Treatment of Lateral Epicondylitis: Is Surgery Still an Option?

Background: The prevailing trend for the treatment of lateral epicondylitis (LE) is nonsurgical. Although many providers consider LE surgery controversial, others consider surgical intervention in patients with recalcitrant symptoms. The purpose of this study is to analyze epidemiological changes in LE surgery over a 9-year period prior to the coronavirus pandemic in 2019. Methods: A cross-sectional analysis of the Texas health care database from 2010 to 2018 was performed. We analyzed all procedures performed for LE during the set time period using Current Procedure Terminology (CPT) codes. Statistical analyses included procedures performed, patient demographics, zone of residence, and insurance designation. Results: There were a total of 12802 records of LE with 1 or more associated surgical procedures. Lateral epicondylar debridement (with/without tendon repair) was the most common procedure recorded, followed by arthroscopic procedures and tendon lengthening. Overall incidence remained low and did not significantly change during the studied period; however, surgical case volumes were significantly higher in metropolitan areas and increased at a faster rate when compared with those of more rural regions. Commercial insurance was the most prevailing form of payment. The incidence was significantly higher in the age group between 45 and 64 years old and most commonly performed in Caucasian females. Conclusions: The benefit of surgery for the treatment of LE has yet to be completely elucidated; however, surgical intervention continues to be offered. Although the incidence of surgery for the treatment of LE remained low over the study period, the volume of cases in metropolitan areas increased at a fast rate between 2010 and 2018. The results of this study found that surgery is still a treatment option in some patients despite the controversy. Level of Evidence: Economic/Decision Analysis, Level IV.

Outcomes of Tracheostomy on Burn Inhalation Injury.

Background: Tracheostomy has been proposed for patients with expected prolonged intubation. This study aims to determine the outcomes of tracheostomy on patients with burn inhalation injuries requiring mechanical ventilation. Methods: This study is a retrospective review from 2011 to 2019. Inclusion criteria were recording of inhalation injury, ventilator support (at least 24 hours), and total body surface area of <15%. The patients were stratified into 2 groups: tracheostomy (group 1) versus no tracheostomy (group 2). The outcome measures were in-hospital mortality rate, hospital length of stay, intensive care unit length of stay, ventilator days, and ventilator- associated pneumonia (VAP). Results: A total of 33 burn patients met our inclusion criteria. Group 1 consisted of 10 patients and group 2 of 23 patients. There was no statistically significant difference in terms of percent total body surface area. There was a higher intensive care unit length of stay at 23.8 days in group 1 compared with 3.16 days in group 2, a higher hospital length of stay at 28.4 days in group 1 compared with 5.26 days in group 2, and higher ventilator days in group 1 with 20.8 days compared with 2.5 days in group 2. There was no statistically significant difference between the 2 groups in terms of mortality. The incidence of VAP was also significantly higher in group 1 than in group 2. Conclusions: The ideal timing and implementation of tracheostomy with inhalation injury has yet to be determined. In this study, tracheostomy was associated with much longer lengths of stay and pneumonia. The impact of the underlying lung injury versus the tracheostomy itself on these observations is unclear. The challenge of characterizing the severity of an inhalation injury based on early visual inspection remains.

Pemphigus Vulgaris: More Than Just a Skin Disease.

INTRODUCTION: Pemphigus is a group of autoimmune diseases of the skin and mucous membranes that is characterized by multiple bullae formation. It is caused by autoantibodies directed against the cell surface of keratinocytes, resulting in the loss of cell-cell adhesion of keratinocytes. This disease can be very debilitating and difficult to treat if large surface areas are involved. METHODS: We performed a retrospective review of a complex case of pemphigus vulgaris in a 24-year-old man who develop partial-thickness skin lesions distributed throughout the entire body with a total body surface of 80% short after an episode of strep throat treated with amoxicillin. RESULTS: The patient had a complicated hospital course in which the standard treatment of the disease led to adverse effects that were successfully managed at our busy burn center. CONCLUSIONS: Pemphigus vulgaris is a complex skin disease in which treatment techniques carry their risk and must be tailored to the patient's specific needs. Treatment of this conditions at a burn center would be beneficial as demonstrated with conditions like Stevens-Johnson syndrome and toxic epidermal necrolysis.

EFOMP Malaga Declaration 2023: An updated vision on Medical Physics in Europe.

In 2006, the European Federation of Organisations for Medical Physics (EFOMP) adopted the "Malaga Declaration". The declaration asserted the fundamental role of Medical Physics professionals in the radiation protection of patients, workers, general public, carers and comforters and research participants in hospitals. However, since that time the Medical Physics profession has evolved in Europe and new regulations and documentation have been issued, such as directive 2013/59/Euratom and the "European Guidelines on Medical Physics Expert" (RP174). EFOMP has published updated core-curricula and strived towards the recognition of the profession at the European level. In view of this, an update of the original Malaga Declaration was deemed necessary, to define the future vision that will guide the actions of the Federation in the years to come. This Declaration, which has been approved by the national member organizations of EFOMP in April 2023, is much broader than the original Malaga version. This is expected considering the rapid evolution of medical device technology over the last 17 years. The Radiation Protection Expert in hospital settings should be an MPE, since the latter has the highest level of radiation protection knowledge and training. Given the passion and energy that animated the debate, which led to the updating of the Malaga Declaration, we are confident that it represents a solid basis for the development of our profession in Europe which is in consonance with the aspirations of us all.

Monitoring metallothionein-like protein concentrations and cholinesterase activity in tropical cup oysters as biomarkers of exposure to metals and pesticides in the southern Caribbean, Colombia.

Metallothionein-like protein concentrations (MT) and three functionally defined fractions of cholinesterase activity (ChE) were quantified in gill and digestive gland homogenates of tropical cup oysters from 5 nearshore locations in the Colombian Caribbean and correlated with sediment and tissue metal (9 metals) and pesticide (22 organophosphates, OPs, and 20 organochlorines-OCPs), as well as water physical-chemical parameters (salinity, pH, temperature, and dissolved oxygen). Tissue and sediment pesticide concentrations were below detection limits in all samples, whereas sediment and tissue metal concentrations exceeded environmental thresholds at several locations. Tissue MT and ChE biomarkers varied by a factor of 5-6 between locations. Inhibition of cholinesterase activity was negligible for all 5 sites, despite spatial-temporal variation in ChE activity, consistent with below-detection OP concentrations. Tissue MT and ChE biomarkers correlated with tissue and metal sediment concentrations, yet, statistically significant covariance between biomarkers and water chemistry parameters was also observed, indicating that both, metal concentrations and physical-chemical variables, are likely to be responsible for generating the observed spatial-temporal variations in biomarker patterns.

The Appendix: A Rare Case of an Appendiceal Collision Tumor.

Appendicitis is a common cause of right lower quadrant pain. However, appropriate diagnostic evaluation and a high clinical suspicion can reveal alternative etiologies that are not so commonly encountered. In this report, we present a rare case of an appendiceal collision tumor involving two distinct neoplasms as the source of the patient's pain and describe how thoughtful clinical maneuvering led to its diagnosis and treatment.

Molecular Analysis of Streptomycin Resistance Genes in Clinical Strains of Mycobacterium tuberculosis and Biocomputational Analysis of the MtGidB L101F Variant.

Globally, tuberculosis (TB) remains a prevalent threat to public health. In 2019, TB affected 10 million people and caused 1.4 million deaths. The major challenge for controlling this infectious disease is the emergence and spread of drug-resistant Mycobacterium tuberculosis, the causative agent of TB. The antibiotic streptomycin is not a current first-line anti-TB drug. However, WHO recommends its use in patients infected with a streptomycin-sensitive strain. Several mutations in the M. tuberculosisrpsL, rrs and gidB genes have proved association with streptomycin resistance. In this study, we performed a molecular analysis of these genes in clinical isolates to determine the prevalence of known or novel mutations. Here, we describe the genetic analysis outcome. Furthermore, a biocomputational analysis of the MtGidB L101F variant, the product of a novel mutation detected in gidB during molecular analysis, is also reported as a theoretical approach to study the apparent genotype-phenotype association.

The Effect of a Triple Combination of Bevacizumab, Sodium Hyaluronate and a Collagen Matrix Implant in a Trabeculectomy Animal Model.

Currently available anti-scarring treatments for glaucoma filtration surgery (GFS) have potentially blinding complications, so there is a need for alternative and safer agents. The effects of the intrableb administration of a new combination of the anti-VEGF bevacizumab, sodium hyaluronate and a collagen matrix implant were investigated in a rabbit model of GFS, with the purpose of modulating inflammation, angiogenesis, fibroblast migration and fibrogenesis in the wound healing process. A comparative-effectiveness study was performed with twenty-four rabbits, randomly assigned to the following treatments: (a) biodegradable collagen matrix implant (Olo), (b) bevacizumab-loaded collagen matrix implant (Olo-BVZ), (c) bevacizumab-loaded collagen matrix implant combined with sodium hyaluronate (Olo-BVZ-H5) and (d) sham-operated animals (control). Rabbits underwent a conventional trabeculectomy and were studied over 30 days in terms of intraocular pressure and bleb characterization (height, area and vascularity in central, peripheral and non-bleb zones). Histologic differences among groups were further evaluated at day 30 (inflammation, total cellularity and degree of fibrosis in the area of surgery). Local delivery of bevacizumab (Olo-BVZ and Olo-BVZ-H5) increased the survival of the filtering bleb by 21% and 31%, respectively, and generated a significant decrease in inflammation and cell infiltration histologically 30 days after surgery, without exhibiting any local toxic effects. Olo-BVZ-H5 showed less lymphocyte infiltration and inflammation than the rest of the treatments. Intraoperative intrableb implantation of bevacizumab, sodium hyaluronate and a collagen matrix may provide an improved trabeculectomy outcome in this model of intense wound healing. This study showed an effective procedure with few surgical complications and a novel combination of active compounds that offer new possibilities to improve the efficacy of filtration surgery.

Detailed Case Reports of Surgical Treatment for Intraneural Ganglion Cysts.

Intraneural ganglion cysts are nonneoplastic mucinous cysts that form by the accumulation of thick mucinous fluid in the epineurium of peripheral nerves. Symptoms arise from mechanical compression of adjacent nerve fascicles from the intraneural ganglion cyst, and include local or radiating pain, paresthesias, weakness, and muscle atrophy. METHODS: Retrospective review of three cases of symptomatic intraneural ganglion cysts affecting the upper and lower extremity. RESULTS: In our cases, the intraneural ganglion cysts were completely decompressed with resection of the articular branches, leading to improvement in the patient's symptoms. CONCLUSIONS: Treatment of intraneural ganglion cysts requires an understanding of the underlying anatomy and pathophysiology; accurate early diagnosis is important and can lead to timely treatment and better outcomes.

Effects of Elevated Blood Alcohol Levels on Burn Patient Outcomes.

Background: Alcohol use has been associated with poor wound healing in traumatic injuries as it impairs immune function and lowers leukocyte production. The aim of this study is to describe the association of alcohol use on the outcomes of patients with burn injuries. It is proposed that the use of alcohol can have a detrimental effect on burn patient outcomes. Methods: A retrospective review of the American Burn Association Burn Registry from 2002 through 2011 was conducted. Patients were stratified into 2 groups: burn patients with a blood alcohol level above the legal limit 0.08 mg/dl on admission (group 1) vs burn patients with a blood alcohol level below the legal limit of 0.08 mg/dl on admission (group 2). The outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit (ICU) LOS, and total days on a ventilator. Results: A total of 11,286 burn patients met the inclusion criteria. There were a total of 1,544 patients in group 1 and a total of 9,742 patients in group 2. The percentage of total body surface area (TBSA) involvement of the burns was statistically similar in both groups, with an average of 2.08% in group 1 and 2.32% in group 2. There was a significantly higher ICU LOS at 5.91 days in group 1 compared to 3.66 in group 2. The days on a ventilator were significantly higher in group 1 at 5.67 days versus group 2 at 3.06 days. The in-hospital mortality was also significantly higher in group 1 at 4.86% compared to group 2 at 3.91%. Conclusion: Burn patients who tested above the legal limit for alcohol on admission were associated with increased inpatient mortality, as well as increased ICU LOS and total days on a ventilator. An elevated admission blood alcohol level may be an independent predictor of worse outcome in patients with burn injury, leading to an increase in resource needs and health care costs.

The Outcomes of Inhalation Injuries in Lesser Burns: Still a Deadly Injury.

Background: Although it has been widely proposed that inhalation injuries worsen burn outcomes, large-scale studies have yet to demonstrate the exact relationship. This study proposes inhalation injuries as an independent risk factor that worsens burn outcomes. Methods: A retrospective review of the American Burn Association Registry from 2002 to 2011 was conducted. Inclusion criteria included burn patients with a total body surface area (TBSA) of less than 15% and adequate data recording of the inhalation injury within the registry. Patients were stratified into 2 groups: inhalation injuries (group 1) vs non-inhalation injuries (group 2). Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on a ventilator. Results: A total of 93781 burn patients met the inclusion criteria. There were 4204 patients in group 1 and 89577 patients in group 2. There was no statistically significant difference between the 2 groups in terms of TBSA, with 3.50% in group 1 and 3.58% in group 2. There was a significantly higher ICU LOS at 8.55 days in group 1 compared to 6.27 days in group 2. There was a significantly higher hospital LOS at 11.48 days in group 1 compared to 6.27 days in group 2. The in-hospital mortality was significantly higher in group 1 at 8.54% vs group 2 at 1.42%. Conclusion: The presence of inhalation injury may be a predictor of increased mortality and poor outcome in burn patients, even in those with small sized burns.

Comparison Between Human Amniotic/Chorionic Membrane and Cryopreserved Allografts in the Treatment of Genital Burns.

BACKGROUND: Genital burns have devastating effects on patient and have been classified by the American Burn Association as major burn injury. The management of these injuries continues to challenge reconstructive surgeons. Cryopreserved skin allografts have been successfully used to manage partial-thickness skin burns; however, dehydrated human amniotic/chorionic membrane (DHACM) represents novel technology. Dehydrated human amniotic/chorionic membrane outcomes have not been sufficiently studied to guide its use on genital burns. The objective of this study was to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing on genital burns injury compared with cryopreserved allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2017. The study population included patients with partial-thickness genital burns admitted between 2012 and 2017 treated with either dehydrated human amniotic/chorionic membrane or cryopreserved allografts. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Thirty patients with genital burns who received DHACM skin and cryopreserved allografts were included in the analysis. The mean age for the DHACM group was 27.6 years compared with 33.5 years for the cryopreserved group. The mean total body surface area was 3.8% in the DHACM group compared with 7.2% in the cryopreserved group (P = non-significant (ns)). The mean injury severity score was not significantly different between groups. Patients receiving cadaveric allografts had a higher number of skin substitute surgical reapplications as compared with the DHACM group (28% vs 0%, P ≤ 0.05). All patients who received DHACM skin substitutes healed by 2 weeks postoperative compared with 76% of patients who received cryopreserved skin allografts (P = 0.03, χ). CONCLUSIONS: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of genital burns. Its use achieves comparable benefits with no major significant difference in terms of complication, supporting the safety of amniotic membrane to treat genital burns.

Admission Carboxyhemoglobin: Is It a Marker for Burn Patient Outcomes?

BACKGROUND: Carbon monoxide is a gas produced by the combustion of hydrocarbon products that binds to heme molecules, 240 times more than oxygen, producing carboxyhemoglobin (COHb). As a result of its high affinity, there is shift of the oxyhemoglobin dissociation curve, compromising oxygen transport and delivery to tissues. Our study aim was to evaluate COHb elevation on admission as a predictor of worse outcomes in burn patients. METHODS: This is a 10-year retrospective review of the American Burn Association Burn Registry from 2002 to 2011. We stratified the patients into 2 groups: adult patients with normal COHb on admission (group 1) versus elevated COHb (group 2). Elevated COHb levels were defined as greater than 10% on the first arterial blood gas. Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit LOS (ICU-LOS), and ventilator days. χ and t test analyses were used with significance defined as a P value of less than 0.05. RESULTS: A total of 6365 burn patients meet our inclusion criteria. There were 5775 patients in group 1 and 590 patients in group 2. Group 1 had an average age of 39.29 years compared with 42.62 years in group 2. The total body surface area was higher in group 1 compared with group 2 (6.24 vs 4.65) and with a statistically significant increase in partial thickness burns at 4.97 in group 1 compared with 3.27 in group 2. There was no statistically significant difference between the 2 groups in terms of full thickness total body surface area. The hospital LOS was significantly higher in group 2 compared with group 1 (15.34 vs 9.66). There was a significantly higher ICU-LOS at 12.89 days in group 2 compared with 4.01 in the group 1 (P = 0.0001, t test). There were higher ventilator days in group 2 at 9.23 than those in group 1 at 2.05 (P < 0.0001, t test). The in-hospital mortality was also significantly higher in group 2 at 15.59% than in group 1 at 1.33% (P = 0.0001, χ). CONCLUSIONS: Elevated COHb on admission was associated with an increased hospital and ICU-LOS, average ventilator days, and in-hospital mortality. The presence of elevated COHb of greater than 10% on an initial arterial blood gas suggests worse outcomes and increased need of resource utilization during the index hospital admission.

Dexamethasone intravitreal implant in cystoid macular edema secondary to paclitaxel therapy.

PURPOSE: To report the first case of cystoid macular edema (CME) induced by nabpaclitaxel treated with intravitreal dexamethasone implant. OBSERVATIONS: A 67 year-old man diagnosed with unresectable pancreatic cancer presented with decreased vision in both eyes while receiving nab-paclitaxel. He was diagnosed with CME and intravitreal dexamethasone implants were administered in both eyes. Central retinal thickness (CRT) of both eye decreased 1 month after the implant but CME persisted. 2 months after Ozurdex implant nabpaclitaxel was discontinued, improving central macular thickness and the CME significantly in both eyes. CONCLUSION AND IMPORTANCE: Cessation of nab-paclitaxel could lead to resolution of CME more than intravitreal dexamethasone implant, although intravitreal dexamethasone implant achieved some reduction in central macular thickness.

The Use of Dehydrated Human Amniotic Membrane Versus Amniotic/Chorionic Membrane Allografts to Treat Partial Thickness Facial Burns.

BACKGROUND: Facial burns have significant physical and psychologic effects on patients. Human dehydrated amniotic membrane represents novel technology, yet its outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the benefits of amniotic membrane (DHAM) to amniotic/chorionic membrane (DHACM) skin substitutes to treat partial thickness facial burns. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. Demographic characteristics including age, total body surface area (TBSA) burn and injury severity scores were collected and outcome measures were compared between the 2 groups. Paired sample t-test and Chi-squared were used with significance defined as P < 0.05. RESULTS: A total of 77 adult patients with partial thickness facial burns who received DHAM and DHACM skin substitutes were included in the analysis. The mean age for the DHAM group was 39.8 compared to 41.4 for the DHACM. Mean TBSA was similar, with 10.9% in the DHAM group compared to 8.3% in the DHACM. Patients receiving DHAM had higher requirement for skin substitute surgical reapplications as compared to the DHACM group (23.7% versus 5.1%, P ≤ 0.05). Remaining morbidities remained low and not significantly different between patients receiving DHAM and DHACM substitutes (P > 0.05). CONCLUSION: The DHAM and DHACM skin substitutes are valid and safe alternatives in the treatment of adult partial thickness facial burns.

Using Dehydrated Amniotic Membrane Skin Substitute in Facial Burns: Is There a Outcome Difference Between Adult and Pediatric Patients?

INTRODUCTION: Facial burns have significant physical and psychological effects on patients, and minimizing morbidity continues to be a challenge for reconstructive surgeons. Advancements have allowed the development of various skin substitutes. Among these, human dehydrated amniotic skin substitutes represent novel technology, yet their outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the safety of amniotic membrane skin substitutes in the treatment of adult and pediatric facial burns. METHODS: The authors performed a retrospective review of our institutional burn registry, with 90 burn patients meeting the inclusion criteria. Demographic and outcome measures included age, percentage of total body surface area (TBSA), Injury Severity Score (ISS), and complications (eg, pigmentation, hypertrophic scar, infection, and delayed healing). Paired sample t test and Chi-squared test were used, with significance defined as P < 0.05. RESULTS: Seventy-seven adults and 13 pediatric patients with facial burns who had received dehydrated amniotic membrane skin substitutes were included in the analysis. The mean age was 40.8 years for adults and 5.6 years for children. Mean TBSA was similar, with 9.6% (1-57%) in adults and 6.0% (2-14%) in children. The mean ISS did not significantly differ between groups (4.0 versus 2.2, P = ns). Pediatric patients with facial burns treated with amniotic membranes had a higher incidence of dyspigmentation relative to adult patients (46.2% versus 9.1%, P ≤ 0.05). Remaining morbidities were not significantly different between adult and pediatric patients. All patients, irrespective of group, healed by the second post-operative week. CONCLUSION: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of facial burns across all ages.

Orbital Decompression for Treatment of Acute Visual Loss After Facial Trauma.

Injury to the orbital region represents a significant proportion of emergency department attendances and it is a common injury in patients with multisystem trauma. To date, trauma remains a leading cause of monocular blindness.Traumatic optic neuropathy may be caused by direct trauma to the optic nerve and from compression caused by foreign bodies and bone fragments. Indirect trauma can lead to visual loss from transmitted force to the optic canal by blunt facial trauma without associated fractures. Occasionally traumatic optic neuropathy is due to reversible changes, such as edema or contusion.High-dose intravenous steroids and surgical decompression of the optic canal have been advocated for the management of acute traumatic optic neuropathy, but the efficacy and safety of these treatments have been questioned.The authors present 3 patients with traumatic optic nerve injury, 1 due to a gunshot wound to the face and 2 caused by blunt facial trauma, where fragments of bone intrude into the orbit leading to compression of its content. These injuries where successfully treated with both preoperative intravenous steroids followed by acute surgical decompression of the orbit with return of visual function.

The Use of Dehydrated Human Amniotic/Chorionic Membrane Skin Substitute in the Treatment of Pediatric Facial Burn.

BACKGROUND: Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%-27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05). CONCLUSION: Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns.

Spontaneous Temporomandibular Joint Dislocation.

Dislocation of the temporomandibular joint (TMJ) is the displacement of the head of the condyle from its normal position in the glenoid fossa. Anterior dislocations are the most common type of TMJ dislocations. Prognathism of the lower jaw, anterior crossbite, and open bite are the classic features in bilateral TMJ dislocations.The treatment of acute TMJ dislocation involves manual reduction with or without general anesthesia. The use of maxillomandibular fixation is reserved for chronic, more complex dislocations. Determining the presence of a predisposing factor is very important in guiding the correct treatment and management for this condition.The authors present a case of acute spontaneous temporomandibular joint dislocation where multiple predisposing factors were recognized, requiring treatment with maxillomandibular fixation after manual reduction.