Incidence and patterns of maxillofacial trauma-a retrospective analysis of 3611 patients-an update

BACKGROUND

Maxillofacial fractures occur in a significant proportion worldwide and can occur as an isolated injury or in combination with other severe injuries including cranial, spinal, and upper and lower body injuries requiring prompt diagnosis with possible emergency interventions. The epidemiology of facial fractures varies with regard to injury type, severity, and cause and depends on the population studied. Hence, understanding of these factors can aid in establishing clinical and research priorities for effective treatment and prevention of these injuries.

MATERIALS AND METHODS

In this present retrospective study, we provide a comprehensive overview regarding cranio-maxillofacial trauma on 3611 patients to assist the clinician in assessment and management of this unique highly specialized area of traumatology. A preformed pro forma was used to analyze the medical records of patients treated for facial trauma in The Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai. The distribution according to age, gender, etiology, type of injury, time interval between accident and treatment, loss of consciousness, facial bones involved, pattern of fracture lines, treatment offered, and postoperative complications were recorded and evaluated.

RESULTS

We inferred male patients sustained more injuries mostly in the third decade of age. Road traffic accidents were the most common cause of injury. Mandible was the most commonly fractured bone in the facial skeleton. Soft tissue injuries occurred more in road traffic accidents and upper lip was the commonest site of injury.

CONCLUSION

Our study provides insights into the epidemiology of facial injuries and associated factors and can be useful not only in developing prevention strategies but also for grading the existing legal regulations and also for framing a more effective treatment protocol.

Unusual planned complex suicide committed with a muzzle-loading pistol in combination with subsequent hanging

In Germany, suicides by firearms are not very common in contrast to deaths by hanging and intoxications. The use of historical muzzle-loading firearms in the context of suicides is a rarity. Contact shots from muzzle loaders cause an unusual wound morphology with extensive soot soiling. We report the case of a 59-year-old man, who committed a planned complex suicide by shooting into his mouth with a replica percussion gun in combination with hanging. The gunshot injury showed strong explosive effects in the oral cavity with fractures of the facial bones and the skull associated with cerebral evisceration (so-called Krönlein shot). Due to the special constellation of the case with hanging immediately after the shot, external bleeding from the head injuries was only moderate. Therefore, the head injuries could be assessed and partially reconstructed already at the scene.

Maxillofacial trauma scoring systems

The changing complexity of maxillofacial fractures in recent years has created a situation where classical systems of classification of maxillofacial injuries fall short of defining trauma particularly that observed with high-velocity collisions where more than one region of the maxillofacial skeleton is affected. Trauma scoring systems designed specifically for the maxillofacial region are aimed to provide a more accurate assessment of the injury, its prognosis, the possible treatment outcomes, economics, length of hospital stay, and triage. The evolution and logic of such systems along with their merits and demerits are discussed. The author also proposes a new system to aid users in quickly and methodically choosing the system best suited to their needs without having to study a plethora of literature available in order to isolate their choice.

Assessment of changing patterns of Le fort fracture lines using computed tomography scan: an observational study

OBJECTIVES

To assess the changing mid-face fracture patterns using a computed tomography scan.

METHODOLOGY

Fifty patients with mid-face trauma requiring open reduction and fixation were studied using 1.6 mm axial, sagittal, coronal and 3D images. Images were evaluated clinically, intra-operatively and finally were compared with standard Le Fort lines. Results. The male population dominated the female at a ratio of 11.5:1. The majority of the mid-face fractures were seen in the age group of 21-30 years. Road traffic accident (78%) was the major etiological factor followed by work-related accidents (12%) and assaults (10%). The CT scan analysis included categorizing the patients into three groups: (1) Fracture patterns resembling Le Fort lines (24%); (2) Fracture patterns partially resembling Le Fort lines (56%); and (3) Fracture patterns that do not resemble Le Fort lines (20%).

CONCLUSION

With the change in the velocity of wounding object, there is a change in the mid-face fracture patterns. The majority of the cases present as a variant of classical Le Fort fractures. Computed tomography is a valuable diagnostic tool in assessing the fractures of the mid-face. 2D images are more sensitive than 3D images. However, both the images are required in delivery of an optimal treatment plan.

[Walcher's hat brim line rule--a literature review]

The first description in the forensic medical literature of a demarcation line for the localization of head injuries resulting from falling to the ground appears in Kratter (1919). Regarding a similar line, Walcher (1931) later introduced the relation to the hat brim (Hutkrempe), which gave the rule its name: the hat brim line rule (Hutkrempenregel). Thenceforth it was supposed to be called Kratter's and Walcher's hat brim line rule (Kratter-Walcher'sche Hutkrempenregel). Over the following decades, not only its content but also the area of application and the definition of the hat brim line rule were repeatedly, and in part significantly, altered. This could be one of the reasons for the confusing diversity of academic opinions about the rule's applicability. Generally, the hat brim line rule should be retained in its original sense: Fall-related injuries do not lie above the hat brim line if the fall occurred from a standing position to the ground, without intermediary blows to the head. If applied in this way, the rule can be a helpful point of orientation for experts. The demarcation line in the original anatomical definition according to Kratter (1919) should also be used henceforth: the line which connects "the frontal eminence, the parietal eminence and the tip of the occipital plate" and lies "somewhat.above the usual saw-line of the calvarium". This line corresponds roughly to the hat brim line as it is understood by hat makers. The hat brim line rule should not be applied with regard to small children, as they show a different falling behaviour due to their disproportionately large and heavy heads. The rule is also in no way applicable to the assessment of injuries from blows, falls from a height (including from stairs) or traffic accidents. There is an urgent need for research as to the applicability of the hat brim line rule in relation to falling backwards, particularly in cases of high alcohol consumption.

[Facial trauma and multiple trauma]

The human face contains the sense organs and is responsible for essential functions: swallowing, chewing, speech, breathing and communication. It is also and most importantly the seat of a person's identity. Multiple trauma adds a life-threatening dimension to the physical and psychological impact of a facial trauma.

[About the Geserick sign--a literature study]

Fractures of the medial and basal orbital wall as well as the petrous part of the temporal bone were described first in 1980 by a Berlin-based study group led by Geserick as new cranium findings resulting from a contrecoup mechanism. Experimental and comparative examinations revealed that indirect fractures of the orbital walls are caused by a coup action of the eyeballs, whereas the mechanogenesis of the petrous bone fractures continues to be unclear. The frequently combined occurrence with the orbital sign nonetheless permits an allocation to the contrecoup mechanism. Both signs are important criteria for forensic and clinical assessment of craniocerebral injuries.

[Modern technology in the surgical treatment of head injury sequelae]

The paper presents main types of surgically relevant posttraumatic lesions in 4136 patients with skull vault as well as skull base defects, craniofacial deformities, recurrent CSF leaks, arterio-venous fistulas, aneurysms and pseudoaneurysms etc. Classification of TBI sequelae and complications as well as its clinical course grading is presented. The use of modern neuroimaging techniques for studying pathophysiologic mechanisms and complications of TBI has been demonstrated. Special emphasis was given to minimally invasive and reconstructive surgery; computer modeling with subsequent full-copy stereolitographic laser implant setup was shown which is of great importance in cases of large and complex skull base and craniofacial deformities. Patient selection for transcranial and endonasal CSF leak closure techniques was justified. Treatment of post-traumatic vascular injuries using Serbinenko balloon-catheters as well as modern techniques such as stents, coils and embolization has been demonstrated.

Temporal Bone Fractures: Traditional Classification and Clinical Relevance

OBJECTIVES/HYPOTHESIS

The objectives were to evaluate the clinical relevance of traditional temporal bone radiographic descriptors and to investigate the efficacy of an alternative fracture classification scheme.

STUDY DESIGN

Retrospective consecutive case series.

METHODS

Charts and computed tomography scans representing 155 temporal bone fractures at a level I trauma center were reviewed. Fracture types were correlated with clinical presentation and outcomes.

RESULTS

The traditional classification system (i.e., longitudinal, transverse, or mixed) correlated poorly with clinical findings such as facial nerve weakness and cerebrospinal fluid leakage. It also had limited utility in predicting conductive hearing loss and sensorineural hearing. An alternative schema distinguishing petrous from nonpetrous involvement demonstrated better correlation with these measures. Cerebrospinal fluid leak was 1.1 times more common in transverse than in longitudinal fractures but was 9.8 times more common in petrous than in nonpetrous fractures. Similarly, facial nerve injury more strongly correlated with fractures through the petrous temporal bone than did the other fracture types. Sensorineural hearing loss did not correlate with the transverse fracture classification but was significantly more prevalent in petrous fractures. Likewise, conductive hearing loss did not correlate with longitudinal fractures but was four times more common in the "middle ear" subcategory of nonpetrous fractures.

CONCLUSION

Traditional temporal bone fracture descriptions correlate poorly with clinical findings. However, simply distinguishing petrous from nonpetrous involvement demonstrates significant correlation with the occurrence of serious sequelae of temporal bone fractures. Subcategories of mastoid and middle ear involvement further refine this classification schema to correlate with minor complications. This simple, radiographically based scheme better focuses clinical resources and attention toward more likely sequelae.

[Delayed pan-facial fractures-injury patterns associated with deficient treatment results and clinical classification]

OBJECTIVE

To analyze the injury patterns in pan-facial fractures (PFF) which potentially lead to deficient treatment outcomes and then to propose a clinical classification.

METHODS

Thirty-nine patients, 31 male and 8 female, with an average age of 33, treated from 1998 to 2007 in the Center of Maxillofacial Trauma, Peking University School and Hospital of Stomatology, were included. Zygomatic complex, maxilla and mandible were involved in the extensive fracture concomitant with nasal-orbital-ethmoid (NOE) fracture or not. All cases experienced a delay of over 4 weeks after injury. An analysis was made to display the relationship between facial architecture demolition and disfigurement and disability. Treatment results were assessed with facial appearance, opening range, occlusion and regional deformities. The associated injury patterns most frequently leading to deficient outcomes were summarized as references to scheme a clinical classification.

RESULTS

Facial deformities presented in 90% of the patients and mostly related to condylar fracture/dislocation and zygomatic complex fracture. Limited mouth opening occurred in 59% of patients and were caused most frequently by displacement of zygomatic complex and joint ankylosis. Malocclusion was found in 100% of cases and there were the associated optical signs in 46%. Thirty-nine cases were divided into two types. Zygomatic, maxillary and mandibular fractures all together constituted type I, which accounted for 46% of patients. Type I plus NOE fracture was type II, which accounted for 54% of patients. Furthermore, A, B and C sub-types were recognized in corresponding to involvement of condylar dislocation/fracture and zygomatic complex fracture. In treatment outcomes, a difference between type I and type II fractures remained with NOE fractures. The outcomes of term "moderate" and "worse" in subtype C group were attributed to severe soft tissue injuries and trauma-induced ankylosis.

CONCLUSIONS

NOE fracture, condylar fracture and dislocation, and zygomatic complex fracture were closely associated with deficient treatment outcomes. Correspondingly, an clinical classification was proposed for PFF.

Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center

PURPOSE

The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy.

MATERIALS AND METHODS

All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis.

RESULTS

A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group.

CONCLUSION

Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

[Emergency ward management of traumatic head injury in children]

BACKGROUND

The controversial situation relating to assessment and management of the traumatic head injury (THI) in children inspired us to study our own patient pool. The aims were to find a significant correlation between skull fracture or clinical symptom and intracranial lesion as well as to determine the importance of each radiological diagnostic method in the initial management of the pediatric THI.

PATIENTS AND METHODS

In 1 year 1,637 children had been treated in the emergency room of pediatric surgery with the diagnosis of THI. Age, sex, injury pattern, symptoms, radiological diagnostic methods, diagnosis, and clinical follow-up had been registered.

RESULTS

A significant correlation between skull fracture or clinical symptom and the intracranial injury in children could not be found, but risk factors exist. Cranial computed tomography is the imaging method of choice. X-ray, ultrasound, and MRI of the head are reserved for a few indications.

CONCLUSION

A management plan for pediatric head and brain injury in the emergency room based on our own and published international results is introduced.

Craniomaxillofacial Injuries in the United Arab Emirates: A Retrospective Study

PURPOSE

To analyze craniomaxillofacial injuries in selected hospitals in the United Arab Emirates (UAE).

PATIENTS AND METHODS

This is a retrospective study of craniomaxillofacial injuries treated in 3 major hospitals in the UAE. Patient files were retrieved, reviewed, and analyzed. The main analysis outcome measures were the patients' name, age, and gender and the injuries' time, site, type, treatment and outcome.

RESULTS

A total of 288 patients sustained 475 craniomaxillofacial injuries; road traffic accidents caused the majority of injuries. The patients ranged in age from 2 to 82 years (mean, 27.3 years), and the male-to-female ratio was 7:1. The yearly distribution of fractures peaked during 2001, and the monthly distribution peaked in January. The greatest number (41%) of patients were UAE nationals. Most patients (70.5%) had mandibular fractures, and the most common site was the body. There were 139 patients (48.3%) with a total of 171 midface fractures (36%); the most common fracture site was the zygomatic complex (29.8%). The most common treatment for jaw fractures was plating plus intermaxillary fixation. Stable zygomatic complex fractures were closely reduced (elevated), and unstable ones were treated by internal fixation. About 25% of the cases had 1 or more postoperative complication.

CONCLUSIONS

Craniomaxillofacial injuries in the UAE included in this study are somewhat similar to those reported in other countries. Differences from other countries are probably related to factors peculiar to the UAE, such as climate, social trends, and the cosmopolitan population.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

A new test set-up for skull fracture characterisation

Skull fracture is a frequently observed type of severe head injury. Historically, a variety of impact test set-ups and techniques have been used for investigating skull fracture. The most frequently used are the free-fall technique, the guided fall or drop tower set-up and the piston-driven impactor set-up. This document proposes a new type of set-up for cadaver head impact testing which combines the strengths of the most frequently used techniques and devices. The set-up consists of two pendulums, which allow for a 1 degree of freedom rotational motion. The first pendulum is the impactor and is used to strike the blow. The head is attached to the second pendulum using a polyester resin. Local skull deformation and impact force are measured with a sample frequency of 65 kHz. From these data, absorbed energy until skull fracture is calculated. A set-up evaluation consisting of 14 frontal skull and head impact tests shows an accurate measurement of both force and local skull deformation until fracture of the skull. Simplified mechanical models are used to analyse the different impacting techniques from literature as well as the new proposed set-up. It is concluded that the proposed test set-up is able to accurately calculate the energy absorbed by the skull until fracture with an uncertainty interval of 10%. Second, it is concluded that skull fracture caused by blunt impact occurs before any significant motion of the head. The two-pendulum set-up is the first head impact device to allow a well-controlled measurement environment without altering the skull stress distribution.

Radiographic Classification of Temporal Bone Fractures

OBJECTIVE

To compare the traditional system of radiographic classification of temporal bone fractures (transverse vs longitudinal vs oblique) with a newer system (otic capsule violating vs otic capsule sparing) with respect to their ability to predict sequelae of temporal bone trauma.

DESIGN

Retrospective chart and radiology review.

SETTING

University trauma center and Department of Otolaryngology-Head and Neck Surgery.

PATIENTS

Patients with temporal bone fractures.

INTERVENTIONS

Clinic records and computed tomographic scans were reviewed to evaluate the clinical predictability of complications of temporal bone fractures.

MAIN OUTCOME MEASURES

Complications of temporal bone fractures (ie, sensorineural hearing loss, conductive hearing loss, cerebrospinal fluid leakage, and facial nerve weakness) were recorded. Two classification schemes for temporal bone fractures were statistically analyzed and compared as to their ability to predict each complication.

RESULTS

A total of 234 temporal bone fractures were identified; 30 cases met our strict criteria for inclusion. The traditional classification system of temporal bone fractures did not significantly predict temporal bone complications (P = .71). On the other hand, the otic capsule-based system did demonstrate statistically significant predictive ability (P < .001). Patients with otic capsule-violating fractures were 5 times more likely to have facial nerve injury, 25 times more likely to have sensorineural hearing loss, and 8 times more likely to have cerebrospinal fluid otorrhea than those with otic capsule-sparing fractures.

CONCLUSIONS

The traditional radiographic classification system failed to demonstrate clinical predictability in our series. Furthermore, the newer system of classification (otic capsule sparing vs otic capsule violating) demonstrated statistically significant predictive ability for serious clinical outcomes associated with temporal bone fractures.

Analysis of nasal bone fractures; a six-year study of 503 patients

The aim of this study is to classify the nasal bone fractures based on computed tomography (CT) analysis and patterns of the nasal bone fractures, and review 503 cases treated between 1998-2004 at the Department of Plastic Surgery, Inha University Hospital, Incheon, South Korea. The age, sex, etiology, associated injuries, pattern of fractures and treatments were reviewed and a radiographic study was analyzed. Plain simple radiographs of lateral and Waters view of the nasal bones combined with computed tomography scans were done. Nasal bone fractures were classified into six types: Type I) Simple without displacement; Type II) Simple with displacement/without telescoping; IIA; Unilateral; IIAs) Unilateral with septal fracture; IIB) Bilateral; IIBs) Bilateral with septal fracture; Type III) Comminuted with telescoping or depression. Diagnosis of nasal bone fractures were made positively by plain x-ray films in 82% of cases, negative finding was 9.5% and 8.5% of cases were suspicious of the fractures. Reliability of the plain film radiographs of the nasal bone fracture was 82% in this study. In the most of the fractured nasal bones (93%) the closed reduction was done, open reduction in 4% and no surgical intervention in 3%. Nasal reduction was carried out in average 6.5 days post the injury. The patterns of the nasal bones fractures classified by CT findings were type IIA (182 cases, 36%), IIBs (105 cases, 21%), IIB (90 cases, 18%), IIAs (66 cases, 13%), I (39 cases, 8%) and III (21 cases, 4.3%). We think the CT is necessary for diagnosing nasal bone fracture because the reliability of the plain film was only 82%.

Management of frontal sinus fractures: a review of 96 cases

OBJECTIVES

The optimal treatment algorithm for frontal sinus fracture management remains ill-defined. The purpose of the study was to classify fracture types, review management methods, document associated injuries, and identify complications associated with various treatment options.

STUDY DESIGN

The authors conducted a retrospective chart review evaluating a 13-year experience with frontal sinus fracture management.

METHODS

Complete medical records of 96 frontal sinus fracture patients treated by the University of Kentucky Otolaryngology Service from 1990 to 2003 were reviewed.

RESULTS

The average patient age was 39 years. Fifty percent of the fractures involved the anterior table of the frontal sinus alone, and 50% involved both anterior and posterior tables. Forty-seven percent of the injuries were managed with observation, whereas 50% of patients underwent surgical repair. In the surgical group, 60% underwent open reduction and internal fixation (ORIF), 23% had a cranialization procedure, and 17% underwent sinus obliteration. The average length of follow up was 9 months. Complications occurred in 17% of the patients (5% in the nonsurgical group and 12% in the surgical group).

CONCLUSION

Our results support conservative management of nondisplaced or minimally displaced fractures based on the low complication rate seen in this series. Significant bone displacement can frequently be managed with simple ORIF. Complex fractures affecting the orbit or intracranial contents require cranialization or possibly obliteration. A subset of patients with suspected frontal sinus outflow obstruction can be considered for observation or simple ORIF with close follow up and endoscopic repair if outflow complications manifest.

A comparison of temporal bone fracture classification systems

OBJECTIVES

To compare the traditional and otic capsule classification system of temporal bone fractures for clinical relevance.

DESIGN

A retrospective review of all patients with a radiological diagnosis of a skull-base fracture over a 5-year period.

SETTING

All patients were seen at Beaumont Hospital, the national tertiary referral centre for Neuro-otology.

PARTICIPANTS

Patients with a clinical diagnosis of skull fracture were identified from the hospitals in patient enquiry (HIPE) database. Of 338 patients, 31 (9%) were identified as having a temporal bone fracture on high-resolution CT scanning.

MAIN OUTCOME AND MEASURES

The rate and distribution of each major clinical complications within each classification system to establish if either one was more clinically useful.

RESULTS

Fractures were classified as mixed in 14 (45%), longitudinal in 9 (29%) and horizontal in 8 (26%). Alternatively, 2 (7%) were otic capsule violating and 29 (93%) were otic capsule sparing. Seventeen patients (54.8%) sustained a hearing loss. Seven patients (23%) sustained a facial nerve injury. Four (13%) developed a cerebrospinal fluid (CSF) leak. Of all clinical findings only sensorineural hearing loss occurred significantly more often in the horizontal as opposed to the longitudinal group (P = 0.029) and in the otic violating as opposed to the otic sparing group (P = 0.013).

CONCLUSIONS

We acknowledge that the relatively small size of our cohort diminishes the statistical power of our conclusions. However, we found that the otic capsule-based classification system was not significantly better than the traditional system in predicting the likelihood of sustaining specific injuries from fractures of the temporal bone.

Occipital condylar fractures. Review of the literature and case report

Fractures of the occipital condyle are rare. Their prompt diagnosis is crucial since there may be associated cranial nerve palsies and cervical spinal instability. The fracture is often not visible on a plain radiograph. We report the case of a 21-year-old man who sustained an occipital condylar fracture without any associated cranial nerve palsy or further injuries. We have also reviewed the literature on this type of injury, in order to assess the incidence, the mechanism and the association with head and cervical spinal injuries as well as classification systems, options for treatment and outcome.

Verletzungen des kraniozervikalen Übergangs

Injuries to the upper cervical spine (C0-C2) play a major role in surgical treatment of traumatic sequelae in the entire cervical spine. Even though the number of such operations has increased in recent years, there are no clear treatment recommendations for most types of cervical spine injuries. In view of the wide range of injury types and the correspondingly large number of treatment options, this review focuses mainly on the following types of injuries: C0 fractures, occipital condyle fractures (OCF), atlanto-occipital dislocation (AOD), atlas fractures, atlantoaxial dislocation (AAD), and axis fractures. Important aspects of the mechanisms of injury, clinical signs and symptoms, diagnostic procedures, and treatment options are discussed. Special emphasis is placed on comparatively reviewing the different treatment options discussed in the literature. A summary in table form is presented at the end of each chapter for quick reference.

Application of a Facial Injury Severity Scale in Craniomaxillofacial Trauma

PURPOSE

To establish a Facial Injury Severity Scale (FISS) that correlates with patient outcome and provides a practical tool for communication between clinicians and healthcare personnel for management of facial trauma.

PATIENTS AND METHODS

All patients presenting to the Emergency Department (ED) at Legacy Emanuel Hospital (Level One Trauma Center) in Portland, Oregon between 01/1993 and 6/2003 with facial fractures with or without concomitant non-facial injuries where identified retrospectively. The diagnosis and treatment of all facial fractures were conducted by the Oral and Maxillofacial Surgery (OMFS) service. The following data were collected; age, gender, mechanism of injury, detailed diagnosis of facial fractures, disposition, and the length of hospital stay (LOS). The hospital operating room charges (ORC) for the treatment of each patient's facial fractures were also obtained. We designed the FISS to be a numeric value composed of the sum of the individual fractures and fracture patterns in a patient. Not all fractures of the face are weighted equally in the FISS because not all fracture patterns are equal in severity. Individual fracture points within the scale were optimized to result in the highest correlation.

RESULTS

A total of 1,115 patient admissions to the ED with blunt or penetrating maxillofacial injuries were identified and reviewed. Full information on operating room charges (ORC) was available for 247 patients (average age: 32, SD +/- 17; range, 2 to 84; male:female, 3:1; blunt:penetrating, 232:15). The FISS scores were calculated for each patient (average FISS: 4.4, SD +/- 2.7; range, 1 to 13). Hospital ORC for the treatment of each patient's maxillofacial injuries were obtained from the hospital financial services (average ORC: 4,135 dollars, SD +/- 2,832 dollars; range, 845 dollars to 18,974 dollars). A significant correlation was identified between the FISS and the ORC (R value = .82). The length of stay was significantly associated with the FISS (t = 4.7, 245 degrees of freedom, P = .000004). Although the association was statistically significant, FISS is not a very good predictor of length of stay. The correlation between the predicted and observed values was 0.38. There were 3 deaths among the 247 entries. Those 3 deaths had higher than average FISS scores, but the difference between the scores of survivors and non-survivors was not significant (P = .08). The number of deaths was small and a larger study would be required to resolve this question.

CONCLUSIONS

We introduce a FISS that is easily calculated and reliably predicts the severity of maxillofacial injuries as measured by the operating room charges required to treat the facial injury. The scale is also an indicator of hospital length of stay. We anticipate this to be a valuable tool for assessment and management of maxillofacial trauma.

Identification and classification in le fort type fractures by using 2D and 3D computed tomography

OBJECTIVE

To evaluate the usefulness of two- dimensional (2D) and three-dimensional (3D) computed tomography (CT) in the identification and classification of Le Fort type fractures.

METHODS

Sixty-two patients with different types of Le Fort fractures underwent CT scanning and 3D-CT reconstruction. The data were analyzed by multiplanar reconstruction (MPR), surface shaded display (SSD) and volume rendering (VR) respectively.

RESULTS

The patients with Le Fort I, Le Fort II fracture and Le Fort III fracture accounted for 16.1%, 14.5% and 12.9% respectively. The compound fractures were the most common type and accounted for 56.5% (n=35, 18 cases with Le Fort I+II fracture, 10 cases with Le Fort II+III fracture and 7 cases with Le Fort I+ II+III fracture). Fifty-five cases coexisted with other fractures in maxillofacial region. 2D-CT could be used to define the tiny fractures and the deep-structure fractures more accurately compared with 3D-CT, but the real impression of Le Fort type fractures could not be correctly evaluated on 2D-CT. 3D-CT could clearly demonstrate the whole shape of Le Fort type fractures and identify the classification of Le Fort fractures.

CONCLUSIONS

3D-CT is the best imaging method for the diagnosis of Le Fort type fractures and can provide valuable information of space relationship, especially for the design of treatment plan before operation.

Comparison of the severity of bilateral Le Fort injuries in isolated midface trauma

PURPOSE

The Le Fort classification pattern established in 1901 by the French surgeon Rene Le Fort is commonly used in describing midface fractures. This frequently used classification system is based on predictable patterns of midface fractures initially described for blunt trauma. The purpose of this study was to compare the profile and outcome of patients with isolated bilateral Le Fort I, II, and III fractures.

PATIENTS AND METHODS

All patients presenting to the emergency department (ED) at Legacy Emanuel Hospital (Level I trauma center) in Portland, OR, between December 1990 and December 2003 with isolated bilateral Le Fort I, II, or III fractures with or without concomitant nonfacial injuries were identified retrospectively using the Hospital Trauma Registry. Patients were classified into study groups I (n = 22), II (n = 22), or III (n = 23) corresponding to the Le Fort classification, respectively.

RESULTS

Sixty-seven patients had a diagnosis of isolated bilateral Le Fort I, II, or III fracture. The average Injury Severity Score (ISS) and hospital length of stay were 18.8 +/- 8.9 and 9.5 +/- 11.9 days, respectively. Blood alcohol was detected in 19 patients. Sixty-four injuries (95.5%) were secondary to blunt trauma, and the remaining 3 (4.5%), penetrating injuries. More than half of the patients (n = 35, 52.2%) were admitted to the intensive care unit (ICU), 18 patients (26.8%) were transferred to the hospital trauma ward from the ED, and 14 patients (20.9%) were taken directly to the operating room. Fifteen (22.4%) patients required a tracheostomy secondary to their maxillofacial injuries. A statistically significant difference in the ISS was detected between patients with Le Fort I versus those with II or III injuries ( P < .0001). Patients with Le Fort II or III fractures had a significantly higher probability of ICU admission or immediate operative intervention. Ten patients (43.5%) with Le Fort III injuries required tracheostomy versus 3 patients (13.6%) with Le Fort I, and 2 patients (9.1%) with Le Fort II injuries. This was statistically significant. None of the patients with Le Fort I injuries had a negative outcome (death); however, 1 patient with Le Fort II injuries (4.5%) and 2 with Le Fort III injuries (8.7%) had a negative outcome. No statistically significant differences or emerging trends were observed among the 3 groups for age, gender, length of stay, number of operations, and number of associated injuries.

CONCLUSIONS

Patients with higher Le Fort injuries are characterized by an overall greater severity of injuries as measured by the ISS and the more frequent need for a surgical airway. Patients with Le Fort III injuries have a higher chance of requiring neurosurgical intervention or of experiencing vision-threatening ocular trauma. Immediate operative intervention and/or ICU care is more frequently indicated in these patients.

Force and acceleration corridors from lateral head impact

This study was conducted to provide force and acceleration corridors at different velocities describing the dynamic biomechanics of the lateral region of the human head. Temporo-parietal impact tests were conducted using specimens from ten unembalmed post-mortem human subjects. The specimens were isolated at the occipital condyle level, and pre-test x-ray and computed tomography images were obtained. They were prepared with multiple triaxial accelerometers and subjected to increasing velocities (up to 7.7 m/s) using free-fall techniques by impacting onto a force plate from which forces were recorded. A 40-durometer padding (50-mm thickness) material covering the force plate served as the impacting boundary condition. Computed tomography images obtained following the final impact test were used to identify pathology. Four specimens sustained skull fractures. Peak force, displacement, acceleration, energy, and head injury criterion variables were used to describe the dynamic biomechanics. Force and acceleration responses obtained from this experimental study along with other data will be of value in validating finite element models. The study underscored the need to enhance the sample size to derive probability-based human tolerance to side impacts.

Immediate reconstruction of frontal sinus fractures: review of 26 cases

PURPOSE

The purpose of this study was to evaluate complications occurring after immediate reconstruction of severe frontal sinus fractures, including cases where the fracture was not limited to the anterior wall and also involved the posterior wall and/or sinus floor.

PATIENTS AND METHODS

The records of twenty-six patients presently undergoing follow-up for frontal sinus fracture reconstruction were reviewed. Information regarding demographics, fracture characteristics and causes, associated facial fractures, use of grafts or implants, type of fixation used, nasofrontal duct management, use of antibiotics, and complications were noted. Patients were asked to return for clinical and radiographic follow-up to access late complications.

RESULTS

The average age of patients with frontal fractures was 29.1 years and 92.3% were male. Mean follow-up was 3.6 years. The most common causes of fracture were motor vehicle accidents and physical aggression. All patients presented with comminuted and dislocated anterior wall fractures, 34.6% presented with posterior wall fractures, and 46% had sinus floor fractures. Complications occurred in 7 patients (26.92%) and included pneumoencephalus, frontal cutaneous fistula, frontal bone irregularity, and sinusitis.

CONCLUSIONS

Frontal sinus reconstruction is a good procedure for immediate fracture treatment if there is not excessive comminution, dislocation, or instability of the posterior wall and if the frontonasal duct area is intact or can be repaired. Most complications result from incorrect indication for reconstruction.

Effect of restraint systems on maxillofacial injury in frontal motor vehicle collisions

PURPOSE

Motor vehicle collisions (MVCs) are the leading cause of maxillofacial fractures. Additionally, maxillofacial injuries are the most common injury related to air bag deployment. We sought to characterize the occupant restraint system (seat belt and air bag) and collision characteristics associated with MVC-related maxillofacial injuries.

MATERIALS AND METHODS

The 1991-2000 National (United States) Automotive Sampling System Crashworthiness Data System (CDS) data files were used. The CDS is a national probability sample of passenger vehicles involved in police-reported tow-away MVCs. Analysis was limited to front seat occupants involved in frontal collisions of delta-V (estimated change in velocity) of greater than 15 km/hr. The risk of facial injury was calculated according to occupants' restraint use (unrestrained, seat belt only, air bag only, and seat belt and air bag combined) and compared using risk ratios (RRs) and associated 95% confidence intervals (CIs).

RESULTS

Occupants restrained with a seat belt only (RR, 0.48; 95% CI, 0.40 to 0.57) or a seat belt and an air bag (RR, 0.83; 95% CI, 0.73 to 0.94) had a significantly reduced risk of any facial injury compared with completely unrestrained occupants. There was no association for those restrained with an air bag only (RR, 1.19; 95% CI, 0.82 to 1.73). A similar pattern of results was observed for moderate to severe facial injuries and for facial fractures.

CONCLUSION

Seat belt use significantly reduces the risk of facial injury in frontal MVCs. Air bag use was not associated with the risk of facial injury.

Identifikation von Hochrisikopatienten nach leichtem Sch�del-Hirn-Trauma

The indication for an initial cranial computed tomography (CCT) in minor head trauma (MHT) patients remains the subject of discussion. The aim of this study was to investigate whether a newly developed, rapid test system (ELECSYS S100, Roche Diagnostics) might allow a diagnostically valid, reproducible measurement of S 100 in MHT patients. Blood samples were drawn from 75 MHT patients, a CCT scan was performed, and those with a post-traumatic intracranial lesion counted as CCT+. Results were compared to a healthy control group (n=17). Of the 75 patients included in the study, 14 were stratified as CCT+. The systemic concentration of S 100 in these CCT+ patients was significantly increased (0.31 microg/l) compared to the healthy control group (0.04 microg/l) as well as to the CCT-negative patients (0.08 microg/l). The ELECSYS S100 system allows a rapid, valid, and reproducible assessment of S 100B in patient serum and this concentration is significantly elevated in patients suffering from intracranial lesions as shown by initial CCT scan. Hence, this study is the basis for a multicenter trial currently underway to confirm the results of our pilot study.

Risk stratification in mild head injury patients: the head injury predictive index

BACKGROUND

Mild Head Injury has classically been defined as patients with a Glasgow Coma Scale (GCS) of 13 to 15. While most of these patients do well, some suffer serious outcomes. The objective of this study was to identify the group at high risk for poor outcome.

METHOD

Analysis of 255 consecutive patients who presented to the Medical Center of Louisiana at New Orleans with GCS from 13 to 15 was performed. A new Head Injury Predictive Index (HIPI) based on Focal Neurological Signs, the verbal response and eye-opening components of the GCS, and CT findings was used to stratify patients into "high" and "low" risk groups.

RESULTS

There were 10 in-hospital decompensations and 7 poor outcomes at discharge. The study shows that the HIPI was predictive of both poor outcomes and in-patient decompensations.

CONCLUSION

When compared to GCS, the inclusion of computed tomographic and focal neurological data gives the HIPI more power in predicting poor outcome and in-hospital decompensations in the mild head injury group.

[Imaging of paranasal sinus trauma]

The role of imaging in the management of maxillofacial trauma is to describe anatomical lesions and to detect complications and associated injuries. Plain films are still useful for minimal trauma, but CT-scan is the gold standard for complex trauma. Helical CT and multidetector row CT simplify the emergency imaging of horizontal struts (skull base, orbital floor, alveolar ridge and palate). The diagnosis, and sometimes the treatment of complications may require CT cisternography, MRI and angiography.

LEARNING OBJECTIVES

review mechanisms and classification of paranasal sinuses trauma; present the imaging techniques with special emphasis on CT; describe paranasal sinuses trauma features and pseudo-fracture patterns; describe complications and associated injuries.

[Prognostic risk factors in children and adolescents with craniocerebral injuries with multiple trauma]

220 of 268 polytraumatized patients (82.1%) presented an additional head injury, which increased the mortality significantly. By the Hannover Polytrauma Score we could demonstrate that the severity of the polytrauma and the prognosis depended on the extent of the brain injury. Important risk factors were skull fractures and shock on arrival. 66.7% of the patients with a severe brain trauma and a skull fracture died; without this fracture, only 36.8% died. 76.1% of the children with a systolic blood pressure (SBP) > 80 mm Hg survived, but only 31.2% with a SBF < or = 80 mm Hg did not die. For all polytraumatized children we recommend a computer tomography of the head. In spite of a negative initial CT a follow up CCT should be performed.

Maxillofacial war injuries during the Iraq-Iran War: an analysis of 300 cases

The following study focuses on three hundred maxillofacial war casualties that were admitted to the Basra Republic Hospital during the Iraq-Iran War. These three hundred cases were chosen on the basis of them being only oral and maxillofacial injuries. Of these cases, there was no mortality recorded. This was in part due to the rapid evacuation, immediate resuscitation and proper management of the casualties. An appropriately staffed hospital, efficient surgical techniques and the presence of highly skilled specialists working as a team also made this result possible. This analysis categorizes, evaluates and discusses the treatment of the casualties based on the severity of the injury and outlines several techniques used to treat such patients.

[Intro-extro cranial approach treat serious post fronto-orbital fracture deformities]

OBJECTIVE

To explore the method of treating serious secondary fronto-orbital fracture deformities through intro-extra cranial approach.

METHODS

The fronto-orbital fracture was divided into two types according to whether there were any large scale fronto-orbital bone defects: type I: Large scale fronto-orbital bone defect; type II: Concave fronto-orbital fracture deformity without large scale bone defect. Both types were treated through intro-extra cranial approach to expose the fracture site. For type I deformity, the bone defects were repaired and reconstructed with outer table of cranial bone and artificial bone. For type II, the deformity was repaired by osteotomy, bone reposition and internal rigid fixation.

RESULTS

18 cases were treated from June 1998 to October 2000, include type I, 12 cases, and type II, 6 cases. All the patients recovered well and the post-operative appearance were greatly improved.

CONCLUSIONS

Intro-extra cranial approach can expose the fractured site better than the simple extrocranio approach, and make the operation more easily done. Combined with the technique of cranio maxillo facial surgery, the treatment can be more complete and the results can be more satisfactory.

Etiology and patterns of facial fractures in the United Arab Emirates

A retrospective study on facial fractures was carried out in the Department of Oral and Maxillofacial Surgery at Tawam Hospital (Al Ain, United Arab Emirates) between January 1, 1998 and December 31, 2001. The study included 144 patients with a mean age of 26.5 years; the most frequently injured patients belonged to the 16- to 20-year-old age group. The male predilection was 83%. Road traffic accident was the most common causative factor (59%), followed by falls (21.5%), accidents where camels were involved (5.5%), work- and sport-related accidents (4.8% and 4.8%, respectively), and assault (4.1%). A total of 53.4% of the patients suffered isolated mandibular fractures, 32.6% had isolated midface fractures, and 13.8% had combined midface and mandibular fractures. Associated injuries were noted in 22.2% of the patients. The number of patients treated increased from 28.3 (1990-1995) to 36 (1998-2001) on an annual average; a reduction in isolated nasal fractures and associated injuries, including facial lacerations, was noted with no change in age or etiology predilection. Sufficient data could not be obtained to determine if the favorable results with the associated injuries were a result of the effect of a compulsory seat belt law introduced on June 1, 1998, but the increasing number of maxillofacial injuries suggests that the seat belt law is ignored in this country.

[Practical application of the Injury Severity Score (ISS) in expert forensic testimony]

The retrospective analysis of the autopsy records of 50 homicides showed that the Injury Severity Score (ISS), a numerical scoring system initially developed to quantify the severity of injuries sustained in road traffic accidents, can also be useful for objectively describing and ranking the overall severity of trauma with regard to forensic issues. The present case report illustrates to what extent the ISS can help to assess the contribution of each assailant in homicides committed by several perpetrators. In the case presented the court was convinced that one perpetrator had inflicted four deep stab wounds to the victim's face (each with bony lesions), 2 stabs to the chest piercing the right lower pulmonary lobe and causing a haemothorax of 200 ml, an abdominal stab wound without involvement of a parenchymatous organ as well as multiple defence wounds of the arms. Thereafter, a second perpetrator was thought to have inflicted several heavy blows with a full water bottle causing severe contusions on the right side of the forehead, the chin, the left side of the face and a spider's web fracture of the frontal bone. Using the ISS an injury severity score of 24 was assigned to the first complex of injuries and a score of 10 to the second complex. The forensic conclusions with regard to prognosis and lethal outcome are discussed.

[Retrospective analysis of facial fractures related to falls in 260 Japanese patients]

OBJECTIVE

Numerous epidemiological studies concerning fall-related injuries have been performed in the geriatric and orthopedic field to clarify the relation between the type of fall and fracture patterns. Although falls are a common cause of facial fractures, there is no study describing these relations. This study thus investigates the relationship between the type of fall and fracture pattern.

MATERIALS AND METHODS

We analyzed 260 patients with fall-related facial fractures treated between 1995 and 2000 at the First Department of Oral and Maxillofacial Surgery, Osaka University Dental Hospital, Japan. These patients were classified into two groups: (1) those who suffered fractures by a fall from a standing position or lower and (2) those who suffered fractures by a fall from a level higher than the standing position.

RESULTS

Fractures caused by falling from a standing position or lower was more common in older patients, especially in women beyond 70 years. The localization of mandibular fractures was not significantly different between the two groups. However, a high incidence of midface fractures was observed in the patients who fell from a higher position. These patients tended to suffer from central midface or dislocated fractures.

CONCLUSION

The results were consistent with recent orthopedic studies, which suggest a relation between fractures in old patients and osteoporosis. A strong force caused by falls from a high position tends to act on the high portion of the midface. Our classification based on the height of the falls was able to demonstrate clearly the relation between etiological factors and fracture patterns. Therefore, it seemed reasonable to analyze patients treated in the Department of Oral and Maxillofacial Surgery, Heidelberg University, Germany, according to the same classification in order to compare both collectives.

A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography

A comprehensive classification of midfacial/craniofacial fractures, based on two- and three-dimensional computed tomography (2D and 3D-CT) is presented. We performed a postmortem analysis of 24 patients who had died from trauma with signs of craniofacial fractures, based on 2D and 3D-CT studies with pathoanatomical findings. In addition, CT findings for 100 patients with craniofacial injuries requiring an emergency CT were correlated with surgical findings and follow-up results. On the basis of the analysis of a total of 377 fractures a classification system is proposed. The system is based on the use of the AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) scheme, defining three types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest). The craniofacial region is divided into three units: the lower midface (I), the upper midface (II) and the craniobasal-facial unit (III). Lateral and central fractures are also distinguished. Type A fractures are non-displaced fractures, type B are displaced fractures and type C are complex/defect fractures. Groups A1, B1 and C1 comprise fractures of an isolated unit; groups A2, B2 and C2, combined fractures without involvement of the skull base; and groups A3, B3 and C3 are those combined fractures with involvement of the skull base. A correlation between the severity of the fracture and (i). the number of posttraumatic functional limitations (Spearman rank test, correlation coefficient r=0.42), (ii). the need for bone grafting or dural plastic (r=0.39) and (iii). facial asymmetry (r=0.37), was observed. The proposed classification system allows standardised documentation of midfacial and craniofacial fractures, including those not precisely defined by the Le Fort classification scheme.

Accurate, firm stabilization using external pins: a proposal for closed reduction of unfavorable nasal bone fractures and their simple classification

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.

Upper cervical spine injuries

The unique anatomy of the upper cervical spine and the typical mechanisms of injury yield a predictable variety of injury patterns. Traumatic ligamentous injuries of the atlanto-occipital joint and transverse atlantal ligament are relatively uncommon, have a poor prognosis for healing, and often respond best to surgical stabilization. Bony injuries, including occipital condyle fractures, atlas fractures, most odontoid fractures, and traumatic spondylolisthesis of the axis, generally respond well to nonsurgical management. Controversy in management remains, however, especially with type II odontoid fractures.

Nasoethmoid orbital fractures: diagnosis and management

BACKGROUND AND OBJECTIVES

Trauma to the central midface may result in complex nasoethmoid orbital fractures. Due to the intricate anatomy of the region, these challenging fractures may often be misdiagnosed or inadequately treated. The purpose of this article is to aid in determining the appropriate exposure and method of fixation.

METHODS AND MATERIALS

This article presents an organized approach to the management of nasoethmoid orbital fractures that emphasizes early diagnosis and identifies the extent and type of fracture pattern. It reviews the anatomy and diagnostic procedures and presents a classification system. The diagnosis of a nasoethmoid orbital fracture is confirmed by physical examination and CT scans. Fractures without any movement on examination or displacement of the NOE complex on the CT scan do not require surgical repair. Four clinical cases serve to illustrate the surgical management of nasoethmoid fractures.

RESULTS AND/OR CONCLUSIONS

Early treatment using aggressive techniques of craniofacial surgery, including reduction of the soft tissue in the medial canthal area and restoration of normal nasal contour, will optimize results and minimize the late post-traumatic deformity. A high index of suspicion in all patients with midfacial trauma avoids delays in diagnosis.

Orbital deformity after craniofacial fracture repair: avoidance and treatment

BACKGROUND AND OBJECTIVES

To achieve the optimal preoperative appearance following craniofacial fracture repair, the surgeon must be facile in the most sophisticated reconstructive techniques and able to determine their application. The purpose of this article is to describe the common deformities following such repairs, outline a strategy to avoid them, and review the surgical techniques to correct them.

METHODS AND MATERIALS

The deformities are categorized by the anatomic zones of the orbit, i.e., zygomatic, frontal, and nasoethmoidal, affected by low-, middle-, and high-energy impact. The common types of deformity and acute and late treatments are discussed for each category.

RESULTS AND/OR CONCLUSIONS

The optimal time to correct posttraumatic orbital deformities is during the acute phase. Extended open reduction and rigid fixation techniques have their own morbidity, which must not outweigh the deformity of an untreated or partially treated injury. The results of late reconstruction are always limited by scarring of the overlaying soft tissue envelope.

Lateral force compared with frontal impact nasal fractures: need for reoperation

Patient concern over the outcome of correction of nasal fractures is usually extremely high; often, a secondary procedure is necessary. Therefore, thorough consultation is mandatory. The clinical data of 50 patients who sustained nasal fractures was retrospectively reviewed to determine if there was any predictive value to classification of nasal fractures and the likelihood of a secondary surgical procedure. Using Stranc and Robertson's nasal fracture classification, 41 of 50 patients were described as lateral force fractures and 9 of 50 were frontal impact fractures. Five of 50 patients underwent a secondary surgical procedure, 4 from the frontal impact and 1 from the lateral force fracture group. The number of patients reoperated on approximately equaled the number who were dissatisfied with the result of the initial procedure (5 versus 6). However, objective assessment by the primary surgeon revealed 21 patients with an anatomic or functional defect. Of these, 15 were lateral force fractures (15 of 41, or 37%) and 6 were frontal impact fractures (6 of 9, or 67%). These results illustrate the difficulty in restoring preinjury nasal anatomy and function, especially in the more severe and complicated frontal impact types of nasal fracture. Using this information can aid in obtaining satisfactory informed patient consent.