Zygomaticomaxillary Complex Fractures Research Articles

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

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

Traumatic Hemifacial Avulsion and Degloving Injury With Left Zygomaticomaxillary Complex Fracture: A Case Report

Traumatic Hemifacial Avulsion and Degloving Injury With Left Zygomaticomaxillary Complex Fracture: A Case Report

Effect of tranexamic acid on postoperative blood loss

ObjectiveThe aim of this article was to evaluate the efficacy of tranexamic acid (TXA) on reducing the blood loss after maxillofacial fracture surgeries. MethodsClinical data were collected retrospectively from patients with unilateral zygomaticomaxillary complex (ZMC) fracture or unilateral mandibular condylar fracture. Patients were further divided into TXA group and control group according to whether TXA was used or not after surgery. The amount of postoperative blood loss was evaluated by negative pressure drainage volume. Data was statistically analyzed. ResultsFor patients with unilateral ZMC fracture, the total postoperative blood loss in the TXA group was about 30 ml less than that in the control group (p=0.006). It was significantly less on the first and second postoperative days. However, for patients with unilateral mandibular condylar fracture, there was no significant difference between the TXA and control groups (p=0.917). ConclusionTXA can reduce postoperative bleeding in patients with ZMC fracture, and the optimal usage time is on the first and second postoperative days. For patients with mandibular condylar fracture, TXA may not be used.

Evaluating Mixed Reality as a Tool for Patient Education of Facial Fractures.

Background: Patients may be educated about facial fractures using two-dimensional computed tomography (2DCT); however, three-dimensional mixed reality (3DMR) goggles may improve patient education by delivering content in an immersive environment. Objective: To compare the effectiveness of 2DCT and 3DMR formats used for patient education on facial fractures, as measured by surveys. Methods: In this prospective, randomized, crossover study, video tutorials intended for facial fracture informed consent were created in 2DCT and 3DMR formats from a single CT data set of a zygomaticomaxillary complex (ZMC) fracture. Subjects were randomly assigned into two groups. Group 1 (n = 25) viewed the 2DCT tutorial, answered self-assessment and information recall surveys, viewed the 3DMR tutorial, repeated the prior surveys as well as a comparison survey. Group 2 (n = 25) followed the same sequence but viewed the 3DMR tutorial and then the 2DCT tutorial. Results: Participants (n = 50) had no differences in age (group 1-51.9 years/standard deviation [SD] 20.9; group 2-44.7 years/SD 17.6 years; p = 0.223), gender (group 1-10 male/15 female; group 2-11 male/14 female; p = 0.999), college education level (group 1-25 yes; group 2-25 yes; p = 0.844), or prior 2DCT or 3DMR experience (group 1-9 yes/16 no; group 2-13 yes/12 no; p = 0.393). The 3DMR format was preferred over 2DCT (p < 0.05), and it was reported to enhance understanding as compared to 2DCT (p < 0.05). No differences for information recall were noted (p = 0.753). Conclusion: In this study, participants preferred 3DMR goggles over 2DCT for a simulated ZMC fracture-informed consent.

A comparison of one point versus two point fixation in the management of zygomatico-maxillary complex fractures

The zygomaticomaxillary complex (ZMC) fractures are highly frequent injuries. There is a variety of operative techniques for fixation of ZMC fractures, with no consensus about the best technique. We aim to compare one-point versus two-point fixation of tripodal zygomatic fractures. This study was carried out on 34 patients admitted to the trauma unit in Sanjay Gandhi Institute of Trauma and Orthopaedics in the period from September 2022 to August 2023. Patients were divided into two groups (group 1; one-point fixation, and group 2; two- point fixation). When compared to the one-point fixation group, only 14 patients had substantial stability with a P-value of &amp;#60;0.05 being statistically significant. In contrast, nearly all patients in the two-point fixation group had higher stability. In the two-point fixation group, nearly all patients had a post-operative scar; in the one-point fixation group, however, only two patients had the same scar, and the mouth opening was also improved. In two-point fixation, paraesthesia was observed in nearly seven patients, while in one-point fixation, it was present in only two patients.The one-point fixation technique for tripodal ZMC fractures is considered effective as the two-point fixation technique; and it offers advantages of scarless operation, reduced operation time, fewer complications, and lower cost.

Effects of melatonin on postoperative pain and sensory recovery following zygomaticomaxillary complex fractures — A randomized controlled trial

Posttraumatic and postsurgical sensory disturbance is a known complication of almost all zygomaticomaxillary (ZMC) complex fractures involving the infraorbital nerve, for which few treatments are effective. Our study used neurosensory assessments to evaluate the efficacy of melatonin on pain and nerve healing following ZMC surgery.Sixty-four randomly allocated ZMC fracture patients were prophylactically administered either oral melatonin or an identical placebo for 15 consecutive days. Pre- and postsurgical clinical parameters included subjective pain, numbness, and objective neurosensory function.Melatonin significantly reduced subjective pain perception in the early postoperative days, with a significant difference in VAS scores between the groups from postoperative day 3 (p = 0.048) until day 7 (p = 0.002). The VAS assessment of subjective numbness perception showed significantly lower self-perceived neurosensory disturbance for patients in the interventional group from the first month (p = 0.039) until the third month (p = 0.005). Objective neurosensory assessment using the pinprick test and two-point discrimination showed statistically significant improvement to almost normal sensation by the first month (p = 0.014) to fully normal sensation by the third month (p = 0.001).The study findings suggest that the prophylactic administration of melatonin confers significant clinical benefits in terms of reduced postoperative pain and improved sensory recovery.

Symmetry recovery in zygomaticomaxillary complex fractures compared to normal unfractured population: A new reliable 3D evaluation

ObjectiveThis study aims to quantify the facial symmetry of surgically treated zygomaticomaxillary complex (ZMC) fractures through a new reliable three-dimensional evaluation method, which is crucial for improving post-operative aesthetic and functional outcomes. Material and methodsHealthy patients and patients with surgically treated ZMC fractures were retrospectively reviewed. Using Brainlab Elements® the zygomatic bone and the orbit of each patient was segmented and mirrored. Subsequently, the mirrored side was matched with the other side via volume-based registration, using the segmented orbit as reference. Volumetric asymmetry was measured using 3-matic software, and a surface-based matching technique was used to calculate the mean absolute differences (MAD) between the surfaces of the two sides of the ZMC. The reliability of this novel method using volume-based registration was tested, and the intra-class correlation coefficient was assessed. ResultsThe MAD between the surfaces of the left and right sides in the control group was 0.51 mm (±0.09). As for the ZMC fracture group, MAD was 0.78 mm (±0.20) and 0.72 mm (±0.15) pre- and post-operatively, respectively. The MAD showed statistically significant differences between pre- and post-operative groups (p = 0.005) and between control and post-operative groups (p < 0.001). The intra-class correlation coefficient was high (≥0.99). ConclusionsThis evaluation method using mirroring and volume-based registration to determine the symmetrical position of the ZMC is reliable. The surface-based measurements revealed an improved symmetry after surgery. However, the symmetry of the treated patients remained lower than the control group.

Is Gillies Temporal Incision Necessary to Successfully Reduce Zygomaticomaxillary Fracture Combined With Orbital Wall Fracture?

Gillies temporal approach has been widely used to reduce zygoma fractures. Traditionally, it is the preferred method to reduce the isolated zygomatic arch fracture. It can be combined with other approaches, such as subciliary and intraoral incisions for more complex zygomatic fractures, so-called tripod fractures. In this study, the author hypothesized that complex zygomaticomaxillary bone fracture reduction can successfully be achieved without Gillies temporal incision. The author retrospectively analyzed the medical records and 3D facial Computed Tomography (CT) scans of 80 patients who had orbitozygomaticomaxillary fractures that affected >3 sites among the frontozygomatic suture, zygomaticomaxillary buttress, zygomatic arch, and orbital walls from May 2021 to August 2023. A single surgeon performed all surgical operations. All fractures were reduced with 2 incisions, lower eyelid incisions (subciliary or subconjunctival) and intraoral incisions (gingivobuccal approach), within a week of the initial traumatic event. After sufficient exposure to fractured sites using 2 incisions, the author reduced the fracture with a bony hook at the inferior orbital rim, lateral wall, or Boise elevator at the intraoral incision. All cases were successfully corrected without any complications. In conclusion, the author can successfully reduce complex zygomaticomaxillary fracture combined with orbital wall fractures without temporal Gillies approach.

Reconstruction Management for Neglected Tripod Fracture with Ophthalmic Injuries: A Case report

Introduction : Tripod fracture or zygomatico-maxillary complex fracture are among the most common injuries to facial structures, which can make reconstruction more difficult. This case highlights the reconstruction of neglected tripod fracture.&#x0D; Case Illustration : A 17-year-old male was presented with enophthalmos in his right eye. He had an accident three months prior and had received head surgery. After that, the patient came back with a pan-facial fracture. VA on RE was 1/300, limited movement upwards, 4 mm lagophthalmos, negative Bell’s phenomenon, infiltrates and cicatrices on the cornea. CT-scan examination showed tripod fractures. The surgery was performed by the reconstruction division with an oral and maxillofacial surgeon. Nineteen days after surgery, there has been some improvement in the orbital misalignment.&#x0D; Discussion : Delayed intervention in this case, increased the difficulty of surgical treatment and could lower the success rate of surgery. If the indication is obvious, an immediate intervention will give better results because soft tissue scarring is minimized and fractures are easily reduced. During the procedure, we released the orbital muscle entrapment and repaired the deviated bone and callus with an osteotome to achieve mobility. Therefore, the tripod fracture was fixed with three-point fixation, followed by reconstruction of the maxilla and mandible. The result after surgery showed some improvements in aesthetics but not in vision.&#x0D; Conclusion : Orbital reconstruction with mini-plate implants in three-point fixation as the management of orbital fractures is effective, but its accuracy is difficult to assess during surgery, especially when coupled with delayed intervention cases. Early reconstruction is recommended for a better cosmetic result.

Evaluation of Efficacy of Different Plating Systems in ZMC Fractures: An Original Research

ABSTRACT Objective: This study’s objective was to assess and contrast the performance of several plating techniques in the treatment of zygomaticomaxillary complex (ZMC) fractures. Group A (Microplate System), Group B (Titanium Mesh System), and Group C (Absorbable Plate System) plating systems were the ones that were studied. Materials and Methods: With 10 patients in each group, a retrospective analysis of 30 patients with ZMC fractures was done. The following information was gathered: fracture reduction, stable fixation, complications, and patient satisfaction. Analysis was done on patient-reported outcomes, surgical outcomes, and demographic factors. Results: Group B (Titanium Mesh System) came in second with rates of 70% and 80%, respectively, while Group A (Microplate System) showed the highest rates of fracture reduction (90%) and stable fixation (100%). For fracture reduction and stable fixation, Group C (Absorbable Plate System) demonstrated rates of 80% and 90%, respectively. For Groups A, B, and C, the complication rates were 20%, 30%, and 10%, respectively. For Groups A, B, and C, the patient satisfaction levels were 90%, 80%, and 70%, respectively. Conclusion: According to the results, the Microplate System (Group A) is better than the Titanium Mesh System (Group B) and the Absorbable Plate System (Group C) in terms of fracture reduction and stable fixation when treating ZMC fractures. All plating systems had acceptable complication rates, and overall patient satisfaction ratings were high. Fracture features and patient-specific considerations should be taken into account while making individualized treatment options.

Evaluation of Zygomaticomaxillary Complex Fractures with Gillies Approach in Al-Baha Region of Saudi Arabia: A Cohort Study.

The aim of this study was to evaluate the accuracy of the degree of fracture reduction after open reduction and internal fixation of Zygomaticomaxillary Complex (ZMC) fractures in the Saudi population of the Al-Baha region, using Gillies approach. Further comparison with preoperative and postoperative standardized computed tomography (CT) views with the calculation of residual deformity percentage, which remained after the ZMC rehabilitation. A 5-year retrospective CT-based study on preoperative and postoperative axial CT scans of 46 male patients with ZMC fractures. The CT measurements were made (in millimeters) at the fracture site of maximum displacement through the anterior orbital rim and orbital floor, posterolateral wall of the maxillary sinus, zygomatic arch, and zygomaticofrontal suture. For the zygomatic arch, measurements were made (in mm) by drawing a tangent to the fractured arch segments and dropping a perpendicular to the inward displaced fractured arch. The total difference in all measured parts between preoperative and postoperative displacement was calculated in percentages. Upon comparison of preoperative and postoperative zygomaticomaxillary complex CTs, three-point fixation at the regions of infraorbital rim, frontozygomatic suture, and posterolateral wall of the maxilla results in a reduction of the fracture sites in the range of 72.85% to 85%. Maximum reduction was noted at the zygomatic arch, that is, 85%, and minimum at the infraorbital rim, that is, 72.85%. The reduction obtained at all four sites was statistically significant, with P values ranging from .011 to .039. Gillies temporal approach and three-point fixation at the regions of the infraorbital rim, frontozygomatic suture, and posterolateral wall of the maxilla results in satisfactory treatment of ZMC fractures and improves patients oral health and quality of life.

Modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex fractures: A 5-year retrospective study

Our study aimed to evaluate modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex (ZMC) fractures.The retrospective non-randomized study was conducted in a single hospital in China. All patients diagnosed with unilateral comminuted ZMC fractures between January 1, 2018 and December 31, 2022 were retrospectively reviewed. All patients underwent preoperative spiral computed tomography (CT). CT data were processed using software to DICOM format and transferred to Proplan CMF3.0 for preoperative virtual surgical planning and postoperative evaluation. All data were extracted from standardized electronic medical records. All statistical analyses were performed using SPSS version 20.0. The chi-square test and t-test were used for statistical analyses.The 54 included patients were divided into two comparable, equal cohorts of 27 patients, and followed up for at least 6 months. Fracture reduction was assisted using the modified patient-specific surgical guides in the guide group (23 males, four females; mean age 37.74 ± 12.07 years) and without the modified patient-specific surgical guides in the control group (20 males, seven females; mean age 37.44 ± 13.58 years).In the guide group, the mean eminence deviation between the affected and unaffected sides was 1.01 ± 0.92 mm, and the mean width deviation between the affected and unaffected sides was 1.29 ± 1.32 mm. In the control group, the mean eminence deviation between the affected and unaffected sides was 1.99 ± 1.69 mm, and the mean width deviation between the affected and unaffected sides was 2.68 ± 2.01 mm. The differences in facial protrusion (p = 0.001) and width (p = 0.003) symmetry between the affected and healthy sides of the two groups were statistically significant (p < 0.05).In conclusion, applying the modified patient-specific surgical guides to unilateral comminuted zygomaticomaxillary complex fracture reduction has the advantages of greater predictability and effectiveness, and improved bilateral ZMC symmetry. It should be noted that this approach would be especially beneficial for less-experienced surgeons.

Intraoral Approach for Zygomaticomaxillary Complex and Orbital Floor Fracture With a Customized Ballooning Technique.

The zygomaticomaxillary complex and the orbital floor are commonly affected by mid-face fractures; their fractures pose challenges in reconstruction and can result in complications, such as enophthalmos. This study explores an intraoral approach with the help of a customized balloon technique and a contrast agent as an alternative to the conventional methods. A case report of a 67-year-old man with complex midfacial trauma is presented. The surgical process involved open reduction through an intraoral approach along with a transantral approach with the customized balloon technique. The procedure aimed to achieve reduction, fixation, and reconstruction of a complex mid-face fracture.

Role of finite element analysis for selection of single point fixation in zygomaticomaxillary complex fracture

BackgroundOne-point fixation was superior to the two and three-points fixation in minimally displaced zygomaticomaxillary complex (ZMC) fracture regarding the cost, invasiveness, scaring, number of wounds, and operation time. Accordingly, this study aimed to predict which one-point fixation is the most stable in managing minimally displaced ZMC fracture.Material & methodsThis study simulated the different one-point fixation approaches on three ZMC models after fracture reduction and application of all forces exerted on the fractured area. The findings were represented as stress impact on the ZMC fracture and plating system as well as the inter-fragments micro-motion.ResultsThe von misses stresses of plates for the zygomaticofrontal, infra-orbital rim, and zygomaticomaxillary buttress model were (66.508, 1.285, and1.16 MPa) respectively. While the screws’ von misses for the infraorbital rim, zygomaticofrontal, and zygomaticomaxillary buttress models were (13.8, 4.05, and 1.60 MPa) respectively. Whereas, the maximum principles stress at zygomaticofrontal, zygomaticomaxillary buttress, and infraorbital rim models were (37.03, 37.01, and 34.46 MPa) respectively. In addition, the inter-fragment micro-motion for zygomaticomaxillary buttress, infraorbital rim, and zygomaticofrontal models were (0.26, 0.25, and 0.15 mm) respectively.ConclusionOne-point fixation at zygomaticomaxillary buttress is the preferred point because it is exposed to low stresses, and the inter-fragment micro-motion is within the approved limit with the elements in the same direction of fixation which indicates the rigid fixation. In addition, it is less palpable and scarless.Trial registrationclinical trial.gov (NCT05819372) at 19/04/2023.

Revisiting the U-Shaped Elevator for Zygomaticomaxillary Fracture: Study and Comparison of Elevators for Zygomaticomaxillary Fracture Reduction

The authors present the case of a 15-year-old male who sustained a unilateral zygomaticomaxillary complex fracture and underwent open reduction and rigid internal fixation, for which a U-shaped elevator was utilized. The authors discuss techniques in reduction and fixation of zygomaticomaxillary complex fractures, focusing on the use of various elevators during reduction, including straight-type and curved elevators. The U-shaped elevator is a handheld tool with bilateral symmetrically curved ends that is seldom used, despite its specific benefits including nonslip serrated tips, symmetrical nature that allows for direct loading needed for accurate reduction, visualization of the fracture site, and avoidance of tissue compression during elevation.

Retrospective Analysis of Trends of Zygomaticomaxillary Complex Fractures in Patients Reporting to a Tertiary Health Center—Our Experience

Methods: A six years retrospective observational study was conducted on 183 patients with Zygomaticomaxillary complex (ZMC) fractures. We analyzed prevalence of age, gender distribution, etiology, location and mode of treatment. Results: In our study, the mean age was 33±14.5, gender distribution 68% males and 32% females, etiology of ZMC fractures was 114 road traffic accident (RTA), 44 falls, 12 sports injuries, five interpersonal violence, four animal bites, and four work-related. Results show that the treatment options applied are 37 conservative management and 146 open reduction internal fixation. Conclusion: In this study, male predilection to ZMC fractures was seen, RTA being the most common etiology and the most common site of fracture was Zygomaticomaxillary buttress region. There are different treatment protocols for the management of ZMC fractures. In our study, two-point fixation was the most common (35%). Concluding upon our experience and the results derived from our study, various methods are used to stabilize zygomaticomaxillary complex fractures. Relying upon the characteristics of the fracture, open reduction and internal fixation with mini plates is the most reliable modality providing three-dimensional stability.

Management of Greenstick Fracture at the Root of Adult Zygomatic Arch.

Greenstick fractures mostly occur in children and rarely in adults. In adult zygomaticomaxillary complex fractures, the greenstick fracture at the root of the zygomatic arch is occasionally encountered. This makes it difficult to move the fracture segment. Therefore, achieving anatomic reduction is very difficult. Our preoperative 3D repaired model shows that if only the maxilla and zygomatic bones are restored, the patient's face will still have depression and protrusion. The greenstick fracture segment at the root of the zygomatic arch needs to undergo osteotomy to achieve anatomic reduction and restore facial symmetry. The patient's facial appearance was restored after the surgery. The postoperative computed tomography scan showed good alignment of the fracture. The authors believe that a fracture at the root of the zygomatic arch can serve as an indication for open reduction and fixation.

Evaluation of one-point fixation surgery with computer-aided root mean square deviation in zygomaticomaxillary complex fractures

Aims: Our paper aimed to present the results of the one-point fixation method in zygomaticomaxillary fractures by computer-aided mirror image superimposition with root mean square (RMS) deviation.&#x0D; Methods: One-point fixation performed zygomaticomaxillary complex fracture patients (n=18) by one surgeon were included in our study. Virtual 3D data of preoperative and postoperative CT-scan images was obtained by Slicer software. Sagittal plan mirror image superpositioning were used to obtain RMS data by Slicer. Mirror image superimposition of the undamaged side to the broken side in preoperative CT-scan imaging was referred as group B or broken group. Superposition of the repaired side’s postoperative imaging to the preoperative broken side was measured as group R or repair group in order to examine zygomatic bone’s postoperative spatial location. Superpositioned mirror 3D images of the non-traumatic side onto post-fixation 3D in postoperative data was measured as group M or mirror group. RMS deviation values of the groups obtained by Slicer were statistically compared.&#x0D; Results: Shapiro-Wilk test of groups were demonstrated normal distribution of the data for each group with no difference (p&gt;0.05). In order to compare between groups, paired t-test covariance analysis were shown statistically similar data distrubition between experimental groups (p&gt;0.05).&#x0D; Conclusion: Considering the nature of maxillofacial surgery, which disapproves even millimetric errors, we believe that the mean square root deviation will become standard as it allows three-dimensional evaluation and precise mathematical measurements. Besides, in accordance with the recent literature, this study might pay the way for future studies that would increase the usage of the one-point fixation method conducted on larger case series, as this method prevents lower eyelid complications without a visible scar.

Refracture at the same area after zygomaticomaxillary complex fracture surgery: a case report

Refracture at the same area after zygomaticomaxillary complex fracture surgery: a case report

Changing Patterns of Zygomaticomaxillary Complex Fractures: A Retrospective Study

Limited research exists regarding the incidence and variations of zygomaticomaxillary complex (ZMC) fracture patterns and their correlation with the mechanism of injury. Hence, further research is indicated. The purpose of this study was to analyze the different ZMC fracture patterns in relation to its etiology using computed tomography scans. This retrospective cohort study was conducted at a single institution. The medical records of maxillofacial trauma patients from 2016 to 2020 were analyzed. Patients from any gender and all age groups with complete records diagnosed with isolated ZMC fractures were included in the study. The primary predictor variable was the etiology of trauma. It was categorized as road traffic accidents (RTAs), falls, interpersonal violence, fall from height, sports injuries, etc. MAIN OUTCOME VARIABLES: The primary outcome variable was the ZMC fracture patterns observed and was defined as similar to or different from the classical fracture patterns. Any type of variation noted from the classical fracture lines was defined as the secondary outcome variable. Covariates included demographic variables such as age, gender, the type of vehicle involved, the type of RTA, side of fracture, associated orbital fractures, and number of ZMC points fractured. Descriptive and bivariate statistics were used to measure association between the predictor and outcome variables using multiple proportions χ2 test. Statistical significance was defined at P value of <.05. Out of the 232 scans assessed, a total of 163 cases were included in this study. A majority of the cases belonged to a range of 21 to 30years and showed a male predilection. The most common mode of injury was found to be RTAs (88.3%). Most cases had fracture patterns different from the classical fracture patterns (65.64%). A statistically significant association was found between the types of ZMC fracture patterns and etiology of trauma (RTA P= <.0001, falls P=.0001, and interpersonal violence P=.0001). Five different variations in ZMC fracture patterns were found and had a statistically significant association with the classical fracture lines (P<.0001). The authors conclude that the variations in fracture patterns encountered today may be attributed to the mechanism of injury. With due consideration to the limitations of this study, the authors suggest that the treatment plan may require slight modification based on the variation of the fracture pattern. Additional intervention may also be indicated.