Global City Innovative College

College of Nursing and International Health Studies

CASE STUDY

MAXILLARY FRACTURE SECONDARY TO VEHICULAR ACCIDENT

(MOTORCYCYLE)

Presented to: PSUPT Michelle Arban RN, MAN

Presented by:

BSN-416 Group D2

Tabingo, Ma, Leona Angela P.

Talledo, Amor Marie E.
Tauro, Akhiro S.
Tolledo, John Ralph S.
Yanto, Czarina Marie S.

August 11, 2010

Philippine National Police General Hospital
(PNPGH)

/jrst2010/

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 Table of Contents

• Introduction
-Yanto, Czarina Marie S.
• General Objectives
-Yanto, Czarina Marie S.
• Nursing History
-Tabingo, Ma, Leona Angela P.
• Physical Assessment
-Tabingo, Ma, Leona Angela P.
• Anatomy and Physiology
-Tauro, Akhiro S.
• Pathophysiology of the Disease
-Tolledo, John Ralph S.
• Laboratory Examinations/ Diagnostic Procedures
-Tauro, Akhiro S.
• Course in the ward
-Tolledo, John Ralph S.
• Nursing Care Plan
-Yanto, Czarina Marie S.
• Drug Study
-Talledo, Amor Marie E.

INTRODUCTION

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 Tripod Fracture is a facial fracture involving the three supports of the malar prominence,
the arch of the zygomatic bone, the zygomatic process of the frontal bone, and the zygomatic
process of the maxillary bone. The zygoma makes up a large portion of the lateral orbital wall
and floor. Fractures are important as they can alter orbital volume. The facial bones form 4
transverse and 4 paired vertical buttresses which support facial function and define the form of
the face. Zygomaticomaxillary complex fractures involve the upper transverse maxillary (along
the zygomaticotemporal suture and zygomaticomaxillary suture) and the lateral vertical
maxillary buttress (along the zygomaticomaxillary and zygomaticofrontal sutures). ZMC
fractures usually involve all three of the sutures allowing for the term “tripod” fractures.
Tripod fractures or zygomaticomaxillary complex fractures are the second most common type of
fracture on the skull which it is about 40% of all facial fracture. It has a much higher percentage
of tripod fracture in males(80%) than in women 20%) and majority of them ages 20-30 years old
due to their lifestyle. The leading cause of tripod fracture is vehicular accidents, which is about
70% of all case. Tripod fracture is so called because of separation of three major attachments of
the zygoma to the rest of the face. It is caused usually by a direct blow to the body of zygoma
which makes up a large portion of the lateral orbital wall and floor. The zygomaticomaxillary
complex (ZMC) plays a key role in the structure, function, and aesthetic appearance of the facial
skeleton. It provides normal cheek contour and separates the orbital contents from the temporal
fossa and the maxillary sinus. This fracture will generally cause contour abnormalities of all
three of the lines of Dolan. It also has a role in vision and mastication. The ZMC provides lateral
globe support necessary for binocular vision. The zygomatic arch is the insertion site for the
masseter muscle and protects the temporalis muscle and the coronoid process.
The patient in this study underwent vehicular accident (motorcycle) that’s why he has
suffered from Tripod Fracture. Open Reduction Internal Fixation was the procedure performed to
him.
According to the Knight and North classification nationwide, Among 70 patients with
tripod fractures, 14 patients (20%) underwent 1-point fixation technique through lateral brow
incisions. Preoperative and postoperative displacements of the infraorbital rim were
radiologically measured. Of these patients, 7 cases (50%) were type III, 6 cases (43%) were type
IV, and 1 case (7%) was type V Simple fracture of the infraorbital rim was seen in 10 patients
(71%), and comminuted fracture was seen in 4 patients (29%). In 11 patients, zygomaticofrontal
sutures were fixed with square microplates with 4 holes and 0.5 mm in thickness, and straight
miniplates with 4 holes and 1.0 mm in thickness were used in 3 patients. Of 14 tripod fractures, 6
(43%) were associated with floor fractures. Seven had displacement of the infraorbital rim
(range, 2.0-7.6 mm; mean, 4.6 ± 0.8 mm), and the other 7 had no displacement of the infraorbital
rim. After surgery, step deformities of the infraorbital rims were improved (range, 0.1-3.8 mm;
mean, 1.4 ± 0.5 mm). All 14 patients were satisfied with their postoperative appearance.
Indications for using 1-point fixation of the tripod fracture are (1) minimal or moderate
displacement of the infraorbital rim in the tripod fracture of the zygoma, (2) no ocular signs of
diplopia or enophthalmos, and (3) comminuted infraorbital rim fractures where internal fixation
is difficult.

Signs and symptoms of experienced by the patient

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* Hematoma
* Abbrasion
* Decreased ocular movement, and
* Edema

Zygomatic fractures are diagnosed clinically by looking down at the patient's face from above
and behind (ie, the fractured side will appear flat), palpating the infraorbital fracture, observing
the patient demonstrate limited eye movement in the upward gaze, and noting swelling in the
injured area. An ophthalmic examination may be required to rule out extensive intraocular
trauma (eg, optic nerve injuries; eyelid, lacrimal, or global lacerations). Surgeons also examine
the patient for evidence of a CSF leak caused by a fractured cribriform plate. Therapeutic
interventions include application of local cold packs, administration of regional anesthesia for
pain, and open or closed reduction of die fracture site.

Fig. 1: Illustration showing the fracture of our patient

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Reason for Studying:
The group chose this case Tripod Fracture because it is new in their vocabulary and as a
students and learners, the group wanted to add additional information and knowledge regarding
the case as well as enhancing their skills in proper nursing care for their future patients.

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 OBJECTIVES
General Objective:

This case presentation aims to identify and determine the general heath problems and
needs of the patient with an admitting diagnosis of Tripod Fracture. This presentation also
intends to help patient promote health and medical understanding of such condition through the
application of the nursing skills

Specific Objectives:

In line with our general objective, the group formulated their specific objectives as
follows, to:

• Cognitive:
o Identify different types of diagnostic procedures and medical management
necessary for treatment of tripod fracture
o Trace the pathophysiology of tripod fracture based on signs and symptoms
manifested by patient
o Determine the action of drugs used on tripod fracture.
o To gain knowledge about zygomaticomaxilly complex fracture

• Psychomotor:
o Recognize skill appropriate to nursing responsibilities for tripod fracture patient
o Render nursing care through proper application of nursing intervention to patient
with tripod fracture
o To learn how to manage and take care of patients with tripod fracture.

• Affective:
o Help patient in motivating him to continue the health care provided by health
workers
o Help the patient to recover from the disease.
o Give health education to patient.

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 Nursing History
Patient’s Profile

Source of Information: Patient himself

Name: RL Sex: Male

Birthday: September 6, 1983 Age: 26 years old
Place of Birth: Camarines Sur
Address: Camarines Sur
Civil Status: Married
Nationality: Filipino
Religion: Roman Catholic
Dialect: Tagalog, Rinconada
Educational Attainment: College Graduate
Occupation: Police officer
Father: RL
Mother: LL

Initial Data on Admission

Date of Admission: July 17, 2010
Time of Admission: 9:30 am
Place of Admission: Philippine National Police General Hospital
Mode of Admission: Ambulatory
Accompanying Person: Mother
Chief Complaint: Maxillary fracture related to Vehicular Accident
Admitting Diagnosis: Maxillary fracture Left secondary to Vehicular accident (Motorcycle)
General Survey: Patient was awake, alert and grimace does not show pain

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Initial Vital Signs:
Temperature: 36.2 C
Respiratory Rate: 20cpm
Pulse Rate: 89bpm
Blood pressure: 140/100mmHg
History of Present Illness
Two weeks before the admission, RL and his partner was called by their senior officer to
report on duty around 11:00 pm. They rode separate motorcycles going to work. RL, during that
time was wearing a regular helmet. While on their way, they came to pass a dark intersection in
which he barely saw a stray dog crossing. This resulted him to dodge his motorcycle against the
stray dog, but upon dodging his face hit the speedometer.
RL’s partner brought him in the tricycle station and asked the driver to bring him to Iriga
City Lourdes Hospital. He immediately received first aid care. He was also given anti tetanus
serum as a prophylaxis and pain relievers during that time. He noticed that his gums got injured,
and for three days he was having epistaxis. His attending physician advised him to seek medical
care from other institution since they lack advance medical equipments so he went to PNPGH to
seek 2nd opinion about his condition.
Past Medical History
RL never experienced hospitalization due to any accidents or injury. He had
immunizations for BCG, DPT, HEPA B, OPV and measles.
Family History
The type of family that they have is Nuclear. They are 3 in the family. He lives by
himself since his wife’s job is assigned far from their home. He has a 2 month old baby boy.
Both of his parents have history of hypertension.
Psycho-social Data
RL fully understands why he was in the hospital and he also understands what his
condition was vehicular accident that’s why he was injured. His mother and his family serve as
support systems for him, especially his mother; she was the one who attend to the needs of RL.

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Birth/Developmental History
RL was born to a G8P8 mother with a regular prenatal check up to a health center. He
was delivered via NSD in a hospital and there was no feto-maternal complication. RL was the
fourth child among the siblings of Mr. RL & Ms. LL.
At the age of 26 he is considered as a young adult, young adults think about partnering
with another person for a long-term relationship. They ask existential questions, and at this age
they form an identity as an adult in the family and in the work world.

Gordon’s Functional Pattern of Health Care

Patterns of Prior to During Analysis &
Health hospitalization Hospitalization Interpretation
1. Self Perception He lives by himself He knows that he will Patient shows positive
since his wife’s job recover soon from the attitude towards his
from their home. He operation. He still has condition this may
has strong faith to strong faith to God lead to faster recovery
God and has a
positive will in almost
every aspects of his
life.
2. Role Perception RL says that he is He says he cannot He is very eager to go
happily married to his attend to his back to his normal
wife of 10 months and responsibilities at life.
that he is a loving home since he’s in the
father 2 month old hospital but still
son. He is a good son hoping for fast
to his parents and a recovery to go back to
good sibling to his his job and family
brothers and sisters

3. Cognitive He doesn’t have any He still doesn’t have This will help him not
Perceptual Pattern problem with hearing, any problem with to totally change his
with his eyesight nor hearing, with his perception about his
with his memory eyesight nor with his self since after the
capacity. memory capacity accident

4. Sexuality His wife used to take His sex life is not He’s willing to wait
reproductive contraceptive pills active for a month for his wife, he

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 before their marriage, now since he is perceives that sex can
and then stopped up hospitalized but he’s wait and he can divert
until now. fine with it. his interest into other
activities

5. Coping Stress Whenever he’s under Because he’s in the Even if he’s in the
Tolerance Pattern stress he goes out with hospital he cannot hospital he still finds
friends to drink, or drink anymore. He ways of how to cope
sometimes he watches just talks to his mom up with stress. This
TV or a movie or to his fellow will promote faster
patients when he feels recovery
stress

6. Value Belief He believes in God. He still believes in This can promote

Pattern He values his religion God. He still values faster recovery
his religion

7. Elimination Pattern He defecates at least 2 The first few hours His operation affected
times a day and after the operation he his elimination pattern
urinates at least 2 had difficulty in but was relieved by
times a day. He urinating and applying warm & cold
doesn’t have any defecating but was compress and by
difficulty in urinating relieved through eating high fiber diet
or defecating warm and cold
compress and by
eating foods high in
fiber

8. Rest and Activity Sleeps 6 hours when Sleeps 8 hours a day Nothing much has
Pattern he doesn’t have any and naps about 3 changed with his
duty but sleeps 4 hours. Having a little sleeping pattern. Rest
hours when he’s on difficulty in sleeping is very essential for
duty. His nap takes 3 position because he is faster recovery
hours. being cautious with
his face lesions

9. Nutritional – Eats balanced diet. Eats balanced diet. He eats a balanced

Metabollic Pattern His viand is His viand is diet. This will help
consisting of meat and consisting of meat and him feel comfortable
vegetables. He eats 3 vegetables. He eats 3 with his
times a day and times a day and hospitalization since

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 snacks 2 times a day. snacks 2 times a day. his preference of food
His snacks are He drinks 2 glasses of didn’t totally changed’
consisting of pancit juice, more than 10
and banancue. He glasses of water
drinks 2 glasses of
juice, more than 10
glasses of water and 1
cup of coffee each
day.

10. Hygiene and He takes a bath about He takes a bath once a He’s comfortable with
Comfort 2 times a day. He day with the the pattern of bathing
doesn’t have any soap assistance of his he has.
preference mother

11. Activity and His work is in lined He doesn’t have time This might slow his
Exercise Pattern with exercise. He jogs for exercise since metabolic rate since
2 times a week for lesions are still under hospitalization
about 2 hours and present.
occasionally plays
basketball for about
an hour.

12. Health Perception Doesn’t have any past Experienced He’s prone to other
and Health medical. 5 months hospitalization diseases since he does
management prior to because of the not take any vitamins
hospitalization he had accident or supplements
to have a tooth pasta.
Doesn’t take any
vitamins or
supplements.

Nurse’s Impressions of client

Patient was awake, alert and grimace does not manifest pain

Finding’s Significant to Nursing Care:

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 Maxillary Fracture related to vehicular accident

Nursing Diagnosis:
1. Impaired Skin Integrity related to destruction of skin layers or tissues as evidenced by
disruption of skin surface and invasion of affected body structure.
2. Hypothermia related to trauma and exposure to cool environment as manifested by shivering,
body temperature below normal range and cool skin
3. Risk for Infection related to inadequate primary defenses as evidenced by traumatized tissue,
tissue destruction and invasive materials introduced to the patients’ affected part.

Physical Assessment
Date Assessed: August 9, 2010
Time Assessed: 4:00 pm

Initial Vital Signs:

Temperature: 37 C
Pulse Rate: 85bpm
Respiratory Rate: 17cpm
Blood pressure: 140/100mmHg

General Survey:
The patient is awake, sitting on the chair beside the bed. Facial grimace shows blunt
affect and he is cooperative; with D5LR at 30 gtts/min hooked at his left hand. Patient has
bandage placed over and around his head. Left part of the face has grade 1 edema. Patient shows
an abrasion on his right & left upper extremities.

AREA METHOD OF NORMAL ACTUAL ANALYISIS AND

ASSESSED EXAMINATION FINDINGS FINDINGS INTERPRETATION
SKIN Inspection >Color: depends on >Brown Skin shows presence
Palpation race, whitish pink presence of of lesions and scars
to a brown shade to scars & lesions due to the accident.
black due to accident Has normal skin
No cyanosis, in the lower turgor.
erythema, jaundice, extremities &
pallor, petichiae, upper
rashes extremities
>Texture: smooth, >Soft, slightly
soft, no leision, no rough with
ulcer, scar, papule, presence of
macule scars

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 >Turgor: skins >Normal skin
snaps back turgor
immediately when
pinched
>Moisture: moist, >Moist and not
not dry dry
>Temperature: >Warm to touch
Warm to touch
NAIL Inspection >Color: Pinkish >Pinkish Normal nails upon
Palpation >Shape: Convex >Convex inspection and
curvature curvature palpation
>Texture: Smooth >Smooth
>Capillary Refill: >2 seconds
2-3 seconds
HAIR Inspection >Color: Depends >Black Has normal
on race, black, distribution and
brown, burgundy texture of hair
>Distribution: >Evenly
Evenly distributed, distributed
no sign of alopecia
>Texture: thick or >Thick
thin, coarse or
smooth
>Moisture: neither >Neither brittle
brittle nor dry nor dry
HEAD Inspection >Normocephalic, >Round, Patient has to be extra
Palpation round, fontanelles fontanelles are cautious on his upper
are closed closed part of his head due to
>No palpable mass, >No mass, the sutures after the
nodules, depression nodules operation
>No pain upon >Presence of
palpation pain pain due to
suture
>Face is >Face is
symmetrical asymmetrical
due to left side
edema
EYES Inspection >Symmetrical >Symmetrical Vision and other parts
Palpation >Eyebrows: >Symmetrical, of the eye is not
Symmetrical, black, evenly affected by the sugery
black(varies), distributed but still feels pain on
Evenly distributed >Black, curved the lower part of the
>Eyelashes: upward left eye due to suture
black(varies), >No Ptosis,
slightly curved with edema on
upward left eyelid,

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 >Eyelids: Covers unequal
small part of the coverage of
eye when open, eyeballs due to
covers the whole edema
eye, No Ptosis

>Conjunctiva: pink >Pink palpebral

and moist conjunctiva

>Cornea: >Transparent
Transparent and and smooth
smooth

>Sclera: white, no >White, with

discoloration, no presence of
pigmentation, no minute
foreign matter capillaries

>Iris: brown >grayish black,

(varies), no visible no visible
materials, materials
>Pupil: Equally >grayish Black,
round, reactive to equally round,
light reactive to light
accommodation accommodation
(PERRLA)

>Visual Acuity: >20/20 Vision

Clear vision >Eyes move
freely
>Ocular >Presence of
movement: Eyes suture under the
moves freely left eye

EARS Inspection >Bean shaped, >Bean shaped, Ears are normal upon
Palpation parallel, parallel with the inspection and
symmetrical eyes palpation. There’s no
presence of lesion and
>Same color with >Brown no erythema
the complexion With normal
>Auricles has firm >Auricles has discharges as well
cartilage firm cartilage

>No redness of >No redness of

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 earlobes earlobes

>No lesion >No lesion

>No tenderness >No tenderness
upon palpation of upon palpation
auricles and of auricles and
mastoid process no tenderness
on the mastoid
process

>No discharges or >No discharges

lesion on ear canal or lesion on ear
canal
>Some cerumen >Presence of
may be present cerumen
>Tympanic >Flat,
membrane: flat, transluscent,
translucent, pearly pearly gray
gray
>Hearing acuity: >Able to hear
Able to hear clearly clearly

NOSE & Inspection >Nose in the >In the midline Presence of tenderness
SINUSES Palpation middle and and on the left sinuses due
symmetrical symmetrical to swelling.

>No discharges >No discharges

>No nasal flaring >No nasal
>Both nares are flaring
patent >Both nares are
patent
>No bone and >No bone and
cartilage deviation cartilage
deviation
>No tenderness >Presence of
upon palpation tenderness upon
palpation

>Nasal septum is in >Nasal septum

the midline is in the midline

>Nasal mucosa is >Nasal mucosa

pink pink
>No tenderness and >Presence of
swelling of the tenderness and
paranasal sinuses swelling of left

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 sinuses
MOUTH Inspection >Lips: >Moist, pinkish, The patient has
symmetrical, no edema difficulty in opening
pinkish, No edema, his mouth due to the
moist surgery
>Gums: pinkish, no >wasn’t able to
gum bleeding, no inspect since
receding gums, no patient is having
swelling a hard time to
open his mouth

>Teeth: no. of > wasn’t able to

teeth: 28, white to inspect since
yellowish in color, patient is having
no dental carries a hard time to
open his mouth

>Buccal mucosa, >wasn’t able to

hard and soft inspect since
palate: Pinkish, patient is having
moist a hard time to
open his mouth

>Tongue: Pinkish, > wasn’t able to

no lesion, in the inspect since
midline, moves patient is having
freely a hard time to
open his mouth
>Uvula: midline, > wasn’t able to
pinkish, no lesion inspect since
patient is having
a hard time to
open his mouth
>Tonsils: pinkish, > with pain and
no swelling tenderness upon
palpation, does
not move freely

>Mandible: Moves
smoothly, no pain
and tenderness
upon palpation
NECK Inspection >In the midline >In the midline The client has limited
Palpation >No visible masses >No visible range of motion since
or lumps masses or lumps he has to be very extra

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 cautious with the
>No tenderness >No tenderness sutures on his head
upon palpation upon palpation

>Trachea is in the >Trachea is

midline palpable and in
the midline
>Moves freely >Moves freely
>ROM: Full range >ROM: there’ a
limited range of
motion due to
surgery
LYMPHNODE Inspection >Not palpable >Not palpable All lymph nodes are
Palpation >Non tender >Non tender normal upon
inspection and
palpation. No signs of
inspection
THORAX & Inspection >Same as skin >Brown Normal upon
LUNGS Palpation color >Symmetrical inspection, palpation,
Percussion >Symmetrical >No kyphosis, percussion and
Auscultation >No kyphosis, scoliosis, auscultation
scoliosis, lordosis lordosis

>Respiratory Rate: >RR: 17cpm

12 – 25 cpm
>No dyspnea, >No dyspnea,
tachypnea, tachypnea &
bradypnea bradypnea

>No retractions >No retractions

>No adventitious >No
breath sounds adventitious
(crackles, breath sounds
wheezing, stridor)
HEART Inspection >Pulse Rate: 75 – >PR: 75bpm Normal upon
Palpation 120 bpm inspection, palpation,
Auscultation >No tachycardia >No and auscultation
and bradycardia tachycardia and
bradycardia
>No dysrhythmia >No
>No lift or heaves dysrhythmia
>No heart murmurs >No lift or
heaves
>No heart
murmurs

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ABDOMEN Inspection >Same as skin >Same as skin Normal upon
Auscultation color color inspection, palpation,
Palpation >No lesion >Presence of percussion and
Percussion >Flat, soft, rounded scars auscultation
>No tenderness >Flat, soft,
upon palpation rounded
>No tenderness
upon palpation
>Audible, soft >Audible, soft
gurgling sound (5 gurgling sound
to 20 seconds)
>No bruit, friction >No bruit,
rubs friction rubs ion
GENITORECTAL Inspection >Urinary: no >Urinary: no Normal upon
URINARY hematuria, no hematuria, no inspection
difficulty urinating, difficulty
no nocturia and urinating, no
urinary nocturia and
incontinence urinary
incontinence
EXTREMITIES Inspection >Whitish pink to a >Brown Upon inspection,
Palpation brown shade to presence of lesion,
black abrasion and scars are
>Equal on both >Equal on both present. These are
sides sides mostly caused by the
>Hair evenly >Hair evenly motorcycle accidents.
distributed distributed

>No lesion, lump, >with presence

masses, no areas of of lesion and
tenderness abrasion on
upper and lower
extremities
Warm to touch >Warm to touch
>ROM: moves >ROM: there is
freely, moves in no limited range
full range, no of motion
crepitus
NEUROLOGIC Inspection >Oriented with >Oriented with Upon inspection,
SYSTEM time, place, person, time, place, patient is well oriented
situation person, with time, place
situation, situation. Alert and
>Alert, can follow >Alert, can very cooperative.
instructions and follow
commands instructions and
commands

18
 >Makes eye >Makes eye
contact with the contact with the
examiner examiner
>Cranial nerves are >Cranial nerves
intact are all intact

Anatomy and Physiology

Anatomy and physiology

The skeletal system

The human skeleton consists of both fused and individual

bones supported and supplemented by ligaments, tendons,
muscles and cartilage. It serves as a scaffold which
supports organs, anchors muscles, and protects organs
such as the brain, lungs and heart. The biggest bone in the
body is the femur in the upper leg, and the smallest is the
stapes bone in the middle ear. In an adult, the skeleton
comprises around 14% of the total body weight, and half
of this weight is water.

Fused bones include those of the pelvis and the cranium.

Not all bones are interconnected directly: There are three
bones in each middle ear called the ossicles that articulate
only with each other. The hyoid bone, which is located in
the neck and serves as the point of attachment for the
tongue, does not articulate with any other bones in the
body, being supported by muscles and ligaments.

Axial skeleton

The axial skeleton (80 bones) is formed by the vertebral

column (26), the thoracic cage (12 pairs of ribs and the
sternum), and the skull (22 bones and 7 associated bones).
The axial skeleton transmits the weight from the head, the
trunk, and the upper extremities down to the lower extremities at the hip joints, and is therefore
responsible for the upright position of the human body. Most of the body weight is located in
back of the spinal column which therefore has the erectors spinae muscles and a large amount of
ligaments attached to it resulting in the curved shape of the spine. The 366 skeletal muscles
acting on the axial skeleton position the spine, allowing for big movements in the thoracic cage
for breathing, and the head. Conclusive research cited by the American Society for Bone Mineral
Research (ASBMR) demonstrates that weight-bearing exercise stimulates bone growthOnly the

19
parts of the skeleton that are directly affected by the exercise will benefit. Non weight-bearing
activity, including swimming and cycling, has no effect on bone growth.

Appendicular skeleton

The appendicular skeleton (126 bones) is formed by the pectoral girdles (4), the upper limbs
(60), the pelvic girdle (2), and the lower limbs (60). Their functions are to make locomotion
possible and to protect the major organs of locomotion, digestion, excretion, and reproduction.

The Human skull

The adult skull is normally made up of 22 bones.

Except for the mandible, all of the bones of the skull
are joined together by sutures, rigid articulations
permitting very little movement. Eight bones —
including one frontal, two parietals, one occipital
bone, one sphenoid, two temporals and one ethmoid
— form the neurocranium (braincase), a protective
vault surrounding the brain. Fourteen bones form the
splanchnocranium, the bones supporting the face.
Encased within the temporal bones are the six ear
ossicles of the middle ears, though these are not part
of the skull. The hyoid bone, supporting the tongue, is usually not considered as part of the skull
either, as it does not articulate with any other bones. The skull is a protector of the brain.

The skull contains the sinus cavities, which are air-filled cavities lined with respiratory
epithelium, which also lines the large airways. The exact functions of the sinuses are unclear;
they may contribute to decreasing the weight of the skull with a minimal decrease in strength, or
they may be important in improving the resonance of the voice. In some animals, such as the
elephant, the sinuses are extensive. The elephant skull needs to be very large, to form an
attachment for muscles of the neck and trunk, but is also unexpectedly light; the comparatively
small brain-case is surrounded by large sinuses which reduce the weight.

The meninges, or the system of membranes which envelops the central nervous system, are the
three membranes which surround the structures of the nervous system. They are known as the
dura mater, the arachnoid mater and the pia mater. Other than being classified together, they
have little in common with each other.

In humans, the anatomical position for the skull is the Frankfurt plane, where the lower margins
of the orbits and the upper borders of the ear canals are all in a horizontal plane. This is the
position where the subject is standing and looking directly forward. For comparison, the skulls of
other species, notably primates and hominids, may sometimes be studied in the Frankfurt plane.
However, this does not always equate to a natural posture in life.

20
Facial bones

The 14 (mainly 7 on each side) facial bones form the framework of the face; provide cavities for
the sense organs of smell, taste, and vision; anchor the teeth; form openings for the passage of
food, water, and air; and provide attachment points
for the muscles that produce facial expressions.
Two maxillae form the upper jaw, contain sockets
for the 16 upper teeth, and link all other facial
bones apart from the mandible (lower jaw). Two
zygomatic bones (cheekbones), form the
prominences of the cheeks and part of the lateral
margins of the orbits. Two lacrimal bones form part
of the medial wall of each orbit. Two nasal bones
form the bridge of the nose. Two palatine bones
from the posterior side walls of the nasal cavity and
posterior part of the hard palate. Two inferior nasal
conchae form part of the lateral wall of the nasal
cavity. The vomer forms part of the nasal septum. The mandible, the only skull bone that is able
to move, articulates with the temporal bone allowing the mouth to open and close, and provides
anchorage for the 16 lower teeth.

Functions:

Support

The skeleton provides the framework which supports the body and maintains its shape. The
pelvis and associated ligaments and muscles provide a floor for the pelvic structures. Without the
ribs, costal cartilages, and the intercostal muscles the lungs would collapse.

Movement

The joints between bones permit movement, some allowing a wider range of movement than
others, e.g. the ball and socket joint allows a greater range of movement than the pivot joint at
the neck. Movement is powered by skeletal muscles, which are attached to the skeleton at
various sites on bones. Muscles, bones, and joints provide the principal mechanics for
movement, all coordinated by the nervous system.

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Protection

The skeleton protects many vital organs:

• The skull protects the brain, the eyes, and the middle and inner ears.
• The vertebrae protect the spinal cord.
• The rib cage, spine, and sternum protect the lungs, heart and major blood vessels.
• The clavicle and scapula protect the shoulder.
• The ilium and spine protect the digestive and urogenital systems and the hip.
• The patella and the ulna protect the knee and the elbow respectively.
• The carpals and tarsals protect the wrist and ankle respectively.

Blood cell production

The skeleton is the site of haematopoiesis, which takes place in red bone marrow. Marrow is
found in the center of long bones.

Storage

Bone matrix can store calcium and is involved in calcium metabolism, and bone marrow can
store iron in ferritin and is involved in iron metabolism. However, bones are not entirely made of
calcium,but a mixture of chondroitin sulfate and hydroxyapatite, the latter making up 70% of a
bone.

Endocrine regulation

Bone cells release a hormone called osteocalcin, which contributes to the regulation of blood
sugar (glucose) and fat deposition. Osteocalcin increases both the insulin secretion and
sensitivity, in addition to boosting the number of insulin-producing cells and reducing stores of
fat.

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23
 Modifiable
Factors PATHOPHYSIOLOGY Non-modifiable
Factors
- Nutritional Status
-Age
-Activity/ Stress
-Gender
-Occupation
Trauma /Accident -Genetics

Break in the continuity of the bone

Destruction of organic & inorganic

matters

Nerve function at the site of the fracture

temporarily lost Numbness

Surrounding muscles become flaccid

Outcome if surgery
is not performed
Facial
Fractured bone reduced Pain
Continuous
bleeding
Muscle spasm & contractions of the
surrounding muscles
Shock

Tripod Fracture Outcome upon Surgery

Death
Signs & Symptoms:
-Epistaxis
Poor Circulation -Facial Pain -Maxillary Fracture will be
-Facial swelling manage
-Loss of facial -Bone put back into place
Cyanosis sensation -Internal fixation device
Loss of blood helps to hold bone together
to the bone
Pallor
Bone tissue Diagnostic Exam.
dies -CT Scan of the Management: Surgery
Facial Bones ORIF- Open Reduction &
Bone -X-ray Internal Fixation
Bone will Necrosis -Blood test (CBC)
collapse
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 Laboratory Examination & Diagnostic Procedure
Regaspi, Rolando
Male
July 19, 2010

HEMATOLOGY
Complete Blood Count

reference ranges result Analysis

interpretation
Hemoglobin 137-175 139.0 normal
Hematocrit 0.40-0.51 0.40 normal
Wbc count 4.23-9.07 7.3 normal
Differential Count

Reference range results Analysis

interpretation
Segmenters 0.34-0.68 0.59 normal
Lymphocytes 0.22-0.53 0.36 normal
Monocytes 0.05-0.12 0.02 A low number of
monocytes in the
blood
(monocytopenia) can
occur in response to
the release of toxins
into the blood by
certain types of
bacteria
(endotoxemia), as
well as in people
receiving
chemotherapy or
corticosteroids.
Eosinophils 0.01-0.07 0.05 normal
Stab
Basophil

Bleeding time: 1min & 45seconds

Clotting time:4 mins and 15 seconds
Blood type: “B+”

25
July 19, 2010
HEMATOLOGY

Partial thromboplastin
Reference Range Result Analysis
interpretation
PTT patient 25.0- 31.30 31.10sec normal
PTT Control 26.28- 32.32 32.20sec normal

PROTHROMBIN TIME
Reference Range Result Analysis
interpretation
PT patient 10- 14 11.10 normal
PT control 11.44- 13.30 12.80 normal
% Activity %
INR

Note: Specimen rechecked, result/s verified, specimen sent to lab.

Tuesday
July 13, 2010
Physically Examined
Impression/ Dx:
(+) fracture maxilla, left
- Seen and examined this date by Pedro A. Nacional M.D

July 19, 2010

CT scan of the Facial Bones
Multiple plain axial images reveal the ff findings:

- Anterior and Lateral walls of the left maxillary sinus with moderate to severe
depression
- Inferior orbital rim and anterior orbital floor with minimal depression. The inferior
rectus is minimally thickened.
- Mid zygomatic arch with minimal depression.
- Soft tissue contusion at the left cheek area with mucosal thickening in the left
maxillary sinus
- The optic globes, lens, optic nerves and rest of the extraocular muscles are intact
- The rest of the orbits; nasal bones; paranasal sinuses; maxilla and mandibles are
intact.

26
 COURSE IN THE WARD

Date & Shift Management to Patient

Patient Response
August 2, 2010 1500H >Patient follows the
3:00-11:00pm >For OR tomorrow instructions given by
morning under the nurse
general anesthesia >Patient was already
>OR and anesthesia informed with
materials completed regards the operation
tracium (atracium) 3
pcs. For delivery
tomorrow morning
by ORIF

1600H
>NPO post midnight
>Routine oral and
body hygiene prior
to OR
>IVF D5LR to run
at 30gtts/min
>Pre-meds at OR

August 03, 2010 0700H > Patient follows the

7:00am-3:00pm >received by instructions given by
stretcher with IVF the nurse
of D5LR 1 liter >Patient doing a
infusing well at the deep breathing
right hand; Blood exercise
pressure of 110/80 >Patient has a sign
mmHg of improvement
>Consent and >Patient chills due
request for surgery to the effect of
secured, pre- anesthesia
operative checklist
rechecked at OR
suite and placed
patient comfortable
at OR
>Latest Blood
pressure
90/60mmHg, Pulse
Rate 82bpm;

27
 transfer via stretcher

1645H
>Monitoring of V/S
q15 until stable
>Monitoring of I
&O and record
every shift
>With O2 inhalation
at 2-3Lpm via nasal
cannula for 2 hours
>Suction secretion
as necessary
>Encourage patient
deep breathing
exercise
>IVF to follow
D5LR to run at
30gtts/min
>Medication:
-Ketorolac
-Tramadol
-Ceftriaxone
>Remove foley
catheter tomorrow
6:00am
3:00-11:00pm 1740H >Patient keep
>In from OR status comfortable in bed
post ORIF under >Patient is stable
GA per stretcher;
patient head is
packed with
dressing and elastic
roller bandage; with
ongoing IVF D5LR
at 600cc level
Regulated at
30gtts/min infusing
well; with 02
inhalation via nasal
cannula at 2 Lpm;
afebrile
>Vital signs
BP=140/90mmHg
P=86bpm
R=16cpm

28
 >Skin testing done
of Ceftriaxone
2000H >Patient vomits two
>02 inhalation times
removed >Patient flat on bed
>Vital signs >Patient keep
monitored q15 comfortable and
rested
2100H
>Tramadol 100mg
TIV
Negative result for
skin test

2200H
>Ceftriaxone 1gram
through slow IV
push
August 04, 2010 1030H >Patient shows signs
7:00am-3:00pm >May have DAT of recovery
>May sit on bed
>May ambulate

29
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