height or high energy motor vehicle collision (MVC). Typically to cause this dislocation, an axial load is applied when the patient has a plantar flexed foot. Patients may get these injuries from lower energy mechanisms such as sport injuries or fall from standing, especially if the patient is elderly or obese. Most injuries tend to be male (3:1 ratio) and in the third decade of life.

Subtalar dislocation is the disruption of the articulation of both the talocalcaneal and the talonavicular joints with an intact ankle joint mortis. This involves disruption of the surrounding ligaments: interosseous talocalcaneal ligament (most important), anterior talocalcaneal ligament, posterior talocalcaneal ligament, lateral talocalcaneal ligament, and medial talocalcaneal ligament.

Approximately 25% of these injuries are open upon presentation to the ED. There is high risk of skin necrosis from tenting over malleolus or talar head, which can convert these injuries to open dislocations.

Types of Subtalar Dislocations

The vast majority of subtalar dislocations are either medial (85%) or lateral (15%). Anterior and posterior dislocations can also occur.

Medial Subtalar Dislocation

This is the most common type of subtalar dislocation. It typically results from an inversion injury with a plantar flexed foot. It is sometimes called “basketball foot” as this is a common mechanism. Another term for this injury is “acquired clubfoot.” On physical exam, you will find that the foot is inverted, the calcaneus is displaced medially, and the foot is locked in supination.

On AP x-ray, the calcaneus will be displaced medially (Figure 3). Lateral x-ray will show that the talar head is superior to the navicular (Figure 4).

Figure 3: AP view of medial subtalar dislocation.   http://www.radpod.org/wp-content/uploads/2011/05/ser000img000011.jpg

Figure 3: AP view of medial subtalar dislocation.

http://www.radpod.org/wp-content/uploads/2011/05/ser000img000011.jpg

Figure 4: Lateral view of medial subtalar dislocation showing that the head of the talus is superior to the navicular.   http://www.orthobullets.com/trauma/1050/subtalar-dislocations

Figure 4: Lateral view of medial subtalar dislocation showing that the head of the talus is superior to the navicular.

http://www.orthobullets.com/trauma/1050/subtalar-dislocations

Lateral Subtalar Dislocation

Lateral subtalar dislocations account for around 15% of subtalar dislocations. On physical examination, you will find that the foot is everted, the calcaneus is lateral to talus, and the foot is locked in pronation. AP x-ray will show lateral displacement of the calcaneus (Figure 5). On lateral views, the talar head with be inferior to the navicular (Figure 6). Lateral dislocations tend to result from higher mechanism injuries; therefore, these injuries are more likely to be open and have more associated injuries.

Figure 5: AP view of a lateral subtalar dislocation.  http://www.wheelessonline.com/image3/i1/subdis1.jpg

Figure 5: AP view of a lateral subtalar dislocation. http://www.wheelessonline.com/image3/i1/subdis1.jpg

Figure 6: Lateral view of lateral subtalar dislocation showing the head of the talus is inferior to the navicular   http://www.orthobullets.com/trauma/1050/subtalar-dislocations

Figure 6: Lateral view of lateral subtalar dislocation showing the head of the talus is inferior to the navicular

http://www.orthobullets.com/trauma/1050/subtalar-dislocations

Figure 7: Physical exam findings for a lateral subtalar dislocation.   https://faoj.files.wordpress.com/2008/11/tdisfig_1.jpg

Figure 7: Physical exam findings for a lateral subtalar dislocation.

https://faoj.files.wordpress.com/2008/11/tdisfig_1.jpg

Anterior and Posterior Dislocations

There are case reports of anterior and posterior dislocations, but these are exceedingly rare. They account for around 1% of subtalar dislocations.

Reduction technique

Reduction should be attempted rapidly due to the threat of skin necrosis if dislocation is prolonged. Reduction should occur prior to obtaining radiographs (either immediately upon presentation to the ED or in the field) if the foot has obvious neurovascular compromise such as absent or thready dorsalis pedis or posterior tibial pulse, decreased capillary refill, or lack of sensation to the bottom of the foot. Obtaining a thorough vascular and sensory exam of the foot before and after any reduction attempts is key. Often procedural sedation is necessary to perform this procedure. The approach to reduction is as follows:

  • Knee bent at 90 degrees to relax gastrocnemius and soleus muscles

  • Apply traction at heel and counter-traction to thigh

  • Accentuate deformity followed by reversal.

    • Medial dislocations: Further invert, pull traction, and then evert

    • Lateral dislocations: Further evert, pull traction, and then invert

  • Apply a splint – short posterior slab splint with side gussets

  • If reduction is successful, then obtain post-reduction x-rays and CT scan of foot and ankle. It is recommended that the patient is non-weight bearing in short leg cast for 4 to 6 weeks.

Associated injuries

Given that most of these injuries occur from a high degree force to the foot, it is not surprising that many of patients have other foot and ankle injuries in addition to the subtalar dislocation. Approximately 55% of medial subtalar dislocations and 72% of lateral dislocations have associated injuries. Common associated injuries include osteochondral lesions of the talus, subtalar debris, ankle fractures, 5th metatarsal fracture, navicular fracture, and cuboid fracture. Given the high percentage of associated injuries and that some of the associated injuries are difficult to see on plain radiographs, it is recommended to get a CT scan of the ankle and foot after reduction. In a case series of 9 patients, CT scan showed additional injuries missed on plain film in 100% of cases, and the CT changed the treatment in 44% of the cases. Fortunately, neurovascular injury and chronic subtalar joint instability are rare complications.

Complications

Approximately 30% of injuries are not reducible by closed means. In medial dislocations, the capsule of the talonavicular joint, peroneal tendons, or the extensor digitorum brevis (EDB) muscle can block reduction. The talar head can “button hole” through the EDB which blocks reduction. In lateral dislocations, the posterior tibialis tendon, flexor halluces longus, or flexor digitorum longus can be interposed into the joint space and block reduction. These injuries are also associated with contusions or lacerations of the posterior tibial artery and nerve.

Open subtalar dislocations have an infection rate of approximately 30% even with aggressive irrigation in the OR. Appropriate antibiotics prophylaxis should be given immediately upon recognizing an open fracture. Cefazolin is sufficient coverage for skin flora in most cases without obvious contamination and with minimal soft tissue damage. If the patient is high risk for MRSA, vancomycin coverage can also be added. For patients with severe soft tissue injury or gross contamination coverage should be expanded to ampicillin-sulbactam, cefoxitin, or cefotetan. If there is exposure to water, then Pseudomonas coverage should be added with an agent like cefepime. If fecal contamination is possible or there is concern for clostridial exposure (agricultural injuries), then high dose penicillin should be used as an adjunct.

Figure 8: Open medial subtalar dislocation.  http://www.orthobullets.com/trauma/1050/subtalar-dislocations

Figure 8: Open medial subtalar dislocation.

http://www.orthobullets.com/trauma/1050/subtalar-dislocations

There also is a risk of avascular necrosis of the talus or navicular after a subtalar dislocation. This is a rare complication more likely to occur after lateral subtalar dislocation. This is more common with tibiotalar dislocation when the ankle mortise is disrupted.

Many patients will go on to have chronic pain in their ankle (30 - 63%); intraarticular debris fragments and open injuries increase the risk of this.

Take Home Points

  • Subtalar dislocations often occur after a high mechanism injury to the foot while it is plantar flexed

  • Medial subtalar dislocations are more common

  • Lateral subtalar dislocations are more likely to be open and to have other associated injuries

  • Open dislocations have very high infection risk even with prompt and appropriate care

  • Fast reduction is key. Put the knee at 90 degrees, apply traction, recreate the injury and then reverse it

  • Get appropriate antibiotics on board quickly for open fractures

  • Approximately 30% of the time, closed reduction is impossible as the dislocated bone is caught on adjacent structures

  • Get a CT scan after reduction to look for other injuries

Faculty Reviewer: Dr. Mark Greve


References:

  1. Bryant, J. and Levis, J.T. 2009. Subtalar dislocation. Western Journal of Emergency Medicine, 10(2).

  2. Bibbo, C., Lin, S.S., and Abidi, N. 2001. Missed and associated injuries after subtalar dislocation: the role of CT. Foot and Ankle International, 22(4).

  3. DeLee, C. 1982. Subtalar dislocation of the foot. The Journal of Bone and Joint Surgery, 64(3): 433-437.

  4. Gustilo RB, Anderson JT. 1976. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am, 58:453.

  5. Gustilo RB, Gruninger RP, Davis T. 1987. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics, 10:1781.

  6. Horning, J. 2009. Subtalar dislocation. Orthopedics, 32(12): 904.

  7. Melenevsky, Y., Mackey, R.A., Abrahams, B., and Thomson, N.B. 2014. Talar fractures and dislocations: a radiologist’s guide to timely diagnosis and classification. Retrieved 7/29/17 from http://pubs.rsna.org/doi/full/10.1148/rg.2015140156

  8. Schmitt, SK. 2018. Osteomyelitis associated with open fractures in adults: preventative antibiotics after open fractures. UpToDate, retrieved on 1/24/19 from https://www.uptodate.com/contents/osteomyelitis-associated-with-open-fractures-in-adults?search=open%20fracture%20antibiotics&sectionRank=1&usage_type=default&anchor=H7&source=machineLearning&selectedTitle=1~150&display_rank=1#H7

  9. Weatherford, B. 2017. Subtalar dislocations. Retrieved on 7/29/17 from http://www.orthobullets.com/trauma/1050/subtalar-dislocations

  10. Weir, A. 2015. MR:EM subtalar dislocation. Retrieved on 7/29/17 from https://www.youtube.com/watch?v=GG3ni7fR__s

  11. Wheeless, C.R. 2012. Wheeless’ Textbook of Orthopaedics: Sub Talar Dislocation. Retrieved on 7/29/17 from http://www.wheelessonline.com/ortho/sub_talar_dislocation

  12. Yoder, W., Nelson, P., Bowen, M., and Frania, S. 2011. Chapter 11: Talocalcaneal navicular dislocation. Retrieved on 7/29/17 from http://www.podiatryinstitute.com/pdfs/Update_2011/2011_11.pdf


Snap, Crackle, and Pop: Imaging and Management of Blunt Laryngeal Trauma

The Case

A 26 year-old male presents after a motorcycle accident. He was the helmeted, single-occupant of a motorcycle that crashed into the back of a stopped car. There are no external signs of injury, but he believes his neck may have hit the handlebars as he was thrown from the bike.  He denies loss of consciousness. His only complaint is that his voice sounds hoarse and he is having difficulty swallowing. He denies any intoxicants.

The patient has a normal primary traumatic survey. His secondary survey is notable for crepitus of the anterior neck. No chest wall crepitus is noted. No stridor or bruit is appreciated on anterior neck auscultation.  There is no cervical hematoma or ecchymosis. There is no midline C-spine tenderness. There is no blood in the oropharynx. His voice is raspy, but he is able to phonate and adequately handle his secretions. He has no other traumatic complaints or physical exam abnormalities on secondary survey.

A chest x-ray is without any evidence of pneumothorax.

You wonder what imaging should be performed next. Does he need a CT brain based on his history? Does crepitus count as a distracting injury? Should he have a CTA in the absence of any hard vascular signs? After discussion with the trauma team, CT imaging including a CTA neck is performed (Figure 1).

Picture1.png
Figure 1: Non-contrast portion of the CTA neck.

Figure 1: Non-contrast portion of the CTA neck.

CT imaging reveals a left hyoid bone fracture, as well as a comminuted fracture of the right thyroid cartilage. His CTA is normal. He has no intracranial injuries, face or C-spine fractures. There is considerable soft tissue emphysema.

Background on blunt laryngeal trauma

Blunt laryngeal trauma is rare.  The reported incidence of laryngeal fractures is 1:30,000 patients presenting to the ER. The low incidence is secondary to the relative protection by adjacent bony structures (the mandible, manubrium, and vertebral bodies). Furthermore, humans are equipped with a protective reflex to flex their heads downward when startled, further shielding this vulnerable region from trauma.  

Laryngotracheal injury occurs when patients lose their ability to protect this area, and are most commonly associated with motor vehicle accidents, when a hyperextended neck strikes a fixed object (steering wheel, dash board).  Recreational vehicles are also increasingly implicated (motorcycles, four-wheelers striking branches). Other mechanisms of injury include strangulation, assault, or hanging.

The patterns of injury vary depending upon the age and gender of the patient. Women are at increased risk for subglottic and cervical tracheal injuries owing to their tendency towards longer necks.  The thyroid and cricoid cartilage also ossify as part of the normal aging process (typically beginning around age 18-20), and for this reason, elderly patients are at increased risk for comminuted fractures of these structures. Conversely, children have flexible cartilage and are much less likely to sustain laryngeal fractures.

Brief review of anatomy

The larynx consists of a cartilaginous skeleton, the intrinsic and extrinsic muscles, and a mucosal lining. The cartilaginous skeleton houses the vocal cords. It consists of the thyroid cartilage, the cricoid cartilage, and the paired arytenoid cartilages. The thyroid cartilage is connected superiorly to the hyoid bone. The extrinsic muscles connect the cartilage of the larynx to other structures of the head and neck (i.e. sternothyroid muscle, etc.). The intrinsic muscles alter the shape, tension and position of the vocal cords (Figure 2).

Figure 2: Anatomy of the laryngotracheal complex.

Figure 2: Anatomy of the laryngotracheal complex.

Injuries range from mucosal hematomas and lacerations to fractured cartilage. The most severe laryngeal injury is complete laryngotracheal separation (Figure 3). Classification of these injuries will be covered in the Classification and Definitive Management section.

Figure 3: Types of laryngotracheal injuries.  http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf

Figure 3: Types of laryngotracheal injuries.
http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf

Signs and Symptoms

The mechanism of injury is important. The provider should take careful consideration of any history which lends itself to the possibility of “clothesline” type injury, namely forced hyperextension and forward propulsion or direct trauma to the anterior neck (strangulation, hanging).

Patients will report dysphonia, odynophagia, dysphagia, neck pain, dyspnea or hemoptysis. Studies suggest that hoarseness is the most common presenting symptom of laryngeal trauma.  Juutilainen et al reviewed 33 cases of external laryngeal trauma, and 28 (85%) of those cases presented with hoarseness. Physical exam may reveal stridor, dyspnea, ecchymosis, subcutaneous emphysema, hemoptysis, loss of the thyroid prominence or drooling. However, it is important to note that no single symptom correlates with injury severity and the absence of these findings does not exclude the possibility of laryngeal injury.

Initial Management

Airway management is crucial. If a patient with a suspected laryngeal injury has no evidence of respiratory distress or airway compromise, proceed with a standard traumatic work-up.

If the airway is not patent (respiratory distress, airway obstruction, stridor, not handling secretions, hypoxic), establishing an airway becomes a priority.  In these cases, tracheotomy is preferred to endotracheal intubation, as intubation can exacerbate laryngeal trauma and precipitate complete obstruction. It can also be extremely challenging to intubate because of distorted anatomy and poor visualization, with a risk for passing the ET tube through a false lumen created by the trauma. Furthermore, adequate positioning can be challenging if there is associated maxillofacial injuries and/or the need for C-spine precautions. That being said, there is no absolute contraindication for endotracheal intubation and if the patient is crashing, the most experienced airway provider should attempt it. Again, most of the otolaryngology literature favors tracheotomy, but if palpation of the larynx reveals continuity of the thyroid cartilage and cricoid cartilage, cricothyroidotomy can be performed if it is the only available, expedient airway. 

Importantly, laryngeal trauma carries a high risk of concomitant injury. There is a 13-15% incidence of associated intracranial injuries; skull base and facial fractures are seen in approximately 21%; C-spine fractures are seen in 8%; and esophageal/pharyngeal injuries occur in approximately 3% of these cases. Thus, it is best to have a low threshold for additional imaging studies. CT is the imaging modality of choice, but should only be undertaken in those patients with a stable or secured airway. There is no definite literature on the utility of CTA in blunt laryngeal trauma, but if a patient has any hard signs of vascular injury (bruit/thrill, expanding hematoma, pulse deficit) or signs of an acute ischemic stroke, there should be significant concern for an associated vascular injury.

Classification and Definitive Management

The Schafer-Fuhrman Classification scheme has been created to characterize laryngeal injuries.

Grade I: Minor endolaryngeal hematomas or lacerations, no fracture

Grade II: Edema, hematoma, minor mucosal disruption without exposed cartilage, non-displaced fracture, varying degrees of airway compromise

Grade III: Massive edema, large mucosal lacerations, exposed cartilage, displaced fracture(s), vocal cord immobility

Grade IV: Group III with severe mucosal disruption, disruption of the anterior commissure, and unstable fracture, 2 or more fracture lines

Grade V: Complete laryngotracheal separation

This classification scheme relies on both CT imaging and direct visualization. As part of the work-up for laryngeal injury, flexible fiberoptic laryngoscopy should be performed, usually by otolaryngology. During laryngoscopy, care should be taken to observe for any deformities, edema, hematomas, lacerations, exposed cartilage and partial or complete vocal cord fixation (suggesting a recurrent laryngeal nerve injury).

There is no definite recommendation for the work-up of esophageal injury. In some instances, esophageal injury can be seen on CT imaging (paraesophageal stranding or gas, lumen communicating with gas/fluid).  If, however, the suspicion for esophageal injury is high, additional studies can be pursued, beginning with a gastrograffin swallow study, followed by a dilute barium swallow for more complete evaluation.

The definitive management of laryngeal injuries depends on the injury pattern. Group I and some Group II injuries can be conservatively managed. This generally consists of humidified air, voice rest, head of bed elevation, steroids, anti-reflux medications, and antibiotics. Patients will often be admitted to the ICU for the first 24-48 hours given the potential airway compromise. They may undergo serial laryngoscopy for daily injury surveillance.

Group III-Group V injuries require operative intervention. These are the injury patterns that usually undergo tracheotomy.  Group V patients always have tracheotomies and represent a significant surgical challenge. Notably, there are multiple operative approaches and interventions for laryngeal trauma that are beyond the scope of this post.

Case Outcome

The patient was seen and scoped by otolaryngology in the ED.  This showed a supraglottic hematoma, but no lacerations or exposed cartilage. His vocal folds were mobile.  He was admitted to the trauma ICU, where he underwent a negative barium swallow, and ultimately, did not require operative intervention.

Faculty Reviewer: Dr. Kristina McAteer


References 

  1. Becker M, Leuchter I, Platon A, Becker CD, Dulguerov P, Varoquaux A. Imaging of laryngeal trauma. Europeal Journal of Radiology. Jan 2014: 83(1):142-154.  

  2. Eller RL, Dion G, Spadaro E. Management of Acute Laryngeal Trauma. http://www.cs.amedd.army.mil/FileDownloadpublic.aspx?docid=a1ab55ed-56b2-4a65-ade1-666e80a582cf. Accessed on 12.05.07.  

  3. Font JP, Quinn FB, Rayan MW. Laryngeal Trauma. http://www.utmb.edu/otoref/grnds/laryng-trauma-070328/laryng trauma-070328.pdf Accessed on 12.05.17.  

  4. Jalisi S, Zoccoli M. Management of laryngeal fractures—A 10-year experience. Journal of Voice. Jul 2011;25(4):473-479.

  5. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Archives of Otolaryngology–Head & Neck Surgery. Aug 1999;125(8):877-880.

  6. Juutilainen M, Vintturi J, Robinson S, Bäck L, Lehtonen H, Mäkitie AA. Laryngeal fractures: clinical findings and considerations on suboptimal outcome. Acta Otolaryngol. Feb 2008: 128(2):213–218.

  7. Murr AH and Amin MR. "Laryngeal Trauma"In CURRENT Diagnosis & Treatment in Otolaryngology - Head & Neck Surgery, 2nd Edition Ed. by Anil K. Lalwani.

  8. Mendelsohn AH, Sidell DR, Berke GS, John MS. Optimal timing of surgical intervention following adult laryngeal trauma. Laryngoscope. Oct 2011;121(10):2122-2127.

  9. Schaefer SD. The acute management of external laryngeal trauma. A 27-year experience. Arch Otolaryngol Head Neck Surg. Jun 1992 :118(6):598–604

  10. Schaefer N, Griffin A, Gerhardy B, Gohchee P. Early Recognition and management of Laryngeal Fractures: A Case Report. Ochsner J. 2014: 14)10):264-265.