Cerebral white matter microstructural changes in isolated maxillofacial trauma and associated neuropsychological outcomes

Mathematical analysis of fracture configuration in predicting outcome in complex anterior skull base trauma

Craniofacial trauma involving the anterior skull base produces a heterogenous injury with variance in fracture pattern, complexity and outcome. Variance is influenced by the biomechanical properties of the craniofacial construct and by the magnitude and vector of the impacting energy. Fractal dimension and other metrics applied to individual fracture patterns allows quantification of fracture complexity and severity, which can be used to correlate with neurological outcome. Frontobasal fractures from 81 patients admitted to two UK major trauma centres were analysed. Patients were divided into two groups: those with anteriorly-based vectors of impact and those with laterally-based vectors. Osseous disruption was quantified by: fractal dimension, fracture length, number of termini, and number of nodes, and then compared with neurological outcome using first recorded Glasgow Coma Score (GCS), and requirement for intubation. As fracture length increased, fractures from anterior impacts became more complex and reticulated compared with lateral impacts; fractal dimension also increased more rapidly for anterior impacts. Longer fracture length in both groups was associated with a significantly lower GCS, and increased requirement for intubation (p < 0.001 and p < 0.001 respectively). Fracture propagation and severity of head injury was different in anterior-directed trauma compared to lateral-directed trauma. Consequently, we suggest that the central region of the anterior skull base acts to primarily absorb impact force thereby behaving as a protective ' crumple zone ' . In severe mechanisms the protective mechanism is exceeded and the fracture length tended to that of the lateral group worsening prognosis.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.