Management and outcome of pediatric skull base fractures

Clinical Features and Management of Skull Base Fractures in the Pediatric Population: A Systematic Review

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

The Observation of Pediatric Skull Fractures Without an Associated Brain Injury in a Non-Trauma Center

Introduction Young children experiencing head trauma are prone to skull fractures. Pediatric skull fractures are distinct from adults as they have a greater capacity to undergo remodeling. The objective of this study was to evaluate whether children with isolated skull fractures without an underlying brain injury and normal neurological exam require a transfer to a tertiary hospital with pediatric neurosurgery service. Methods A retrospective chart review was performed to review children under five years old presenting to the emergency department of a non-pediatric trauma center with an isolated skull fracture resulting from head trauma without intracerebral hemorrhage between 2015 and 2021. The inclusion criteria consisted of children who have isolated skull fractures without underlying injuries and normal neurological examination. We reviewed these patients' injury characteristics, disposition, and clinical outcomes. The t-test and chi-square were used for evaluating the groups and evaluating the transfer to a dedicated trauma care facility. Results We identified 26 children who had isolated skull fractures with no underlying brain injury and normal neurological examination. The two most common mechanisms of injury were falls (64%) and motor vehicle collisions (MVC) (11%). The median age of patients was six months old. The location of the skull fractures was as follows: parietal (46%), occipital (19%), temporal (15%), frontal (7.7%), occipital + parietal (7.7%), and parietal + frontal (3.8%). Four fractures were depressed (15%) and the remainder were non-displaced. Eleven children with skull fractures (42%) were transferred to a designated pediatric trauma center and the remaining 58% were hospitalized for observation and monitored at the primary hospital. None of the children with skull fractures required intubation or other advanced interventions. Conclusion In this relatively limited sample, approximately one-third of the children with isolated skull fractures without brain injury were managed successfully in a non-tertiary care center. However, none of them required surgical intervention. Thus, we propose that patients akin to those in this study can be observed at a local hospital without being transferred to a pediatric trauma center.

Pediatric Cranial Vault and Skull Base Fractures

Cranial vault and skull base fractures in children are distinctly different from those seen in adults. Pediatric skull fractures have the benefit of greater capacity to remodel; however, the developing pediatric brain and craniofacial skeleton present unique challenges to diagnosis, natural history, and management. This article discusses the role of surgical treatment of these fractures, its indications, and techniques.

Pediatric basilar skull fractures from multi-level falls: A systematic review and retrospective analysis

OBJECTIVE

Multi-level fall (MLF) accounts for 26.5%-37.7% of traumatic pediatric basilar skull fractures (BSFs). There is a dearth of information concerning recommendations for work-up, diagnosis, treatment, and otolaryngological follow-up of pediatric basilar skull fractures secondary to MLFs. Through a systematic literature review and retrospective review of an institution's trauma experience, we sought to identify clinical findings among pediatric MLF patients that indicate the need for otolaryngological follow-up.

METHODS

A two-researcher team following the PRISMA guidelines performed a systematic literature review. PubMed, Web of Science, and EBSCO databases were searched August 16th^, 2020 and again on November 20th^, 2021 for English language articles published after 1980 using search terms Pediatric AND (fall OR "multi level fall" OR "fall from height") AND ("basilar fracture" OR "basilar skull fracture" OR "skull base fracture" OR "skull fracture"). Simultaneously, an institutional trauma database and retrospective chart review was performed for all patients under age 18 who presented with a MLF to a pediatric tertiary care center between 2007 and 2018.

RESULTS

168 publications were identified and 13 articles reporting pediatric basilar skull fracture data and MLF as a mechanism of injury were selected for review. MLF is the most common etiology of BSF, accounting for 26.5-37.7% of pediatric BSFs. In the retrospective review, there were 180 cases of BSF from MLF in the study period (4.2%). BSF and fall height were significantly associated (p < 0.001), as well as presence of a CSF leak and fall height (p = 0.02), intracranial hemorrhage (ICH) (p = 0.047), and BSF fracture type (p < 0.001). However, when stratified by age, these associations were only present in the younger group. Of those with non-temporal bone BSFs (n = 71), children with hemotympanum (n = 7) were approximately 18 times more likely (RR 18.3, 95% CI 1.89 to 177.02) than children without hemotympanum (n = 64) to have hearing loss at presentation (28.6% vs. 1.6% of patients).

CONCLUSIONS

MLF is the most common cause of pediatric basilar skull fractures. However, there is limited information on the appropriate work-up or otolaryngologic follow-up for this mechanism of injury. Our retrospective review suggests fall height is predictive for BSF, ICH, and CSF leak in younger children. Also, children with non-temporal bone BSFs and hemotympanum may represent a significant population requiring otolaryngology follow-up.

[Skull and skull base injuries in children and adolescents : Results of a monocentric analysis]

BACKGROUND

The present study comprises a retrospective analysis of skull, skull base, and midface fractures in children, to provide clinical orientation for their management. To date, only few data are available on these injuries in this patient group.

METHODS

Data from inpatient cases diagnosed with a midface, skull, or skull base fracture in the Children's Hospital Auf der Bult from 2015 to 2020 were evaluated. Age, gender, fracture mechanism, diagnosis, treatment, and possible complications were analyzed. Data of 224 children were grouped into 107 cases with nose fractures, 104 cases with skull fractures, 9 patients with temporal bone fractures, 4 patients with rhinobasal fractures, and 2 cases with fractures of the orbital floor.

RESULTS

Among patients with nose fractures, the average age was 10.9 years (64% males), among patients with skull fractures 1.0 year (64% males), and in children with skull base fractures 6.0 years (85% males). Falls were the most frequent genesis (63%), followed by car accidents, collisions (25%), and violence (10%). Patients with skull fractures underwent sonography in 94% of cases; in 87% the fracture was verified. Patients with nose fractures underwent x‑ray in 92% of cases, or sonography only in 8%; 95% of patients with nose fractures underwent operative repositioning. Typical fracture signs (i.e., hemotympanum, ophthalmic symptoms) or signs of central nervous system involvement (i.e., nausea, amnesia) occurred in 12 of 13 children with skull base fractures, and CT was performed in all these cases (none of whom developed a cerebrospinal fluid leak).

CONCLUSION

The imaging modality should be selected based on the clinically suspected diagnosis and the course. Most fractures can be sufficiently treated without any permanent sequelae, except for nose fractures, which frequently require operative repositioning.

Research in Cerebrospinal Fluid Leak (Rhinorrhea and Otorrhea): A Bibliometric Analysis From 1945 to 2018

Objective

In this study, we aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF rhinorrhea and otorrhea in particular and to identify the main topic clusters in these areas.

Methods

We identified all relevant documents, using the medical subject heading (MeSH) term “Cerebrospinal Fluid Leak”, that are indexed in the MEDLINE database between 1945 and 2018. We performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research.

Results

From 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type (86.8% of the documents analyzed), while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were “Postoperative Complications,” “Tomography, X-Ray Computed,” and “Magnetic Resonance Imaging.” The terms “Adults,” “Young Adult,” and “Middle-Aged” were most common in CSF rhinorrhea research; and the terms “Infant,” “Child, Preschool,” “Child,” and “Adolescent” were more common in CSF otorrhea.

Conclusions

Based on our findings, articles and case reports related to “Surgery” and “Postoperative Complications” associated with the diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field.

Maxillofacial trauma in children: Association between age and mandibular fracture site

PURPOSE

To describe the association between age and location of facial fractures in the pediatric population.

MATERIALS AND METHODS

A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) from the 2016 Kids' Inpatient Database (KID) in children aged ≤18 years was conducted. International Statistical Classification of Diseases, 10th Revision (ICD-10) codes were used to extract facial fracture diagnoses. Logistic regression was used to evaluate and compare the contribution of various demographic factors among patients who had different types of facial fractures.

RESULTS

A total of 5568 admitted patients were identified who sustained any type of facial bone fracture. Patients who had facial fractures were significantly more likely to be male (68.2% versus 31.8%; p<0.001) and were older with a mean age of 12.86 years (95% confidence interval [CI]: 12.72-12.99). Approximately one-third of patients with a facial fracture had a concomitant skull base or vault fracture. Maxillary fractures were seen in 30.9% of the cohort while mandibular fractures occurred in 36.9% of patients. The most common mandibular fracture site was the symphysis (N=574, 27.9% of all mandibular fractures). Condylar fractures were more common in younger children while angle fractures were more common in teenagers. Regression analysis found that age was the only significant contributor to the presence of a mandibular fracture (β=0.027, p<0.001) and race was the only significant contributor to maxillary fractures (β=-0.090, p<0.001).

CONCLUSIONS

Facial fractures increase in frequency with increasing age in children. The mandible was the most commonly fractured facial bone, with an age-related pattern in fracture location.

Pediatric Basilar Skull Fracture Mechanisms and Trends From 2007 to 2018

OBJECTIVES

To evaluate the specific mechanism and trend of injury resulting in pediatric basilar skull fractures.

STUDY DESIGN

Retrospective chart review of a trauma database.

SETTING

Tertiary care children's hospital.

METHODS

Patients ≤18 years old with basilar skull fractures were identified via the trauma database for admissions from 2007 to 2018. Patients were identified with ICD-9 codes (801.0, 801.1, 801.2, 801.3 or 801.4) and ICD-10 codes (S02.1, S02.10, S02.11, S02.19) for skull base fractures (International Classification of Diseases, Ninth Revision and Tenth Revision).

RESULTS

A total of 729 patients were included: 251 females and 478 males. The 2 most common mechanisms of injury are multilevel falls and unhelmeted rider falls. Multilevel falls occur more in the toddler age group (average age, 4 years), and unhelmeted rider falls are seen in the older age group (average age, 11.2 years). Helmeted rider and motor vehicle accident basilar skull injuries are relatively uncommon. There was a spike in television/entertainment center mechanisms of injury in toddlers from 2007 to 2011 but has since decreased.

CONCLUSION

Pediatric basilar skull fractures are costly to the health care system, as patients spent more time in intensive care unit beds with a charge limited to hospital rooms between $1.7 and $2.7 million per year. The protective effect of helmets is demonstrated by unhelmeted rider injuries being the second-most common mechanism of basilar skull fractures and by helmeted rider injuries being rare. The small proportion of basilar skull fractures from motor vehicle accidents is an example of policy and behavioral changes resulting in decreased injury.

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

OBJECTIVE

Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.

METHODS

The authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.

RESULTS

The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).

CONCLUSIONS

The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

Prediction of Poor Prognosis After Severe Head Injury in Children Using Logistic Regression

OBJECTIVES

Head trauma is one of the main causes of death in childhood and often leaves severe disability with serious neurological damage. Appropriate treatment must be provided immediately to improve outcomes. This study was performed to identify factors associated with a poor prognosis at an early stage of severe head injury in children.

METHODS

The subjects were registered in the Japan Neurotrauma Data Bank. They were 119 children (mean age, 8 years; male, 67.2%) with severe head injury registered during a period of 4 years (from July 1, 2004 to June 30, 2006 and from July 1, 2009 to June 30, 2011). Univariate and multivariate analyses were performed to examine relationships among factors and outcome 6 months after discharge. Logistic regression analysis was performed to develop models for poor prognosis and death.

RESULTS

Outcome was evaluated based on the Glasgow Outcome Scale: 73 children (61.3%) had good recovery, 11 (9.2%) had moderate disability, 8 (6.7%) had severe disability, 4 (3.3%) were in a vegetative state, and 23 (19.3%) had died. Four factors were identified as predictors of a poor prognosis: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, presence of mydriasis, and presence of traumatic subarachnoid hemorrhage. Three factors were identified as predictors of death: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, and presence of mydriasis.

CONCLUSIONS

Using these predictors, subsequent exacerbation may be predicted just after arrival at the hospital and appropriate treatment can be provided immediately.

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture

OBJECTIVE

To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture.

METHODS

We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014.

RESULTS

A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis.

CONCLUSIONS

This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Scandinavian guidelines for initial management of minor and moderate head trauma in children

BACKGROUND

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.

RESULTS

The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.

CONCLUSIONS

We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.

Cost effective use of audiograms after pediatric temporal bone fractures

OBJECTIVE

To identify the relationship of pediatric temporal fractures to the incidence and type of hearing loss present. To analyze the timing and utility of audiometric testing in children with temporal bone fractures.

METHODS

Retrospective case series of 50 pediatric patients with temporal bone fractures who were treated at an urban, tertiary care children's hospital from 2008 to 2014. A statistical analysis of predictors of hearing loss after temporal bone fracture was performed.

RESULTS

Fifty-three fractures (69.7%) in 50 patients involved the petrous portion of the temporal bone. The mean age of patients was 7.13 years, and 39 (73.6%) were male. A fall was the most common mechanism of injury in 28 (52.8%) patients, followed by crush injury (n=14, 26.2%), and vehicular trauma (n=10, 18.9%). All otic capsule violating fractures were associated with a sensorineural hearing loss (n=4, 7.5%, p=0.002). Three of four otic capsule sparing fractures were associated with ossicular dislocation, with a corresponding mixed or conductive hearing loss on follow up audiometric testing. The majority of otic capsule sparing fracture patients (n=19/43, 44.2%) who had follow up audiograms had normal hearing, and those with otic capsule violating fractures were statistically more likely to have persistent hearing loss than those with otic capsule sparing fractures (p=0.01).

CONCLUSIONS

Patients with otic capsule violating fractures or those with ossicular disruption are at higher risk for persistent hearing loss. Cost-saving may be accrued by selecting only those patients at high risk for persistent hearing loss for audiometric testing after temporal bone fractures.

Audiometric Outcomes in Pediatric Temporal Bone Trauma

OBJECTIVE

To characterize pediatric temporal bone trauma, focusing on audiometric outcomes.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care children's hospital.

SUBJECTS AND METHODS

Cases were reviewed of children (<18 years) presenting over a 3-year period with computed tomography-proven temporal bone fracture and audiology examination. All scans were read by a neuroradiologist and reviewed by a pediatric otolaryngologist. Demographics, fracture pattern, and audiometric data were recorded.

RESULTS

Fifty-eight patients (60 fractures) met inclusion criteria. The majority (93%) were otic capsule-sparing fractures. The types and severity of hearing loss were significantly different between the 2 fracture patterns. Based on pure-tone average, all otic capsule-violating fractures had abnormal initial audiograms; 75% of these losses were severe. Approximately half (54%) of otic capsule-sparing fractures had abnormal initial audiograms; a majority were mild losses (85%). All classifiable losses in otic capsule-violating cases were of mixed type, whereas the majority (75%) of losses in otic capsule-sparing cases were conductive. Regardless of classification, 72% of patients with otic capsule-sparing fractures and initially abnormal audiograms improved to normal levels at a mean of 48 days posttrauma; this increased to 83% when only conductive losses were considered.

CONCLUSIONS

Hearing loss type and severity differ in otic capsule-sparing and otic capsule-violating temporal bone fractures. A majority of children with otic capsule-sparing fractures and associated hearing loss improve to normal levels in about 6 weeks, especially if the original loss is classified as solely conductive. Children who do not improve within this time frame may warrant early investigation into surgically correctable causes.

Pediatric Cranial Vault Fractures: Analysis of Demographics, Injury Patterns, and Factors Predictive of Mortality

BACKGROUND

Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures.

METHODS

A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL).

RESULTS

A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death.

CONCLUSIONS

Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.

Open reduction and internal fixation of severely dislocated fractures of condylar neck and base using bioabsorbable miniplate in children: a 3-10 years follow-up study

OBJECTIVE

To evaluate the long-term clinical and radiologic outcomes of treating severely dislocated fractures of condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth sustained in childhood using bioabsorbable miniplate with open reduction and internal fixation (ORIF).

METHODS

Five children (age ranged from 3 to 11 years old averaged 8.2 years; 3 boys and 2 girls) with severely (the condyle dislocated from the glenoid fossa) dislocated fractures of condylar neck or base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth were treated with ORIF using 1 or 2 bioabsorbable miniplates (through preauricular approach and an oral vestibular approach). All patients have been followed-up clinically and radiographically for a mean of 5.6 years (range, 3-10 years).

RESULTS

All patients were cured satisfactorily with excellent occluding relation without restricted mandibular movement, facial asymmetry, retrognathism and ankylosis. 3-10 years follow-up study did not occur any mandibular development disorder.

CONCLUSION

The results suggested that ORIF using bioabsorbable miniplate was a reliable fixation technique for use in the treatment of severely dislocated fractures of the condylar neck and base with the comminuted fractures of parasymphysis or mental foramen, specially with crown fracture of deciduous molar and permanent molar or dislocation of the teeth in children when the non-invasive or occlusal therapies were ineffective.

Subcranial craniotomy approach for frontobasal fracture correction

OBJECTIVE

Frontobasilar fracture types and the outcome of patients after management with the subcranial approach technique were evaluated.

MATERIAL AND METHODS

A retrospective analysis of 48 patients (45 males, mean age 38,5 years; range 16-82 years) who had a subcranial approach for frontal base fracture correction between April 1996 and April 2011 at a tertiary care academic hospital in Turku, Finland.

RESULTS

Sixteen (33%) patients had fractures including all frontobasilar fracture types (Type I-IV) i.e. fractures that involved frontal sinuses, orbital roofs, ethmoidal region, cribriform plate and sphenoidal region. Twenty-seven (56%) patients were considered to have had brain damage at presentation. Forty percent of patients were suffering from synchronous trauma. Peroperatively, 31 (65%) patients had exposure or defect of the dura due to bone dehiscence but only two patients suffered from cerebrospinal fluid (CSF) fistula following surgery. CSF fistulae were covered by pericranium in most of the cases (68%). There was no postoperative meningitis. Thirty-eight percent of the patients needed further operation with a subcranial craniotomy following primary reconstruction. At the last follow-up visit 35% were suffering from permanent neurological problems following brain injury.

CONCLUSIONS

Subcranial approach seemed successful in the management of all frontobasilar fractures in this series with reasonably low complication rate. Therefore, we would recommend it as the technique of choice in multiple and even in the most complicated frontal base fractures.

Frontobasilar fractures: proposal for image reviewing algorithm

OBJECTIVE

The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface.

MATERIAL AND METHODS

The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports.

RESULTS

The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed.

CONCLUSIONS

Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.

Skull Base Fractures are Markers of Severe Forces in the First Two Years of Life

While experience indicates that basilar skull fractures are an uncommon injury in the first two years of life, an evidential basis for this observation is lacking in the forensic pathology literature. The aim of this study was to determine the incidence and forensic significance of basilar skull fractures in the first two years of life. This retrospective analysis reviewed pediatric deaths over a 17-year period in a large metropolitan medical examiner jurisdiction and included the deaths of infants and children under 24 months of age. All cases had a cause of death statement of “blunt head trauma”, “blunt head and neck trauma” or “blunt trauma”. Sixty-three cases were found, 23 of which had basilar skull fractures. The most common circumstance with basilar skull fracture was pedestrian versus motor vehicle accidents (57%), followed by inflicted injury (30%), and vehicle accidents in which the child was an occupant (13%). As such, basilar skull fractures are uncommon injuries that are the end result of the application of significant forces to the head. The discovery of a basilar skull fracture without an appropriate history of the accidental application of severe forces should cause those tasked with the investigation of child injuries and death to carefully consider inflicted head trauma.

Traumatic Acute Brain Herniation through the Ear in a Child: Concealed compound fracture

A seven-year-old girl presented to Sultan Qaboos University Hospital, Oman, with a history of having been hit by a motor vehicle. After this, she had right-sided cerebrospinal fluid otorrhoea, and a week later, brain matter extruded through the right ear. A computed tomography scan of the brain demonstrated a tegmen fracture communicating with the external auditory canal. There was no hearing or facial nerve impairment and an otoscopic examination showed an intact tympanic membrane. She underwent a transcranial repair of the middle cranial fossa base, which revealed a wide dural and bony defect of the tegmen with herniation of the temporal lobe. Repair was made with an intradural patch of artificial dura. The rarity of this type of presentation of temporal bone fracture and its management are discussed.

Post-traumatic morbidity is frequent in children with frontobasilar fractures

OBJECTIVE

Frontobasilar fractures are potentially life-threatening injuries also in pediatric populations, often due to associated intracranial trauma. This retrospective study was performed at a tertiary care university hospital to evaluate the management and outcome of pediatric frontobasilar fractures. The secondary aim was to re-evaluate the computerized tomography images to reveal all the skull base fracture sites predicting morbidity.

METHODS

A retrospective analysis of all the 20 consecutive pediatric patients diagnosed with and treated for a frontobasilar fracture at the Turku University Hospital, Turku, Finland during 1995-2010 was performed. The referral area of this tertiary care university hospital covers 750,000 inhabitants of whom approximately 20% are 18 years or younger.

RESULTS

The mean annual incidence of frontobasilar fractures was 1.1 per 100,000 children aged 18 years and under. A road traffic accident was the most common etiological factor. Other factors included being hit by a heavy object, falling from a height, and falling to the ground. The mean Glasgow Coma Scale score was 10 and loss of consciousness was initially detected in 15 (75%) patients in the emergency unit. Twelve (60%) patients had an intracranial injury, 17 (85%) had facial bone fractures, and 15 (75%) had a fracture of the anterior cranial base. The middle cranial fossa and sella were affected in five (25%) of the patients. There seem to be no long-term neuroendocrine sequelae following brain injury, not even when the sella or the hypophyseal area was affected. Twelve (60%) patients were treated operatively. One patient died after one week of intensive care treatment. Only four (20%) patients had no post-traumatic implications, eight (40%) suffered from various long-term sequelae, and five (25%) had permanent neurological or neuropsychological sequelae.

CONCLUSIONS

Frontobasilar fractures in childhood are rare and often associated with intracranial trauma and long-term morbidity. However, according to this study, 75% of the patients showed no permanent neurological or neuropsychological sequelae.