Imaging Findings Day 1 - Fast scan: No evidence of free abdominal fluid. Urinary bladder intact.

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Rosaline Shelton
5 years ago
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Head Trauma Case Report Sabrina Ha, DVM Reviewed By: Jennifer Simpson, DVM, DACVS Signalment: "Indy" Theuret, 1 yo MN DLH History: Indy was suspected to be hit by a car shortly prior to presentation.

Clinical Exam: On presentation, Indy was responsive and alert enough to stand and bear weight on all limbs.

1 Head Trauma Case Report Sabrina Ha, DVM Reviewed By: Jennifer Simpson, DVM, DACVS Signalment: "Indy" Theuret, 1 yo MN DLH History: Indy was suspected to be hit by a car shortly prior to presentation. He was found near the road, laying recumbent and shaking. Indy was a previously healthy outdoor cat. Clinical Exam: On presentation, Indy was responsive and alert enough to stand and bear weight on all limbs. He was tachypneic with normal lung sounds in all fields and tachycardiac with thready, synchronous and symmetrical femoral pulses. His left eye had hyphema, scleral hemorrhage and was moderately proptosed, with the globe protruding from the orbit and decreased retropulsion but still retained within eyelid margins. His menace response and palpebral reflex were intact in the right eye and absent in his left. He had bilateral hemorrhagic nasal discharge. On oral examination, he had a fracture and separation of the palatine and maxillary bones along midline. His mandible was markedly swollen with a palpable symphyseal separation and a dropped jaw appearance. The rest of his examination was unremarkable, with a small urinary bladder palpable. Image 1: Day 2 after presentation. Hyphema, scleral hemorrhage and moderate proptosis of the left globe visible. Esophagostomy tube in place. Laboratory Findings - Blood work on presentation revealed a mild elevation in lactate (3.0 mmol/l) with the remainder of the blood work unremarkable (PCV/TS 40%, 6.6). - Subsequent blood work after anesthesia and mandibular symphyseal fracture repair revealed a moderate to severe anemia (PCV 25-28%) that was static. Prior to discharge, the PCV/TS was 25%, 7.2. Imaging Findings Day 1 - Fast scan: No evidence of free abdominal fluid. Urinary bladder intact.

- Thoracic radiographs: Unremarkable thorax. Cardiac silhouette and vasculature are within normal limits for size. Unremarkable pulmonary parenchyma and pleural space.

2 - Thoracic radiographs: Unremarkable thorax. Cardiac silhouette and vasculature are within normal limits for size. Unremarkable pulmonary parenchyma and pleural space. Day 2 - Skull CT: Mild displacement and widening of the mandibular symphysis. Numerous mildly to moderately displaced fractures of the maxilla bilaterally including the turbinates and nasal septum with crushing of the nasal cavity. Nasal bone displaced ventrally into the nasal passages. Fractures of the hard palate and separation/mild displacement of the incisive bone on midline. Fractures include the orbital wall bilaterally, cribiform plate, parts of the rostral calvarium, pterygoid bone, frontal bones (especially on the right) and right zygomatic arch. There is fluid within the frontal sinuses, more severe on the right. There is a fracture involving the condyloid process of the right temporomandibular joint. The right temporomandibular joint including the zygomatic process of the temporal bone are fractured off and displaced from the skull with a remaining defect in the calvarium. The left globe has an ill defined scleral margin laterally with hyperattenuating material within the vitreous likely representing hemorrhage. There is increased soft tissue opacity within the nasal passages with surrounding emphysema. Diagnosis - Mandibular symphyseal separation - Right temporomandibular joint fracture with displacement of the temporal bone from the skull - Multiple skull fractures (maxillary, crushing of nasal cavity, frontal, right zygomatic arch) - Left globe trauma and exophthalmia with corneal ulceration - Hard palate fracture - Anemia Treatment/Management Day 1 (1/16/14): Indy was fluid resuscitated with Plasmalyte-A (12.5ml/kg) then maintained on IV fluids (1.5x maintenance). He received supplemental oxygen overnight until his tachypnea resolved. - Oxymorphone 0.05 mg/kg IV QID - Ampicillin 22 mg/kg IV TID - Eye medications: Artificial tears ointment OD QID, Gentamicin ophthalmic ointment OS QID Day 2 (1/17/14): Indy was anesthetized for his skull CT and for placement of an esophagostomy feeding tube (Mila 18f). The soft tissue overlying his hard palate was sutured closed. His mandibular symphyseal separation was wired together with 20g cerclage wire. Indy s maxillary and mandibular canines were bonded together with acrylic to stabilize his oral fractures. Indy was mildly hypotensive during anesthesia and was treated with Plasmalyte-A bolus (10ml/kg) and a Fentanyl CRI (2mcg/kg) to allow for decreasing his inhalant anesthesia. He recovered well from anesthesia. - Buprenorphine 0.01 mg/kg IV Image 2: Note the acrylic straws bonding the maxillary and mandibular canines together.

3 Day 3 (1/18/14) to day 11 (1/26/14): Indy was gradually introduced to e-tube feedings and tolerated an a/d slurry fed at q6h starting at 25%, then 50% and 75% MER over the course of 3 days. He regurgitated when transitioned to 100% MER and his feedings were decreased to 75% for an additional day. He tolerated 100% MER with the addition of Famotidine 0.5mg/kg q12h and Metoclopramide 0.4mg/kg q6h via e-tube 30 min prior to feedings. Indy developed profuse diarrhea which progressed to hematochezia. His diet was transitioned to z/d to decrease the fat content and Metronidazole 10mg/kg q12h was given via e-tube. - Additionally, he was nebulized and his nares cleaned q6h. - Buprenorphine 0.01mg/kg SL q8h - Eye medications: Artificial tears ointment OD TID, Prednisolone acetate ophthalmic solution OD BID, Gentamicin ophthalmic ointment OS BID - E-tube medications: Clavamox 13.75mg q12h, Tramadol 3.2mg/kg q8h, Doxycycline 5.4mg/kg q12h via e-tube Follow Up Care After discharge, Indy's care was continued with the previously noted medications. Indy had been doing well on his routine 2 week recheck on 1/31/14 with a healing corneal ulcer OD and ophthalmic medications were discontinued. On 2/2/14, Indy presented for an emergency follow up after dislodging his e-tube. On presentation, the e-tube had backed out 3" and was immediately replaced. Indy was sedated with Oxymorphone 0.1mg/kg IV and Dexmedetomidine 5mcg/kg IV to facilitate handling. Thoracic radiographs and Optiray contrast were used to verify appropriate placement of the e-tube and it was re-sutured in place. While recovering from sedation, he developed profound hematochezia and diarrhea and was prescribed Baytril 5mg/kg via e-tube q24h and Doxycycline discontinued. Indy was discharged but re-presented that evening after the acrylic tubes on his canines became loose but were still attached. A tape muzzle was attempted but did not provide enough stability. On 2/4/14, Indy was anesthetized for removal of the acrylics. The mandibular canines were slightly loose on examination, likely due to maxillary trauma, but the occlusion appeared satisfactory. The sutures from the soft palate repair were removed. Metoclopramide, Tramadol were discontinued. On a routine recheck on 2/14/14, Indy anesthetized and the mandibular symphyseal wire removed. His occlusion was appropriate and he was able to open and close his mouth easily. He did not have any corneal ulcers when fluorescein stain was applied and his ophthalmic medications were discontinued. Due to his intermittent diarrhea after resolution of hematochezia, Tylosin 150mg q12h and Panacur 250mg q24h via e-tube were started for 10 day courses. A fecal ova/parasites with giardia was negative. His e-tube feedings were also decreased to 50% over the course of 5 days and he was encouraged to eat. At the last recheck on 4/9/14, Indy s e-tube had been removed previously and he was eating voluntarily but was very finicky. His occlusion was appropriate and Indy was overall doing well.

4 Discussion Head trauma is a common cause of mandibular fractures. Other causes include severe periodontal disease and neoplasia causing pathologic fractures (1). The most common result of trauma is symphyseal separation accounting for 73% of cases, likely due to the fibrocartilaginous symphysis separating (3,4). Fractures of the mandibular body and temporomandibular joint, including luxations, also occur. Many stabilization techniques have been described to manage mandibular fractures including: tape muzzle, symphyseal wire, interdental/intraoral wire and splints, intercanine bonding, bignathic encircling and retaining device (BEARD), cerclage wire, external fixators, bone plates, and condylectomy (1, 2). The stabilization and repair of mandibular fractures depends on the location and severity of the fractures. In this patient, the mandibular symphysis was separated and the right temporomandibular joint was unstable with a displaced calvarium fracture. In addition, he had multiple rostral maxillary and skull fractures. The mandibular symphysis was stabilized with symphyseal wiring and the remainder of the fractures stabilized with intercanine acrylic bonding. Ideally, the bonding would leave a gap of 10-14mm between the incisors, enabling the patient to lap and swallow normally (5). In Indy's case, an esophagostomy tube was placed and was used to provide nutrition since he was not interested in food and preferentially ate hard food. Fracture healing typically takes 4-8 weeks and alignment is maintained for 3-6 weeks (1-5). Prolonged stabilization of the temporomandibular joint can result in ankylosis. Due to Indy dislodging his acrylics, the intercanine acrylic bonding was removed at 4 weeks with sufficient stabilization of his maxillofacial fractures. Complications of severe maxillofacial trauma can include malocclusion, oronasal fistulas and/or palatal defects, osteomyelitis, delayed or nonunion and facial deformities. In younger patients with deciduous dentition, there may also be abnormalities in dental eruption and development (1-2). A complication rate of approximately 25% has been reported, with malocclusion and osteomyelitis the most common at 35% and 27%, respectively (2).

$the skull with fracture and ventral displacement of the nasal$ $bone (white arrows), fracture of the hard palate (red arrows),$ $Image 5: Note the fracture and displacement of the right$

5 Images 3 & 4: Sagittal (on left) and transverse (right) views of the skull with fracture and ventral displacement of the nasal bone (white arrows), fracture of the hard palate (red arrows), and displacement and widening of the mandibular symphysis (green arrow) noted. Image 5: Note the fracture and displacement of the right temporomandibular joint with a defect in the calvarium (arrow).

6 References 1) Zacher AM, Marretta SM. Oral and Maxillofacial Surgery in Dogs and Cats. Veterinary Clinics of North America: Small Animal Practice 43 (3): , ) Bennett JW, Kapatkin AS, Marretta SM. Dental Composite for the Fixation of Mandibular Fractures and Luxations in 11 cats and 6 dogs. Veterinary Surgery 23: , ) Woodbridge N, Owen M. Feline Mandibular Fractures: A significant surgical challenge. Journal of Feline Medicine and Surgery 15: , ) Umphlet, RC, Johnson AL. Mandibular Fractures in the Cat: A Retrospective Study. Veterinary Surgery 17 (6): , ) Moores, AP. Maxillomandibular external skeletal fixation in five cats with caudal jaw trauma. Journal of Small Animal Practice 52: 38-41, 2011.

Modified Labial Button Technique for Maintaining Occlusion After Caudal Mandibular Fracture/Temporomandibular Joint Luxation in the Cat

Step-By-Step Modified Labial Button Technique for Maintaining Occlusion After Caudal Mandibular Fracture/Temporomandibular Joint Luxation in the Cat Journal of Veterinary Dentistry 2016, Vol. 33(1) 47-52