A trans-eyebrow zig-zag approach for frontal bone fractures✰.

Frontal bone fractures are amongst the most common facial fractures and surgical management, which has traditionally involved access via a coronal flap, can result in unsightly scarring, alopecia, paraesthesia, facial nerve weakness and temporal hollowing. Alternative approaches include use of endoscopically-assisted surgery, often through the eyebrow, which minimises the risk of unsightly scarring but may also sacrifice access in the process. In this technical note, we discuss a surgical technique for open reduction and internal fixation of fractures of the bone overlying the frontal sinus and supra-orbital rim, which the authors have not found in the literature, which involves the making of a "zig-zag" incision through the eyebrow in a trichophytic manner which reduces the risk of unsightly scarring whilst simultaneously allowing for sufficient surgical access to the fracture site.

[Trauma of the midface : Symptoms, diagnostics and treatment]. / Trauma des Mittelgesichts : Symptomatik, Diagnostik und Therapie.

Midface fractures present a clinical challenge in otorhinolaryngology due to their often complex injury pattern and nonspecific symptoms. Precise diagnostics, including differentiated imaging procedures, are required. Interdisciplinary consultation between otorhinolaryngology, maxillofacial surgery, neurosurgery, and ophthalmology is often necessary. When selecting radiographic modalities, radiation hygiene should be taken into account. Sonography provides a radiation-free imaging alternative for fractures of the nasal framework and anterior wall of the frontal sinus. The goal of treatment is to achieve stable and symmetrical reconstruction. Depending on the injury pattern, different osteosynthesis materials, individual access routes, and various surgical procedures can be used. In clinical practice, the management of midface fractures requires a multidisciplinary, flexible, and pragmatic approach based on the fracture pattern and clinical experience.

Automatic detection of midfacial fractures in facial bone CT images using deep learning-based object detection models.

BACKGROUND: Midfacial fractures are among the most frequent facial fractures. Surgery is recommended within 2 weeks of injury, but this time frame is often extended because the fracture is missed on diagnostic imaging in the busy emergency medicine setting. Using deep learning technology, which has progressed markedly in various fields, we attempted to develop a system for the automatic detection of midfacial fractures. The purpose of this study was to use this system to diagnose fractures accurately and rapidly, with the intention of benefiting both patients and emergency room physicians. METHODS: One hundred computed tomography images that included midfacial fractures (e.g., maxillary, zygomatic, nasal, and orbital fractures) were prepared. In each axial image, the fracture area was surrounded by a rectangular region to create the annotation data. Eighty images were randomly classified as the training dataset (3736 slices) and 20 as the validation dataset (883 slices). Training and validation were performed using Single Shot MultiBox Detector (SSD) and version 8 of You Only Look Once (YOLOv8), which are object detection algorithms. RESULTS: The performance indicators for SSD and YOLOv8 were respectively: precision, 0.872 and 0.871; recall, 0.823 and 0.775; F1 score, 0.846 and 0.82; average precision, 0.899 and 0.769. CONCLUSIONS: The use of deep learning techniques allowed the automatic detection of midfacial fractures with good accuracy and high speed. The system developed in this study is promising for automated detection of midfacial fractures and may provide a quick and accurate solution for emergency medical care and other settings.

Evaluation of Concomitant Facial Fracture in Traumatic Brain Injury Patients-Simplification and External Validation of a Prediction Model.

BACKGROUND: Patients with traumatic brain injuries (TBIs) often experience concurrent facial bone fractures. In 2021, a prediction model with 10 variables was published and precisely predicted concomitant facial fractures in TBI patients. Herein, external validation and simplification of this model was performed. METHODS: Traumatic brain injury patients treated at a major referral trauma center were retrospectively reviewed for 1 year. The original prediction model (published in 2021), which was developed from a rural level II trauma center, was applied for external validation. A new and simplified model from our level I trauma center was developed and backwardly validated by rural level II trauma center data. RESULTS: In total, 313 TBI patients were enrolled; 101 (32.3%) had concomitant facial fractures. When the previous prediction model was applied to the validation cohort, it achieved acceptable discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.713 and good precision, with a Brier score of 0.083. A new and simplified model with 6 variables (age, tooth rupture, epistaxis, facial lesion, eye injury, and intracranial hemorrhage) was created with excellent discrimination (AUC = 0.836) and good precision (Brier score of 0.055). The backward validation of this new model also showed excellent discrimination in the cohort used to develop the original model (AUC = 0.875). CONCLUSION: The original model provides an acceptable and reproducible prediction of concomitant facial fractures among TBI patients. A simplified model with fewer variables and the same accuracy could be applied in the emergency department and at higher- and lower-level trauma centers.

Pediatric Cranial Vault and Skull Base Fractures.

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

Pediatric Panfacial Fractures.

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Traumatic brain injuries and maxillofacial fractures: a systematic review and meta-analysis.

Traumatic brain injuries (TBIs) associated with maxillofacial fractures (MFFs) are a public health concern worldwide, especially among adult-aged males. There is an urgent need for early detection of associated TBIs in patients with MFFs during the initial assessment and treatment stage to reduce morbidity and mortality. The objective of the present study was to systematically review the literature to determine specific MFF situations associated with TBIs and to identify the factors associated with TBIs in patients with MFFs. The protocol was developed in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and was registered to the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42020155912. Overall, of 26,774 patients recorded, 13,667 patients (51.04%) sustained MFFs with an associated TBI. The male to female ratio was 4.8:1. RTA was the most common cause. The most common TBIs were concussions, contusions, and closed brain injuries. Within the limits of this study, it was concluded that TBI-related MFFs should be suspected whenever maxillary or mandibular bone fractures occur, especially among adults, males, and people with injuries caused by RTAs and assaults. There is a need to increase the awareness of maxillofacial surgeons on the possible associations of combined maxillofacial trauma and brain injuries.

Contrecoup epidural hematoma: a rare case report.

Epidural hematoma (EDH) is defined as a traumatic accretion of blood separating the dural membrane and the internal table of the skull that caused from contact bending or skull fracture. The cases of contrecoup EDH are as not common, and there are just 10 recorded cases on this. As a result of its uncommonness, we disclose one subject of a 33-year-old man having countrecoup EDH who suffered from a head trauma caused by falling from 4 meters high. The main symptoms were decreasing consciousness and vomiting. Clinical findings showed a Glasgow Coma Scale score of 9, laceration in the left parietal region with stable hemodynamic. Head Computed tomography showed a large EDH in the right frontal and temporal region with coronal suture diastasis. The patient immediately underwent surgery, and craniotomy with evacuation of extradural hematoma were performed. This case presents that a force, which creates an angle, can propagates and causes opposite coronal suture diastasis and makes contrecoup EDH.

Nasal Fractures.

This article outlines current methods in the evaluation and management of nasal fractures including clinical workup, imaging, and treatment.

Epidemiology of Nasal Bone Fractures.

Importance: Although nasal bones are the most common type of facial fracture given their natural projection and vulnerability to trauma, there is a paucity of data on its trends. Objective: To report on the trends and costs associated with open and closed nasal bone fractures across the United States. Methods: A retrospective analysis from 2006 to 2014 was conducted of the Nationwide Emergency Department Sample by using the International Classification of Disease, Ninth Revision codes for closed and open nasal bone fractures (802.0 and 802.1) presenting to emergency departments (ED). Trend analysis of total number and rate of visits, discharges, admissions, and associated costs were conducted. Results: Data from 1,253,399.741 records were collected. The total number of ED visits decreased by 2.05% for both open and closed nasal fractures from 2006 to 2014 whereas their associated costs increased (p < 0.001 and p < 0.05 for closed and open nasal fractures). Notably, open fractures were consistently costlier whereas closed fractures had a greater percent-increase in costs (76.65%). Conclusions and Relevance: This study identified a significant rise in nasal fracture costs, which can be reduced via use of cheaper diagnostic modalities and cost-effective endoscopic procedures.

Can we increase detection? A nationwide analysis of age-related fractures in child abuse.

PURPOSE: The purpose of this study was to stratify fractures associated with child abuse in relation to the child's age. METHODS: The Kids' Inpatient Database (1997-2012) was queried for all patients (<18 years old) with a diagnosis of fracture and child abuse. The primary outcome was age-related determinants of fracture distribution. Chi-squared analysis was used for statistical analysis where appropriate, with significance set at p < 0.05. RESULTS: More than 39,000 children were admitted for child abuse, and 26% sustained fractures. Most were infants (median age 0 year [IQR 0-1]). 28% sustained multiple fractures, and 27% had skull fractures. By age, infants had the highest rate of multiple fractures (33% vs 16% 1-4 years), and the highest rate of closed skull fractures (33% vs 21% ages 1-4), while adolescents had more facial fractures (43% vs 11% ages 9-12), all p < 0.001. Multiple rib fractures were more commonly seen in infants (28% vs 8% ages 1-4), while children 5-8 years had the highest rates of clavicular fractures (7% vs 3% in infants), all p < 0.001. CONCLUSION: Age-related fracture patterns exist and may be due to changing mechanism of abuse as a child grows. These age-related fracture patterns can help aid in healthcare detection of child abuse in hopes to thwart further abuse. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

High-Resolution Maxillofacial Computed Tomography Is Superior to Head Computed Tomography in Determining the Operative Management of Facial Fractures.

BACKGROUND: Computed tomography of the head (CTH) and maxillofacial bones (CTMF) can be performed concurrently, but CTMF is frequently ordered separately, after facial fractures identified on CTH scans. This study aims to evaluate whether obtaining additional CTMF after CTH changes operative management of patients with facial trauma. MATERIALS AND METHODS: A retrospective chart review was performed of all patients with facial trauma who presented to our level 1 trauma center between January 2009 and May 2019. CTH and CTMF were reviewed for each patient. Fracture numbers and patterns were compared to determine if CTMF provided additional information that necessitated change in management, based on predetermined criteria. RESULTS: A total of 1215 patients were assessed for facial trauma. Of them, 899 patients underwent both CTH and CTMF scans. CTH identified 22.7% less fractures than CTMF (P < 0.001); specifically, more orbital, nasal, naso-orbito-ethmoid, zygoma, midface, and mandible fractures (P < 0.001). Of all patients 9.2% (n = 83) of patients with nonoperative fractures on CTH were reclassified as operative on CTMF; 0.6% (n = 5) with operative patterns on CTH were reclassified as nonoperative on CTMF, and 18.1% (n = 163) experienced a changed in their operative plan though operative fractures were seen on both imaging modalities. Additional findings seen on CTMF delegated change in the operative plan in 27.9% (n = 251) of cases. CONCLUSIONS: CTMF scans are necessary to determine operative intervention. As CTH and CTMF are constructed from the data, physicians should consider ordering both scans simultaneously for all patients with facial trauma to limit radiation exposure, control costs, and avoid delays in care.

Nasal Bone Fractures: Differences Amongst Sub-Specialty Consultants.

BACKGROUND: Nasal fractures constitute the largest proportion of facial trauma each year, however, there is no consensus management. In this study, we investingated the role of the consultant and the functional and aesthetic outcomes of procedures performed to address nasal bone fractures. METHODS: A retrospective chart review of patients who sustained nasal bone fractures was conducted from 8/1/14 through 1/23/18. Categorical variables were analyzed using chi-squared testing and Fisher's exact test, where appropriate, while continuous variables were compared using Mann-Whitney U testing. RESULTS: During the study period, 136 patients met inclusion criteria for full analysis. The mean age of this cohort was 47.6 ± 20.2 years with the majority identifying as African-American (53.7%) and male (67.2%). Otolaryngologists were significantly more likely to assess pre-operative nasal obstruction (100%) compared to plastic surgeons (24.1%) (P < .001). Otolaryngology elected operative management (53.3%) at a significantly higher rate than plastic surgery (24.1%) (P = .005). Additionally, otolaryngology was significantly more likely to manage patients in an outpatient setting (91.2%), whereas plastic surgery more commonly performed inpatient management (57.1%) (P = .006). Plastic surgery averaged a significantly shorter amount of time from presentation to operative management (7.3 ± 10.7 days) compared to otolaryngology (20 ± 27.7) (P = .019). Consulting service was not associated with a need for revision surgery. CONCLUSIONS: Consultants across subspecialties differ in the management of nasal bone trauma. A more standardized approach is warranted by all individuals involved in the care of maxillofacial trauma patients.

Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution's Experience.

BACKGROUND: Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors' institutional experience managing this rare entity. METHODS: A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression. RESULTS: A total of 905 patients met the authors' inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures. CONCLUSIONS: The authors' analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.

Importance: The nasal bone is one of the most commonly fractured bones of the midface. However, the frequency of coincident fractures of adjacent bones such as the frontal process of the maxillary bone, nasal septum, and medial or inferior orbital walls has not been fully evaluated. Objective: The purpose of this study was to investigate the incidence of fractures of adjacent structures in the setting of a nasal bone fracture. Second, we propose a new classification system of nasal bone fractures with involvement of adjacent bony structures. Design, Setting, and Participants: One thousand, one hundred ninety-three patients with midfacial fractures were retrospectively reviewed. The characteristics of fractures of the nasal bone and the incidence of coincident fractures of the frontal process of maxilla, bony nasal septum, medial, or inferior orbital walls were analyzed. Exposure: All patients included in the study presented with nasal trauma. Main Outcomes and Measures: The coincident fractures of adjacent midfacial structures were assessed, and a new classification of midfacial fractures based on computed tomography (CT) scan images was proposed. Results: Among the 1193 cases, bilateral fractures of the nasal bone were most common (69.24%), and coexistent fracture of the frontal process of the maxilla and bony nasal septum was 66.89% and 42.25%, respectively. Coincident fracture of the orbital walls was observed in 16.51% of cases. The major etiology of fracture for the younger and elderly groups was falls, compared with assault as the most common etiology in the adult group. A classification scheme was generated in which fractures of the nasal bone were divided into five types depending on coexisting fractures of adjacent structures. Conclusions and Relevance: External force applied to the nasal bone can also lead to coexistent fracture of adjacent bony structures including the frontal process of the maxilla, nasal septum, and orbital walls. The proposed classification of nasal fracture based on CT imaging helps to incorporate coincident disruption of adjacent structures.

Growing Skull Fracture of Temporal Bone in Adults: A Case Report and Literature Review.

Growing skull fracture (GSF) is an uncommon post-traumatic complication, which accounts for approximately 0.05% to 1% of all skull fractures. Delayed diagnosis of GSF in adulthood is rare and often involved with a variety of neurological symptoms. Here, we reported an adult patient, with an interval of 17 years from initial head trauma to first diagnosis of GSF. The patient complained of short periods of fainting and bilateral visual hallucinations, with a hard palpable bulge around his right occipitomastoid suture region. Computed tomographic imaging demonstrated an arachnoid cyst extending into right mastoid cavity. Consequently, the delayed diagnosis of GSF was confirmed, and the patient was managed with duroplasty and cranioplasty. At the 8-month follow-up, the patient showed an uneventful postoperative recovery. A comprehensive literature review was also conducted, and a total of 70 GSF cases were identified and summarized. According to the literature review, patients with GSF generally have a history of head trauma in their childhood, and delayed diagnosis is a common situation. Diagnosis of GSF should include complete retrospective medical history, physical, and imaging examinations. Once the diagnosis is confirmed, cranioplasty accompanied with duroplasty might be the most effective way to relieve symptoms and prevent further damage.

Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

BACKGROUND: Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. METHODS: The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. RESULTS: The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). CONCLUSIONS: These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.

Analysis of blunt cerebrovascular injury in pediatric trauma.

BACKGROUND: Blunt cerebrovascular injury (BCVI) occurs in <1% of pediatric patients. The two principal screening criteria for BCVI in children are the Utah and McGovern Score with motor vehicle accident (MVA) considered to be a predictor for BCVI. We sought to confirm previously reported risk factors and identify novel associations with BCVI in pediatric patients. METHODS: The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients younger than 16 years presenting after blunt trauma. A multivariable logistic regression was used to determine risk of BCVI. RESULTS: From 69,149 pediatric patients, 109 (<0.2%) had BCVI. The median age was 13 years, and the median Injury Severity Score was 25. More than half the patients were involved in MVAs (53.2%) and had a skull base fracture (53.2%). Factors independently associated with BCVI include skull base fracture (odds ratio [OR], 3.84; 95% confidence interval [CI], 2.40-6.14; p < 0.001), cervical spine fracture (OR, 3.15; 95% CI, 1.91-5.18; p < 0.001), intracranial hemorrhage (OR, 3.11; 95% CI, 1.89-5.14; p < 0.001), Glasgow Coma Scale score of 8 or less (OR, 2.11; 95% CI, 1.33-3.54; p = 0.003), and mandible fracture (OR, 1.99; 95% CI, 1.05-3.84; p = 0.04). Motor vehicle accident was not an independent predictor for BCVI (p = 0.07). CONCLUSION: In the largest analysis of pediatric BCVI to date, skull base fracture had the strongest association with BCVI. Other associations to pediatric BCVI included cervical spine and mandible fracture. Motor vehicle accident, previously identified to be associated with BCVI, was not an independent risk factor in our analysis. A future multicenter study incorporating newly identified variables in a scoring system to screen for BCVI is warranted. LEVEL OF EVIDENCE: Level IV (Prognostic/Epidemiologic).

Correlation Between the Existing Classifications of Nasal Bone Fractures and Subjective Patient Satisfaction.

Since the nose is at the center of the face, small changes to it can cause a big overall change. Therefore, a nasal fracture needs to be operated on when deformity is expected. Although many taxonomies have been developed for nasal bone fractures, no study has aimed to predict individual patient satisfaction. Herein, the authors tried to determine any correlation between the existing classifications of nasal bone fractures and subjective patient satisfaction. A retrospective study and telephone survey were conducted in 149 patients who underwent closed reduction for a pure nasal bone fracture. Pretraumatic, prereduction, and postoperative patient satisfactions were measured on a numerical scale from 1 to 5. The difference between pretraumatic and prereduction satisfactions was calculated to confirm the change in short-term satisfaction after trauma. The difference between pretraumatic and preoperative satisfactions was measured to determine change in long-term satisfaction postoperatively. The Stranc Robertson classification, modified Murray classification, and the presence of septal fracture were used to classify fractures. Independent and Jonckheere-Terpstra t tests were used in statistical analysis. Only 86 of 149 were included in the study. There was no significant difference in patient satisfaction among frontal/lateral (P = 0.70, 0.56), frontal I/II (P = 1.00, 0.24), and lateral I/II groups (P = 0.57, 0.67) according to the Stranc Robertson classification. Septal fracture (P = 0.21, 0.44) and the modified Murray classification (P = 0.14, 0.47) also had no effect on satisfaction. Existing classification systems have the advantage of reflecting and distinguishing the characteristics of fractures, but there is a limit in their ability to reflect subjective patient satisfaction.