Question 1 – Which patient has sustained a panfacial fracture?
- A patient with fractures of the mandible and maxilla
- A patient with fractures of both orbits, the maxilla, zygomatic bones, and the nose
- A patient with fractures of the frontal bone, maxilla, and mandible
- A patient with fractures of the mandible and frontal bone
Question 2 – Which of the following statements regarding panfacial fractures is
TRUE?
- Panfacial fractures involve injuries to the middle and lower face
- Panfacial fractures are the result of low-energy injuries
- Panfacial fractures often occur along side life-threatening conditions
- Panfacial fractures can generally be treated adequately in the Emergency
Department
Question 3 – When a patient presents with a panfacial fracture, what is the first course of action?
- Conduct a Primary Survey, with immediate assessment of the status of the patient’s airway, breathing, circulation, and c-spine
- Conduct a thorough physical exam of the facial skeleton to identify all fractures
- Immediately consult the necessary specialty services such as neurosurgery and ophthalmology
- Obtain a thorough history from witnesses or emergency personnel
Question 4 – Which of the following patients would have a high risk of sustaining panfacial fractures?
- A driver injured in a head-on collision at highway speeds
- A patient with a self-inflicted gunshot wound to the face
- A man physically assaulted by multiple assailants
- All of the above
Question 5 – A patient presents to you with multiple facial fractures and suspected injury of the c-spine following a motor vehicle accident. What is the most appropriate imaging study to order?
- A series of facial x-rays, including at least 4 views of the skull
- A Panorex (a.k.a. orthopantomogram)
- An MRI
- A CT scan
- None of the above: imaging is of limited value in the context of acute trauma
Question 6 – Which of the following statements regarding the support structures of the facial skeleton and their relation to panfacial fractures is FALSE?

- Horizontal support is provided by the frontal bar, infraorbital rims, zygomatic arches, and basal portion of mandible
- Vertical support is provided by the zygomaticomaxillary, pterygomaxillary, and nasofrontal buttresses
- Severe comminution generally does not influence the reduction and fixation of a facial buttress
- The central midface is especially prone to comminuted fractures with collapse and loss of projection because of its relative deficit of sagittal support
Question 7 – Which of the following physical signs is NOT important to note in the management of panfacial fractures?
- Raccoon sign
- Hutchinson’s sign
- Marcus-Gunn Pupil
- Battle’s sign
Question 8 – Which of the following statements regarding the appropriate consultations to consider for panfacial fractures is FALSE?
- Any periocular trauma needs to be evaluated by the ophthalmology service, and a posterior chamber exam should be conducted despite its difficulty in the ER
- Neurosurgery should be consulted if there is any evidence of head and/or spinal trauma
- All patients presenting with severe trauma should be assessed by the dedicated trauma service before any other consultations
- All of the above statements are true
Question 9 – Which of the following statements regarding the initial non-operative management of facial trauma patients is TRUE?
- Analgesics and sedatives can be given as needed, but only after a thorough exam is performed to identify sites of pain and tenderness
- Fluid resuscitation is seldom a concern in patients with panfacial fractures, therefore IV access is not a priority
- Supplemental oxygen is generally not considered safe for the panfacial fracture patient
- Hypothermia is not a concern in facial trauma patients, and efforts to keep them warm is a misdirected use of time and resources
- Monitoring urine output is usually not necessary in panfacial fracture patients
Question 10 – Which of the following statements about the optimal timing for panfacial fracture repair is FALSE?
- It is optimal to treat facial fractures within the first few days after injury

- Severe facial trauma frequently occurs in the context of other life-threatening conditions that take precedence in terms of treatment
- The facial soft tissue envelope remains pliable for several weeks, maintaining the possibility of adequate reconstruction for an extended period of time
- Definitive intervention may be delayed for up to 2 weeks, but will be more difficult due to soft-tissue scarring, callus formation, and contraction of the facial soft tissue envelope over regions of bone volume loss
Question 11 – You are carrying out your preoperative planning for a patient with panfacial fractures, which of the following are important components?
1. Assessment of potential need for bone grafting and discussion about this with patient
2. A review of the options for flap coverage
3. Careful physical exam to identify all fractures present, and asses them for displacement, comminution, and bone loss
4. Obtain CT imaging to achieve accurate picture of fracture status
5. Obtain dental impressions
6. Ensure all necessary preoperative evaluations have been conducted by the appropriate consulting services
- 1, 2, 3, and 4 only
- 1, 2, 3, 4, 5, and 6
- 3, 4, and 6 only
- 3 and 4 only
Question 12 – A patient requires fixation of a fractured mandible. Which of the following incisions will allow access to the ascending ramus and mandibular condyle?
- Mandibular gingivobuccal sulcus incision
- Maxillary gingivobuccal sulcus incision
- Transconjuctival incision with lateral canthotomy
- Preauricular/retromandibular incision
Question 13 – How should existing lacerations be managed in the patient with panfacial fractures?
- In some cases the laceration may provide direct access to underlying structures, and may be utilized during operative repair
- All lacerations should be irrigated, debrided and closed as soon as possible according to wound management guidelines
- Lacerations of the face should only be closed with steri-strips
- Facial lacerations should always be closed by delayed primary intention

Question 14 – Which of the following statements regarding soft tissue considerations in the management of panfacial fractures is FALSE?
- High-energy injuries have a greater possibility of significant tissue loss than lowenergy injuries
- Determining the viability of soft tissue in panfacial fracture patients is difficult and may take 24-48 hours before definitive conclusions can be made
- Primary closure of facial wounds is always the most desirable option
- Nonviable tissue must always be removed, even if it is tissue of the face, scalp and oral mucosa
Question 15 – You need to repair a skin defect of the face of a patient who presented to you with panfacial fractures. In considering your options, what is the general order starting with the most optimal to least optimal?
- primary closure > regional flaps > local flaps > distant flaps
- distant flaps> local flaps > regional flaps > primary closure
- primary closure > local flaps > regional flaps > distant flaps
- regional flaps > local flaps > primary closure > distant flaps
Question 16 – Which of the following statements regarding frontal bone and sinus fractures is TRUE?
- Due to their location, these fractures exclusively present with obvious deformities
- Management depends on the status of the anterior and posterior tables of the frontal sinus
- Incidence of associated CNS injury is negligible, only consider if pneumocephalus is present
- Observation alone is adequate for displaced anterior table fractures
Question 17 – In the presence of pure orbital floor fracture, which of the following is an indication for exploration?
- mechanical muscle entrapment
- acute enopthalmos
- defects >1cm on coronal CT
- All of the above
Question 18 – Which of the following pairs is INCORRECT?
- Occlusal splint : alignment of maxillary and/or mandibular arches
- Nasal trumpets : maintain patency of nasal airway in context of soft tissue injury
- External nasal splint : prevents contraction of soft tissue following nasal fracture
- Prosthesis : can be fabricated to act as a spacer, which is useful if bone loss has occurred

Question 19 – Which of the following statements regarding complications after craniofacial trauma is FALSE?
- Malunion is generally only a concern with maxillary and/or mandibular fractures
- Infections can be especially serious in frontal sinus fractures
- Lid retraction can be a late complication that results from fracture repair
- One of the most common complications after naso-orbito-ethmoid fracture repair is telecanthus
Question 20 – Which of the following may result in long-term deformity in the panfacial fracture patient?
- Incorrect diagnosis
- inadequate fracture exposure and/or reduction
- lack of rigid fracture fixation
- contraction of the soft tissue envelope
- all of the above
Question 21 – Which of the following is not generally a common functional problem that may persist despite satisfactory treatment of panfacial fractures?
- seizures
- ectropion
- difficulties with mastication and impaired speech
- Diplopia
Question 22 – A patient presents to you with panfacial fractures and airway issues.
You need to consider performing a tracheotomy, which of the following considerations is INCORRECT?
- Management of severe panfacial fractures usually involves tracheotomy for intraoperative airway management in addition to post-op airway protection.
- If the patient does not need maxillomandibular fixation, an oral airway may be sufficient
- An oral airway generally cannot be used in fully dentate patients who need maxillomandibular fixation, but nasal intubation may be an option
- severe midfacial trauma patients should be nasally intubated whenever possible
Question 23 – Which of the following fractures may be difficult to detect, even with high-resolution CT?
- fractures of the pterygoid plates
- non-displaced fractures
- fractures to certain portions of the mandible
- all of the above

Question 24 – Which of the following statements regarding nasal fractures are true?
1. They may be treated early with closed reduction using local anesthesia within the first few weeks
2. Repair of nasal fractures after bony union has occurred does not require osteotomy
3. Internal packing and external splints are applied following reduction and kept in place for 35-42 days
4. Associated hematomas of the septum should be immediately evacuated to prevent distortion and collapse
- 1, 2, 3, and 4
- 1 and 4 only
- 2 and 3 only
- 2, 3, and 4 only
Question 25 – Which of the following statements regarding the management of panfacial fractures is FALSE?
- Enopthalmos may not present post-injury despite significant displacement of the bony orbit because of edema
- If underlying bone volume decreases, the facial soft tissue envelope contracts rapidly which interferes with optimal soft tissue redraping
- Midface reconstruction is usually the first step in the operative repair of panfacial fractures
- Fractures in the region of the symphysis and parasymphysis may be overlooked on a panoramic study of the mandible due to overlap causing blurring in this area.