Base Fractures Research Articles

Ten-Year Analysis of Complications Related to Simple Basilar Skull Fractures in Children Presenting to a Trauma Center.

Head trauma is a common presenting complaint among children requiring urgent medical attention, accounting for more than 600,000 emergency department (ED) visits annually, 4% to 30% of which identify skull fractures among the patient's injuries. Previous literature shows that children with basilar skull fractures (BSFs) are usually admitted for observation. We studied whether children with an isolated BSF have complications precluding them from safe discharge home from the ED. We performed a retrospective review of ED patients aged 0 to 18 years given a simple BSF diagnosis (defined by nondisplaced fracture, with normal neurologic examination, Glasgow Coma Score of 15, no intracranial hemorrhage, no pneumocephalus) during a 10-year period to identify complications associated with their injury. Complications were defined as death, vascular injury, delayed intracranial hemorrhage, sinus thrombosis, or meningitis. We also considered hospital length of stay (LOS) longer than 24 hours or any return visit within 3 weeks of the original injury. Of the 174 patients included in the analysis, there were no deaths, cases of meningitis, vascular injury, nor delayed bleeding events. Thirty (17.2%) patients required a hospital LOS longer than 24 hours and 9 (5.2%) returned to the hospital within 3 weeks of discharge. Of those with LOS longer than 24 hours, 22 (12.6%) patients needed subspecialty consultation or intravenous fluids, 3 (1.7%) had cerebrospinal fluid leak, and 2 (1.2%) had a concern for facial nerve abnormality. On the return visits, only 1 (0.6%) patient required readmission for intravenous fluids because of nausea and vomiting. Our findings suggest that patients with uncomplicated BSFs can be safely discharged from the ED if the patient has reliable follow-up, is tolerating oral fluids, has no evidence of cerebrospinal fluid leak, and has been evaluated by appropriate subspecialists before discharge.

Unilateral Severe Condylar Resorption Following Internal Fixation in Bilateral Mandibular Condylar Fracture

Study Design Case Report Objective: A severe condylar resorption following internal fixation of the mandibular condylar fracture is rarely reported. Methods A 35-year-old female caused bilateral condylar base fracture due to fall. She had no connective tissue autoimmune disease, no temporomandibular joint (TMJ) problems, and no history of the orthodontic treatment. Each fractures of condyles were fixed by 2 none-locking titanium miniplates on ideal lines of the osteosynthesis. Results: 6 months after surgery, although patient showed no malocclusion and no TMJ pain, panoramic X-ray showed left side condylar head resorption. Twelve months after surgery, bilateral plate removal was performed. Twenty-six months after internal fixation, panoramic X-ray showed bone formation at the left side of the condylar head. Magnetic resonance imaging of the TMJ showed left TMJ disc displacement without reduction and severe deformity of the left condylar head. Conclusions The condylar resorption might be caused by increasing functional loading due to new position of the condyle following osteosynthesis. Possible contributors for condylar resorption following osteosynthesis were: (1) internal fixation in bilateral condylar fracture, (2) disc displacement without reduction, and (3) female patient (hormonally-mediated theory, eg estrogen). However, the mechanize of condylar resorption was unclear and the further studies were necessary.

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines. To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request. This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022. All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines. Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture. Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians. In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

Dynamic Suzuki frame for the interphalangeal joint fracture: A case report

Proximal interphalangeal (PIP) joint injuries are one of the common injuries of hand. Most common in motor vehicle accidents and sports injury. Various treatment modalities are available to treat such fractures like buddy strapping with or without extension block splint, CRPP, ORIF with interfragmentary screws, Schenck dynamic traction, Hynes and Giddings device and many other modalities. This is one of the challenging fractures as there is high incidence of stiffness, loss of function and deformity leading to disability following the treatment. The pins and rubber traction frame (Suzuki frame) system is one of the novel technique to reduce the disability.Case: 66 years old male with history of motor vehicle accident, presented with comminuted intra-articular fracture of base of middle phalanx (PIP joint) extending distally to DIP joint of the fourth finger of left hand. We used Suzuki frame for the treatment of the fracture.Suzuki frame technique is a simple, minimally invasive, soft tissue sparing, cost effective, dynamic external fixation technique, can be done at minimal resource setting, which allows early ROM at PIP and DIP joint, enabling good bone and joint remodeling and good function of the finger, leading to disability free hand with minimal complication rate.

Guillain-Barré Syndrome Mimicking Brainstem Death Following Traumatic Intracerebral Hemorrhage (P12-7.006)

<h3>Objective:</h3> NA <h3>Background:</h3> NA <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 73-year-old man attended the ED following an assault where he sustained multiple traumatic blows to the head. He was alert, complained of headache but provided a detailed account. There were facial injuries but no clinical signs of cranial or skull base fractures. There was injury to the right eye, in which he had pre-existing visual impairment from previous injury. Vision was normal in the left. Right pupillary light reflex was absent but left was normal. The remainder of the neurological examination was unremarkable. CT-Head identified a small traumatic subarachnoid hemorrhage over the left cerebral convexity and a small contusion in the left temporo-parietal region. Vitreous hemorrhage was evident in the right eye. Clinically stable, follow-up CT on day 3 showed small intra-cerebral haemorrhage within the contusion, with minimal mass effect. However, on day 8, his GCS dropped and he was admitted to the ITU for airway management. Both pupils were non-responsive to light. Expansion of haemorrhage was suspected, however repeat CT was stable. EEG showed slowing over the left hemisphere without epileptiform activity. MRI excluded alternative causes for his neurological status such as brainstem ischaemia. With no clinical improvement, formal brainstem death testing was initiated. No potential confounders were recognised. The pupillary, corneal, oculocephalic, cough and gag reflexes were absent. Unexpectedly, deep tendon reflexes were absent in all limbs. A peripheral nerve stimulator using a train-of-four test protocol found no response. Post-traumatic Guillain-Barré syndrome (GBS) was suspected. Intravenous immunoglobulin was commenced. Nerve conduction studies found absent motor and sensory responses in all limbs. EMG showed fibrillation potentials and sharp waves. These findings were consistent with acute motor-sensory axonal neuropathy (AMSAN) variant of GBS. Serum Anti-GM1 antibodies were identified. After multiple rounds of plasmapheresis the patient was weaned from the ventilator. Nevertheless, severe neurological disability remained. <h3>Conclusions:</h3> NA <b>Disclosure:</b> Dr. Finegan has nothing to disclose. Dr. Ryan has nothing to disclose. Michael J. Hennessy has nothing to disclose. Kevin Murphy has nothing to disclose. Dr. Crowley has nothing to disclose. Dr. Elamin has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche .

Infinitesimal Periangular Pterygomasseteric Transectioning Approach for the Base Fractures of the Mandibular Condyle: A Technical Note and Quality of Life Outcome.

Purpose Infinitesimal Periangular Pterygomasseteric Transectioning Approach (IPPTA) is a minimal access surgical approach utilized for the management of base fractures of the mandibular condyle. The aim of the study was to evaluate and report the long-term post-operative functional outcomeusing this surgical access approach. Materials and method A prospective clinical study involving 20 patients was undertaken to evaluate the post-operative functional and aesthetic outcome for the patients that underwent surgery for base fractures of the mandibular condyle using IPPTA. The various parameters assessed were wound healing, marginal mandibular nerve injury, diet intake, mandibular function, and any other complications at twelfth post-operative month. Results IPPTA provided adequate exposure to the condylar base fracture for open reduction and internal fixation (ORIF) and was found to have an uneventful post-operative recovery phase in terms of functional and aesthetic outcomes. Conclusion IPPTA involves utilizing a smaller incision and provides adequate exposure to the condylar base region for ORIF to establish a satisfactory form and function with a predictable outcome.

Переломы основания черепа у пациентов детского возраста. Часть 3: хирургическое лечение

В статье приводится обзор отечественной и зарубежной литературы, описывающий современные подходы к хирургическому лечению переломов основания черепа (ПОЧ) и их осложнений. Уделяется внимание показаниям к оперативному лечению и срокам его выполнения. Подняты вопросы эндоскопического и транскраниального способов лечения ликвореи при ПОЧ, приводятся основные преимущества и недостатки данных методик в зависимости от локализации и размеров ликворной фистулы. Изложены основные принципы оперативного лечения, виды хирургических подходов (открытый, эндоскопический) и материалов для пластики основания черепа с акцентом на пациентов детского возраста. The article provides a review of domestic and foreign literature describing current approaches to surgical treatment of skull base fractures and their complications. Attention is paid to indications for surgical treatment and its terms. Issues of endoscopic and transcranial methods of cerebrospinal fluid leak treatment are raise, and the main advantages and disadvantages of these techniques depending on liquor fistula localization and size are presented. The main principles of surgical treatment, types of surgical approaches (open, endoscopic) and materials for skull base plasty with an emphasis on pediatric patients are outlined.

Post traumatic pneumocephalus, its complications and management outcome: A prospective study in tertiary care center

To study clinical course and complications in patients diagnosed to have post-traumatic pneumocephalus based on: 1. Patterns of associated skull fractures; 2 Findings seen in CT scan which may be risk factors for development of CSFR, meningitis or tension pneumocephalus. To study clinical outcome in patients with PTP This prospective observational study was conducted over a period of 14 months from 15 Nov. 2017 to 15 Jan. 2019 in Goa Medical College, a tertiary care centre for the management of all kind of trauma patients including TBI. The study included all cases of TBI with CT head showing PTP alonwith there radiological findings, clinical course, complications and its management outcome. A total of 102 cases of post-traumatic pneumocephalus were included in the study. Motor vehicle accident was found to be major cause of PTP (79.41%). The most common site of post traumatic PTP was subdural (45.1%). Majority of the patients with PTP had focal PTP underlying the fracture segment (63.73%). Majority of the patients (30) had either isolated fracture frontal sinus (18) or multiple basal (12). CSFR was seen in 13 patients. Majority (74.51%) of patients were treated conservatively. Most of operative interventions were done for associated EDH, SDH, Contusion or diffuse brain injuries. Comminuted depressed fracture frontal sinus is most common fracture associated in patients with massive pneumocephalus and CSFR. All patients with evidence of post traumatic PTP and basal skull fracture must be followed over longer period as delayed onset TP, CSF leak and meningitis didn’t show any specific pattern with initial presentation.The use of prophylactic anticonvulsants should be based on the presence of other indications for it.Patients with PTP can be managed without prophylactic antibiotics which can be reserved then only for those with contaminated injuries.TP, CSF leak and meningitis are life threatening complications of PTP. Early recognition and high index of clinical suspicion and prompt treatment results in improvement of vast majority of patients.

Headache, vision changes and cranial nerve palsy after head trauma.

A 43-year-old female was brought to the hospital after a ground level fall and her Glasgow Coma Scale was 15. Non-contrast head computed tomography (CT) scan showed small bilateral subdural hematomas, left traumatic subarachnoid hemorrhage, left occipital bone and left longitudinal temporal bone fractures. She was managed conservatively. Interval repeat non-contrast head CT scans showed resolution of the hemorrhage. Two and a half months later she presented to the hospital with headaches, intermittent diplopia, blurry vision and a right lateral gaze palsy. Non-contrast head CT scan showed mild hyperattenuation in the cavernous sinus. Subsequently, a CT angiogram of the head was obtained that showed opacification of the bilateral cavernous sinus and distention of the orbital veins (Figure 1A,B). Evaluation with diagnostic cerebral angiogram showed direct bilateral carotid-cavernous fistulas (CCFs) (Figures 2 and 3). She underwent staged embolization of the CCFs. Direct CCF is the abnormal connection between the internal carotid artery and the cavernous sinus.1, 2 CCFs can present with the classic triad of chemosis, pulsatile proptosis and ocular bruit.3, 4 Other symptoms include orbital pain, abducens nerve palsy, deterioration of visual acuity and ophthalmoplegia.4, 5 Causes of CCF formation are traumatic, iatrogenic, connective tissue disorders and spontaneous.2, 6-9 Traumatic CCFs formation occurs in up to 1.25% of patients with traumatic brain injury or facial and skull base fractures.10, 11 Bilateral CCF formation is rare after trauma and symptoms develop in a delayed fashion.10-15 Treatment options include conservative management, open surgery, endovascular procedures and radiosurgery.16-18

Unstable Middle Phalanx Base Fractures Treated With an Internal Joint Stabilizer: Preliminary Results.

Unstable fractures of the base of the middle phalanx are notorious for causing chronic loss of proximal interphalangeal (PIP) joint function, and they remain a challenge for the hand surgeon. We report on a temporary intraoperatively constructed internal joint stabilizer for unstable PIP joint injuries. Across 2 institutions, a retrospective chart review was performed for cases with acute presentation of pilon fracture or fracture-dislocation of the base of the middle phalanx which were surgically treated with an internal joint stabilizer. Information collected included time from injury to surgical intervention, time from implantation to device removal, complications, and preoperative and postoperative range of motion. Seven patients met the inclusion criteria with a mean age of 51 (range: 24-72) years and a mean follow-up of 29 (range: 11-72) months. After removal of the fixator, the mean arc of PIP joint motion was 8° to 88° (range: 0°-100°). There were no infections, no hardware loosening or failures, and no revision procedures. The current findings are comparable to the results for dynamic external fixators. An internal joint stabilizer for unstable injuries to the base of the middle phalanx provides satisfactory functional outcomes, allows early postoperative motion, and mitigates the routine complications which may arise with external fixation.

Effect of zirconia addition amount in glaze on mechanical properties of porcelain slabs

Applying toughened glaze layer on porcelain slabs can improve the fracture toughness of slabs and greatly reduce the production cost. In this study, porcelain slabs glaze with high toughness was fabricated by the processes of impregnation glazing and single firing method, using opaque frits, kaolin clay as the main raw materials, zirconia as an additive, and the effect of the addition amount of zirconia in glaze on fracture toughness of porcelain slabs was investigated. The results showed that the type and content of crystal phase of the glaze were greatly influenced by the addition amount of zirconia. Meanwhile, compared with the base glaze, the hardness and fracture toughness of the sample with zirconia glaze were significantly improved. Porcelain slabs with 10 wt% zirconia in glaze, sintering at 1200 °C, exhibited higher quality glaze and outstanding properties, including a water absorption of 1.95%, a Vickers hardness of 6.36 GPa, and a fracture toughness of 2.71 MPa m1/2. The toughening mechanism of the glaze layer was as follows: a large number of zirconium silicate grains with high hardness were generated by the reaction of added zirconia with silica in the glass phase, which increased the content of crystal phase and then prevented the propagation of cracks; moreover during the martensitic transformation of the tetragonal zirconia grains, the volume and shear strain were generated to offset the stress field generated by the crack tip, thus toughening the material.

Epidemiology of Anterior and Lateral Basilar Skull Fractures With CSF Leak: A National Trauma Data Bank Analysis.

Cerebrospinal fluid (CSF) leaks are a complication from dural violations that can occur in the setting of skull base fractures. No prior study provides a nationwide epidemiological analysis of traumatic CSF leaks. The objective of this report is to characterize patient demographics, injury-related variables, and operative management. The national trauma data bank was queried for both anterior and lateral skull base fracture cases between 2008 and 2016. Clinical data were extracted. A total of 242 skull base fractures with CSF leak were identified. Most patients were male (84.3%), and the median patient age was 39.7±17.6 years old. Glasgow Coma Scale was 14.0 [interquartile range (IQR): 6.5-10.6] for lateral fractures, 13.0 (IQR: 3.0-10.0) for anterior fractures, and severe range for combined fractures at 7.0 (IQR: 5.0-9.0) (analysis of variance, P =0.122). Common mechanisms of injury were motor vehicle accidents (107, 44.2%), followed by falls and firearms (65, 26.9% and 20, 8.3%, respectively). The median length of stay was 2 weeks, with a median of 14 days (IQR: 10-25) for the anterior fractures and 10 days (IQR 5-19) among the lateral fractures ( P =0.592). Patients were most commonly discharged home in both the anterior (43.8%) and lateral (49.2%) groups. The prototypical patient tends to be a young adult male presenting with moderate-to-severe range neurological dysfunction after a vehicular accident. The overall prognosis of skull base fractures with CSF leak remains encouraging, with nearly half of these patients being discharged home within 2 weeks.

Case Report: Competitive causes of death: a case report of non-mutilated but fatal traumatic railway injury

Background: Railway-related accidents can cause severe injuries, and, most of the time, death. In a country with frequent railway-related accidents, a complete autopsy is vital to determine the cause and mechanism of death, reconstruct the events before death, and identify the victim. It is also essential to determine whether the deceased died by suicide or homicide. This article reports an autopsy of a non-identified victim from a train crash with two fatal injuries. In addition, we reported the challenges in establishing the cause and manner of death. Case presentation: A man was hit by a Pertamina train on Tuesday, 19 July 2022, at 00:24 West Indonesian Time (UTC+07:00), and this was reported to the police for investigation. The body was then examined at Dr. Soetomo General Academic Hospital by a forensic expert. The external examination suggested the presence of abrasions on the face, waist, and all four limbs, lacerations on the face and right earlobe, and open head fractures. In an internal examination, skull-base fractures, fourth and sixth right rib fractures, bleeding in the chest cavity, shrinking lungs, lacerations to the liver and lower right and left lungs, and blood infiltration in the chest cavity wall muscles and scalp muscles were found. The pneumothorax test was positive on the left chest but negative for heart air embolism. Investigation of the base of the skull revealed the presence of fractures. Conclusions: Determining the cause of death in a patient with multiple injuries was challenging and required a thorough investigation. Pneumothorax and air embolism could be the primary cause of death and their presence had to be investigated. Fractures of the base of the skull were established as the cause of death. According to the investigations at the crime scene and the injury profile, suicide was concluded as the manner of death.

Comparing Conservative Treatment of Distal Ulna Fractures with Operative treatment

Objective: To compare the outcome of conservative treatment of distal ulna fractures with operative treatment Study design: A randomized control trial Place and duration: This study was conducted at Muhammad Medical College and Hospital Mirpurkhas from September 2021 to September 2022 Methodology:Patients with different types of ulnar fractures (base fractures, head fractures, and subchondral fractures) were divided into two groups based on a systematic approach that established the course of treatment for forearm fractures. The fractures of the distal radius in Group A were treated with plating osteosynthesis, while the fractures of the distal ulna were taken care of with a surgical procedure involving the implantation of an LCP Distal Ulna Plate (De PuySynthes, USA) Results: A total of 120 patients were enrolled in the study, 8 of whom had to be excluded due to the development of carpal ligament damage symptoms. The 112 patients who remained were divided into three groups: 36 in group A, 42 in group B, and 34 in group C. The results of distal forearm fractures were initially treated with closed repositioning in local anesthesia and plaster fixation in 89 cases. In 10 cases, external fixation was primarily applied due to soft tissue conditions. The definitive surgical procedure was performed on average 10 days (3-19) from the injury. In group A, osteosynthesis of both bones was performed during one operation in 30 patients. In 7 cases, it was necessary to perform a two-phase procedure due to the state of the soft tissues. Conclusion: Based on the study's results, osteosynthesis is the more successful treatment for sub-capital fractures, as it results in better early outcomes than a conservative approach. However, due to the low number of patients with this type of fracture, it is impossible to make definitive treatment recommendations Keywords: distal ulnar fracture, osteosynthesis, conservative treatment

Geometry of Freezing Impacts Ice Composition: Implications for Icy Satellites

AbstractNon‐ice impurities within the ice shells of ocean worlds (e.g., Europa, Enceladus, Titan, Ganymede) are believed to play a fundamental role in their geophysics and habitability and may become a surface expression of subsurface ocean properties. Heterogeneous entrainment and distribution of impurities within planetary ice shells have been proposed as mechanisms that can drive ice shell overturns, generate diverse geological features, and facilitate ocean‐surface material transport critical for maintaining a habitable subsurface ocean. However, current models of ice shell composition suggest that impurity rejection at the ice‐ocean interface of thick contemporary ice shells will be exceptionally efficient, resulting in relatively pure, homogeneous ice. As such, additional mechanisms capable of facilitating enhanced and heterogeneous impurity entrainment are needed to reconcile the observed physicochemical diversity of planetary ice shells. Here we investigate the potential for hydrologic features within planetary ice shells (sills and basal fractures), and the unique freezing geometries they promote, to provide such a mechanism. By simulating the two‐dimensional thermal and physicochemical evolution of these hydrological features as they solidify, we demonstrate that bottom‐up solidification at sill floors and horizontal solidification at fracture walls generate distinct ice compositions and provide mechanisms for both enhanced and heterogeneous impurity entrainment. We compare our results with magmatic and metallurgic analogs that exhibit similar micro‐ and macroscale chemical zonation patterns during solidification. Our results suggest variations in ice‐ocean/brine interface geometry could play a fundamental role in introducing compositional heterogeneities into planetary ice shells and cryoconcentrating impurities in (re)frozen hydrologic features.

Anterograde Intramedullary Headless Compression Screw for Managing Extra-articular Thumb Metacarpal Base Fracture: Technique and Report.

Extra-articular base fractures of the thumb are typical in hand surgeon practice. Nonoperative methods (spica) and operative methods are available for its management. There are operative methods described, such as plate and screws, Kirschner wires, and intramedullary screws. However, there is only a retrograde technique described. This study aims to present a new technique of an anterograde intramedullary headless compression screw to manage the extra-articular thumb metacarpal base fracture. This minimally invasive method allows an early range of motion and does not cross the articular surface of the thumb. This alternative fixation method has the advantage of low damage to soft tissues and good functional outcomes.

Abstract Number ‐ 70: Combined Trans‐arterial Flow Diversion and Trans‐venous Embolization Management of High‐Flow Traumatic Cavernous‐Carotid Fistula (CCF)

Introduction Carotid‐Cavernous fistulas (CCF) are abnormal vascular shunts between the internal carotid artery (ICA) and the cavernous sinus. Most commonly due to trauma (75%), CCF occurs in 4%(1) of skull‐base fracture patients. Visual impairment, diplopia, and headache are typical presenting symptoms (88%). Proptosis, chemosis, ophthalmoparesis, and orbital bruits are notable exam findings. Cerebral angiography is the gold standard for diagnosis, showing cavernous sinus enlargement and ophthalmic vein or leptomeningeal vessel dilatation. CCF is typically treated endovascularly andballoon embolization has achieved cure rates of 88–99%(2). Successful obliteration using stents, however, has been reported(3, 4). While both trans‐arterial and the trans‐venous approach embolization are feasible depending on local vascular anatomy and accessibility of fistula points, the combination of trans‐arterial and trans‐venous approach is rarely employed.We present a case of traumatic, high‐flow CCF treated with combined trans‐arterial and trans‐venous coiling embolization and telescoped flow‐diverting stents. Methods A case report of successful treatment of traumatic high‐flow CCF with a combined trans‐arterial and trans‐venous coiling embolization with telescoped flow‐diverting stents. Results A 26‐year‐old woman presented with right eye proptosis, periorbital ecchymosis, and chemosistwo weeks after severe closed head injury treated with decompressive hemicraniectomy and subdural hematoma evacuation. Examination was notable for right eye blindness without light perception and right‐sided third, fourth, and sixth cranial nerve palsies and elevated intraocular pressure. CT head showed a skull base fracture involving the right carotid canal and angiography of ICA confirmed a high‐flow multi‐channel right CCF with diminished intracranial arterial flow and engorged bilateral ophthalmic veins. After unsuccessful attempts to catheterize the fistula via arterial approach, superior‐segment coil embolization was performed using an inferior petrosal venous approach; but further embolization of the cavernous sinus was unsuccessful. Using the cavernous‐petrous segment of the right ICA, a flow‐diversion stent was placed that significantly decreased cross‐fistula blood flow, improved intracranial arterial flow, and reduced bilateral ophthalmic vein congestion. After two months, intraocular pressure normalized and right eye vision returned, though moderate exophthalmos persisted. Angiography showed decreased but persistent residual CCF flow. Another flow‐diversion stent was successfully placed via trans‐arterial approach, covering the previous pipeline stent through petrous‐to‐ophthalmic right ICA. Three‐month follow‐up angiogram showed closure of the CCF with complete restoration of right eye vision. She ultimately underwent right cranioplasty and was able to return to work. Conclusions A combined trans‐venous coiling embolization and trans‐arterial flow‐diversion stenting may be effectively employed in the treatment of CCF with reversal of clinical symptoms and restoration of visual loss. Larger studies are needed to explore the role of this combined approach in the management of CCF.

Computed tomography in skull base fractures in infants and young children

Aim of the study is to show the possibilities of multiplanar reformation and 3D reconstructions of computed tomography in the diagnosis of skull base fractures in young children.&#x0D; Materials and methods. In one thousand three hundred thirty four children under 3 years of age with traumatic brain injury (TBI) CT was performed on a 128-slice Philips Ingenuity CT scanner; in 707 (53%) in the first 6 hours, in 254 (19%) — after 6 hours, but during the first 24 hours, in 205 (15%) children within 3 days and in 168 (13%) children later on 3 days after injury. Scanning of the area of interest (head + cervical spine) was made with the maximum possible reduction in parameters to minimize the radiation dose. Contrast was not used in children from 0 to 3 years of age with TBI. Post-processing included isotropic multi-planar reformatted (MPR) and 3D images.&#x0D; Results. Of the 1334 children examined, 730 were boys and 604 were girls. In 448 (33.58%) children, fractures of the skull bones were diagnosed, in 366 (81.7%) of them, fractures were combined with intracranial injuries. Fractures of the skull base were in 83 (18.52%) of 448 children. In 65% (n = 54) of cases, basal fractures were combined with fractures of the temporal bones, 31.5% &#x0D; (n = 17) of these children had liquorrhea. Fractures of the anterior fossa (12% of the total number of fractures of the base of the skull) of the base of the skull or fronto-basal fractures were accompanied by additional fractures of the orbits and/or other bones of the facial skull in 56.6% of cases. Fractures of the middle cranial fossa were diagnosed in 54 (65%) children. Fractures of the posterior cranial fossa were found in 19 (23%) of 83 children. In addition to fractures of the bones of the base of the skull, 32 (38.6%) children were diagnosed with fractures of the bones of the vault and intracranial injuries.&#x0D; Conclusion. The use of multiplanar reformation and 3D reconstruction increased the sensitivity and specificity of diagnosing skull base fractures in children compared to conventional axial CT. The essential advantages of using 3D reconstruction are the availability of the technique, the absence of additional scanning time and radiation exposure.

Current Frequency of Mandibular Condylar Process Fractures.

There are significant discrepancies in the reported prevalence of condylar process fractures among all mandibular fractures (16.5-56%) in the available literature. In addition, it seems that the actual number of difficult-to-treat fractures of the mandibular head is unknown. The purpose of this study is to present the current incidence of the different types of mandibular process fractures with a special focus on mandibular head fractures. The medical records of 386 patients with single or multiple mandibular fractures were reviewed. Of the fractures found, 58% were body fractures, 32% were angle fractures, 7% were ramus fractures, 2% were coronoid process fractures, and 45% were condylar process fractures. The most common fracture of the condylar process was a basal fracture (54% of condylar fractures), and the second most common fracture was a fracture of the mandibular head (34% of condylar process fractures). Further, 16% of patients had low-neck fractures, and 16% had high-neck fractures. Of the patients with head fractures, 8% had a type A fracture, 34% had a type B fracture, and 73% had a type C fracture. A total of 89.6% of the patients were surgically treated with ORIF. Mandibular head fractures are not as rare as previously thought. Head fractures occur twice as often in the pediatric population than in adults. A mandibular fracture is most likely related to a mandible head fracture. Such evidence can guide the diagnostic procedure in the future.

A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating.

Background Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion Large prospective studies of the "WRIST" protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.