Craniofacial Fractures Research Articles

Computed Tomography Study of the Mummy of King Seqenenre Taa II: New Insights Into His Violent Death

Seqenenre-Taa-II, The Brave, (c.1558–1553 BC) ruled Southern Egypt during the occupation of Egypt by the Hyksos. The mummy was physically examined and X-rayed in the 1960s, which showed severe head wounds that have prompted various theories about the circumstances of his death. We postulated that Computed Tomography (CT) study of Seqenenre-Taa-II's mummy would give insights into the circumstances of his death. We examined Seqenenre's mummy using CT and compared the findings with the archaeological literature as well as with five Asian weapons found in Tell-el-Dabaa. CT findings indicate that Seqenenre died in his forties. The mummies deformed hands suggest that the King was likely imprisoned with his hands tied. CT images provided detailed analysis of Seqenenre's previously reported injuries to the forehead, right supra-orbital, nose-right orbit, left chick, and skull base. This study revealed additional craniofacial fractures in the right lateral side of the skull that had been concealed by the embalmers beneath layers of material. Analysis of the morphology of the injuries enabled a better understanding of the mechanism of trauma, possible number of the attackers, and their relative position to the King. The size and shape of the fractures correlated well with the studied Hyksos weapons. The lethal attack was aimed at the King's face, likely in an attempt to disgrace him. Mummification of Seqenenre's body was limited to evisceration without brain removal. The desiccated brain is shifted to the left side of the skull. This may indicate that the King's dead body stayed on its left side for some time—long enough for decomposition start before the mummification began. This suggests that the King likely died at a location distant from the funeral place, possibly on a battlefield. The embalmers attempted to conceal the King's injuries; the methods used suggest that the mummification took place in a royal mummification workshop rather than in a poorly equipped location. CT findings of Seqenenre's mummy helped us to better understand the circumstances of his violent death. His death motivated his successors to continue the fight to unify Egypt and start The New Kingdom.

Craniofacial Fractures in Equine-Related Injuries: What Should a Maxillofacial Surgeon Expect?

Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.

Trends in Craniofacial Injuries Associated with the Introduction of Electric Scooter Sharing Services

Electric scooters are an increasingly common and convenient mode of transportation worldwide and have effectively revolutionized the shared micromobility industry. As electric scooter sharing companies have increased in popularity there has been a concomitant increase in the frequency of all electric scooter-related injuries. The purpose of this study is to describe the most up-to-date trends in craniofacial fractures and lacerations related to electric scooter use among all age groups. We queried the National Electronic Injury Surveillance System (NEISS) for craniofacial fractures and lacerations related to e-scooters between 2010 and 2019. We then compared injury trends over time and between time periods before and after 2017 when electric scooter share apps revolutionized micromobility. We compared incidence of injury overall and by day of the week, patient demographics, and case severity based on clinical disposition. We identified an increase in the frequency of craniofacial lacerations and fractures in the 3 years following the introduction of electric scooter share services in 2017 (2017 and 2019), compared to the 3 years before this time (2014-2016). Young adults (18-39 years) were the age group with the greatest interval increase in craniofacial injuries. There was also an increase in number of craniofacial injuries occurring on Mondays and a decrease number occurring on Fridays in the later time period. Finally, patients who presented with electric scooter-related craniofacial injuries in this later time period showed a higher frequency of overnight observation and hospital admission for their injuries. The number of craniofacial injuries secondary to electric scooter use has increased dramatically since the introduction of share services. Craniofacial fractures and lacerations are a common reason for craniofacial or maxillofacial surgery consultation and understanding these patterns of injury will help prepare surgeons for patient care, preventative education, and public advocacy.

Cervical spine injuries in facial fracture patients − injury mechanism and fracture type matter

Evidence supports the notion that craniofacial fractures are significant predictors of cervical spine injuries (CSIs), but some debate remains on the injury mechanism of co-existing CSIs in craniofacial fractures and the relationship between CSI and specific facial fractures. In this retrospective study, we aim to assess the incidence rates of specific facial fracture types as well as other important variables and their relationship with CSIs. The primary outcome variable, CSI, and several predictor variables, including facial fracture type, were evaluated with logistic regression analyses. Of 2919 patients, the total CSI incidence rate was 3.0%. Rates of CSI in patients with isolated mandibular fractures (OR 0.26 CI 0.10, 0.63; p = 0.006) were lower than those previously reported, whereas isolated nasal fractures were strongly associated with CSI (OR 2.67 CI 1.36, 5.22; p = 0.004). Patients with concomitant cranial injuries were twice as likely to have CSI (OR 2.00, CI 1.22, 3.27; p = 0.006). Even though there is a strong occurrence rate of CSIs in patients with cranial injuries, clinicians should be aware that patients presenting with isolated facial fractures are at significant risk for sustaining CSIs also.

Associated Injuries Are Common Among Patients With Bicycle-Related Craniofacial Fractures

Ample evidence exists on the relationship between bicycle injuries and craniofacial fractures. However, as the mechanism behind these injuries is often multifactorial, the presence of associated injuries (AIs) in this study population requires further examination. We hypothesized that patients with craniofacial fracture injured in bicycle accidents are at high risk of sustaining severe AIs, especially those of the head and neck region. The investigators performed a retrospective study on all patients with bicycle-related craniofacial fracture admitted to a tertiary trauma centre during 2013 to 2018. The predictor variable was defined as any type of craniofacial fracture. The outcome variable was defined as any kind of AI. Other study variables included demographic and injury-related parameters. Variables were analyzed using bivariate and Firth's logistic regression analyses. A total of 407 patients were included in the analysis. Our results revealed that AIs were present in 150 (36.9%) patients; there were multiple AIs in 47 cases. Traumatic brain injuries followed by upper limb injuries were the most frequent AIs. Severe head and neck injuries were present in 20.1% of all patients with craniofacial fracture. AIs were observed in 57.4% of patients with combined midfacial fractures (P<.001). Helmet use had a protective effect against traumatic brain injuries (P<.001). Our results suggest that AIs are relatively common in this specific patient population. Close co-operation in multidisciplinary trauma centers allowing comprehensive evaluation and treatment can be recommended for patients with bicycle-related craniofacial fracture.

The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland.

Retrospective, quasi-experimental difference-in-differences investigation. Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland's All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid's Inpatient Database (Healthcare Cost and Utilization Project). Between 2009-2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals (p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: -1.1 fewer admissions, 95% confidence interval: -2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. Maryland's APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.

Evaluation of pediatric high-energy trauma patients with whole-body computed tomography.

We aimed to evaluate the findings of whole-body computed tomography (WBCT) in pediatric high-energy trauma patients and to determine the distribution of injuries. The WBCT images of 1132 pediatric patients who were admitted to emergency department between 2013 and 2018 for high-energy trauma were evaluated retrospectively. Six hundred and twenty patients with abdominal, chest, head, and skeletal injuries were included. Using the WBCT images, we detected skeletal injuries in 557 pediatric patients; spinal, rib, extremity, and pelvic fractures were detected in 113, 57, 51, and 37 patients, respectively. Craniofacial fractures were viewed in 299 patients. We detected intracranial hemorrhage, pulmonary contusion, pneumothorax, and solid organ injuries in 102, 115, 45, and 55 pediatric patients, respectively. The frequency and distribution of injuries in trauma cases vary between adults and children. While there are many studies about whole-body CT findings of adult trauma, there are only a few studies about pediatric high-energy trauma patients. The traumatic injury types also differ in pediatric age groups. WBCT scan (with pediatric radiation dose) is the fast and accurate diagnostic tool in high-energy trauma cases and therefore is associated with low mortality rates.

Facial Fractures

The understanding and management of craniofacial fractures have evolved through remarkable innovations in high-resolution imaging, surgical and fixation techniques, endoscopy, biomaterials and implants, bone grafting, new and refined classification frameworks, and algorithms for intervention. The concept of facial buttresses first described forty years ago now serves as a guide to reconstruction of the underlying skeleton to re-establish the height, width, and projection of the face. With the advent of 3D computed tomography and intraoperative imaging, surgeons have expanded the armamentarium for surgical planning and navigation, especially beneficial for accurate repair in complex cases. All of these advances have improved patient outcomes and raised expectations for functionally and aesthetically acceptable results. A brief overview of the assessment and management of facial fractures is presented. This review contains 1 figure, 4 tables, and 43 references. Key words: facial fracture, facial trauma, plastic surgery, orbital, maxillofacial, injury, Le Fort, malocclusion, skeletal buttress

Analysis using the finite element method of a novel modular system of additively manufactured osteofixation plates for mandibular fractures - A preclinical study

Titanium fixation plates and screws are commonly used in craniofacial fracture treatment and reconstructions. Depending on the design and clinical condition, they display better or worse clinical outcomes giving researchers space for improvement in this field. A model was designed by finite element method (FEM) to reconstruct a fractured human mandible body and investigate how different configurations of modular fixation plates (rectangular plate and star-shaped plate) behave under 100 N, 150 N, and 200 N bite loading forces and analyze the stress distribution. The preliminary numerical analysis allowed determining the range and stress limits occurring in the plate-jaw system. Consideration of screw-bone stress showed that with the same load, smaller stress is obtained with a larger screw diameter. Configuration with two “stars” and one “plate” shows the best stress distribution due to the lowest maximum stresses and small stresses in the remaining plate area. The results of this study show that patients with mandible body fractures can be successfully treated using 3D printed modular plates.

Fore! A 10-year Analysis of Golf-related Facial Fractures.

Background:Over 30 million people in the United States play golf, which, while considered a low-impact sport, involves balls and clubs moving >100 miles/h (>160.93 km/h), creating potential for a significant facial trauma. The objective of this study was to characterize the epidemiology of golf-related facial fractures in the United States.Methods:The National Electronic Injury Surveillance System, which records injuries from approximately 100 US emergency departments, was queried for golf-related facial fractures from 2009 to 2018. Entries were tabulated for mechanism of injury and fracture location. Age, gender, seasonality of injury, type of fracture, and injury mechanism were analyzed using SPSS. Because of the different nature and management of pediatric fractures, we looked at pediatric patients as a distinct subgroup.Results:There were 114 reported cases of golf-related craniofacial fractures in patients 2–91 years of age with male predominance (73.7%). This rate extrapolates to an estimated 3,850 ED presentations. Although accounting for about 10% of total players, patients under 18, commonly referred to as “junior golfers,” comprised 55.3% of the cohort. Nasal fractures (25.4%), skull fractures (23.7%), unspecified facial fractures (17.5%), and mandible fractures (10.5%) predominated, which most commonly result from clubs (63.2%), balls (23.7%), and falls (11.4%).Conclusions:Facial fractures resulting from golf clubs and balls may not be as common as in other traditionally identified “high-impact sports,” but they affect pediatric patients disproportionately and with a greater morbidity. Parents and children engaging the sport should be aware of the risk of head trauma, especially with any form of off-course participation.

Blunt cerebrovascular injuries in the craniofacial fracture population—Are we screening the right patients?

Current knowledge of blunt cerebrovascular injuries (BCVIs) in craniomaxillofacial fracture (CMF) patients is limited. The purpose of this study was to determine the occurrence of BCVIs in patients with all types of CMF. This retrospective study included CMF patients in a level 1 trauma centre during a 3-year period. Patients who were not imaged with computed tomography angiography and patients with mechanisms other than blunt injury were excluded. The primary outcome variable was BCVI. A total of 753 patients were included in the analysis. A BCVI was detected in 4.4% of the patients screened. BCVIs occurred in 8.7% of cranial fracture patients, 7.1% of combined craniofacial fracture patients, and 3.1% of facial fracture patients. The risk of BCVI was significantly increased in patients with isolated cranial fractures (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.18–5.50; P=0.017), those involved in motor vehicle accidents (OR 3.42, 95% CI 1.63–7.17; P=0.001), and those sustaining high-energy injuries (OR 3.17, 95% CI 1.57–6.40; P=0.001). BCVIs in CMF patients are relatively common in high-energy injuries. However, these injuries also occur in minor traumas. Imaging thresholds should be kept low in this patient population when BCVIs are suspected.

DIVA, a 3D virtual reality platform, improves undergraduate craniofacial trauma education

Craniofacial fractures management is challenging to teach due to the complex anatomy of the head, even when using three-dimensional CT-scan images. DIVA is a software allowing the straightforward visualization of CT-scans in a user-friendly three-dimensional virtual reality environment. Here, we assess DIVA as an educational tool for craniofacial trauma for undergraduate medical students.Three craniofacial trauma cases (jaw fracture, naso-orbital-ethmoid complex fracture and Le Fort 3 fracture) were submitted to 50 undergraduate medical students, who had to provide diagnoses and treatment plans. Each student then filled an 8-item questionnaire assessing satisfaction, potential benefit, ease of use and tolerance. Additionally, 4 postgraduate students were requested to explore these cases and to place 6 anatomical landmarks on both virtual reality renderings and usual slice-based three-dimensional CT-scan visualizations.High degrees of satisfaction (98%) without specific tolerance issues (86%) were reported. The potential benefit in a better understanding of craniofacial trauma using virtual reality was reported by almost all students (98%). Virtual reality allowed a reliable localization of key anatomical landmarks when compared with standard three-dimensional CT-scan visualization.Virtual reality interfaces such DIVA are beneficial to medical students for a better understanding of craniofacial trauma and allow a reliable rendering of craniofacial anatomy.

Craneoplastía con implante de polimetilmetacrilato (PMMA) para corregir secuela de trauma. Reporte de caso

Introducción: los defectos del cráneo y las anomalías del hueso craneofacial que requieren reconstrucción son comunes en una variedad de procedimientos neuroquirúrgicos. Después de una craniectomía o de fracturas craneofaciales posteriores a traumatismos cráneoencefálicos, los pacientes pueden desarrollar defectos cosméticos importantes. Algunos de estos son la depresión de la piel y un defecto de hundimiento que lleva a una apariencia asimétrica de la cabeza, sin dejar de lado las repercusiones físicas, neurológicas y psicológicas que estas lesiones conllevan. La reconstrucción craneofacial y la craneoplastía tienen una larga historia, pero las nuevas técnicas quirúrgicas y una multitud de opciones de materiales han impulsado recientemente el avance en esta área. Los implantes de polimetilmetacrilato (PMMA) han demostrado ser estables, biocompatibles, no conductores, radiotransparentes y de bajo costo. Es así que se pueden colocar y modificar fácilmente, con lo que se elimina la morbilidad del sitio donante. Presentación del caso: en este artículo presentamos un caso de craneoplastía de defecto frontal, posterior a traumatismo, cuya reconstrucción fue realizada mediante una prótesis de polimetilmetacrilato (PMMA) en el Hospital General Xoco de la Cuidad de México. Conclusión: se reporta la reducción del tiempo quirúrgico, además de un costo de la prótesis accesible para el paciente; de esta manera, se obtuvieron resultados satisfactorios y mejoras en el contorno estético facial, en tanto se permitió cobertura y protección para el tejido encefálico.La reconstrucción craneofacial y la craneoplastía tienen una larga historia, pero las nuevas técnicas quirúrgicas y una multitud de opciones de materiales han impulsado recientemente el avance en esta área.1 Los implantes de polimetilmetacrilato (PMMA) han demostrado ser estables, biocompatibles, no conductores, radiotransparentes y de bajo costo.6 Se pueden colocar y modificar fácilmente y se elimina la morbilidad del sitio donante. En este artículo presentamos un caso de craneoplastía de defecto frontal posterior a traumatismo realizada mediante una prótesis de polimetilmetacrilato (PMMA) en el Hospital General Xoco de la Cuidad de México, con la cual se logró reducir el tiempo quirúrgico, además el costo de la prótesis fue accesible para el paciente y se obtuvieron resultados satisfactorios.

Surgical Management of Zygomatico-Maxillary Complex Fractures with Two Point Fixation- A Clinical Case Presentation &amp; Review of Literature

&Background: Zygomatico-maxillary complex fractures are the most common mid face among all craniofacial fractures. Various surgical approaches and their complications can be done to check the outcome measurement for displaced type of Zygomatico-Maxillary Complex (ZMC) fractures &amp; long term follow up. &Objectives: This case presentation are to check the treatment outcome of zygomatic fractures after treatment with Open Reduction Internal Fixation (ORIF) using 2 point fixation technique. &Case Report: Patient reported to the Department of Oral &amp; Maxillofacial Surgery at Swargiya Dadasaheb Kalmegh Smruti Dental College &amp; Hospital, Nagpur with chief complaints of pain &amp; swelling over right side of face with Periorbital edema &amp; Subconjuctival hemorrhage. On investigation it was diagnosed as Unilateral Displaced ZMC Fractured which was treated with Open Reduction Internal Fixation (ORIF) using two-point fixation technique. &Conclusion: We found that postoperative facial &amp; neurological complications are minimum in two point fixation technique. Open reduction and internal fixation using two-point fixation by miniplates is sufficient for reduction of fracture &amp; postoperative stability at the fracture site and minimize the chance of postoperative complications.

Surface Modeling from 2D Contours with an Application to Craniofacial Fracture Construction

Treating trauma to the cranio-maxillofacial region is a great challenge and requires expert clinical skills and sophisticated radiological imaging. The aim of reconstruction of the facial fractures is to rehabilitate the patient both functionally and aesthetically. Bio-modeling is an important tool for constructing surfaces using 2D cross sections. The aim of this manuscript was to show 3D construction using 2D CT scan contours. The fractured part of the cranial vault were constructed using a Ball curve with two shape parameters, later the 2D contours were flipped into 3D with an equidistant z component. The surface created was represented by a bi-cubic rational Ball surface with C2 continuity. At the end of this article, we present two real cases, in which we had constructed the frontal and parietal bone fractures using a bi-cubic rational Ball surface. The proposed method was validated by constructing the non-fractured part.

In vitro effect of three-dimensional (3D) titanium mini-plate systems used for surgical treatment of condylar fractures on interleukin 1 (IL-1) and interleukin 6 (IL-6) concentration in THP-1 macrophages

About 20 %–35 % of mandibular fractures occur in the condylar process, a complication frequently associated with craniofacial traumas. Compared to other craniofacial fractures, some controversy remains around the effectiveness of the various treatment methods. It has been suggested that condylar osteosynthesis using mini-plates – a technique widely used by maxillofacial surgeons – may activate a pro-inflammatory response which is mediated by interleukins, later involved in bone remodelling and tissue regeneration. This study aimed at examining the influence of three-dimensional (3D) titanium mini-plate systems and the dedicated screws used in the surgical treatment of condylar fractions on the concentrations of interleukin 1(IL-1) and interleukin 6 (IL-6) in macrophages obtained from THP-1 monocytes. The cells were cultured for 24 h and 48 h with the 3D titanium condylar plates and dedicated screws (Synthes, Martin, Medartis manufacturer). The concentrations of IL-1 and IL-6 were measured using the ELISA method. Incubation of macrophages with plates did not cause a significant increase in IL-1 (for: Synthes 0.89−0.86 pg/mg protein; Martin 1.10−0.80 pg/mg protein; Medartis 1.20−0.84 pg/mg protein) and IL-6 (for Synthes 16.00−14.00 pg/mg protein, Martin 13.0−10.0 pg/mg protein; Medartis 9.0–12.0 pg/mg protein) expression for any of the plates used, compared to THP-1 macrophages incubated for 48 h under control conditions. Neither three-dimensional titanium mini-plates nor dedicated screws caused any changes in IL-1 and IL-6 expression in THP-1 macrophages, which is an important observation for clinicians treating condylar fractures. It confirms that titanium plates can be a safe/neutral material for humans, especially considering their significant influence on the osteoclast functions and bone remodelling processes after implantation.

Assessment of Craniomaxillofacial Injuries After Electric Scooter Accidents in Turku, Finland, in 2019

Since the introduction of rental electric scooters (ESs), clinicians have increasingly encountered facial trauma patients whose injuries were caused by ES use. Despite this fact, few studies have analyzed these patients, particularly in Nordic countries, where the climate may cause additional challenges. We hypothesized that ESs have caused several facial trauma cases in Turku, Finland, that might be related to the timing of ES use, that is, month, day, and hour. The medical records of all patients in whom craniofacial fractures or dental injuries caused by ES use were diagnosed at Turku University Hospital, Turku, Finland, in 2019 were reviewed. The occurrence and characteristics of injuries, with special reference to time of the accident, intoxication, hospital stay, and additional injuries sustained were analyzed. A total of 23 patients were identified for this analysis. The mean age was 30years, and most patients (n=16) were men. Four patients had not used helmets, whereas for 19, there was no mention whatsoever about helmet use. Of the patients, 21 were intoxicated and 18 had a blood alcohol content greater than 0.1%.A great majority of the accidents occurred in the nighttime (n=17) and during weekends (n=19). Most injuries (n=15) occurred between September and November. We observed craniofacial fractures in 15 patients and dental injuries in 14; brain injuries occurred in 5 patients, and multiple chest injuries occurred in 1. All patients with dental injuries and 9 of the 15 patients with craniofacial fractures required interventions. An average of 3days of hospitalization was required for 14 patients. Injuries associated with ESs result from driving under the heavy influence of alcohol and occur mostly during weekend nights without helmet use.

Combining trauma severity indices to create a unified craniofacial disruption index: addition of the frontobasal unit to the ZS model.

Craniomaxillofacial injuries account for a large number of emergency attendances and a substantial proportion of the workload of acute clinicians. Although data exist on frequency of involvement of the craniofacial bones, assessments of severity are lacking, and scoring systems for fractures of individual bones and complex craniomaxillofacial trauma often fail to include the frontobasal unit. To rectify this, we have devised a validated scoring system to evaluate the severity of trauma to this region and have merged it with a pre-existing model to create a cohesive craniofacial disruption index. Published papers were reviewed and the frontobasal unit defined. Clinically important anatomical regions were assigned a graduated score that depended on the severity of disruption, and this was applied in the cases of 13 patients with known craniofacial fractures of varying severity. Correlation with existing models was calculated and used as a marker of validity. Our frontobasal system showed strong positive correlation with a consensus of OMFS clinicians (r=0.783, p<0.01). When amalgamated with the pre-existing ZS score to create the Craniofacial Disruption Index, it correlated strongly with all previous scoring systems (r≥0.729, p<0.001). The index is a user-friendly, validated model that enables comparison of the severity of complex craniofacial injuries. It has many potential uses because of its digital, automated method of calculation.

Skull fractures in forensic putrefied/skeletonised cases: The challenge of estimating the post-traumatic interval

The objective of our study was to assess the reliability of the estimation of posttraumatic survival time (PTST) in forensic cases based on microCT and histology of putrefied/dry bone samples with comparison of initial macroscopic fracture classification performed during autopsy. Macroscopic morphological patterns of bone fracture are routinely used in forensic pathology and anthropology to distinguish between antemortem, perimortem and postmortem injuries. Based on macroscopic and microscopic analysis of six craniofacial fractures, our study results illustrate the need to complete macroscopical findings and initial fracture classification with microscopic analysis to avoid any inaccuracy. MicroCT has become a powerful technique to identify early bone healing signs but histology remains the gold standard to estimate the PTST and determine vital fracture based on hemorrhage marker. Raman microspectroscopy can identify a blood clot in the fracture line.

&lt;p&gt;Submental Intubations in Panfacial Fractures&lt;/p&gt;

IntroductionAirway management in patients with panfacial fracture remains a challenge to anesthesiologists and surgeons. Submental intubation is an effective and less invasive alternative to tracheostomy during intraoperative airway management where orotracheal and nasotracheal intubation are not appropriate options. In addition, submental intubation allows proper access to oronasal airways and occlusion during intraoperative management.MethodsThe descriptive retrospective study was carried out and evaluated the outcomes of submental intubation in the management of panfacial fracture, complex maxillary or mandible fracture associated with nasal bone fracture and naso-orbito-ethmoid (NOE) fracture. The medical records of 23 patients who received submental endotracheal intubation were reviewed at UCMS College of Dental Surgery, Bhairahawa, Rupandehi, Nepal from March 2014 to December 2018. The following parameters were evaluated: mode of trauma, time required for intubation, accidental extubation, accidental perforation of the pilot balloon during its insertion, period of hospital stay, post-operative complications, such as the healing of submental scars both intraorally and extraorally.ResultsThe submental intubation was successfully done in all patients with minimal obvious post-operative complications. The mode of trauma for majority of cases of panfacial fracture who underwent submental intubation was road traffic accident (69.56%). The mean time required for intubation was 8.43 (±0.84) minutes. No accidental extubations occurred. Accidental perforation of the pilot balloon was seen in one patient (4.35%) during tube manipulation which was managed successfully by changing the tube. The healing of submental scars was uneventful intraorally and extraorally in almost every case. The mean period of hospital stay in patients with submental intubation was 7.95 (±1.49) days.DiscussionSubmental intubation is an effective and safe method as it is not associated with complications of tracheostomy during management of panfacial fracture, NOE fracture and craniofacial fracture. In addition, it does not interfere with IMF during intraoperative period.