Pediatric Facial Fractures: Demographics, Injury Patterns, and Associated Injuries in 3334 Patients.

Pediatric craniofacial fractures are fundamentally distinct from their adult counterparts because of unique injury patterns and effects on future growth. Understanding patterns and injury context informs management and risk mitigation. Previous studies include only inpatients, operative patients, or are specialty-specific. In contrast, our study presents a comprehensive assessment of all pediatric facial fracture patients seen at a single institution. Patients under 18 years old who were evaluated for facial fractures at a level I pediatric trauma center between 2006 and 2021 were reviewed. Subanalysis was performed for groups defined by age. Variables studied included demographics, etiology, fracture pattern, associated injuries, management, and outcomes. Three thousand thirty-four patients were included. Mean age at presentation was 11.5 to 4.9 years. The majority were Caucasian (82.6%) and male (68.4%). Sports were the leading cause of injury in older patients (42.2% of patients over 12 y), compared with activities of daily living in patients under 6 years (45.5%). Thirty-two percent of patients were hospitalized, 6.0% required ICU care, and 48.4% required surgery. Frequency of ICU admission decreased with age (P<0.001), whereas operative intervention increased with age (P<0.001). Zygomaticomaxillary complex (P=0.002) and nasal fractures (P<0.001) were common in older patients, whereas younger patients experienced more skull (P<0.001) and orbital fractures (P<0.001). The most associated injuries were soft tissue (55.7%) and neurologic (23.6%). This large-scale study provides updated characterization of craniofacial fractures in the pediatric population, providing a necessary framework for future studies on outcomes assessments and preventative care.

Pediatric Nasoorbitoethmoid Fractures: A Single Institution's 15-Year Experience.

BACKGROUND: Nasoorbitoethmoid (NOE) fractures impact growth of the craniofacial skeleton in children, which may necessitate differentiated management from adult injuries. This study describes characteristics, management, and outcomes of NOE fractures in children seen at a single institution. METHODS: A retrospective review of patients under 18 years who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Data collected included demographics, mechanism of injury, fracture type, management, and outcomes. RESULTS: Fifty-eight patients met inclusion criteria; 77.6% presented with Manson-Marcowitz Type I fractures, 17.2% with Type II, and 5.2% with Type III. The most common cause of injury was motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Scale and injury mechanism were not predictive of injury severity in the pediatric population ( P =0.353, P =0.493). Orbital fractures were the most common associated fractures (n=55, 94.8%); parietal bone fractures were more likely in Type III fractures ( P =0.047). LeFort III fractures were more likely in type II fractures ( P =0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). There was no significant difference in type of operative management or in the rates of adverse outcomes between types of NOE fractures. CONCLUSIONS: These findings suggest that pediatric NOE fractures, although rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

Improved Testing and Design of Intubation Boxes During the COVID-19 Pandemic.

STUDY OBJECTIVE: Throughout the coronavirus disease 2019 pandemic, many emergency departments have been using passive protective enclosures ("intubation boxes") during intubation. The effectiveness of these enclosures remains uncertain. We sought to quantify their ability to contain aerosols using industry standard test protocols. METHODS: We tested a commercially available passive protective enclosure representing the most common design and compared this with a modified enclosure that incorporated a vacuum system for active air filtration during simulated intubations and negative-pressure isolation. We evaluated the enclosures by using the same 3 tests air filtration experts use to certify class I biosafety cabinets: visual smoke pattern analysis using neutrally buoyant smoke, aerosol leak testing using a test aerosol that mimics the size of virus-containing particulates, and air velocity measurements. RESULTS: Qualitative evaluation revealed smoke escaping from all passive enclosure openings. Aerosol leak testing demonstrated elevated particle concentrations outside the enclosure during simulated intubations. In contrast, vacuum-filter-equipped enclosures fully contained the visible smoke and test aerosol to standards consistent with class I biosafety cabinet certification. CONCLUSION: Passive enclosures for intubation failed to contain aerosols, but the addition of a vacuum and active air filtration reduced aerosol spread during simulated intubation and patient isolation.

Undiagnosed Normocephalic Pancraniosynostosis Presenting as Bilateral Abducens Nerve Palsy.

ABSTRACT: Primary pancraniosynostosis is a rare variant of craniosynostosis in which the major cranial sutures prematurely fuse. Single-suture craniosynostosis is often recognized early in life due to an abnormal head shape. In contrast, primary pancraniosynostosis may be diagnosed later in life due to a grossly normal head shape and size. As such, these children can present with symptoms related to chronically elevated intracranial pressure (eg, vision loss or cognitive impairment). This report highlights a patient with primary pancraniosynostosis associated with unique neurologic sequelae-namely, bilateral abducens nerve palsy. A 9-year-old boy presented to the ophthalmologist with a 1-month history of double vision, drifting of his right eye toward the nasal bridge, and intracranial hypertension evident with papilledema. Physical examination was notable for mild bitemporal narrowing. A computed tomography study demonstrated radiologic thumbprinting, diffuse osseous sclerosis, and fusion of the bilateral coronal, sagittal, metopic, and lambdoid sutures. The patient underwent emergent cranial vault expansion with fronto-orbital advancement. Papilledema had resolved 4 months following surgery. At 2-year follow-up, abducens nerve palsy and head shape were significantly improved. This study brings attention to an unreported presenting symptom of pancraniosynostosis (bilateral abducens nerve palsy). This information may lead to quicker diagnosis and treatment of pancraniosynostosis-induced intracranial hypertension, which is critical to prevent long-term sequelae.

Objective Analysis of Fronto-Orbital Dysmorphology in Unilateral Coronal Craniosynostosis.

ABSTRACT: Correction (and over-correction) of asymmetries of the orbital shape and brow position in unilateral coronal craniosynostosis (UCS) is critical to successful fronto-orbital advancement. Here we quantify and three-dimensionally assess fronto-orbital irregularities in UCS patients compared to controls.Twenty-three patients with UCS evaluated at the Children's Hospital of Pittsburgh between 2006 and 2016 were age and gender-matched to controls. Computed tomography scans were reconstructed and evaluated for orbital metrics. A three-dimensional heat map of orbital regions was generated and evaluated for shape differences.Brow protrusion of the orbit ipsilateral to the synostotic suture did not differ significantly from healthy controls. Orbital height was significantly increased while orbital width was decreased on the UCS ipsilateral side compared to the contralateral side and controls. The ipsilateral cornea was overprojected relative to the brow and the infraorbital rim, but similar to controls relative to the lateral rim. The contralateral orbit had increased brow protrusion with decreased orbital height. The cornea was underprojected relative to the brow, but overprojected relative to the lateral orbital rim and similar to controls at the infraorbital rim. Three-dimensional comparison demonstrated significant overprojection of the contralateral brow, with some more mild and inconsistent underprojection of the lateral aspect of the ipsilateral brow.Key orbital and brow differences exist between the affected and unaffected sides in UCS. This study provides quantitative data that further characterize the orbital dysmorphology observed in UCS and identifies unique aspects of the diagnosis that should be taken into consideration during surgical planning.

Posterior Cranial Vault Distraction Osteogenesis Utilizing a Posterior-Superior Distraction Vector in the Treatment of Mercedes Benz Pattern Craniosynostosis.

ABSTRACT: Bilateral lambdoid and sagittal synostosis, or Mercedes Benz Syndrome, is a rare complex craniosynostosis resulting in frontal bossing, a tapered posterior fossa, and an anteriorly displaced cranial vertex. Its ideal surgical correction must result in posterior expansion, skull elongation, and caudal repositioning of the vertex. We present a craniometric analysis of skull changes with posterior-superior distraction and introduce a novel craniometric measure: vertex position. In this study, a retrospective review was performed to analyze outcomes of posterior cranial vault distraction osteogenesis (PVDO) using a posterior-superior distraction vector from 2016 to 2019. Cranial vertex position was measured as a fraction of the occipitofrontal diameter from rostral to caudal (0-1.0). Four patients underwent PVDO at mean age 10.61 ±â€Š3.16 months utilizing a posterior-superior distraction vector. Linear distraction distance averaged 30.30 ±â€Š0.90 mm with a mean consolidation period of 3.98 ±â€Š0.72 months. Mean corrected change in intra-cranial volume was 236.30 ±â€Š3.71 mL, at an average rate of 7.81 ±â€Š2.00 mL/mm of distraction. Increases in anterior cranial height (7.83 ±â€Š2.51 mm), middle cranial height (8.43 ±â€Š4.21 mm), posterior cranial height (13.15 ±â€Š7.45 mm), and posterior cranial fossa height (21.99 ±â€Š8.55 mm) were observed. Cranial vertex demonstrated a mean posterior movement of 0.18 ±â€Š0.13. PVDO utilizing a posterior-superior distraction vector for management of nonsyndromic bilateral lambdoid and sagittal synostosis effectively increases intracranial volume and height and provides an esthetic outcome with posterior movement of the cranial vertex.

Decompressive Cranial Vault Remodeling in Osteosclerotic Robinow Syndrome.

We present a novel application of endocranial burr contouring for cranial vault expansion as a surgical adjunct during decompressive craniectomy in patients with cranial osteosclerosis. A 16-year-old female with osteosclerotic Robinow syndrome complicated by slit ventricle syndrome presented with refractory intracranial hypertension following external ventricular drain placement. Symptoms included severe headaches and altered mental status. Given the severe intracranial volume restriction secondary to massive calvarial thickening (2.5 cm), the patient was taken to the operating room for urgent surgical decompression. After frontal and parietal craniectomy, burr and osteotome contouring were used to remove two-thirds of the endocranial calvarial bone flap thickness resulting in a 9% cranial vault expansion while preserving an overall normal head size. There were no immediate postoperative complications. At over 3 years postoperatively, the patient had reduced headaches, maintained adequate shunt function, and has not required further vault reconstruction.

Quantifying the Severity of Metopic Craniosynostosis: A Pilot Study Application of Machine Learning in Craniofacial Surgery.

The standard for diagnosing metopic craniosynostosis (CS) utilizes computed tomography (CT) imaging and physical exam, but there is no standardized method for determining disease severity. Previous studies using interfrontal angles have evaluated differences in specific skull landmarks; however, these measurements are difficult to readily ascertain in clinical practice and fail to assess the complete skull contour. This pilot project employs machine learning algorithms to combine statistical shape information with expert ratings to generate a novel objective method of measuring the severity of metopic CS.Expert ratings of normal and metopic skull CT images were collected. Skull-shape analysis was conducted using ShapeWorks software. Machine-learning was used to combine the expert ratings with our shape analysis model to predict the severity of metopic CS using CT images. Our model was then compared to the gold standard using interfrontal angles.Seventeen metopic skull CT images of patients 5 to 15 months old were assigned a severity by 18 craniofacial surgeons, and 65 nonaffected controls were included with a 0 severity. Our model accurately correlated the level of skull deformity with severity (P < 0.10) and predicted the severity of metopic CS more often than models using interfrontal angles (χ = 5.46, P = 0.019).This is the first study that combines shape information with expert ratings to generate an objective measure of severity for metopic CS. This method may help clinicians easily quantify the severity and perform robust longitudinal assessments of the condition.

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps.

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.

Cone-Beam Computed Tomography Incidental Findings in Individuals With Cleft Lip and Palate.

OBJECTIVES: The use of cone-beam computed tomography (CBCT) is well-established in clinical practice. This study seeks to categorize and quantify the incidental finding (IF) rate on CBCT in patients with cleft lip and palate (CLP) prior to orthodontic or surgical treatment. METHODS: This is systematic retrospective review of head and neck CBCTs in patients with nonsyndromic CLP taken between 2012 and 2019 at a single tertiary referral center. All assessments were performed independently by 4 observers (a head and neck radiologist and 3 orthodontists, including 2 fellowship-trained cleft-craniofacial orthodontists ). The images were divided into 9 anatomical areas and screened using serial axial slices and 3D reconstructions. The absolute number of IFs was reported for each area and statistical analysis was performed. RESULTS: Incidental findings were found in 106 (95.5%) of the 111 patients. The most common sites were the maxilla (87.4%, principally dental anomalies), paranasal sinuses (46.8%, principally inflammatory opacification), and inner ear cavities (18.9%, principally inflammatory opacification). Eleven patients had skull malformations. Thirty-three patients had IFs in 1 anatomical area, 49 patients in 2 anatomical areas, 19 patients in 3 areas, and 5 patients presented with IFs in 4 of the 9 anatomical areas. DISCUSSION: In patients with CLP, IFs on CBCT exam were present in the majority of cases. Most patients with IFs had them in multiple anatomical areas of the head and neck. The maxillary dental-alveolar complex was the most common area. Inflammatory changes in the inner ear cavities and paranasal sinuses were also common; however, cervical spine and skull abnormalities were also identified. Clinicians caring for patients with CLP should be aware of IFs, which may warrant further investigation and treatment.

Quick Calculation of Breast Resection Mass Using the Schnur Scale.

In 1991, Dr Paul Schnur and his colleagues published an article correlating the weight of breast tissue to be removed in a breast reduction operation with the total body surface area (BSA) of the patient. They presented a very cogent argument for selecting three groups of patients: those with medical indications for operation, those who merit review, and those whose operation could be considered cosmetic. The Schnur Sliding Scale is widely used by insurance companies in the western United States in the process of preauthorizing breast reduction operations, and its use may be spreading eastward. The Schnur group presented a nomogram for calculating BSA and a scale in the form of a table for guiding a determination of whether the patient is a reconstructive patient as opposed to an aesthetic patient. We have combined the scale and the BSA nomogram for a simplified nomogram calculator that facilitates rapid determination of anticipated tissue weight of resection for a patient of a given size. This calculator yields the required weight of tissue to remove with just knowledge of the patient's height and weight and the use of a straight edge. We demonstrate and compare performance of this calculation by hand and by nomogram. There is ample evidence that the practice of applying the Schnur Sliding Scale may be prohibitive to symptomatic patients seeking reduction mammaplasty and should be abandoned. While this practice continues, our simplified Schnur Sliding Scale nomogram is meant to help easily determine the insurer-required minimum breast resection weight and thereby both improve patient counseling prior to planning surgery and assist the surgeon with achieving insurer reimbursement for the procedure while avoiding rejected claims.

A Road Map to Creating a High-Quality Clinical Database in Plastic Surgery.

BACKGROUND: Detailed in-house databases are a staple of surgical research and a crucial source of data for many studies from which clinical guidelines are built. Despite the importance of generating a clear and thorough developmental design, the literature on database creation and management is limited. In this article, the authors present their stepwise single-institution process of developing a clinical facial fracture database. METHODS: The authors outline the process of development of a large single-institution clinical pediatric facial fracture database. The authors highlight critical steps from conception, regulatory approval, data safety/integrity, human resource allocation, data collection, quality assurance, and error remediation. The authors recorded patient characteristics, comorbidities, details of the sustained fracture, associated injuries, hospitalization information, treatments, outcomes, and follow-up information on Research Electronic Data Capture. Protocols were created to ensure data quality assurance and control. Error identification analysis was subsequently performed on the database to evaluate the completeness and accuracy of the data. RESULTS: A total of 4451 records from 3334 patients between 2006 and 2021 were identified and evaluated to generate a clinical database. Overall, there were 259 incorrect entries of 120,177 total entries, yielding a 99.8% completion rate and a 0.216% error rate. CONCLUSIONS: The quality of clinical research is intrinsically linked to the quality and accuracy of the data collection. Close attention must be paid to quality control at every stage of a database setup. More studies outlining the process of database design are needed to promote transparent, accurate, and replicable research practices.

Low-Cost, Three-Dimensionally-Printed, Anatomical Models for Optimization of Orbital Wall Reconstruction.

BACKGROUND: Orbital blowout fracture reconstruction often requires an implant, which must be shaped at the time of surgical intervention. This process is time-consuming and requires multiple placement trials, possibly risking complications. Three-dimensional printing technology has enabled health care facilities to generate custom anatomical models to which implants can be molded to precisely match orbital anatomy. The authors present their early experience with these models and their use in optimizing orbital fracture fixation. METHODS: Maxillofacial computed tomographic scans from patients with orbital floor or wall fractures were prospectively obtained and digitally reconstructed. Both injured-side and mirrored unaffected-side models were produced in-house by stereolithography printing technique. Models were used as templates for molding titanium reconstruction plates, and plates were implanted to reconstruct the patients' orbital walls. RESULTS: Nine patients (mean age, 15.5 years) were included. Enophthalmos was present in seven patients preoperatively and resolved in six patients with surgery. All patients had excellent conformation of the implant to the fracture site on postoperative computed tomographic scan. Postoperative fracture-side orbital volumes were significantly less than preoperative, and not significantly different from unfractured-side orbital volumes. Total model preparation time was approximately 10 hours. Materials cost was at most $21. Plate bending time was approximately 60 seconds. CONCLUSIONS: Patient-specific orbital models can speed the shaping of orbital reconstruction implants and potentially improve surgical correction of orbital fractures. Production of these models with consumer-grade technology confers the same advantages as commercial production at a fraction of the cost and time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Demineralized Bone Matrix and Resorbable Mesh Bilaminate Cranioplasty Is Ineffective for Secondary Reconstruction of Large Pediatric Cranial Defects.

Replacement of the autologous bone flap after decompressive craniectomy can be complicated by significant osteolysis or infection with large defects over scarred dura. Demineralized bone matrix is an alternative to autologous reconstruction, effective when reconstructing large defects using a resorbable mesh bilaminate technique in primary cranioplasty, but this technique has not been studied for revision cranioplasty and the setting of scarred dura. Retrospective review was performed of patients receiving demineralized bone matrix and resorbable mesh bilaminate cranioplasty for postdecompressive craniectomy defects. Seven patients (mean age, 4.2 years) were identified with a mean follow-up of 4.0 years. Computed tomography before the demineralized bone matrix and resorbable mesh bilaminate cranioplasty and at least 1 year postoperatively were compared. Defects were characterized and need for revision was assessed. All patients had craniectomy with associated hemidural scarring. Five patients had autologous bone flap cranioplasty associated with nearly total osteolysis, and two patients had deferral of bone flap before demineralized bone matrix and resorbable mesh bilaminate cranioplasty. Demineralized bone matrix and resorbable mesh bilaminate cranioplasty demonstrated unpredictable and poor ossification, with bony coverage unchanged at postoperative follow-up. All patients required major revision cranioplasty at a mean time of 2.5 years. Porous polyethylene was successfully used in six of the revisions, whereas exchange cranioplasty was used in the remaining patient, with a mean follow-up of 1.4 years. Although demineralized bone matrix and resorbable mesh bilaminate is appropriate for primary cranioplasty, it should be avoided in the setting of scarred or infected dura in favor of synthetic materials or exchange cranioplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Comparison of Traditional versus Normative Cephalic Index in Patients with Sagittal Synostosis: Measure of Scaphocephaly and Postoperative Outcome.

BACKGROUND: Preoperative severity and postoperative success for patients with sagittal synostosis are measured by cephalic index, but this metric does not describe the appropriateness of euryon location. The authors hypothesize that cephalic index in patients with sagittal synostosis is an inaccurate measure of scaphocephaly. METHODS: Preoperative and 1-year postoperative cranial computed tomographic scans of children with sagittal synostosis treated before 6 months of age by either total calvarial reconstruction or endoscope-assisted craniectomy and helmet therapy (n = 10 for each) were reviewed retrospectively. The location of euryons in age-matched controls was measured as a fraction of the glabella-opisthocranion distance (horizontal point of maximum width) and as the fraction of the nasion-vertex vertical distance (vertical point of maximum width). Cephalic index at this ideal location (normative cephalic index) and traditional cephalic index were determined in all patients. RESULTS: Ideal euryon location from preoperative controls was 56 percent by the horizontal point of maximum width and 56 percent by the vertical point of maximum width. Normative cephalic index (0.60) was significantly less than traditional cephalic index (0.66) in patients preoperatively (p < 0.001) and remained smaller postoperatively (0.68 versus 0.73) for patients who underwent open reconstruction (p < 0.001). Patients treated endoscopically also had a smaller normative cephalic index (0.71) than traditional cephalic index (0.76) postoperatively (p < 0.001). CONCLUSIONS: Anterocaudal displacement of euryon in patients with sagittal synostosis influences cephalic index. Normative cephalic index, assessed at ideal euryon location, is a more accurate measure of preoperative severity and postoperative outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Lovastatin inhibits oxidized L-A-phosphatidylcholine B-arachidonoyl-gamma-palmitoyl (ox-PAPC)-stimulated interleukin-8 mRNA and protein synthesis in human aortic endothelial cells by depleting stores of geranylgeranyl pyrophosphate.

Human aortic endothelial cells (HAEC) exposed to 50 microg/ml oxidized L-A-phosphatidylcholine B-arachidonoyl-gamma-palmitoyl (ox-PAPC) for 6h increased in interleukin-8 mRNA and protein levels. Preincubation of HAEC with the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG CoA) inhibitor, (20 microM), significantly inhibited ox-PAPC-stimulated interleukin-8 mRNA and protein levels. Mevalonate (200 microM) reversed the inhibition of ox-PAPC-stimulated mRNA and protein levels by lovastatin, indicating the inhibitory effect of lovastatin was due to inhibition of mevalonate synthesis. Addition of the geranylgeraniol (GGOL, 10 microM) but not farnesol (FOL, 10 microM), reversed the inhibitory effect of lovastatin on interleukin-8 mRNA and protein levels stimulated by ox-PAPC, indicating that lovastatin exerted its effect by inhibiting stores of geranylgeranyl pyrophosphate (GGPP) which are necessary for geranylgeranylation of proteins. These results suggest a new mechanism for lovastatin in preventing atherosclerosis by inhibiting the inflammatory response that takes place in the vascular wall.