Caracterización y retos en la clasificación de fracturas malares. Serie de casos en un hospital de tercer nivel en la ciudad de Cali, Colombia / Characterization and challenges in the classification of malar fractures. Case series in a third level hospital in the city of Cali, Colombia

Introducción y objetivo: Las fracturas del malar son las fracturas faciales más frecuentes después de las nasales y se asocian preferentemente a accidentes de tránsito. En nuestro medio no disponemos de trabajos que exploren las caracteriticas de esta condicion. Nuestro objetivo es caracterizar las condiciones asociadas a las fracturas malares en la ciudad de Cali, Colombia. Material y método: Estudio observacional descriptivo en pacientes que consultan en el Hospital Universitario del Valle y atendidos por Cirugía Plástica entre agosto de 2019 y marzo de 2020 con diagnóstico de fractura malar por escáner facial. Registramos las variables edad, sexo, origen, procedencia, escolaridad, ocupacion, estado civil, mecanismo de trauma, ciudad del trauma, clasificacion de fracturas del malar, lateralidad, fractura del arco cigomático y fracturas faciales asociadas. No incluimos análisis sobre el manejo de las fracturas. Resultados: Identificamos 25 fracturas malares en 24 pacientes. El 88% en mayores de 18 años; 83.3% varones; el grupo etáreo con más casos fue el de 21-30 años (25%). La causa más común fue el trauma contuso (50%), seguido por las caídas (21%) y accidentes de tránsito (21%). La fractura malar tipo 3 impactada según Knight y North fue la más común (36%). Conclusiones: Encontramos que, en nuestro estudio, el trauma contuso fue la causa más frecuente de fractura malar. Consideramos que la información obtenida puede ser util para que la autoridad local se plantee estrategias para reducir su incidencia. Al clasificar el patron de fractura no se encuentra un tipo único de fractura, sino de combinaciones, lo que nos lleva a pensar que se requiere una nueva clasificación. (AU)

Background and objective: Malar fractures have been described as the most frequent facial fractures after nasal ones. These are frequently associated with traffic accidents. In our environment we do not have studies that explore the characteristics of this condition. Our objective is to characterize the conditions associated with malar fractures in the city of Cali, Colombia. Methods: A descriptive observational study is carried out in patients who consult at the Hospital Universitario del Valle and are cared for by the Plastic Surgery Section between August 2019 and March 2020, with a diagnosis of malar fracture in the facial scan. The variables age, sex, origin, education, occupation, marital status, mechanism of trauma, city of trauma, classification of malar fractures, laterality, fracture of the zygomatic arch and associated facial fractures were recorded. Analysis of the management of fractures is not included. Results: We identified 25 malar fractures in 24 patients; 88% in people over 18 years old; 83.3% were men; the age group with the most cases were 21-30 years old (25%); the most common cause was blunt trauma (50%), followed by falls (21%) and traffic accidents (21%). Type 3 malar fracture impacted according to Knight and North was the most common (36%). Conclusions: Blunt trauma is the most frequent cause of malar fracture in our study. The information obtained can be useful for the local authority to consider strategies to reduce its incidence. When classifying the fracture pattern, a single type of fracture is often not found and, on the contrary, there were combinations which leads us to think that a new classification is required. (AU)

Cutaneous wound metallic residues pattern analysis with SEM-EDX in a forensic case of overkill.

The term overkill identifies the infliction of massive injuries that greatly exceed those needed to kill the victim both in number and intensity. We present the case of a Peruvian transsexual, who was choked and hit by 11 sharp-force wounds all in the facial area. The scanning electron microscopy with energy dispersion X-ray analysis carried out on the skin of the facial wounds proved crucial in proving that two different point-and-edge weapons were used, following the finding of metallic micro-traces of heterogeneous composition. This discovery and the autopsy highlighted the use of two distinct types of injury (mechanical asphyxia and sharp-force trauma) showed that this murder amounted to overkill.

The CFI score: Validation of a new comprehensive severity scoring system for facial injuries.

At the time of writing there is no measuring scale for the severity of facial trauma that can effectively summarize its clinical relevance, and can therefore be proposed as a definitive tool in trauma center decision making. This paper introduces a new, simple, comprehensive, and reproducible score for facial trauma, in which its severity is expressed in relation to the surgical duration necessary for definitive treatment. This parameter is identified as the most significant in expressing the commitment of care required. Statistical validation of this comprehensive facial injury (CFI) score involved a sample of 1050 patients, treated by the same team in two highly specialized trauma centers. It demonstrated a linear regression between CFI score and surgical duration, and a high degree of accuracy in forecasting overall surgical time for each type of facial injury. The descriptive capacity of CFI score, and its extremely simple use, make it a perfect tool for widespread application and for facilitating communication inside trauma centers. It also allows the classification of homogeneous groups of patients - a prerequisite for benchmarking and effective analysis of results. The CFI model is definitively proposed for the classification of facial injuries, and therefore for the integration of maxillofacial skills, within the trauma team.

Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications.

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. ©RSNA, 2018.

Classifying and Standardizing Panfacial Trauma With a New Bony Facial Trauma Score.

IMPORTANCE: The practice of facial trauma surgery would benefit from a useful quantitative scale that measures the extent of injury. OBJECTIVE: To develop a facial trauma scale that incorporates only reducible fractures and is able to be reliably communicated to health care professionals. DESIGN AND SETTING: A cadaveric tissue study was conducted from October 1 to 3, 2014. Ten cadaveric heads were subjected to various degrees of facial trauma by dropping a fixed mass onto each head. The heads were then imaged with fine-cut computed tomography. A Bony Facial Trauma Scale (BFTS) for grading facial trauma was developed based only on clinically relevant (reducible) fractures. The traumatized cadaveric heads were then scored using this scale as well as 3 existing scoring systems. Regression analysis was used to determine correlation between degree of incursion of the fixed mass on the cadaveric heads and trauma severity as rated by the scoring systems. Statistical analysis was performed to determine correlation of the scores obtained using the BFTS with those of the 3 existing scoring systems. Scores obtained using the BFTS were not correlated with dentition (95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (95% CI, -0.068 to 0.944; P = .08). MAIN OUTCOME MEASURES: Facial trauma scores. RESULTS: Among all 10 cadaveric specimens (9 male donors and 1 female donor; age range, 41-87 years; mean age, 57.2 years), the facial trauma scores obtained using the BFTS correlated with depth of penetration of the mass into the face (odds ratio, 4.071; 95% CI, 1.676-6.448) P = .007) when controlling for presence of dentition and age. The BFTS scores also correlated with scores obtained using 3 existing facial trauma models (Facial Fracture Severity Scale, rs = 0.920; Craniofacial Disruption Score, rs = 0.945; and ZS Score, rs = 0.902; P < .001 for all 3 models). In addition, the BFTS was found to have excellent interrater reliability (0.908; P = .001), which was similar to the interrater reliability of the other 3 tested trauma scales. Scores obtained using the BFTS were not correlated with dentition (odds ratio, .482; 95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (odds ratio, .436; 95% CI, -0.068 to 0.944; P = .08). CONCLUSIONS AND RELEVANCE: Facial trauma severity as measured by the BFTS correlated with depth of penetration of the fixed mass into the face. In this study, the BFTS was clinically relevant, had high fidelity in communicating the fractures sustained in facial trauma, and correlated well with previously validated models. LEVEL OF EVIDENCE: NA.

A Novel Classification System for Injuries After Electronic Cigarette Explosions.

Electronic cigarettes (e-cigarettes) contain lithium batteries that have been known to explode and/or cause fires that have resulted in burn injury. The purpose of this article is to present a case study, review injuries caused by e-cigarettes, and present a novel classification system from the newly emerging patterns of burns. A case study was presented and online media reports for e-cigarette burns were queried with search terms "e-cigarette burns" and "electronic cigarette burns." The reports and injury patterns were tabulated. Analysis was then performed to create a novel classification system based on the distinct injury patterns seen in the study. Two patients were seen at our regional burn center after e-cigarette burns. One had an injury to his thigh and penis that required operative intervention after ignition of this device in his pocket. The second had a facial burn and corneal abrasions when the device exploded while he was inhaling vapor. The Internet search and case studies resulted in 26 cases for evaluation. The burn patterns were divided in direct injury from the device igniting and indirect injury when the device caused a house or car fire. A numerical classification was created: direct injury: type 1 (hand injury) 7 cases, type 2 (face injury) 8 cases, type 3 (waist/groin injury) 11 cases, and type 5a (inhalation injury from using device) 2 cases; indirect injury: type 4 (house fire injury) 7 cases and type 5b (inhalation injury from fire started by the device) 4 cases. Multiple e-cigarette injuries are occurring in the United States and distinct patterns of burns are emerging. The classification system developed in this article will aid in further study and future regulation of these dangerous devices.

The Evolution of Complex Microsurgical Midface Reconstruction: A Classification Scheme and Reconstructive Algorithm.

Orbito-malar reconstruction after oncological resection represents one of the most challenging facial reconstructive procedures. Until the last few decades, rehabilitation was typically prosthesis based with a limited role for surgery. The advent of microsurgical techniques allowed large-volume tissue reconstitution from a distant donor site, revolutionizing the potential approaches to these defects. The authors report a novel surgery-based algorithm and a classification scheme for complete midface reconstruction with a foundation in the Gillies principles of like-to-like reconstruction and with a significant role of computer-aided virtual planning. With this approach, the authors have been able to achieve significantly better patient outcomes.

Facial trauma among victims of terrestrial transport accidents / Traumas faciais entre vítimas de acidentes de transporte terrestre

ABSTRACT INTRODUCTION: In developing countries, terrestrial transport accidents - TTA, especially those involving automobiles and motorcycles - are a major cause of facial trauma, surpassing urban violence. OBJECTIVE: This cross-sectional census study attempted to determine facial trauma occurrence with terrestrial transport accidents etiology, involving cars, motorcycles, or accidents with pedestrians in the northeastern region of Brazil, and examine victims' socio-demographic characteristics. METHODS: Morbidity data from forensic service reports of victims who sought care from January to December 2012 were analyzed. RESULTS: Altogether, 2379 reports were evaluated, of which 673 were related to terrestrial transport accidents and 103 involved facial trauma. Three previously trained and calibrated researchers collected data using a specific form. Facial trauma occurrence rate was 15.3% (n = 103). The most affected age group was 20-29 years (48.3%), and more men than women were affected (2.81:1). Motorcycles were involved in the majority of accidents resulting in facial trauma (66.3%). CONCLUSION: The occurrence of facial trauma in terrestrial transport accident victims tends to affect a greater proportion of young and male subjects, and the most prevalent accidents involve motorcycles.

Resumo Introdução: Nos países em desenvolvimento, os acidentes de transporte terrestre (ATTs) são uma das principais causas de trauma facial, superando os casos de violência urbana, especialmente aqueles envolvendo automóveis e motocicletas. Objetivo: O objetivo deste estudo transversal censitário foi determinar a ocorrência de traumas faciais com etiologia de acidente de transporte terrestre (ATT): automóveis, motocicletas ou atropelamentos, em uma cidade do Nordeste do Brasil. Método: Foram analisados os dados de morbidade em laudos de um serviço forense de vítimas que procuraram o serviço de janeiro a dezembro de 2010. Resultados: Ao todo, foram avaliados 2.379 laudos; 673 eram referentes a ATTs, e 103 apresentaram traumas faciais. A coleta de dados foi realizada por três pesquisadores previamente treinados e calibrados, sendo elaborado um formulário específico para coleta das informações contidas nos laudos. Destes, 15,3% (n = 103) sofreram trauma facial. A faixa etária predominante para os eventos de trauma facial foi de 20-29 anos (48,3%), acometendo mais homens do que mulheres (2,81:1). A motocicleta foi o principal tipo de veículo com envolvimento de vítimas (66,3%). Conclusões: A ocorrência de traumas faciais em vítimas de acidente de transporte terrestreten de a afetar, em maior proporção, indivíduos homens e jovens, com maior prevalência para os acidentes envolvendo motocicletas.

Facial trauma among victims of terrestrial transport accidents.

INTRODUCTION: In developing countries, terrestrial transport accidents - TTA, especially those involving automobiles and motorcycles - are a major cause of facial trauma, surpassing urban violence. OBJECTIVE: This cross-sectional census study attempted to determine facial trauma occurrence with terrestrial transport accidents etiology, involving cars, motorcycles, or accidents with pedestrians in the northeastern region of Brazil, and examine victims' socio-demographic characteristics. METHODS: Morbidity data from forensic service reports of victims who sought care from January to December 2012 were analyzed. RESULTS: Altogether, 2379 reports were evaluated, of which 673 were related to terrestrial transport accidents and 103 involved facial trauma. Three previously trained and calibrated researchers collected data using a specific form. Facial trauma occurrence rate was 15.3% (n=103). The most affected age group was 20-29 years (48.3%), and more men than women were affected (2.81:1). Motorcycles were involved in the majority of accidents resulting in facial trauma (66.3%). CONCLUSION: The occurrence of facial trauma in terrestrial transport accident victims tends to affect a greater proportion of young and male subjects, and the most prevalent accidents involve motorcycles.

Análise de lesões orofaciais registradas no Instituto Médico-Legal de São Luís (MA), no período de 2011-2013 / Analysis of orofacial injuries recorded in the Forensic Medicine Institute of São Luís (MA), from 2011 to 2013

Introdução: Os traumas são causas comuns de morbidades e mortalidade da população mundial. Um dos mais prevalentes é o bucomaxilofacial, pois a face é uma região muito exposta e pouco protegida.Traumas faciais podem resultar em lesões de tecidos moles e fraturas ósseas, causando graves complicações e até danos irreversíveis, e seu autor deve ser enquadrado corretamente segundo a legislação brasileira. Objetivo: Analisar o perfil das vítimas, as causas, as características das lesões orofaciais, bem como o profissional responsável pela perícia e a classificação da lesão de acordo com o artigo 129 do Código Penal Brasileiro. Método: Foram analisados laudos emitidos por médicos e odontolegistas do Instituto Médico Legal da cidade de São Luís (MA), no ano de 2011 à 2013 de vítimas acometidas por lesões orofaciais. Resultados: Os resultados demonstraram que o sexo masculino foi omais atingido (55,4%), a faixa etária mais envolvida foi 20-29 anos (40,3%), a etiologia principal foi agressão física (73,4%), a lesão mais frequente foi escoriação (25,3%) e a região mais acometida da facefoi a orbitária (26%). O profissional que mais emitiu laudos foi o médico-legista (90,8%). Das lesõesorofaciais qualificadas (39,8%), 23,0% resultaram em debilidade da função mastigatória, 4,5% emdebilidade da função mastigatória e estética e 22,3% em deformidade permanente. Conclusão: Conclui-seque é grande o número de lesões orofaciais registradas no IML de São Luís e que essas lesões foram avaliadas mais criteriosamente pelo odontolegista, ressaltando-se, com isso, a fundamental atuação desse profissional nas perícias dessa natureza.

Introduction: Traumas are common causes of morbidities and mortality in world's population. Maxillofacialtrauma is one of the most prevalent, because face is very exposed and unprotected. Facial trauma canresult in soft tissue injuries and bone fractures, causing serious complications and even permanen tdamages, making necessary the appropriate legal framework of attackers. Objective: To analyze theprofile of the victims, reason and the characteristics of orofacial lesions recorded in Forensic MedicineInstitute data, São Luís (MA), Brazil, between years of 2011 to 2013, as well as the professional responsible for expertise (doctors and dentists) and classifications in accordance with Article 129 of theBrazilian Penal Code. Methods: It were analyzed reports issued by doctors and dentistry in the period of2011 to 2013, for affected patients with orofacial injuries. Results: Results showed that male sex was themost affected (55,4%), age most involved was 20-29 years (40,3%), the main etiology was physicalaggression (73,4%), the most common injury was abrasion (25,3%) and the region most affected was theorbital (24,9%). The professional that issued more reports was the coroner (90,8%). Between the qualifiedorofacial lesions (39,8%), 23,0% resulted in weakness of masticatory function, 4,5% in weakness ofmasticatory function and aesthetics and 22,3% in permanent deformity. Conclusion: It was concluded that the number of orofacial injuries registered in the IML of São Luís data was great and these lesions wereevaluated more critically by forensics dentists, requiring their presence of this professional.

Dog bites and maxillofacial surgery: what can we do?

The number of injuries caused by dog bites is increasing in the United Kingdom. We review patients admitted with dog bites to a single maxillofacial department in a district general hospital over a 21-month period. Data include patients' characteristics, and the site and severity of injury. The relationship of the victim to the animal and its breed and classification were added where possible. In total, 65 patients, mean age 22 years (range 1-71, median 14) were included. There were 84 wounds, and their site and severity were recorded according to the Lackmann classification. Twelve different breeds of dog were responsible for the bites. An appreciable proportion of those injured were young children. Educational strategies should aim to reduce the incidence of all dog bites, particularly in young children, as their needs after initial treatment are complex. We propose specific strategies to reduce the number of these injuries.

Epidemiology and classification of dog bite injuries to the face: A prospective study of 108 patients.

BACKGROUND: Dog bites are considered to be septic injuries, and their location on the face, with its highly symbolic topography and important social functions, is particularly pertinent. In addition to specific medical aspects, such as their psychological impact, they are also of relevance in terms of child protection measures. In light of the far-reaching importance of this subject, we were prompted to carry out a prospective study, over 13 years, to identify risk factors. Our results highlight specific risk factors, and they may hence assist with the implementation of concrete primary prevention measures against dog bites. METHODS: An information sheet was prepared and filled out during the intake of patients who had been bitten on the face. Data analysis was performed using Epi Info Version 6.04dfr software to find a correlation between the factors studied and the dog bite to the face. RESULTS: Dog bites to the face represented 0.83% of the emergency admissions to our service. A considerable majority of these involved children, with 68.5% of patients <16 years of age, and 33.3% of patients aged between 2 and 5 years. The wounds were multiple and of variable severity. The type of dog involved was frequently a German Shepherd. Strikingly, 91.3% of bites had occurred in a single-parent environment. CONCLUSIONS: Our study has determined that the fundamental factors that increase the probability of a dog bite to the face are as follows: the child being 2-5 years old, a single-parent context, and involvement of a German Shepherd-type dog.

Prevalence and pattern of facial burns: a 5-year assessment of 808 patients.

PURPOSE: Retrospective studies on the types and causes of facial burns are important because the patterns might vary in different societies. Our aim was to assess the burn-related factors of significance that might be useful in healthcare planning and implementing preventive strategies, adding to the body of current data on the subject. MATERIALS AND METHODS: A retrospective cross-sectional study was conducted to assess the data from a major burns referral center during a 5-year period (2009 to 2013). The data relevant to age, gender, cause, source, location, burn degree, extent (body surface area [BSA]) of the burns, and mortality were gathered from comprehensive patient medical records, recorded, and analyzed using SPSS, version 20, software (SPSS, Chicago, IL). RESULTS: Within the study period, we found 808 documented cases of second- and third-degree facial burns. These burns were more common in men (81.9%) and in the 16- to 35-year age group (42.3%). The mean hospitalization was 9.85 ± 8.94 days. In 443 patients (54.83%), 10 to 19% of their BSA was burned, and 3.06% had associated inhalation burns. The most common burn was scalding (19%), and the deadliest was burns from acid, with a mortality rate of 7.4%. Accidents accounted for 776 burns (96.03%). Other causes were attempted homicide (16 cases, 1.98%) and suicide attempts (16 cases, 1.98%). The overall mortality was 1.6%. CONCLUSIONS: The key findings were that second- and third-degree facial burns were more common in males aged 16 to 35 years with burns covering 10 to 19% of the BSA. Accidental scalding was commonly responsible for the second-degree burns, and electrical accidents were commonly responsible for third-degree facial burns. Burn accidents occurred more often at the patient's home.

Novel method for comparing coverage by future methods of ballistic facial protection.

The wearing of eye protection by United Kingdom soldiers in Afghanistan has reduced the morbidity caused by explosive fragments. However, the remaining face remains uncovered because there is a lack of evidence to substantiate the procurement of methods to protect it. Using a new computerised tool we entered details of the entry sites of surface wounds caused by explosive fragments in all UK soldiers who were injured in the face between 1 January 2010 and 31 December 2011. We compared clinical and predicted immediate and long term outcomes (as defined by the Abbreviated Injury Score (AIS) and the Functional Capacity Index (pFCI), respectively). We also used the tool to predict how additional protection in the form of a visor and mandible guard would affect outcomes. A soldier wearing eye protection was 9 times (1.03/0.12) less likely to sustain an eye injury than one without. However, 38% of soldiers in this series were not wearing eye protection at the time of injury. There was no significant difference between the AIS and pFCI scores predicted by the tool and those found clinically. There is limited evidence to support the use of a mandible guard; its greatest asset is better protection of the nose, but a visor would be expected to reduce long-term morbidity more than eye protection alone, and we recommend future trials to assess its acceptability to users. We think that use of this novel tool can help in the selection of future methods of ballistic facial protection.

[Facial trauma and multiple trauma]. / Traumatisme facial et polytraumatisme.

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

Surgical treatment of facial soft-tissue deformities in postburn patients: a proposed classification based on a retrospective study.

BACKGROUND: Postburn soft-tissue defects or scars can cause disfigurement and functional impairment and constitute a major therapeutic challenge. In the past 30 years, developments in reconstructive techniques have improved the treatment outcomes. However, these techniques are selected mainly according to the surgeon's preference. There is no classification for postburn facial deformities that might contribute to high-level evidence and optimize management. METHODS: The authors reviewed the clinical cases of preexpanded local flaps, perforator flaps, and prefabricated flaps between January of 2005 and September of 2012 in their unit. Deformities were categorized according to their size and location, in accordance with the concept of facial aesthetic units, to show the relationship between different deformities and the indicated surgical techniques. The findings were assessed to develop a classification system. RESULTS: The study included 174 patients with facial deformities ranging from partial unit to total face defects. The authors classified postburn facial skin and soft-tissue deformities as follows: type I, single partial unit defect; type II, total unit defect or deformities that partially involved two adjacent units; type III, multiunit defects; and type IV, total/subtotal defects. The authors recommended reconstructive techniques for each deformity and developed a system to score postoperative aesthetic and functional improvements. CONCLUSIONS: The authors have proposed a classification and scoring system for postburn facial deformities that will aid in the selection of reconstructive techniques. The proposed systems may facilitate multicenter studies with high-level evidence and improve the outcomes of postburn patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Systematic assessment of the patient with facial trauma.

The systematic assessment of patients with facial injuries is the culmination of wisdom from trials and errors, audits of failures and successes, careful and mindful reflection of current practice, and a willingness to change. Emerging technology has positively impacted the practice of management of facial trauma. A systematic evaluation and physical examination of the trauma victim remain the gold standard and the first step toward effective care.