Surgical treatment of headshaking by removal of a paracondylar process fragment via modified hyovertebrotomy approach: A detailed anatomical and surgical description in an adult horse.

OBJECTIVE: To describe, in detail, the relevant anatomy and surgical approach to access the paracondylar process (PCP) and report its application in a clinical case of headshaking. ANIMAL: A seven-year-old, mixed breed mare. STUDY DESIGN: Experimental study/case report. METHODS: A seven-year-old mixed breed mare was presented for investigation of acute onset progressing violent headshaking, resulting in the horse falling on multiple occasions. The horse was highly reactive to palpation over the right PCP. Standing computed tomographic (CT) investigation and ultrasonographic examination of the head detected a fracture of the right PCP. Five equine heads of mixed breeds and sizes were dissected to demonstrate the relevant anatomy surrounding the PCP with regard to surgical access. A modified hyovertebrotomy approach was used to remove the fracture fragment under general anesthesia. RESULTS: The anatomy surrounding the PCP was described. The fragment was successfully removed resulting in gradual resolution of clinical signs. The horse recovered well postoperatively and was back into light levels of work with no signs of headshaking present two and a half years following surgery. CONCLUSION: The caudal meningeal artery and vein as well as the glossopharyngeal and hypoglossal nerves are adjacent to the PCP and must be avoided during dissections. The modified hyovertebrotomy approach allows safe surgical access to the PCP. Surgical excision of a PCP fragment can result in complete resolution of clinical signs of headshaking. Computed tomography and ultrasonography are valuable diagnostic tools to identify a fracture of the PCP.

BoneTape: A novel osteosynthetic device for the stabilization of zygomatic fractures.

BACKGROUND: The study aims to assess the safety and effectiveness of BoneTape™, a new resorbable bone fixation device, using a zygomatic fracture model in rabbits. METHODS: The study followed BoneTape™ samples and control (sham) groups over 2-, 6-, and 12-week periods post-zygomaticomaxillary (ZM) osteotomy and zygomaticofrontal (ZF) disarticulation. The osteotomized segments were analyzed for bone healing, inflammatory response, and tissue healing. µCT imaging and histological analysis were used to examine the axial alignment, offset, and quality of new bone formation. RESULTS: BoneTape™ samples demonstrated enhanced maintenance of the initial intraoperative positioning, reduced axial offset, and better alignment when compared with the control group, enabling stable bone healing under physiological loading conditions. Complete union was observed at 12-weeks in both groups. The BoneTape™ group experienced minimal immune and tissue reactions, classically associated with wound healing, and showed an increased number of giant cells at 6 and 12-weeks. CONCLUSION: BoneTape™ represents a promising advancement in osteosynthesis, demonstrating efficacy in maintaining stable zygomatic reconstruction and eliciting minimal immune response in a rabbit model. This study introduces BoneTape™ as a disruptive solution specifically designed for clinical application in cranio-maxillofacial fracture fixation, with the potential to eliminate the use of over-engineered solutions while offering benefits such as ease of application and fewer biologically disruptive steps.

Management of frontal sinus fractures requiring surgical intervention: An analysis of a case series.

<b><br>Introduction:</b> Isolated frontal bone fractures constitute 5-15% of traumatic facial fractures cases, with frontal sinus fractures categorized into anterior wall, posterior wall, or complex fractures. The approach is tailored to fracture type and bone fragment displacement. This paper presents the summary of surgical management in patients with isolated and complex fractures of the anterior wall of the frontal sinus.</br> <b><br>Material and Methods:</b> Five patients with different frontal sinus fractures were treated surgically. The same management protocol - diagnosis and surgical intervention was implemented in all cases The retrospective analysis included fracture assessment, surgical approach, and long-term outcomes evaluation.</br> <b><br>Results:</b> The most common cause of fractures was falls, while two complex fractures involved the anterior and posterior walls. External approach, bone fragment removal, endoscopy, and external stabilization were employed in all cases. One patent required delayed revision surgery due to retaining metallic foreign body. Follow-up radiological examinations showed proper healing and cosmetic outcomes were satisfactory in all of the cases.</br> <b><br>Conclusion:</b> Surgical management of isolated fractures of the frontal sinus anterior wall, involving bone fragment removal, realignment, and endoscopy, yielded satisfactory functional and cosmetic outcomes without internal or external stabilization. Long-term monitoring and symptom assessment are crucial, especially in cases with penetrating injuries and foreign body risk.</br>.

Development of AI-Based Diagnostic Algorithm for Nasal Bone Fracture Using Deep Learning.

Facial bone fractures are relatively common, with the nasal bone the most frequently fractured facial bone. Computed tomography is the gold standard for diagnosing such fractures. Most nasal bone fractures can be treated using a closed reduction. However, delayed diagnosis may cause nasal deformity or other complications that are difficult and expensive to treat. In this study, the authors developed an algorithm for diagnosing nasal fractures by learning computed tomography images of facial bones with artificial intelligence through deep learning. A significant concordance with human doctors' reading results of 100% sensitivity and 77% specificity was achieved. Herein, the authors report the results of a pilot study on the first stage of developing an algorithm for analyzing fractures in the facial bone.

A Method for Precise Reduction of Facial Bone Fractures Using Intraoperative Ultrasound With a Solid Gel Pad as a Coupling Medium.

This study introduces a method to overcome technical challenges in using intraoperative ultrasound for the closed reduction of nasal bone and zygomatic arch fractures. The curvature of the face makes it difficult to apply an ultrasound probe to the facial area. We used a solid gel pad as a coupling medium during surgery to improve the scanning of facial bone fractures. The results show that the fracture sites observed on preoperative computed tomography scans can be easily visualized using intraoperative ultrasound, and real-time manipulation confirms successful reduction. The solid gel pad is light, malleable, easy to use, and provides accurate images. Overall, the use of ultrasound with a solid gel pad enhances the accuracy of closed reduction in facial bone fracture surgeries, confirming fracture patterns and ensuring precise reduction.

Utility of CT or X-ray in the management of adult nasal fracture.

PURPOSE: The primary objective of this study is to evaluate the use of imaging in the management of nasal fracture in adults and determine if imaging is beneficial to clinical decision making when planning for surgery. A secondary objective of this study is to compare surgical rates for nasal fracture between pediatric and adult populations. METHODS: This is a retrospective case-control study of 357 patients seen at University Hospitals Cleveland Medical Center from January 2015 through January 2020 with a diagnosis of nasal fracture. An odds ratio was calculated to determine likelihood of surgical intervention between patients who had imaging of the nasal bones and patients who did not. RESULTS: 82 % of patients had either CT or X-ray imaging. The odds ratio of patients who had surgery after CT or X-ray imaging compared to patients who had surgery without prior imaging was 0.092 (95 % CI: 0.0448-0.1898, p-value <0.0001). A total of 54 (15 %) adult patients had surgery, in comparison to 50 % of pediatric patients with diagnosis of nasal fracture. 202 (57 %) of patients did not follow up after initial diagnosis by radiology. CONCLUSION: The statistical analysis suggests that while CT and X-ray are frequently obtained in the setting of nasal fracture, patients without imaging are more likely to have surgery (p < 0.05) than patients with imaging. This indicates that imaging is likely unnecessary for surgical planning. Most adults do not pursue surgery, and surgical rates for adults with nasal fracture are much lower than those of pediatric patients with nasal fracture.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System.

BACKGROUND: The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures. METHODS: The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome. RESULTS: The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications. CONCLUSIONS: Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

Electric Scooter-related Craniofacial Injuries.

OBJECTIVES: Injuries associated with the use of electric scooters are a serious problem in modern society and traffic in relation to their increasing frequency of use. Although injuries involving all body parts are seen in such injuries, craniofacial ones are also very common. The aim of this study was to evaluate the craniofacial and other accompanying injuries in electric scooter-related accidents in Istanbul. MATERIALS AND METHODS: Between January 2020 and December 2022, patients with electric scooter-related trauma among the patients admitted to the emergency unit for trauma were evaluated retrospectively. All electronic medical records, CT scans, other examinations, and treatments were retrospectively reviewed, and craniofacial fractures and other injuries seen in the patients were classified. RESULTS: A total of 20.358 patients were admitted to the trauma unit between January 2020 and December 2022. Two hundred ten patients (142 male, 68 female) had electric scooter-related trauma and 58.1 % of them had craniofacial injuries. Thirty patients (14.3 %) (23 male, 7 female) had craniofacial fractures, whereas 43.8 % of them had craniofacial soft tissue injuries. The nasal fracture was the most common craniofacial fracture (14 patients, 46.7%). Orbital wall and zygomaticomaxillary complex fractures were found to be the second most common fractures. CONCLUSIONS: The rate of electric scooter-related injuries among all trauma patients admitted to the emergency trauma unit during the mentioned period was 1.03%. The results of this study were found to be in accordance with the data in the literature. The craniofacial region is the most frequently injured body part in patients with electric scooter-related trauma, and patients should be comprehensively evaluated for possible soft tissue injuries, craniofacial fractures, and other accompanying system injuries.

Analysis of Nasal Bone Fractures: A 17-year Study of 3785 Patients.

In our previous study, we classified nasal bone fractures into 6 types based on computed tomography and the patterns of the nasal bone fractures (NBF) in 503 patients treated between 1998 and 2004. In the present study, we analyzed 3785 patients treated between 2005 and 2021. The age, sex, etiology, associated injuries, pattern of fractures, and treatments were reviewed, and radiographic studies were analyzed. The highest incidence was in the age group of 10 to 19 years (N=870, 23.0%), followed by 20 to 29 years (N=792, 20.9%) and 30 to 39 years (N=635, 16.8%). The most common causes of injury were slip or fall-down (42.3%), violence (24.3%), sports (19.2%), traffic accidents (8.9%), and work-related (5.3%). Most of the patients had tenderness (96.1%) and swelling (78.8%). Other findings were depression (27.1%) and nasal deviation (25.8%). Crepitus was heard in only 0.4% of the patients. The patterns of the NBFs classified by computed tomography findings were type IIA (unilateral simple fracture with displacement/without telescoping, 1283 cases, 33.9%), IIB (bilateral simple fracture with displacement/without telescoping, 786 cases, 20.8%), IIAs (unilateral simple fracture with septal fracture and displacement/without telescoping, 566 cases, 14.9%), IIBs (bilateral simple fracture with septal fracture and displacement/without telescoping 530 cases, 14.0%), I (simple fracture without displacement, 522 cases, 13.8%), and III (comminuted with telescoping or depression, 98 cases, 2.6%). In most of the cases (3,666, 96.9%), closed reduction was performed. The present analysis is one of the largest data sets on NBF in Korea, which could provide reference values for diagnosing and managing nasal bone fractures.

Pediatric Le Fort, Zygomatic, and Naso-Orbito-Ethmoid Fractures.

Fractures of the pediatric midface are infrequent, particularly in children in the primary dentition, due to the prominence of the upper face relative to the midface and mandible. With downward and forward growth of the face, there is an increasing frequency of midface injuries seen in children in the mixed and adult dentitions. Midface fracture patterns seen in young children are quite variable; those in children at or near skeletal maturity mimic patterns seen in adults. Non-displaced injuries can typically be managed with observation. Displaced fractures require treatment with appropriate reduction and fixation and longitudinal follow-up to evaluate growth.

Spontaneous Repositioning of Significant Blow-out Orbital Roof Fracture Associated With Intracranial Hematoma.

Orbital roof fractures are relatively rare facial bone fractures that usually occur in conjunction with other facial bone fractures or intracranial hematoma during high-velocity facial trauma. This study reports a patient with a significant blow-out orbital roof fracture combined with a nondisplaced frontal bone fracture and epidural hematoma at the superior aspect of unilateral frontoparietal convexity. Despite the severe superiorly-displaced fracture segment, the follow-up computed tomography scans taken 4 days after the injury showed a spontaneous reduction of blow-out orbital roof fracture. At the 1-week follow-up, the coronal image of craniofacial magnetic resonance imaging was taken, showing spontaneous realignment of orbital roof fracture and physiological evolution of cerebral contusion. In conclusion, conservative treatment can acquire the best outcome regarding cosmesis and function unless the patient requires an emergent operation for other medical conditions. This is key for successfully returning the patient's form and function.

Growing skull fracture in a child with Ehlers-Danlos syndrome: case report and literature review.

INTRODUCTION: Growing skull fracture (GSF) is a rare complication of head trauma in the pediatric population, commonly observed in children younger than 3 years. DISCUSSION: In this report, the authors describe a case of a 3-year-old male child, with clinical features of Ehlers-Danlos syndrome (EDS), who developed a GSF in frontal bone after a crib fall, treated with duraplasty and cranioplasty with autologous craft. Here, pertinent literature was reviewed with an emphasis on surgical techniques, and correlation with the mentioned syndrome. CONCLUSION: This is the first case of GSF in association with EDS in the literature. The relevance of the case described concerns the rarity of the condition itself, the atypical presentation, and the intraoperative findings, which showed the important fragility of the dura mater, probably due to EDS. Therefore, this syndrome, besides having influenced the pathogenesis, was also a challenging factor in the surgical treatment.

Closed reduction of nasoseptal fractures: key concepts for predictable results.

Nasal complex injuries are the most common facial fracture encountered in the trauma population. Multiple surgical techniques for treatment of these fractures have been described with varying results. The goal of this study was to review the efficacy of closed reduction of nasal and septal fractures using a technique based upon several key concepts. We reviewed the records of patients who had undergone isolated nasal and/or septal fractures with closed reduction at our institution between January 2013 and November 2021. Inclusion criteria consisted of preoperative CT imaging, surgical treatment within fourteen days of initial injury, and follow up of at least one year. All patients were treated under general or deep sedation. The same surgical technique was applied with closed reduction of the septum and nasal bones with internal and external postoperative splints. Of the 232 records initially reviewed, 103 met inclusion criteria. Four patients had undergone revision septorhinoplasty (3.9%). Mean (range) follow up was 2.7 (1-8.2) years. Three patients had undergone revision nasal repair due to persistent airflow obstruction with complete resolution of symptoms after revision. The other patient received multiple revisions at another institution as a result of their dissatisfaction with cosmesis without improvement. Closed reduction of nasal and septal fractures can be a highly successful procedure and yield predictable results, limiting the need for post-traumatic open septorhinoplastic surgery. Five critical concepts of nasal fracture repair can help surgeons achieve predictable functional and cosmetic results: selection, timing, anaesthesia, reduction, and support.

Craniomaxillofacial Trauma: The Past, Present and the Future.

Reconstruction of facial trauma has seen a significant evolutionary leap in the last 100 years. The current surgical management of facial fractures was made possible by the efforts and creativity of pioneer surgeons, advances in anatomic understanding, and the continued development of biomaterials and imaging technologies. Virtual surgical planning (VSP) and 3-dimensional printing (3DP) are being incorporated into the management of acute facial trauma. The integration of this technology at the point of care is rapidly expanding globally. This article reviews the history of the management of craniomaxillofacial trauma, current practices, and future directions. The use of VSP and 3DP in facial trauma care is highlighted with a description of EPPOCRATIS, a rapid point-of-care process incorporating VSP and 3DP at the trauma center.

Flipped Nasal Bone Fracture: Peculiar Fracture Pattern in a Pediatric Patient.

Fractures to the facial bone in the pediatric population often show a different fracture pattern from that of the adult population. In this brief report, the authors share their experience with a nasal bone fracture in a 12-year-old child showing a bizarre fracture pattern, an inside-out displacement of the nasal bone. The authors share the detailed findings of this fracture and describe the method for reducing the fracture back to the proper position.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. STUDY DESIGN: Retrospective review. SETTING: Single institution, level 1 trauma center. METHODS: Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. RESULTS: Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoid complex fractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. CONCLUSION: Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

The effect of a new topographic classification on determining the prognosis of nasal fracture and treatment modality.

BACKGROUND: Classifications of nasal fracture are based on clinical findings or radiological findings. The classification systems of nasal fracture usually determine the type of nasal fracture. It is important that a classification gives information about treatment modality and prognosis rather than determining the type of fracture. The objective of this study was to show the effect of the new topographic classification on determining the parameters of prognosis and deciding on treatment modality of the nasal fracture. METHODS: We reviewed patients with nasal fracture that was referred from emergency department between December 2018 and September 2020. The views of lateral nasal radiography, the facial view of computed tomography (CT), and/or the views of three-dimensional CT were examined to analyze 120 patients with nasal bone fractures. The length of the nasal bone from the top to the base was divided into equal three levels by two lines perpendicular to the length of the nose. The location of fracture was determined as level I, II, and III, respectively, from caudal part to cranial part of the nasal bone. The demographic features of patients, the side of the fracture, the pattern of fracture, accompanying fractures, and the treatment modality were noted. RESULTS: The frequencies of location of nasal fractures were 44%, 28%, and 27% at level I, level II, and level III, respectively, in 120 cases. It was an expected result that the frequency of fractures was low in parts with the thick bone. Considering the rates of being bilateral or unilateral, it was found that the frequency of unilateral was higher in group of level I, where the thickness of nasal bone was thin, but it was less in group of level III (p<0.05). Non-depressed/minimal-depressed pattern of fracture in group of level I accounted for 92.6% which was the highest frequency (p<0.05). Depressed/elevated fracture patterns were more common in group of level II (p<0.05). Comminuted pattern was mostly observed in group of level III. The rate of accompanying fractures and the applied treatment modality was consistent with anatomic feature of fracture's level. CONCLUSION: We believe that the new topographic classification evaluates the parameters of clinical prognosis such as accompanying fracture, site of fracture and pattern of fracture, and also requirement of closed or open reduction better than other classifications.

Skull Fracture Healing in Children Up to 36 Months - A Cohort Analysis.

During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December 2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.

Efficacy of X-ray in the diagnosis of pediatric nasal fracture.

OBJECTIVE: Nasal fracture is one of the most common pediatric fractures, and diagnosis can be made with clinical findings or with radiographic imaging. The objective of this study is to determine the extent of x-ray utilization in decision-making regarding closed reduction of pediatric nasal fracture. METHODS: This a case-control study of 117 patients ages 0-18 with a diagnosis of nasal fracture seen at University Hospitals Cleveland Medical Center between January 2015 and January 2020. The exposure group had x-ray imaging of the nasal bones, and the control group had no x-ray imaging. RESULTS: A total of 59 (50.4%) patients had surgical intervention. The odds ratio to compare x-ray utilization to the control group for patients who underwent closed reduction surgery was .3951 (95% CI: 0.1848-0.8448, p-value = .0166). CONCLUSION: The statistical analysis suggests that x-ray use is associated with decreased rates of closed reduction surgery. It is likely that while not necessary for the diagnosis of nasal fracture, x-ray serves as an additional data point for diagnosis confirmation, and may reduce the rate of unnecessary surgery for false positive cases of nasal fracture.

Tension pneumocephalus: case report and review.

Tension pneumocephalus is a rare complication of frontal sinus fracture or neurosurgical intervention resulting from compression of the brain by entrapped air, leading to seizure, altered mental status, brain herniation, and death. This report presents a case of traumatic tension pneumocephalus associated with an anterior and posterior table frontal sinus fracture in a patient with pneumosinus dilatans and osteogenesis imperfecta.