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Oxford Specialist
Handbooks in Surgery
Oral and
Maxillofacial
Surgery
third edition

edited by
Carrie Newlands
Consultant Surgeon
Oral and Maxillofacial Surgery
Royal Surrey County Hospital
Guildford, UK

Cyrus Kerawala
Consultant Maxillofacial/​Head and Neck Surgeon
Head and Neck Unit
The Royal Marsden Hospital
London, UK
Visiting Professor
Faculty of Health and Wellbeing
University of Winchester
Winchester, UK

1
iv

1
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Third Edition published in 2020
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 v

Foreword
I am delighted and honoured to have been asked to provide a foreword to
this third edition of Oral and Maxillofacial Surgery.
I doubt that there are many oral and maxillofacial surgery (OMFS) sur-
geons who have not relied upon one or more of the Oxford University
Press pocket handbooks in the course of their careers. While the Internet,
social media, and increasingly sophisticated search engines can often pro-
vide information to a portable device within seconds, there is to my mind
no real substitute for an authoritative textbook, compiled with care, and
drawing together in one place the peer-​validated expertise of our profes-
sion. The current concerns about ‘fake news’ perhaps serve to emphasize
the importance of ensuring the veracity of evidence upon which we rely
when making important decisions which affect the safety of patients. This
book is designed to fit in a pocket, and be an everyday practical aid for the
busy clinician at every stage of their career. The ever increasing complexity
of medicine and surgery makes it imperative that all clinicians have access
to reliable and up-​to-​date information about our rapidly changing and wide-​
ranging specialty.
Carrie Newlands and Cyrus Kerawala are not only internationally ac-
claimed for their clinical contributions to our surgical discipline, but are also
recognized as expert teachers and examiners. Once again, they have suc-
cessfully managed to corral busy clinicians from all branches of the specialty
to bring the third edition of this text fully up to date.

Ian C Martin, LLM, FDSRCS, FRCS

Chairman NCEPOD
Past President: BAOMS, EACMFS, BAHNO, and FSSA
vi
 vii

Preface to the third

edition
We remain committed to surgical teaching, and are active in examining can-
didates for the exit FRCS in OMFS. This third edition provides further up-
dates from previous and new authors, all of whom are expert in their fields.
We hope you continue to find it useful in your careers.

Carrie Newlands and Cyrus Kerawala, 2020

vii
 ix

Preface to the second

edition
Since the first edition of this book the editors have maintained their strong
interest in teaching and examining candidates for the exit FRCS in OMFS.
They are definitely older, and possibly a little wiser. Like many specialties,
oral and maxillofacial surgery develops over time so this new edition builds
on the success and popularity of the first with updates by previous and new
authors. We hope you find it useful.

Cyrus Kerawala and Carrie Newlands, 2014

x
 xi

Preface to the first edition

This handbook is edited by two young consultants in oral and maxillofacial
surgery, who both maintain a strong interest in teaching and are involved
in examining for the exit FRCS. The content closely follows the syllabus
of higher surgical training in oral and maxillofacial surgery in the UK. We
hope it will prove useful and stimulating for trainees in the specialty, both
throughout their training and at that potentially worrying time when the
exit exam approaches. It may even contain snippets that our more senior
colleagues will find of interest.
Oral and maxillofacial surgery is an evolving and unique surgical specialty,
with increasing numbers of young dentists and doctors continually attracted
by its charms. We trust this book will further whet their appetites. It may
also find a place on the bookshelves of those who are working and training
in other allied surgical disciplines, or accident and emergency.
We have tried to present the information contained within, in a familiar
and accessible format, with an emphasis on current evidence where avail-
able. In those many surgical situations where the literature does not provide
an evidence base, we have outlined current UK practice and thinking. We
would like to think that some of our readers will be inspired to help improve
the scientific rationale for what we do where gaps are apparent.
Feedback and comments are welcomed and will be gratefully acknow-
ledged, should this first attempt prove popular enough to give birth to fur-
ther editions.

Carrie Newlands and Cyrus Kerawala, 2009

xii
 xiii

Acknowledgements
We would like to thank the following for their advice and assistance:
Our fellow past and present authors.
Many respected OMFS colleagues, trainers, and trainees, past and pre-
sent, especially for their useful comments about the first and second
editions.
Colleagues in other specialties, with whom we are always glad and often
fortunate to collaborate.
Mr Mick Gilhooly for providing some of the Chapter 1 photographs in
this and previous editions.
The team at Oxford University Press for helpful guidance.
Victoria Rundle for her expert editorial skills.
Our loved ones.
And, of course, our readers—​we hope you enjoy this book as much as
we have, and we hope also that it stands you in good stead to do well in
your examinations and your career.
xvi
 xv

Contents

Contributors xvii
Symbols and abbreviations xxi

1 Trauma 1
2 Oral cavity and oropharyngeal cancer 61
3 Surgical dermatology 143
4 Salivary glands 177
5 Orthognathic surgery 211
6 Craniofacial surgery 289
7 Cleft lip and palate 315
8 Aesthetics 351
9 The temporomandibular joint 377
10 Surgical principles and oral surgery 397
11 Oral medicine 453
12 Eponyms in OMFS 513
13 Other useful facts 521

Index 533
xvi
 xvii

Contributors
Brian Bisase Katharine Fleming
FDSRCS(Eng), FRCS(OMFS) FRCS(OMFS), FDSRCS, PGDipME,
Consultant Head & Neck/​OMF MBBS, BChD
Surgeon Consultant Oral and Maxillofacial
Queen Victoria Hospital Surgeon
Foundation Trust Countess of Chester
East Grinstead, UK Foundation Trust
Chapter 2: Oral cavity and oropharyn- Chester;
geal cancer and Chapter 12: Eponyms Regional Maxillofacial Unit
in OMFS Aintree, UK
Chapter 11: Oral medicine
Emer Campbell
MBChB, FRCS(SN) Katherine George
Consultant Paediatric Neurosurgeon BDS, MBBS, BSc(Hons), MFDS RCS,
and Honorary Senior Clinical FRCS(OMFS)
Lecturer Consultant Oral and Maxillofacial
Paediatric Neurosurgery Surgeon
Royal Hospital for Children and King’s College Hospital NHS
University of Glasgow Foundation Trust
Glasgow, UK London, UK
Chapter 6: Craniofacial surgery Chapter 4: Salivary glands
Roger Currie Siddharth Gowrishankar
FDS, FRCS, FFST(Ed), MDS, MFDS, FFDSRCSI, FDSRCS,
FRCS(OMFS) FRCS(OMFS)
Consultant Oral and Maxillofacial Consultant Oral and Maxillofacial
Surgeon Surgeon
University Hospital Crosshouse Oxford University Hospital NHS
Kilmarnock, UK Foundation Trust
Chapter 3: Surgical dermatology Oxford, UK
Chapter 5: Orthognathic surgery
Daljit Dhariwal
BDS, FDSRCS, FRCS(CSiG), Ben Gurney
FRCS(OMFS) MBChB, BDS, FRCS(OMFS)
Consultant Oral and Maxillofacial Consultant Oral and Maxillofacial
Surgeon Surgeon
Oxford University Hospitals NHS Royal Surrey County Hospital
Foundation Trust Guildford, UK
Oxford, UK Chapter 3: Surgical dermatology
Chapter 5: Orthognathic surgery
xviii Contributors

Ben Hechler Nicholas Lewis

DDS, MD BDS(Hons), MSc, LLM, MFDS Ed.,
Fellow—​Oral, Head, and Neck FDS(Rest Dent) RCS, FFGDP
Oncologic Surgery Consultant in Restorative Dentistry
University of Tennessee Royal Surrey NHS Foundation Trust
Medical Center Surrey, UK
Knoxville, TN, USA Chapter 10: Surgical principles and
Chapter 9: The oral surgery
temporomandibular joint
Nigel Shaun Matthews
Ian Holland FDS, FRCS, FRCS(OMFS)
FDS, FRCS Associate Professor
Consultant Oral and Maxillofacial Oral and Maxillofacial Surgery
Surgeon University of North Carolina,
Queen Elizabeth University Hospital Adams School of Dentistry
Glasgow, UK Chapel Hill, NC, USA
Chapter 1: Trauma Chapter 9: The
temporomandibular joint
Paul Johnson
BSc(Hons), MA, BChD(Hons), Carrie Newlands
MB.Bchir, FDSRCS, FRCS FDSRCS, FRCS(OMFS)
Consultant Oral and Maxillofacial Consultant Surgeon
Surgeon Oral and Maxillofacial Surgery
Royal Surrey County Hospital Royal Surrey County Hospital
Guildford, UK Guildford, UK
Chapter 8: Aesthetics Chapter 3: Surgical dermatology and
Chapter 13: Other useful facts
Cyrus Kerawala
BDS (Hons), FDSRCS (Eng), MBBS Rafal Niziol
(Hons), FRCS Ed, FRCS (OMFS) MBBS, BSc, BDS, MRCS
Consultant Maxillofacial/Head and Speciality Registrar in Oral and
Neck Surgeon Maxillofacial Surgery
Head and Neck Unit King’s College Hospital NHS
The Royal Marsden Hospital Foundation Trust
London, UK London, UK
Visiting Professor Chapter 4: Salivary glands
Faculty of Health and Wellbeing
University of Winchester
Muneer Patel
Winchester, UK DipDSed, MEd(Surg),
Chapter 2: Oral cavity and oropharyn- FFD(OSOM), FDS
geal cancer and Chapter 13: Other Specialist Oral Surgeon
useful facts William Harvey Hospital
Ashford, UK
David Koppel Chapter 10: Surgical principles and
BDS, MBBS, FDSRCS, FRCS oral surgery
Consultant Craniofacial/​Oral
Maxillofacial Surgeon
Royal Hospital for Children
Glasgow, UK
Chapter 6: Craniofacial surgery
 Contributors xix

Meharpal Sangra Simon Van Eeden

MBChB, BSc(Hons), MML(Gla) FRCS(OMS), FRCS(Ed),
Consultant Paediatric Neurosurgeon MChD(Hons), MBChB(Hons),
and Craniofacial Surgeon BDS, BSc
Royal Hospital for Children Consultant Cleft and Maxillofacial
Glasgow, UK Surgeon
Chapter 6: Craniofacial surgery Alder Hey Children’s Hospital
Liverpool, UK
Harsh Saxena Chapter 7: Cleft lip and palate
FRCA
Consultant Anaesthetist Helen Witherow
Royal Surrey County Hospital NHS FRCS(OMFS)
Foundation Trust Consultant Maxillofacial Surgeon
Guildford, UK St George’s Hospital
Chapter 10: Surgical principles and London, UK
oral surgery Chapter 8: Aesthetics
Nigel Taylor
BDS, MDSc, FDS RCS(Ed), MOrth
RCS(Ed), FDTF (Ed)
Consultant Orththodontist
Orthodontic Unit
Royal Surrey Hospital
Guildford, UK
Chapter 5: Orthognathic surgery
x
 xxi

Symbols and abbreviations

% cross reference CCF congestive cardiac failure
 bomb (controversial topic) CL cleft lip
~ approximately CLAPA Cleft Lip and Palate
# fracture Association
♀ female CLP cleft lip and palate
♂ male cM cutaneous melanoma
d decreased CMV cytomegalovirus
i increased CNS central nervous system
l leading to CO2 carbon dioxide
M website COPD chronic obstructive pulmonary
disease
± with or without
COX cyclooxygenase
2D two-​dimensional
CP cleft palate
3D three-​dimensional
CRP C-​reactive protein
ACE angiotensin-​converting enzyme
CSF cerebrospinal fluid
ACE-​27 Adult Co-​morbidity Evaluation
CT computed tomography
ADA American Dental Association
CTA computed tomography
ADP adenosine diphosphate angiography
AJCC American Joint Committee CTD connective tissue disorder
on Cancer
CXR chest X-​ray
ALARP as low as reasonably possible
DCIA deep circumflex iliac artery
ALP alkaline phosphatase
DM diabetes mellitus
ANB point A to nasion to point B
DUSS duplex ultrasound scanning
AP anteroposterior
DVT deep venous thrombosis
ARDS acute respiratory distress
syndrome EAM external auditory meatus
ASA American Association of EAT extra-​alveolar time
Anaesthesiologists EBV Epstein–​Barr virus
ATLS advanced trauma life support ECG electrocardiogram
AVPU Alert, Voice, Pain, ELND elective lymph node dissection
Unresponsive EM erythema multiforme
BAD British Association of END elective neck dissection
Dermatologists
ENT ear, nose, and throat
BCC basal cell carcinoma
EORTC European Organisation for
BCLP bilateral cleft lip and palate Research Treatment of Cancer
BDA British Dental Association ESR erythrocyte sedimentation rate
BLCP bilateral cleft lip and palate ET endotracheal
BMI body mass index ETT endotracheal tube
BP blood pressure EUA examination under anaesthesia
BSSO bilateral sagittal split EUT Eustachian tube
osteotomy
FACT-​HNS Functional Assessment of
CAD computer-​aided design Cancer Therapy, H + N Scale
CAM computer-​aided manufacturing FBC full blood count
CBCT cone beam computed FDG fluorodeoxyglucose
tomography
xxii Symbols and abbreviations

FESS functional endoscopic sinus MRA magnetic resonance

surgery angiography
FGFR fibroblast growth factor MRI magnetic resonance imaging
receptor MRONJ medicine-​related
FNA fine needle aspiration osteonecrosis of the jaw
FNAB fine needle aspiration biopsy MRSA methicillin-​resistant
FNAC fine needle aspiration cytology Staphylococcus aureus
FRCS Fellowship of the Royal MTHFR methylenetetrahydrofolate
Colleges of Surgeons reductase
FTSG full-​thickness skin graft NAM nasoalveolar moulding
GA general anaesthesia/​ ND neck dissection
anaesthetic NG nasogastric
GCS Glasgow Coma Scale NGT nasogastric tube
GDC General Dental Council NICE National Institute for Health
GDP general dental practitioner and Care Excellence
GMC General Medical Council NMSC non-​melanoma skin cancer
GMP general medical practitioner NO nitrous oxide
GPP gingivoperiosteoplasty NSAID non-​steroidal
anti-​inflammatory drug
HADS Hospital Anxiety and
Depression Scale O2 oxygen
HBO hyperbaric oxygen OCP oral contraceptive pill
HIV human immunodeficiency virus OH oral hygiene
HLA human leucocyte antigen OHI oral hygiene instruction
HPV human papilloma virus OM occipitomental
HRQOL health-​related quality of life OME otitis media with effusion
HSV herpes simplex virus OMENS orbital distortion, mandibular
hypoplasia, ear anomaly,
ICP intracranial pressure nerve involvement, soft tissue
ID inferior dental deficiency
IDB inferior dental bundle OMFS oral and maxillofacial surgery
IE infective endocarditis ON osteonecrosis
Ig immunoglobulin ONJ osteonecrosis of the jaws
IHD ischaemic heart disease OPG/​OPT orthopantomogram
IJV internal jugular vein ORIF open reduction internal
IM intramuscular fixation
IMF intermaxillary fixation ORN osteoradionecrosis
INR international normalized ratio OSA obstructive sleep apnoea
IRM intermediate restorative PA posteroanterior
material PCR polymerase chain reaction
IU international units PE pulmonary embolus
IV intravenous PEG percutaneous endoscopic
LA local anaesthesia/​anaesthetic gastrostomy
LMA laryngeal mask airway PET positron emission tomography
LMWH low-​molecular-​weight heparin PMOL potentially malignant
LN lymph node oral lesion
LP lichen planus PRP platelet-​rich plasma
MAPK mitogen-​activated PSA pleomorphic salivary adenoma
protein kinase PTH parathyroid hormone
MDT multidisciplinary team QOL quality of life
MI myocardial infarction RAPD relative afferent papillary defect
 Symbols and abbreviations xxiii

RCT randomized controlled trial SPECT single photon emission

RED rigid external distractor tomography
REM rapid eye movement SS Sjögren’s syndrome
RNA ribonucleic acid TB tuberculosis
RND radical neck dissection TED thromboembolic deterrent
RT radiotherapy TGF transforming growth factor
SALT speech and language therapy/​ TMJ temporomandibular joint
therapist TMJDS temporomandibular joint
SARPE surgically assisted rapid palatal dysfunction syndrome
expansion TNF tumour necrosis factor
SC subcutaneous TNM tumour, lymph nodes, distant
SCC squamous cell carcinoma metastases system
SCM sternocleidomastoid muscle UCLP unilateral cleft lip and palate
SDCEP Scottish Dental Clinical UICC Union for International Cancer
Effectiveness Programme Control
SEND selective elective neck USS ultrasound scanning
dissection UV ultraviolet
SMAS superficial VCF velocardiofacial syndrome
musculo-​aponeurotic system VPI velopharyngeal incompetence
SMV submentovertex VSS vertical subsigmoid osteotomy
SNA point S to nasion to point A VZV varicella zoster virus
SNB sentinel node biopsy/​point S WHO World Health Organization
to nasion to point B
WLE wide local excision
SND selective neck dissection
ZN Ziehl–​Neelsen
xvxi
 Chapter  1

Trauma
Introduction 2
Initial assessment 3
‘Advanced trauma life support’ and facial trauma 4
Priority setting in polytrauma 5
‘How to do’ emergency procedures 6
Initial management of head injuries 12
Initial management of ocular injuries 14
‘First aid’, antibiotics, and tetanus 16
Definitive diagnosis 18
Investigations 24
Definitive surgery 26
Principles of hard tissue management 32
Mid-​face fractures 40
Zygomatic fractures 44
Orbital fractures 48
Frontal bone fractures 52
Pan-​facial fractures 56
Isolated nasal fractures 57
Dental injuries 58
Post-​traumatic deformity 59
2

2 Chapter  Trauma

Introduction
Maxillofacial trauma can affect any part of the head and neck and frequently
occurs in conjunction with other injuries, particularly ophthalmic and neuro-
surgical. Over the last several decades there has been a change in the aeti-
ology of this form of trauma in the UK. Prior to seatbelt legislation and
motor vehicle safety developments, such as airbags, there were large num-
bers of high-​energy road traffic accidents with drivers and passengers sus-
taining injuries from unrestrained impacts on dashboards or windscreens.
Such injuries are now far less common. There is, however, a large work-
load from injuries as a result of interpersonal violence and, with an ageing
population, an increasing number of elderly patients sustaining injuries from
falls. This pattern of injury is mirrored in most of Western Europe and
North America. In some parts of the world, e.g. Asia, road traffic injuries
still predominate.
Following the development of internal fixation, popularized in the 980s
with the introduction of titanium, miniplate open reduction and internal
fixation is now established as a routine approach to the management of
displaced facial fractures.
 Initial assessment 3

Initial assessment
History: the importance of the mechanism of injury and medical and
drug histories
The history of any injury is important and indirectly provides a guide not
only to its treatment, but also the potential surgical outcome. Important
factors relate to the patient and nature of the injury itself.
Patient factors
• Medical history: details of general health and medications taken should
be sought in case they influence treatment pathways or provision of
care, e.g. COVID-​9.
• Social history: a significant proportion of patients with facial injuries
have underlying social problems with housing, and the recreational
use of drugs and alcohol. Patients with addictions to alcohol or
recreational drugs are frequently malnourished and can be relatively
immunocompromised. Consideration should be given to whether
domestic violence is involved in the mechanism of injury.
Injury factors
• Sharp or blunt trauma: exclusively sharp trauma produces an incised
wound, with the nature of the injury indicating if there is likely to be
contamination of the wound, e.g. glass.
• Energy transfer of trauma: although energy transfer is a concept
originally used to understand ballistic trauma, it is relevant to all types
of injury. High-​energy transfer is exemplified by an object that is either
fast moving or has a large inherent mass colliding with an object and
stopping. Kinetic energy is transferred to that object. This occurs in road
traffic accidents where the mass of the patient’s head moves rapidly and
then stops. It is also the case with blunt trauma imparted by an object,
such as a baseball bat or the force from a kick. By contrast, the energy
transfer in a punch is lower, as a fist has less mass and moves more
slowly.
• Contamination of wounds: cuts with knives are frequently clean and
non-​contaminated. Lacerations are often contaminated with particles
from the surface that have produced the injury and often require
thorough debridement under general anaesthesia (GA).
4

4 Chapter  Trauma

‘Advanced trauma life support’ and

facial trauma
Life-​threatening conditions
• Airway with cervical spine control: if the airway is compromised in
facial injuries it is frequently due to:
• debris obscuring the airway, such as blood, and fragments of teeth
and bone;
• oedema in the pharyngeal tissues as result of injury;
• a grossly displaced mandibular injury resulting in lack of tongue
support and secondary obstruction of the airway is possible, although
in the conscious patient rarely seen.
• Breathing.
• Circulation: the head and neck has a rich blood supply. This is beneficial
in soft tissue and fracture healing, but can cause problems with acute
haemorrhage. Torrential haemorrhage is likely to arise from:
• the maxillary artery and pterygoid venous plexus in grossly displaced
maxillary fractures;
• branches of the carotid artery and tributaries of the internal jugular
vein in penetrating neck trauma.
• Although head and neck haemorrhage can result in hypovolaemic
shock, the shocked patient with facial injuries must have all other
potential causes of blood loss investigated and excluded as appropriate.
• Disability.
• Exposure.
• Head injury: cerebral injury is frequently associated with facial injury.
Head injury in the presence of severe facial injuries may be milder
than expected as, to some extent, the face acts as a ‘crumple zone’
protecting the cranial contents from injury. Patients should be assessed
using the Glasgow Coma Scale (GCS). Many patients with facial injury
will have consumed alcohol or drugs that can mask the symptoms of
head injury. This needs to be borne in mind when assessing the patient.
There needs to be a low threshold for computed tomography (CT)
scanning to exclude intracranial injury or mass effects.
• <C>ABCDE has superseded ABC (catastrophic haemorrhage, airway
with spinal protection, breathing, circulation, disability (neurological) and
exposure and environment). People with suspected major trauma are
usually taken to the nearest major trauma centre for management.
• The CRASH-​2 trial showed that tranexamic acid reduces death rates in
the trauma patient who is bleeding or at risk of bleeding.
Sight-​threatening conditions
The eyes lie in the centre of the face surrounded inferiorly by the maxilla,
laterally by the zygoma, and medially by the frontal, nasal, and lacrimal bones.
Orbital trauma is frequently associated with ocular injury. All patients with a
suspected orbital injury should have their visual acuity documented at their
time of initial assessment. Loss of visual acuity should raise the question of
whether there is intraocular injury, primary optic nerve injury, or i pressure
within the orbit leading to secondary injury of the optic nerve. Retrobulbar
haemorrhage is an example of a condition that causes acute compression of
the optic nerve. (See % Initial management of ocular injuries, p. 14.)
 Priority setting in polytrauma 5

Priority setting in polytrauma

Multidisciplinary considerations
Life-​or sight-​threatening facial injuries should be treated immediately. Facial
lacerations and unstable mandibular fractures should be treated early ideally,
within 24h. Most other bony facial injury can be treated on a delayed basis.
The delay involved is dependent upon the amount of facial oedema present.
Mid-​face and orbital injuries should either be treated before the onset of
facial oedema (in the first 24–​48h) or after facial oedema has settled. The
decision of definitive timing to treat injuries is also affected by other injuries,
and the need to treat major chest, abdominal, pelvic, limb and head trauma
(M https://​www.nice.org.uk/​guidance/​ng39/​chapter/​Context).
Imaging
Polytrauma patients are often immobilized or supine due to potential spinal
injuries.
Plain film radiographs for facial injuries include:
• Occipitomental (OM) views.
• Orthopantomogram (OPG).
• Posteroanterior (PA) mandible.
These views require the patient to be upright. However, in a patient with
multiple injuries this is not possible. If the patient cannot stand and has clin-
ical indicators that suggest significant bony facial injury, a fine cut (0.5mm)
CT scan of the head and neck should be undertaken. With the advent
of 64-​slice spiral CT scanners in most trauma units, this should be easily
achievable. Every effort should be made to incorporate facial imaging into
trauma protocols. If a patient is having a CT of their head and cervical spine,
they should have simultaneous imaging of the face.
6

6 Chapter  Trauma

‘How to do’ emergency procedures

Airway management
Except in the management of battlefield trauma, where control of massive
haemorrhage from extremities may supervene, the airway always takes first
priority and should be managed in association with protection of the cer-
vical spine. Airway management can be summarized as follows:
• Clear debris from the airway.
• Posture—​in the absence of associated spinal injuries it is appropriate
to sit the patient up. Patients with grossly displaced mandibular injuries,
such as those from gunshot wounds, should be allowed to sit leaning
forward so that the tongue and any debris from the oral cavity is
allowed to fall away from the airway.
• Neck extension and jaw thrust also helps to clear the airway, although
neck extension is not permitted in the case of suspected injuries to the
cervical spine.
• A Guedel airway can be used to help maintain the airway temporarily in
a patient with reduced consciousness (Fig. .). The majority of these
patients will need a definitive airway, i.e. one in which there is a tracheal
cuff to prevent debris escaping into the lungs. The best example of this
is the endotracheal tube (ETT; Fig. .2), the establishment of which
should be the first choice for managing the compromised airway in
the trauma patient. If it is not possible, other surgical options exist for
establishing an airway.
Vomiting in the immobilized patient
Patients immobilized on a spinal board who vomit are in danger of aspir-
ation, as they cannot sit up to clear their airway. If such a patient is about to
vomit, they should immediately be turned on their side on the spinal board.
Surgical airways
An emergency surgical airway can be achieved in one of two ways.
Needle cricothyroidotomy
This provides a temporary surgical airway. In essence, it supplies the pa-
tient with oxygen (O2), but without a definitive surgical airway there is an
inevitable build-​up of carbon dioxide (CO2), which limits the usefulness of
this technique.
Technique
• Ensure an O2 supply and tubing is available.
• Place patient in a supine position.
• Assemble a 2-​or 4-​gauge needle with a 5mL syringe.
• Surgically prepare the neck using antiseptic swabs.
• Identify the cricothyroid membrane, between the cricoid cartilage and
the thyroid cartilage. Stabilize the trachea with the thumb and forefinger
of one hand to prevent lateral movement of the trachea during
performance of the procedure.
 ‘How to do’ emergency procedures 7

Fig. . Initial airway management of multiple facial injuries with a Guedel airway.

Fig. .2 Initial airway management of multiple facial injuries with an ETT.
8

8 Chapter  Trauma

• Puncture the skin in the midline with the needle attached to the syringe,
directly over the cricothyroid membrane. A small incision with a No. 
blade may facilitate passage of the needle through the skin.
• Direct the needle at a 45° angle inferiorly, while applying negative
pressure to the syringe, and carefully insert the needle through the
lower half of the cricothyroid membrane. Aspiration of air signifies
entry into the tracheal lumen.
• Remove the syringe and attach the O2 tubing over the needle hub.
Intermittent ventilation can be achieved by occluding the open hole cut
into the O2 tubing with your thumb for s and releasing it for 4s.
Cricothyroidotomy
Surgical cricothyroidotomy provides a definitive surgical airway. It is a
procedure that can be performed extremely rapidly and, in an emer-
gency, any rigid tube with a hollow lumen can used. Specially designed
cricothyroidotomy tubes are available.
Technique
• Place the patient in a supine position with the neck in a neutral position.
Palpate the thyroid notch, cricothyroid membrane, and the sternal
notch for orientation. Surgically prepare and anaesthetize the area (if
there is time and the patient is conscious).
• Stabilize the thyroid cartilage with the left hand. Make a transverse
skin incision over the cricothyroid membrane. Carefully incise through
the membrane. Insert the scalpel handle into the incision and rotate it
90° to open the airway. Insert an appropriately sized, cuffed ETT or
tracheostomy tube into the cricothyroid membrane incision, directing
the tube inferiorly into the trachea. Inflate the cuff and ventilate the
patient (Fig. .3 and Fig. .4).
Conscious patients with a compromised airway will often shows signs of
agitation and will not want to lie supine as this causes the tongue to fall back
into the airway. There may also be stridor present and signs of i respiratory
effort. Hypoxia may reveal itself by:
• Agitated patient.
• Varying level of consciousness.
• Inappropriate behaviour.
• Signs of airway compromise.
• Combination of the above signs.
Spinal immobilization
Patients with suspected spinal injuries or patients who are unconscious
should be immobilized in the in-​line spinal position. The cervical spine can
be immobilized at the same time as establishing an airway.
Moving the patient
Multiple-​injury patients should be immobilized on a spinal board for the
purposes of transfer.
Intravenous access
Intravenous (IV) access should be established with two large-​bore can-
nulas (brown 4-​or grey 6-​gauge) at two peripheral sites, such as the
antecubital fossae.
 ‘How to do’ emergency procedures 9

Fig. .3 Cricothyroidotomy: surface landmarks.

Fig. .4 Cricothyroidotomy: airway secured with an ETT.

10

10 Chapter  Trauma

Facial bleeding
Sitting the patient up not only improves the airway and breathing, but also
reduces venous pressure with a consequent beneficial effect on bleeding
from injury. Most facial bleeding from soft tissue injuries can be controlled
with direct pressure. Torrential haemorrhage from mid-​facial fractures is
not so easily controlled. Anterior and posterior nasal packing is used to
staunch haemorrhage from the nose. It is often also helpful to prop the
mouth open, impacting the maxilla against the skull base and compressing
bleeding vessels. Hypovolaemia may be clinically apparent by:
• Tachycardia.
• Tachypnoea.
• Peripheral shutdown.
• Anxiety.
• Narrowing of pulse pressure.
• Hypotension is a late sign of hypovolaemia and a normotensive patient
should not be assumed to be necessarily normovolaemic.
The first priority in the presence of appreciable facial haemorrhage always
remains protection of the airway.
Bleeding from the neck
• Bleeding from penetrating neck trauma is potentially serious.
• The neck is divided into three zones:
• zone I (base)—​thoracic inlet to cricoid cartilage (highest mortality);
• zone II (mid-​portion)—​cricoid cartilage to angle of mandible;
• zone III (superior)—​angle of mandible to skull base.

External haemorrhage
If the haemorrhage is external, then local temporary measures such as
isolating the bleeding point if clearly identifiable with a haemostat are ap-
propriate. Bleeding from the tissues overlying the mandible from the facial
artery can be controlled by pressure. Bleeding from the major vessels in
the neck, such as the internal jugular vein, cannot be so easily controlled by
pressure and will need prompt surgical exploration.
Concealed haemorrhage
Penetrating neck trauma from sharp implements such as knives can cause
internal bleeding from damage to the great vessels without signs of external
haemorrhage. This is potentially serious, as the consequences of rapid neck
swelling can be fatal. Patients showing signs of neck swelling or patients who
show signs of haemodynamic instability should have the airway assessed
and protected if required and either urgent surgical exploration or imaging
if time allows. Bear in mind that penetrating neck injuries may have neck
vessel sources of bleeding or more distant thoracic sources.
 ‘How to do’ emergency procedures 11

Imaging
• CT head and neck with consideration of inclusion of upper thorax with
contrast.
• Consider CT angiography.
• Chest X-​ray (CXR).
• Computed tomography angiography (CTA).
• Conventional angiography.
• Magnetic resonance imaging (MRI)/​magnetic resonance angiography
(MRA).
• Ultrasound scanning (USS).
12

12 Chapter  Trauma

Initial management of head injuries

Patients with head injuries can initially be assessed using the ‘Alert, Voice,
Pain, Unresponsive’ (AVPU) system before formal GCS assessment.
AVPU
A Alert.
V Voice, able to respond to verbal command.
P Does not respond to verbal command, will respond to pain.
U Unresponsive.
The first priority is to prevent secondary brain injury from inadequate cere-
bral circulation.
• Airway:
• provide 00% O2;
• consider intubation in the presence of hypoxia, hypercapnia,
respiratory distress, or in a patient unable to protect their own airway.
• Breathing: assess and treat chest injuries.
• Circulation:
• evaluate and treat hypovolaemia;
• identify and control haemorrhage;
• use isotonic fluids (crystalloid vs colloid controversy, usually 0.9%
saline, increasing use of permissive hypotension which has been
shown to improve outcomes).
Glasgow Coma Scale
d level of consciousness as assessed by the GCS score:
Best eye response (E)
There are four grades starting with the most severe:
• Grade : no eye opening.
• Grade 2: eye opening in response to pain (patient responds to pressure
on fingernail bed; if this does not elicit a response, supraorbital and
sternal pressure or rub may be used).
• Grade 3: eye opening to speech (not to be confused with an awaking of
a sleeping person; such patients receive a score of 4, not 3).
• Grade 4: eyes opening spontaneously.
Best verbal response (V)
There are five grades, starting with the most severe:
• Grade : no verbal response.
• Grade 2: incomprehensible sounds (moaning, but no words).
• Grade 3: inappropriate words (random or exclamatory articulated
speech, but no conversational exchange).
• Grade 4: confused (patient responds to questions coherently, but there
is some disorientation and confusion).
• Grade 5: orientated (patient responds coherently and appropriately to
questions such as name and age, etc.).
 Initial management of head injuries 13

Best motor response (M)

There are six grades, starting with the most severe:
• Grade : no motor response.
• Grade 2: extension to pain (adduction of arm, internal rotation of
shoulder, pronation of forearm, extension of wrist—​decerebrate
response).
• Grade 3: abnormal flexion to pain (adduction of arm, internal rotation
of shoulder, pronation of forearm, flexion of wrist—​decorticate
response).
• Grade 4: flexion/​withdrawal to pain (flexion of elbow, supination of
forearm, flexion of wrist when supraorbital pressure applied, pulls part
of body away when nail bed pinched).
• Grade 5: localizes to pain (purposeful movements towards painful
stimuli, e.g. hand crosses mid-​line and gets above clavicle when
supraorbital pressure applied).
• Grade 6: obeys commands (patient carries out simple requests).
A fully conscious patient scores 5. A patient scoring less than 8 should be
considered to be in a coma and, as such, unable to protect their own airway.
The minimum score is 3.
Indication for computed tomography imaging in head injury
CT imaging should be performed in all patients with significant risk of an
intracranial injury:
• Moderate and severe head injuries or deteriorating GCS score.
• Loss of consciousness.
• Amnesia.
• Focal neurological deficits.
• Suspected skull fractures or penetrating injury.
• Large scalp haematomas and lacerations (>0cm).
• Cerebrospinal fluid (CSF) leak and other signs of base of skull fractures.
14

14 Chapter  Trauma

Initial management of ocular injuries

A high proportion of patients with orbital injuries will have coexisting ocular
injuries. It is essential to make an initial basic assessment of ocular function.
In a conscious patient, this should consist of an assessment of visual acuity
using a pocket Snellen chart. If the patient cannot read the top line on the
Snellen chart, then assessment is as follows:
• Can the patient count fingers?
• Can the patient see hand movement?
• Has the patient any light perception?
Relative afferent pupillary defect (RAPD) is an indication of damage to the
visual system that is useful in an unconscious patient. It is assessed by the
swinging light test in which a pen torch is alternatively shone into one eye
and then the other. Swinging the torch from the normal eye to the affected
eye results in bilateral pupillary dilatation (Marcus Gunn sign). The presence
of a RAPD usually indicates damage to the retina or optic nerve.
Directly examine the eye for the following clinical features:
• Hyphaema: blood in anterior chamber.
• Irregular pupil: sign of underlying ocular injury.
• Constricted pupils (meiosis): consider coexisting opiate abuse.
• Dilated pupil (mydriasis): suspect local trauma, optic nerve or retinal
injury, rising intracranial pressure (ICP), or cocaine abuse (bilateral).
Retrobulbar haemorrhage
Retrobulbar haemorrhage is best thought of as an example of acute or-
bital compression syndrome as a result of an intraconal bleed. The com-
monest causes are orbital trauma or as a complication of orbital surgery.
Haemorrhage causes i pressure within the orbit, reducing flow in the ret-
inal artery (an anatomical end-​artery), which in turn leads to irreversible
vascular changes within the optic nerve, resulting in visual loss. Consider
retrobulbar haemorrhage if:
• Tense proptosed eye: eye pushed forward under pressure compared
with contralateral eye.
• Ophthalmoplegic eye: no eye movement.
• Acute reduction in visual acuity.
• Chemosis and orbital pain.
• RAPD.
• Raised intraocular pressure.
• Retinal signs:
• papilloedema;
• lack of central retinal artery pulsation;
• pale optic disc (occurs late);
• cherry red macula.

Treatment of retrobulbar haemorrhage needs to be prompt in order to

avoid permanent visual loss.
 Initial management of ocular injuries 15

Treatment options
Medical decompression
• Mannitol (osmotic diuretic) 20% 2g/​kg IV over 5min.
• Dexamethasone 8mg IV.
• Acetazolamide (carbonic anhydrase inhibitor, reduces production of
aqueous humour), 500mg IV and then 000mg orally over 24h.
Surgical decompression
Lateral canthotomy and cantholysis.
Canthotomy technique
• Clean the area with sterile saline.
• Inject local anaesthetic (LA) into the lateral canthus.
• Apply a haemostat/​clamp with one side anterior and one side posterior
to the lateral canthus and advance until the rim of the bony orbit is felt.
• Clamp for 30–​60s.
• Perform the lateral canthotomy by carefully cutting through the crushed,
demarcated line to the orbital rim/​lateral fornix to avoid traumatizing
the orbit.
Cantholysis technique
• Grasp lower eyelid with forceps and pull outwards/​downwards away
from eye.
• Identify the canthal ligament by either inspection or palpation. Incise
the inferior crus of the lateral canthal ligament with scissors to avoid
traumatizing the orbit.
• Recheck the orbit for reduction in intraorbital and intraocular pressure.
If pressure is still high, dissect the superior limb of the canthal ligament
in a similar fashion. Care should be taken to avoid any trauma to the
lacrimal gland.
16

16 Chapter  Trauma

‘First aid’, antibiotics, and tetanus

Antibiotic usage
Indications for prophylactic usage of antibiotics in trauma include:
• Contaminated soft tissue injury.
• Mandibular fractures which are compound to the mouth.
• Surgical emphysema.
The importance of prompt surgical debridement cannot be overempha-
sized in the management of contaminated wounds and compound frac-
tures. Without surgical debridement infection will eventually occur even
with antibiotic prophylaxis. Antibiotic prophylaxis should therefore start
promptly and continue until surgical debridement has occurred.
In the case of grossly infected wounds and systemic signs, such as rigor,
pyrexia, and tachycardia, antibiotics should continue for at least 5 days.
The choice of antibiotic will depend upon local policy.
Bite injuries should be covered with co-​amoxiclav.
Antibiotic prophylaxis is no longer routinely recommended for patients
with CSF leaks.
Tetanus prophylaxis
Consideration of tetanus prophylaxis depends upon the immunization
status of the patient and the status of the wound (Table .).

Table . Immunization status and wound type

Immunization status Wound type
Clean wound Tetanus prone
Clean incised wound Wound >6h old
Superficial graze Contact with soil, manure
Puncture wound
Infected wound
Devitalized tissue
Animal or human bite
Last of 3-​dose course or Nil Nil
reinforcing dose within Human tetanus
last 0 years immunoglobulin if high
contamination, e.g. stable
manure
Last of 3-​dose course Reinforcing dose of Reinforcing dose of adsorbed
or reinforcing dose adsorbed tetanus tetanus vaccine + human
>0 years ago vaccine tetanus immunoglobulin
Not immunized or Full course of Full course of adsorbed
immunization status not adsorbed tetanus tetanus + human tetanus
known with certainty immunoglobulin
 ‘First aid’, antibiotics, and tetanus 17

Adsorbed tetanus vaccine

• Adsorbed tetanus vaccine is given as 0.5mL by deep subcutaneous (SC)
or intramuscular (IM) injection into the deltoid or gluteal muscle.
• A full course of adsorbed tetanus vaccine consists of three doses of
0.5mL at intervals of not less than 4 weeks.
• Tetanus vaccine must not be given to anyone who has received a
reinforcing dose in the preceding year.
• Patients with impaired immunity who suffer a tetanus-​prone wound
may not respond to vaccine and may therefore require anti-​tetanus
immunoglobulin in addition.
Human tetanus immunoglobulin for prophylaxis
• Human tetanus immunoglobulin is given as 250 IU in mL by IM
injection into the deltoid or gluteal region.
• If more than 24h have elapsed since injury, or there is risk of heavy
contamination, or following burns, the recommended dose is 500 IU.
Tetanus vaccine and immunoglobulin must be given by separate syringes
into separate sites.
Metronidazole is the drug of choice for treatment of tetanus.
18

18 Chapter  Trauma

Definitive diagnosis
Full assessment of the maxillofacial region requires careful examination of
the soft and hard tissues.
Inspection: facial
Soft tissue
Facial soft tissue injuries should be carefully recorded.
A laceration is caused by blunt trauma—​an incised wound caused by a
sharp object.
The use of clinical photography is to be commended especially for com-
plex lacerations. Such photographs are helpful for medicolegal purposes
and are always a useful adjunct to planning revision surgery. Each laceration
should have the following recorded:
• Contamination: the greatest influence on management is the presence
or absence of wound contamination. Heavily contaminated wounds,
regardless of size and depth, need debridement, which often needs to
be completed under GA.
• Condition of wound margins:
• sharp clean cut edge—​this results from sharp injury such as injury on
a metal edge. These lacerations are simple to repair after appropriate
debridement;
• serrated edge—​this can implicate glass fractured in the aetiology
of the wound. Under these circumstance there are usually glass
fragments in the wound and they will need careful removal;
• rounded edge—​if the edge of wound is rounded then it is likely that
the wound has arisen as a result of friction over a bony protuberance.
This is the case for the common paediatric injuries, such as cuts on
the forehead, eyebrows, and chin;
• necrotic edge—​higher energy transfer to the wound causes
irreversible damage to the soft tissue edge, such that it is dusky or
black. Judicious trimming of wound edges needs to be considered in
such cases.
• Size: measure length of the laceration with a ruler.
• Depth:
• up to dermal depth—​abrasion;
• up to fat depth—​laceration likely to require suture;
• Muscle involvement—​consider the possibility of facial nerve or
parotid involvement in mid-​facial lacerations (the surface anatomy of
the parotid duct is middle third of line drawn from the tragus to the
corner of the mouth). The buccal branch of facial nerve is closely
associated with the parotid duct;
• bony involvement.
• Orientation to relaxed skin tension lines: lacerations that are
orientated in the direction of relaxed skin tension lines are likely to heal
better than lacerations orientated away from relaxed skin tension lines.
 Definitive diagnosis 19

The following signs of bruising raise suspicion of an underlying fracture:

• Bruising over the skin of the mastoid bone: ‘Battle’s sign’ (can indicate a
base of skull fracture).
• Bilateral periorbital bruising: ‘raccoon eyes’ (can indicate a fracture of
the base of the skull, nasoethmoid region, frontal sinus, or Le Fort II/​III
fracture).
• Bilateral inner canthus bruising: can indicate a nasal bone fracture.
• Bruising overlying the lower border of the mandible: can indicate a
mandibular fracture.
The presence of facial swelling should be noted, although it correlates
poorly with the severity of the underlying bony injury. Swelling often masks
underlying bony deformity described in the following section.
Bony/​cartilaginous deformity
• Evidence of deformity in the frontal and nasoethmoid area:
• frontal bone deformity—​this is most commonly seen in patients with
fractures of the anterior wall of the frontal sinus. The appearance
is of a midline depression in the area immediately above the
supraorbital ridge;
• nasoethmoidal deformity—​this is often associated with frontal
deformity. The classic appearance includes telecanthus, depression of
nasal bridge, and elevation of the nasal tip.
• Nasal bone deformity: the nose is frequently disrupted in facial injuries.
Anatomically, only the upper third of nose is bony. Nasal fractures often
present with deviation of the nose.
• Evidence of malar flattening: the zygomatic bone forms most of the
lateral and inferior orbital rim. Inferolateral to this is the prominence of
the zygoma. Displaced fractures of the zygoma produce flattening of this
area that it is easy to underestimate in the acute setting as facial swelling
obscures the appearance.
• Evidence of zygomatic arch deformity:
• in-​fracture of the arch of the zygoma—​may be an isolated fracture of
the arch or may be associated with an externally rotated zygomatic
fracture;
• out-​fracture of the arch of the zygoma—​seen as bowing of the
zygomatic arch. Often associated with posterior displacement and
an internally rotated zygomatic fracture. This is an important clinical
sign as bowing of the zygomatic arch is hard to correct surgically
and, if left untreated, leads to persistent bony swelling overlying the
zygomatic arch.
20

20 Chapter  Trauma

Inspection: oral
Examination of the mouth is mandatory since clinical signs indicating frac-
tures of the maxilla and mandible are often reflected in intraoral changes
that are not obscured by general facial swelling.
• Bruising: sublingual haematoma is highly suggestive of a mandibular
fracture.
• Gingival lacerations: laceration of the gingivae in the lower jaw is
suggestive of a mandibular fracture, and in the upper jaw is suggestive of
a segmental maxillary fracture.
• Palatal bruising: indicates either a split palate or Le Fort fracture.
• Gross deformity of mandible.
• Disorders of occlusion (Fig. .5):
• anterior open bite—​either bilateral mandibular condylar fracture or a
posteriorly displaced Le Fort fracture;
• lateral open bite—​the patient’s teeth meet normally on one side, but
on the opposite side there is no contact. The most common cause for
this is a mandibular condylar fracture on the contralateral side to the
open bite.

Fig. .5 Step in occlusion with mandibular fracture.

Inspection: orbital
Swelling may obscure a full view of the patient’s eye. If this is the case, it is
still important to obtain a basic assessment of visual function (see % Initial
management of ocular injuries, p. 14). Systematic examination of the orbit
is as follows:
• Pupillary level: is the pupil at the same level as the opposite eye? If
one eye is lower, then a hypoglobus exists that may be the result of a
zygomatic or orbital floor fractures.
• Anteroposterior eye position: are the eyes in the same position?
Enophthalmos can be associated with internal orbital wall injury.
Exophthalmos is one sign of retrobulbar haemorrhage (see % Initial
management of ocular injuries, p. 14).
 Definitive diagnosis 21

• Intercanthal distance (normally same width as palpebral fissure): an

increase in the intercanthal width (normal range in Caucasians 28–​
35mm) results from lateral displacement of the medial canthal tendon.
The result is telecanthus. The usual cause is a nasoethmoidal fracture.
Inspection: nasal
The nose should be examined externally and internally. Internal examin-
ation of the nose is facilitated by the use of a Thuddicum’s speculum.
• External nasal examination: look for deviation of the nose and
asymmetry of nasal bones.
• Internal nasal examination:
• septal haematoma—​this is seen as a bulge on one or both sides of
the nasal septum that often totally obscures the nasal airway. It is a
surgical emergency and requires immediate drainage to prevent long-​
term damage to the septal cartilage.
• septal deviation/​dislocation—​this is common and should be elicited
during the initial examination. Acute management may be required.
• CSF rhinorrhoea: this is seen as clear fluid leaking from the nose
(detected by beta-​2 transferrin assay). It occurs in high-​level mid-​face
injuries, as well as nasoethmoidal and frontal bone injury. The fluid is
often seen tram lining—​blood leaking from the nose forms clotted
streaks of blood down the face with CSF washing away the central
portion of clotted blood.
Inspection: ear
Inspect the pinna for signs of laceration and haematoma.
• Haematoma of the pinna can compromise the blood supply to the
underlying cartilage producing a ‘cauliflower’ ear. These haematomas
need drainage.
• CSF otorrhoea.
• Bleeding from the external auditory meatus (EAM)—​this can result
from a number of injuries:
• base of skull fracture (Battle’s sign usually coexists);
• laceration of the cartilaginous auditory meatus—​can be a sign of
mandibular condylar injury;
• bleeding from tympanic membrane—​usually associated with rupture
of the tympanic membrane.
Active range of movement
Mandibular
Normal mandibular opening is around 35–​45mm. Reduced mandibular
opening is not a reliable indicator of mandibular fracture, since it can be
secondary to soft tissue injuries and effusions of the temporomandibular
joint (TMJ).
2

22 Chapter  Trauma

Ocular
Examine the eyes in primary gaze (looking straight ahead), as well as the
other eight positions of gaze (left and right central; left, central, and right
upward gaze; left, central, and right downward gaze). Patients may report
double vision.
• Monocular: lens dislocation or retinal detachment.
• Binocular:
• entrapment of extraocular muscles and orbital contents;
• haematoma;
• dysfunction of extraocular muscles;
• periglobular oedema;
• neuropathy of cranial nerves supplying extraocular muscles (III, IV,
and VI).
Diplopia on upward gaze is a clinical sign of orbital floor entrapment with
the false imaging originating in the injured eye. Diplopia in downward gaze
can be associated with dysfunction of the inferior rectus usually due to
muscle bruising. All patients with reduced acuity, diplopia, and/​or ocular
motility abnormalities should be referred for ophthalmology and orthoptic
assessments.
Sensory changes and facial fractures
Assessment should be made of the three divisions of the trigeminal nerve:
• Supraorbital/​supratrochlear nerves: rarely injured. If sensory
abnormality exists, it is either a localized injury to the nerve itself (i.e.
neuropraxia) without an underlying fracture or secondary to a superior
orbital rim fracture.
• Infraorbital nerve: commonly injured in orbital floor and zygomatic
fractures.
• Mental nerve/​inferior dental (ID) nerve: commonly injured in fractures
of the mandible. Usually indicates an angle, body, or parasymphyseal
fracture.
Specific signs of abnormal mobility
These signs should be elicited carefully in a conscious patient, since they
can be painful.
Maxillary
Hold the maxilla in a gloved hand and attempt to move it, while restraining
the forehead. See if movement can be elicited at:
• Nasal bones and lateral orbital rims—​Le Fort III level fracture.
• Nasal bones and infraorbital rims—​Le Fort II fracture.
Mandible
Inspect the occlusal plane for obvious steps, ask the patient to open their
mouth and look for displacement/​gaps evident between teeth on jaw
movement, not present at rest. Press bilaterally at both mandibular angles
to see if movement in the region anterior to the angles can be elicited. If no
movement can be appreciated and the patient can protrude their mandible
normally, a fracture is less likely. The test should not be pursued in the pres-
ence of an obvious fracture as it will elicit pain.
Definitive diagnosis 23
24

24 Chapter  Trauma

Investigations
Radiography
Plain film radiographs are sometimes undertaken as a screening tool. In
simple fractures they are often the only necessary investigation, e.g. frac-
tures of the tooth-​bearing portion of the mandible or single-​piece fractures
of the zygoma.
Occipitomental views
Otherwise known as ‘Water’s view’, the OM view is taken with the film at
the chin and the radiographic source at the occiput. High-​quality films need
the patient to extend their neck, which is not always possible in the acute
setting. The angulation of the OM view is recorded in degrees and refers to
the extension of the neck that is present when the film is taken—​a 30° OM
is commonly ordered (film taken with a 30° neck extension). OM views are
indicated if a fracture of the zygoma or zygomatic arch is suspected.
Orthopantomogram
This is a tomogram of the mandible and is effectively two lateral views of
the mandible joined together. A second view of the mandible (usually PA)
is required.
Posteroanterior mandible
This is a PA view of the mandible with the film placed at the patient’s chin.
Computed tomography
CT has been available since 972. The use of cross-​sectional imaging has
revolutionized the diagnosis of complex facial trauma. Modifications such
as helical and multislice scanning mean that CT can be acquired quickly.
There is also no need for the patient to stand to gain adequate CT images.
CT images can be reformatted in any plane and three-​dimensional (3D)
reconstructions can be derived from the original scan data. The other main
advantage of CT scanning is that good-​quality images can be gained from
patients in cervical spine immobilization who are supine.
Indications for CT scanning for facial trauma include:
• Any unconscious patient who has an associated facial injury.
• Injuries of the frontal sinus and nasoethmoidal area.
• Injuries of the middle third of the face.
• Imaging of orbital floor and orbital wall injuries.
• Bilateral injuries of the mandibular condylar region.
• High-​energy transfer injuries to facial region, e.g. gun shots.
• Pan-​facial fractures.
Cone beam computed tomography scanning
The main disadvantage of CT scanning is the radiation dose involved. Since
CT scanning for facial injuries is finer cut than brain CT, there is a higher
radiation dose per patient volume (risk of iatrogenic cataracts), hence the
development of low-​dose cone beam computed tomography (CBCT)
scanning. The reduction in radiation dose results in a loss of the number
of Hounsfield units that the scanner can detect. Soft tissue definition of the
images are therefore inferior to conventional CT scanning. However, for
diagnostic and reconstructive use in hard tissue facial trauma, CBCT scan-
ning is adequate for mandibular and basic orbital imaging.
 Investigations 25

Magnetic resonance imaging

MRI may be of use in orbital trauma and can help with detection of site of
CSF leaks well.
Ultrasound scanning
USS is of limited value in diagnosing fractures of the facial skeleton. There
are some proponents of its use in hard and soft tissue orbital trauma.
Imaging of specific areas
Upper third
• Plain films: of limited value.
• CT: standard imaging for assessment.
• MRI: CSF leaks.
Middle third
• Plain films: simple fractures (OMs, submentovertex (SMV)).
• CT: orbits, consider stereolithography/​navigation.
• MRI: orbits.
Lower third
• Plain films: usually sufficient.
• CT: condylar fractures and polytrauma.
Soft tissue
• Plain films: foreign bodies.
• CT: metallic foreign bodies.
• MRI: non-​metallic foreign bodies.
• Sialography: parotid duct injuries.
• Dacryocystography: nasolacrimal injuries.
• Angiography: penetrating neck trauma (see % ‘How to do’ emergency
procedures, p. 6).
Orthoptic assessment
Orthoptic examination is the specialized assessment of eye movement. This
examination requires individual items of equipment and the patient has to
able to open both eyes. As a result, this form of assessment is only practical
when any facial swelling has resolved. An orthoptic assessment includes a
Hess chart and documentation of fields of binocular single vision.
Other documents randomly have
different content
 Motion Pictures, 1912-1939
SERIES LIST

An alphabetical list of the series titles given in the main entries

included in the first section of this catalog.
 A
ACE HIGH SERIES. SEE ALSO Vagabond-Ace High Series. Van Beuren
Corp.
Six Day Grind. 1935.
ADVENTURE SERIES.
International Film Service, inc. Jockey of Death. 1916.
ADVENTURES OF BILL AND BOB.
Pathe Exchange, Inc.
American Badger. © 1921.
Fox. © 1921.
Opossum. © 1922.
Trapping the Bobcat. © 1921.
ADVENTURES OF PEACEFUL RAFFERTY.
O'Hara, Charles C.
Adventures of Peaceful Rafferty. © 1915.
Rafferty Settles the War. © 1915.
Rafferty Stops a Marathon Runner. © 1915.
ADVENTURES OF THE NEWSREEL CAMERAMAN.
Fox Film Corp.
Casting for Luck. 1935.
Chasing the Champions. 1934.
Filming the Great. 1934.
Hazardous Occupations. 1935.
Man's Mania for Speed. 1934.
Night Life of Europe. 1935.
On Foreign Service. 1934.
On Western Trails! 1936.
Outdoing the Daredevils. 1934.
Shooting the Record Breakers. 1935.
Tracking the Explorers. 1935.
 When Disaster Strikes. 1934.
With the Navies of the World. 1934.
Twentieth Century-Fox Film Corp.
Athletic Oddities. 1938.
Bone Bender Parade. 1937.
Daily Diet of Danger. 1938.
Dogging It Around the World. 1936.
Filming Feminine Headliners. 1935.
Filming Modern Youth. 1937.
Filming Nature's Wonders. 1937.
Filming the Big Thrills. 1938.
Filming the Fantastic. 1936.
Laughing at Fate. 1937.
Looking for Trouble. 1936.
Motor Maniacs. 1937.
Pacing the Thoroughbreds! 1936.
Recording Modern Science. 1938.
Scouring the Skies. 1936.
Ski Parade. 1937.
Sport Headliners of 1936. 1936.
Trailing Animal Stories. 1937.
AESOP'S FABLES. SEE ALSO Fables.
Pathe Exchange, Inc.
Animal Fair. 1931.
Ball Park. 1929.
Barnyard Melody. 1929.
Big Cheese. 1930.
Bonehead Age. © 1925.
Bughouse College Days. 1929.
Bugville Romance. 1930.
Close Call. 1929.
Cowboy Blues. 1931.
Custard Pies. 1929.
Day's Outing. © 1925.
Dixie Days. 1930.
English Channel Swim. © 1925.
Faithful Pup. 1929.
Farm Foolery. 1930.
Fight Game. 1929.
Fish Day. 1929.
Flying Age. 1928.
Fly's Bride. 1929.
Frozen Frolics. 1930.
Gyped in Egypt. 1930.
Haunted House. © 1925.
Haunted Ship. 1930.
Homeless Cats. 1929.
Hot Tamale. 1930.
House Cleaning Time. 1929.
Jail Breakers. 1929.
Jungle Fool. 1929.
Jungle Jazz. 1930.
King of Bugs. 1930.
Little Game Hunter. 1929.
Mill Pond. 1929.
More Mice Than Brains. © 1925.
Night Club. 1929.
Noah Had His Troubles. © 1925.
Noah Knew His Ark. 1930.
Office Boy. 1930.
Oom Pah Pah. 1930.
Presto-Chango. 1929.
Radio Racket. 1931.
Red Riding Hood. 1931.
Romeo Robin. 1930.
Skating Hounds. 1929.
Snow Time. 1930.
Stage Struck. 1929.
Summertime. 1929.
Toytown Tale. 1931.
Tuning In. 1929.
 War Bride. 1928.
Wash Day. 1929.
Western Whoopee. 1930.
Wood Choppers. 1929.
RKO Pathe Distributing Corp.
Big Game. 1931.
College Capers. 1931.
Fairyland Follies. 1931.
Fisherman's Luck. 1931.
Fly Guy. 1931.
Fly Hi. 1931.
Fun on the Ice. 1931.
Mad Melody. 1931.
Makin' Em Move. 1931.
Paleface Pup. 1931.
Play Ball. 1931.
RKO Radio Pictures. Inc.
A. M. to P. M. 1933.
Barking Dogs. 1933.
Bring 'Em Back Half Shot. 1932.
Bubbles and Troubles. 1933.
Bugs and Books. 1932.
Bully's End. 1933.
Cat-Fish Romance. 1932.
Cubby's World Flight. 1933.
Dizzy Day. 1933.
Down in Dixie. 1932.
Feathered Follies. 1932.
Fresh Ham. 1933.
Hokum Hotel. 1932.
Indian Whoopee. 1933.
Last Mail. 1933.
Love's Labor Won. 1933.
Nut Factory. 1933.
Opening Night. 1933.
Panicky Pup. 1933.
 Pickaninny Blues. 1932.
Rough on Rats. 1933.
Runaway Blackie. 1933.
Silvery Moon. 1933.
Tumble Down Town. 1933.
Venice Vamp. 1932.
Yarn of Wool. 1932.
Van Beuren Corp.
Art for Art's Sake. 1934.
Cat's Canary. 1932.
Cowboy Cabaret. 1931.
Croon Crazy. 1933.
Cubby's Picnic. 1933.
Cubby's Stratosphere Flight. 1934.
Family Shoe. 1931.
Farmerette. 1932.
Fly Frolic. 1932.
Galloping Fanny. 1933.
Gay Gaucho. 1933.
Goode Knight. 1934.
Happy Polo. 1932.
How's Crops. 1934.
In Dutch. 1931.
Last Dance. 1931.
Magic Art. 1932.
Mild Cargo. 1934.
Nursery Scandal. 1932.
Romeo Monk. 1932.
Sinister Stuff. 1934.
Spring Antics. 1932.
Stone Age Error. 1932.
Toy Time. 1931.
Walker, John Randolph.
Goose That Laid the Golden Eggs. 1921.
ALL STAR COMEDY. SEE ALSO Hal Roach All Star Comedy; Roach
Star Comedies.
Metro-Goldwyn-Mayer Corp.
Apples to You! 1934.
Caretaker's Daughter. 1934.
Mrs. Barnacle Bill. 1934.
Mixed Nuts. 1934.
Next Week-End. 1934.
Twin Screws. 1933.
ALONG THE ROAD TO ROMANCE ON THE MAGIC CARPET OF
MOVIETONE. SEE Magic Carpet of Movietone.
ALONG THE ROYAL ROAD TO ROMANCE ON THE MAGIC CARPET OF
MOVIETONE. SEE Magic Carpet of Movietone.
AMERICAN HOME LIFE SERIES.
Aralma Film Co., Inc.
Disposing of Mother. 1923.
This Wife Business. 1923.
AMOS 'N' ANDY.
Van Beuren Corp.
Lion Tamer. 1934.
Rasslin' Match. 1934.
ANDY CLYDE COMEDY. SEE ALSO Educational-Mack Sennett-Andy
Clyde Comedies.
Educational Film Exchanges, Inc.
Sunkissed Sweeties. 1932.
Educational Films Corp. of America.
Dora's Dunking Doughnuts. 1933.
His Weak Moment. 1933.
ANIMATED GROUCH CHASER.
Edison (Thomas A.) Inc.
Adventures of Tom the Tamer and Kid Kelly. 1916.
Black's Mysterious Box and Hicks in Nightmareland. 1915.
Cartoons in a Sanitarium. 1915.
 Cartoons in the Barber Shop. 1915.
Cartoons in the Hotel. 1915.
Cartoons in the Kitchen. 1915.
Cartoons in the Laundry. 1915.
Cartoons in the Parlor. 1915.
Cartoons on a Yacht. 1915.
Cartoons on the Beach. 1915.
Cartoons on Tour. 1915.
Story of Cook Vs. Chef and Hicks in Nightmareland. 1916.
ANOTHER ROMANCE OF CELLULOID. SEE Romance of Celluloid.
AROUND THE WORLD.
Columbia Pictures Corp. of California, Ltd.
City of the Golden Gate. 1937.
El Salvador. 1938.
Friendly Neighbors. 1938.
AROUND THE WORLD WITH BURTON HOLMES.
Metro-Goldwyn-Mayer Distributing Corp.
Busy Barcelona. 1930.
China's Old Man River. 1930.
Dublin and Nearby. 1913.
Glories of Nikko. 1930.
Into Morocco. 1930.
Modern Madrid. 1930.
Peeps at Pekin. 1930.
Spain's Maddest Fiesta. 1930.
Sultan's Camp of Victory. 1930.
Tale of the Alhambra. 1930.
That Little Bit of Heaven. 1930.
Through the Yangtze Gorges. 1930.
ARTHUR LAKE COMEDY.
Universal Pictures Corp.
Doing His Stuff. 1929.
Follow Me. 1930.
Her Bashful Beau. 1930.
 His Girl's Wedding. 1929.
Night Owls. 1929.
Some Show. 1930.
AS A DOG THINKS SERIES.
Skibo Productions.
Walking the Dog. 1933.
You and I and the Gate Post. 1933.
ASHTON KIRK, INVESTIGATOR, SERIES.
Pathé Frères.
Menace of the Mute. © 1915.
ATLAS HEALTH SERIES.
Miller & Glick.
Your Teeth. 1922.
 B
BABE RUTH BASEBALL SERIES.
Universal Pictures Corp.
Slide, Babe, Slide. 1932.
BABY BURLESKS. SEE ALSO Jack Hays Baby Burlesk.
Educational Film Exchanges, Inc.
Pie Covered Wagon. 1932.
War Babies. 1932.
Educational Films Corp. of America.
Kids' Last Fight. 1933.
BARNEY GOOGLE.
Standard Cinema Corp.
Beefsteaks. 1928.
Horse on Barney. 1929.
Horsefeathers. 1928.
Just a Stall. 1929.
Money Balks. 1928.
Neigh, Neigh, Spark Plug. 1929.
OK MNX. 1928.
Pace That Thrills. 1929.
Runnin' Thru the Rye. 1929.
Slide, Sparky, Slide. 1929.
Sunshine's Dark Moment. 1929.
T-Bone Handicap. 1928.
Screen Gems Inc.
Tetched in the Head. 1935.
BASKETBALL.
Universal Pictures Corp.
Basketball Tactics and Plays. 1931.
Defensive Play. 1931.
Fundamentals of Offense. 1931.
BASKETTE.
Universal Pictures Corp.
Fiddlin' Buckaroo. 1933.
Strawberry Roan. 1933.
Trail Drive. 1933.
BATTLE FOR LIFE.
Audio Productions, Inc.
Nature's Gangster. 1934.
Spotted Wings. 1934.
Nathan, Woodard & Fairbanks.
Battle of the Centuries. 1932.
Desert Demons. 1932.
Sea. 1932.
Skibo Productions, Inc.
Born To Die. 1934.
Woodard, Stacy R.
Beneath Our Feet. 1933.
BEAUTY PARLOR SERIES.
R-C Pictures Corp.
Beloved Rouge. 1927.
Boys Will Be Girls. 1927.
Chin He Loved To Lift. 1927.
Fresh Hair Fiends. 1927.
Helene of Troy, N. Y. 1927.
Last Nose of Summers. 1927.
New Faces for Old. 1927.
Peter's Pan. 1927.
She Troupes To Conquer. 1927.
Toupay or Not Toupay. 1927.
BED-TIME STORY FOR GROWN-UPS.
Columbia Pictures Corp.
Blonde Pressure. 1931.
She Served Him Right. 1931.
Soldier of Misfortune. 1931.
 Wolf in Cheap Clothing. 1932.
BENNY RUBIN COMEDY.
Universal Pictures Corp.
Actor. 1929.
Broken Statutes. 1929.
Delicatessen Kid. 1929.
Hotsy Totsy. 1929.
Income Tact. 1929.
Pilgrim Papas. 1929.
Pop and Son. 1929.
BETTY BOOP CARTOON.
Paramount Pictures, Inc.
Be Up to Date. 1938.
Ding Dong Doggie. 1937.
Foxy Hunter. 1937.
Grampy's Indoor Outing. 1936.
Honest Love and True. 1938.
Hot Air Salesman. 1937.
House Cleaning Blues. 1937.
Impractical Joker. 1937.
Making Friends. 1936.
Making Stars. 1935.
New Deal Show. 1937.
Not Now. 1936.
Out of the Inkwell. 1938.
Pudgy and the Lost Kitten. 1938.
Pudgy Picks a Fight. 1937.
Pudgy Takes a Bow-Wow. 1937.
Pudgy the Watchman. 1938.
Rhythm on the Reservation. 1939.
Riding the Rails. 1938.
Service with a Smile. 1937.
Song a Day. 1936.
Swing School. 1938.
Training Pigeons. 1936.
 Whoops! I'm a Cowboy. 1937.
Yip Yip Yippy. 1939.
You're Not Built That Way. 1936.
Zula Hula. 1937.
Paramount Productions, Inc.
Baby Be Good. 1935.
Betty in Blunderland. 1934.
Ha! Ha! Ha! 1934.
Keep in Style. 1934.
Little Nobody. 1936.
Little Soap and Water. 1935.
Morning, Noon, and Night. 1933.
Red Hot Mama. 1934.
She Wronged Him Right. 1934.
Stop That Noise. 1935.
Taking the Blame. 1935.
There's Something About a Soldier. 1934.
When My Ship Comes In. 1934.
BIG BOY JUVENILE COMEDIES.
Educational Film Exchanges. Inc.
Angel Eyes. 1928.
Chilly Days. 1928.
Come to Papa. 1928.
Fixer. 1929.
Ginger Snaps. 1929.
Gloom Chaser. 1928.
Helter Skelter. 1929.
Hot Luck. 1928.
Joy Toric. 1929.
Kid Hayseed. 1928.
Navy Beans. 1928.
No Fare. 1928.
Shamrock Alley. 1927.
She's a Boy. 1927.
BIG TIME VAUDEVILLE.
 Vitaphone Corp.
Bring on the Girls. 1937.
Vaude-Festival. 1937.
BILL AND BOB. SEE Adventures of Bill and Bob.
BILL CORUM SERIES. SEE ALSO Sports with Bill Corum.
Van Beuren Corp.
Beach Sports. 1937.
Big League. 1937.
Foreign Sports. 1937.
Goals for Gold and Glory. 1936.
High, Wide, and Dashing. 1936.
Ice Men. 1937.
Ladies Day. 1936.
Pardon My Spray. 1936.
Puttin' on the Dog. 1937.
Row, Mister, Row. 1936.
Royal Steeds. 1937.
Saratoga Summers. 1937.
Singing Wheels. 1936.
BILL CUNNINGHAM SPORTS REVIEW.
Brown-Nagel Productions, Inc.
Canine Capers. 1931.
He-Man Hockey. 1931.
Inside Baseball. 1931.
No Holds Barred. 1931.
Slides and Glides. 1932.
Speedway. 1932.
BILLY DOOLEY COMEDY.
Christie Film Co.
Dumb Belles. 1927.
Have Courage. 1926.
Christie Film Co., Inc.
Dippy Tar. 1926.
Sailor, Beware! 1927.
 Educational Film Exchanges, Inc.
Briny Boob. 1926.
Wild Wallops. 1927.
BIOLOGICAL SCIENCE SERIES.
Erpi Picture Consultants, Inc.
House-Fly. 1936.
Leaves. 1936.
BLINKHORN'S NATURAL HISTORY TRAVELS.
Blinkhorn, Albert.
Capture of a Sea Elephant and Hunting Wild Game in the South
Pacific Islands. © 1914.
BLUE FLAME SERIES.
Selig Polyscope Co.
Black Diamond. 1915.
BLUE RIBBON COMEDIES.
Standard Cinema Corp.
Adorable Dora. 1926.
Black and Blue Eyes. 1926.
Fraternity Mixup. 1926.
Hold Tight. 1925.
Hurricane. 1926.
Lame Brains. 1925.
Mummy Love. 1926.
Peaceful Riot. 1925.
Salute. 1925.
She's a Prince. 1926.
Vamping Babies. 1926.
What! No Spinach? 1926.
BLUE STREAK WESTERN.
Universal Pictures Corp.
Blazing Days. 1927.
Blue Blazes. 1926.
Border Cavalier. 1927.
Border Sheriff. 1926.
Broncho Buster. 1927.
Bucking the Truth. 1926.
Bustin' Thru. 1925.
Call of Courage. 1925.
Chasing Trouble. 1926.
Circus Cyclone. 1925.
Daring Days. 1925.
Demon. 1925.
Desperate Game. 1926.
Escape. 1926.
Fighting Peacemaker. 1926.
Fighting Three. 1927.
Grinning Guns. 1927.
Hands Off. 1927.
Hard Fists. 1927.
Hidden Loot. 1926.
Lazy Lightning. 1926.
Loco Luck. 1926.
Looking for Trouble. 1926.
Man from the West. 1926.
One Man Game. 1926.
Outlaw's Daughter. 1925.
Prowlers of the Night. 1926.
Queen of the Hills. 1926.
Rambling Ranger. 1927.
Range Courage. 1927.
Red Hot Leather. 1926.
Red Rider. 1925.
Ridin' Rascal. 1926.
Riding Thunder. 1925.
Roaring Adventure. 1925.
Rough and Ready. 1926.
Rustlers' Ranch. 1926.
Scrapping Kid. 1926.
Set Free. 1927.
 Set-up. 1926.
Six Shootin' Romance. 1925.
Sky High Corral. 1925.
Spurs and Saddles. 1927.
Stolen Ranch. 1926.
Terror. 1926.
Triple Action. 1925.
Two-Fisted Jones. 1925.
Western Pluck. 1925.
Western Rover. 1927.
Western Whirlwind. 1926.
White Outlaw. 1925.
Wild Horse Stampede. 1926.
Yellow Back. 1926.
BOBBY VERNON COMEDIES. SEE ALSO Educational-Bobby Vernon
Comedy.
Christie Film Co.
Jail Birdies. 1927.
Christie Film Co., Inc.
Air Tight. 1925.
Bright Lights. 1924.
Broken China. 1926.
Don't Pinch. 1925.
Dummy Love. 1926.
French Pastry. 1925.
Great Guns. 1925.
High Gear. 1924.
Hoot Mon! 1926.
Page Me. 1926.
Slippery Feet. 1925.
Sure Fire. 1926.
Till We Eat Again. 1926.
Watch Out. 1925.
Wife Shy. 1926.
Yes, Yes, Babette. 1926.
 Educational Film Exchanges, Inc.
Dead Easy. 1927.
BRAY NATURE.
Bray Productions, Inc.
Furry Tale. 1927.
Heralds of the Spring. 1927.
Little Brother of the Wild. 1927.
Low Down. 1927.
Marine Parade. 1927.
BRAY NATURGRAPH.
Bray Pictures Corp.
Giants of the North. 1933.
Oregon Camera Hunt. 1932.
Our Bird Citizens. 1932.
Our Noble Ancestors. 1932.
Pirates of the Deep. 1933.
Stable Manners. 1932.
Wild Company. 1933.
Woodland Pals. 1933.
BRIGHTEN THE CORNER WHERE YOU ARE. THE GLAD SERIES.
Kay (A.) Co.
Dust unto Dust. 1917.
BRINGING UP FATHER.
International Film Service, Inc.
Father Gets into the Movies. 1916.
Great Hansom Cab Mystery. © 1917.
Hansom Cab Mystery. © 1917.
He Tries His Hand at Hypnotism. © 1917.
Hot Time in the Gym. © 1917.
Just Like a Woman. 1917.
Music Hath Charms. © 1917.
Pathe Exchange, Inc.
Father's Close Shave. © 1920.
Jiggs and the Social Lion. © 1920.
 Jiggs in Society. © 1920.
BRITISH BEAUTY SPOTS.
Edison (Thomas A.) Inc.
Cornwall, the English Riviera. 1913.
Wild Wales. 1913.
BROADWAY BREVITIES.
Vitaphone Corp.
Around the Clock. 1934.
Backyard Broadcast. 1936.
Blonde Bomber. 1936.
Boarder Trouble. 1938.
Bring on the Girls. 1937.
Broadway Buckaroo. 1939.
Calling All Kids. 1937.
Can't Think of It. 1936.
Cleaning Up. 1938.
Day at Santa Anita. 1937.
Echo Mountain. 1936.
Fat Chance. 1939.
Give Me Liberty. 1937.
Here Comes the Circus. 1936.
Home, Cheap Home. 1939.
Ice Frolic. 1939.
I'm Much Obliged. 1936.
Little Pioneer. 1937.
Mail and Female. 1937.
Murder with Reservations. 1938.
Newsboy's Nocturne. 1937.
No Contest. 1935.
No Man. 1933.
Play Street. 1937.
Prisoner of Swing. 1938.
Projection Room. 1939.
Rainbow's End. 1938.
Rollin' in Rhythm. 1939.
 Romance in the Air. 1936.
Romance of Robert Burns, 1937.
Rush Hour Rhapsody. 1936.
Seasoned Greetings. 1933.
Seeing Red. 1939.
Seeing Spots. 1939.
Slapsie Maxie's. 1939.
Sons of the Plains. 1938.
Sophomore Swing. 1939.
Sound Defects. 1937.
Stardust. 1938.
Sundae Serenade. 1939.
Swing Opera. 1939.
That's Pictures. 1936.
Thirst Aid. 1937.
Toyland Casino. 1938.
Under Southern Stars. 1937.
Wardrobe Girl. 1939.
Wash Your Step. 1936.
World's Fair Junior. 1939.
You're Next—to Closing. 1939.
Zero Girl. 1938.
BROADWAY COMEDY.
Arrow Film Corp.
All at Sea. 1921.
Be Yourself. 1923.
But a Butler. 1922.
Cleo's Easy Mark. 1921.
Hello Bill. 1923.
Hello Stranger. 1923.
Home Blues. 1921.
Ko Koo Kids. 1922.
Not Wanted. 1924.
One Exciting Evening. 1923.
Rented Trouble. 1922.
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