Cranial Reconstruction in a Pediatric Patient Using a Tissue Expander and Custom-made Hydroxyapatite Implant.

A tissue expansion technique in conjunction with a custom-made artificial bone implant was effective for a large cranial reconstruction in a pediatric patient. The patient was an eight-year-old boy with cranial bone fracture, acute subdural hematoma in the left lobe, and acute epidural hematoma in the right lobe due to an accident. Wound dehiscence and artificial dura infection were observed as postoperative complications. Because of insufficiency of the skin flap caused by scar contracture, a scalp skin expansion using a tissue expander was necessary before reconstruction with the artificial bone implant. This combined procedure provided safe coverage of the implant and resulted in good wound healing. There are relatively few reports involving the use of tissue expanders for cranioplasty; furthermore, our search of the literature did not reveal any reports involving children. We believe that this procedure is safe and effective for early rehabilitation in pediatric patients.

Cranial injuries secondary to assault with a machete.

BACKGROUND: Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit. MATERIALS AND METHODS: Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover. RESULTS: Of 185 patients treated 172 (93%) were male. Mean age was 31±11.4 years. Mean GCS on admission was 13±2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1-145). The median GOS at discharge was 5 (range 1-5). Twelve patients died within the same admission (6.5%). CONCLUSION: Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.

The clinical features of periorbital ecchymosis in a series of trauma patients.

INTRODUCTION: Periorbital ecchymosis (PE) is caused by blood tracking along tissue plains into periorbital tissues, causing discoloration in the upper and lower eyelids. This clinical feature is most commonly associated with basal skull fractures. Our objective is to present the first patient series describing the clinical features associated with traumatically induced PE. METHODS: The authors retrospectively reviewed 36 consecutive cases of patients presenting to the emergency department with PE over a three-year period at St. Michael's Hospital in Toronto. Data were obtained using a standardised data acquisition template. RESULTS: All patients presented to the emergency department with PE. The mean age in our series was 39 years (range 19-88 years), 31 patients were male. PE was associated with a variety of injuries including: 15 basal skull fractures, 9 soft tissue injuries without fractures, 8 convexity fractures, and 3 facial fractures. The other classic signs of basal skull fracture (Battle's sign, hemotympanum, cerebrospinal fluid otorrhea, cerebrospinal fluid rhinorrhea) were observed in 3, 7, 1, and 3 patients with PE, respectively. The most common clinical feature associated with PE was cranial nerve injury, observed in 10 patients. Surgical intervention was required in 8 patients. Five patients were discharged to a rehabilitation centre. No meningitis, cerebral abscess, encephalitis or deaths were observed. CONCLUSION: Periorbital ecchymosis is a useful clinic sign that should alert the clinician to assess for skull fractures, intracranial haemorrhage, and cranial nerve injury. However, this series shows that PE can be associated with a variety of clinical features, is rarely accompanied by other classic signs of basal skull fracture, and most patients with PE do not have injuries severe enough to require surgical intervention or post-discharge rehabilitation.

Patients with mild traumatic brain injury: immediate and long-term outcome compared to intra-cranial injuries on CT scan.

BACKGROUND: Mild traumatic brain injury (MTBI) defined as Glasgow Coma Scale (GCS) 14 or 15 has shown contradictory short- and long-term outcomes. The objective of this study was to correlate intra-cranial injuries (ICI) on CT scan to neurocognitive tests at admission and to complaints after 1 year. METHODS: Two hundred and five patients with MTBI underwent a CT scan and were examined with neurocognitive tests. After 1 year complaints were assessed by phone interviews. RESULTS: The neurocognitive tests in 51% of the patients showed significant deficits; there was no difference for patients with GCS 14-15, nor was there a difference between patients with ICI to patients without. After 1 year patients with ICI had significantly more complaints than patients without ICI, the most frequent complaint was headache and memory deficits. CONCLUSIONS: No correlation was found between GCS or ICI and the neurocognitive tests upon admission. After 1 year, patients with ICI have significantly more complaints than patients without ICI. No cost savings resulted by doing immediate CT scan on all.

Bilateral occipital condylar fracture with associated haematomas.

Occipital condylar fractures (OCFs) seem to be rare. The exact incidence is unknown, but a few studies reported a 3-4% incidence of OCFs in patients with severe head injury and altered Glasgow Coma Scale score. The low incidence of OCFs and missed diagnoses in these patients may result in late neurological deficits. We report the history of a patient with bilateral OCFs, a combined fracture of the anterior arcus of the atlas and associated retropharyngeal and epidural cervical haematomas, who presented without life-threatening symptoms or neurological deficits.

Traumas of the middle skull base with TMJ involvement. Case report.

The authors report their experience with temporomandibular joint (TMJ) traumas involving breakage of the roof of the glenoid cavity, an infrequent event that occurs in those cases in which, as a result of the condylar neck not fracturing, the traumatic energy is transmitted to the middle skull base. As the literature contains no valid series for establishing standardized protocols for the treatment of these fractures, we propose our own orthopedic-functional approach. The patient observed by us had suffered a cranio-facial trauma and presented the classical symptoms and signs of TMJ traumas and complete bilateral Bell paralysis. He was subjected to a CAT scan and then to 2-stage treatment consisting of functional rest with liquid diet followed by physiotherapy. An almost total recovery in TMJ function was observed after 1 month. At 1-year follow-up the facial paralysis had resolved completely. On the basis of our experience, breakages of the glenoid cavity can be compared, in terms of treatment procedure, to intracapsular fractures of the TMJ with surgery confined to cases of ankylosis sequelae. To avoid the onset of ankylosis careful control of clinical, functional and radiological follow-up is required.

Atypical traumatic craniocervical junction focal spinal subdural hematoma.

Spinal subdural hematoma (SSDH) is a rare entity and post-traumatic cervical SSDH is very rare. Review of the literature revealed 8 reported cases of traumatic SSDH and only 2 were cervical. The exact mechanism and pathogenesis of SSDHs are unclear. There are still controversies about the source of bleeding and mechanisms of formation of a hematoma. Here we report a case of a unique traumatic craniocervical junction focal subdural hematoma in an 8-year-old boy and discuss the possible mechanisms of SSDHs in trauma cases.

Subjective well-being and quality of life following traumatic brain injury in adults: a long-term population-based follow-up.

PRIMARY OBJECTIVE: To assess subjective well-being and quality-of-life in nationally representative samples of patients at long intervals following traumatic brain injuries. METHODS AND PROCEDURES: Patients with either cranial fractures or cerebral lesions were identified in a national computer-based register of hospital admissions and random samples were selected among those who had suffered the injury at 5, 10 or 15 years prior to the follow-up. Postal questionnaires were sent to them covering quality of life, e.g. return to employment, family relations and current subjective well-being in terms of symptomatology, e.g. somatic complaints, cognitive dysfunction. A response rate of 76% was obtained, comprising 114 patients with cranial fracture and 126 with cerebral lesions. MAIN OUTCOMES AND RESULTS: The group with cerebral lesions had markedly poorer quality of life and subjective well-being than the group with cranial fractures and this did not vary across time. In both groups, the most common symptoms concerned cognition. Among the cerebral lesion group, quality of life outcome was fairly well predicted by severity of injury, but subjective well-being was less well predicted. CONCLUSIONS: The negative consequences of traumatic cerebral lesions are marked and do not vary at long periods following injury.

Psychosocial outcome following traumatic brain injury in adults: a long-term population-based follow-up.

PRIMARY OBJECTIVE: On a national basis to conduct a 5, 10 and 15 year follow-up study of representative samples of survivors after traumatic brain injury (TBI) and to identify factors of importance for long-term survival and life satisfaction after TBI occurring in 1982, 1987 or 1992. RESEARCH DESIGN: Epidemiological, register-based questionnaire survey. MAIN OUTCOMES, RESULT AND CONCLUSIONS: Out of 389 survivors randomly chosen from a national complete hospital register, 173 had suffered a cranial fracture, 186 a cerebral lesion (brain contusion or traumatic haemorrhage) and 30 patients a chronic subdural haematoma. Out of 337 survivors found eligible for a questionnaire, 76% responded. Among the data registered according to the above mentioned areas, the main findings were that 23-31% of the cerebral lesion responders were unable to maintain earlier work/education at pre-injury level, against up to 14% of cranial fracture patients. Significantly more cerebral lesion patients than cranial fracture patients found emotional control more difficult, as well as increased difficulties with memory and concentration, maintenance of leisure time interests and general life satisfaction. In the long run, an important factor influencing survival among cerebral lesion patients seemed to be whether relations with family and friends could be maintained at the pre-injury level.

[Individualized facial protection after fracture management of the nasal bone and zygomatic arch in professional soccer players]. / Individueller Gesichtsschutz nach Frakturversorgung am Nasenbein und Jochbogen bei Profifussballern.

BACKGROUND: The treatment of sport accidents in professional athletes requires special treatment modalities, especially concerning quick rehabilitation. CASE REPORT: As early as 5 days after treatment of a nasal bone fracture under local anesthesia on an outpatient basis, an individual nasal shield out of silicone and acrylate could be manufactured from a facial impression for a professional soccer player. This shield enabled unlimited participation in the ensuing premier league matches 7 and 14 days after the accident. The same treatment was performed for another team member after closed reposition of a zygomatic arch fracture. Treatment modalities and manufacturing of the facial protection masks in these two cases are presented as examples.

[Management of simple midfacial fractures, particularly in professional soccer players]. / Das Management einfacher Mittelgesichtsfrakturen unter besonderer Berücksichtigung des Profifussballs.

Uncomplicated midfacial fractures represent a frequent and typical injury of soccer-players in oral and maxillofacial surgery. The treatment of these fractures in professional players requires special treatment modalities, especially concerning quick rehabilitation. The examples of a nasal bone fracture, a malar bone fracture and a zygomatic arch fracture in 3 professional soccer players demonstrate the therapeutic principles of these most common uncomplicated midfacial fractures. In this context the fabrication of individual facial masks is presented, which allow an improved postoperative protection and therefore an earlier participation of the player in training and matches.

[Occipital condyle fractures and clivus epidural hematoma. Case report]. / Fracture des deux condyles occipitaux avec hématome épidural rétroclival. A propos d'une observation.

A 47-year-old woman presented with a rare case of epidural hematoma of the clivus. The patient had bilateral occipital condyle fractures (a comminuted fracture on the right side, an avulsion fracture on left side and a lower clivus fracture). On admission the patient was tetraparetic with left abducens palsy. Preoperative imaging showed no atlanto-axial or occipito-atlantal dislocation. The patient was operated with a posterior approach. An occipital craniectomy with C1 laminectomy was achieved without atlanto-occipital fusion. Two years after the trauma, the patient had mild left hemiparesis but was able to walk normally. Head motion was normal, but just mildly decreased by pain in flexion and extension. Imaging control did not show any occipito-atlantal instability. We describe the imaging features allowing precise diagnosis and discuss the management of a rare entity: bilateral occipital condyle fractures and epidural hematoma of the clivus.

[Maxillofacial fractures. Surgical and prosthetic procedures]. / Fracas maxillo-facial. Episodes chirurgicaux et prothétiques.

A patient presented complex fractures of the face and skull with leg trauma after a traffic accident. Maxillofacial repair used sophisticated procedures: bone grafts, muscle flaps and multiple osteotomies. After reconstructing the mid face and the mandibular repair, bone implants were used to stabilize the maxillary prosthesis. The psychological and functions problems raised in this case are discussed considering the occupational and social outcome.

Maxillofacial trauma: case managing patients with Le Fort I, II, or III fractures.

TOPIC: Maxillofacial trauma case management. PURPOSE: To present a collaborative team approach to the patient with maxillofacial injuries. SOURCES: Published information and clinical experience. CONCLUSIONS: Outcome management is facilitated by a plan of care addressing acute, intermediate and rehabilitation phases of care.

[Diagnostic problems in fractures of the occipital condyles]. / Diagnostische Probleme bei Frakturen der okzipitalen Kondylen.

Three cases involving fractures of the occipital condyle were recently treated by the authors. Since plain radiographs of the upper cervical spine often fail to reveal this lesion, it can be difficult to diagnose. It seems to be more common than previously suspected and described. We found one axial compression fracture and two avulsion fractures with different degrees of atlanto-occipital instability. Mandibular fracture occurred in all cases. There was no severe craniocervical trauma. The atlanto-occipital junction should always be included in the CT evaluation of facial or craniocervical trauma. Thin-section CT of the craniocervical region can best visualize this fracture and should be used when it is suspected. All cases were treated by orthotic immobilisation.

Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome.

To determine what consequences cognitive, behavioural or somatic impairments had on disabilities and recovery after a head injury (HI), a population-based sample of 231 adult patients was studied 5 years after an HI. Eighty lower-limb-injured (LLI) patients were considered as controls. Sixty-four LLI and 176 HI patients were reviewed (114 minor, 35 moderate, and 27 severe HI). Prevalence values of headaches (44-54%), dizziness (26-37%), and anxiety (47-63%) were not significantly different in the three HI severity groups, but were significantly lower in patients with an isolated limb injury (12-15%). Memory problems and depressive mood increased with injury severity. Mental impairments were frequent in severe HI patients (18-40% of patients). In minor and moderate HI patients, most disabilities were related to associated injuries. According to the Glasgow Outcome Scale (GOS), recovery was not considered as good because of somatic, behavioural or cognitive complaints in 2.5%, 5.7% and 59.2% of surviving patients in each of the above HI groups. Somatic or behavioural complaints may have considerable consequences in some minor HI patients, and the long-term management of certain patients needs improvement because these impairments are misunderstood.

Maxillofacial fractures sustained during sports.

PURPOSE: This study investigated the number and type of maxillofacial fractures caused by various athletic activities. PATIENTS AND METHODS: The ninety-eight patients were treated between 1977 and 1993, and the type of sport involved, patient age and sex, cause of accident, site of injury, and mode of treatment were evaluated. RESULTS: Sports-related maxillofacial fractures accounted for 10.4% of all patients with facial bone fractures. The number of different sports was 19, with the incidence of the fractures being most common in rugby and skiing, followed by baseball and soccer. The ratio of males to females was 5.5:1, and most of the patients were between 10 and 29 years of age. Total restriction from sports activity was between 8 and 12 weeks after initial treatment. CONCLUSION: The treatment for sports-related maxillofacial fractures is not different from that for fractures from other causes. However, it is important to establish some standard for deciding the time when it is possible to participate in sports after a fracture.