Facial Trauma: General Principles of Management

Bone Incorporation of a Poly (L-Lactide-Co-D, L-Lactide) Internal Fixation Device in a Rat's Tibia: Microtomographic, Confocal LASER, and Histomorphometric Analysis

This study evaluated the bone incorporation process of a screw-shaped internal fixation device made of poly (L-lactide-co-D, L-lactide) (PLDLLA). Thirty-two male Wistar rats received 32 fixation devices (2 mm × 6 mm) randomly assigned to either the right or left tibia and one implant in each animal. After 7, 14, 28, and 42 days, the rats were euthanized and the specimens were subjected to microtomographic computed tomography (microCT) and histomorphometric analyses to evaluate bone interface contact (BIC%) and new bone formation (NBF%) in cortical and cancellous bone areas. The animals euthanized on days 28 and 42 were treated with calcein and alizarin red, and confocal LASER microscopy was performed to determine the mineral apposition rate (MAR). Micro-CT revealed a higher percentage of bone volume (p < 0.006), trabecular separation (p < 0.001), and BIC in the cortical (p < 0.001) and cancellous (p = 0.003) areas at 28 and 42 days than at 7 and 14 days. The cortical NBF at 42 days was greater than that at 7 and 14 days (p = 0.022). No statistically significant differences were observed in cancellous NBF or MAR at 28 and 42 days. Based on these results, it can be seen that the PLDLLA internal fixation device is biocompatible and allows new bone formation around the screw thread.

30-Day Post-Operative Complications of Facial Fracture Repairs: A United States Database Study

Study Design

Cross-sectional database analysis.

Objective

To define post-operative complication rates in facial fracture repair and to assess this data for patient characteristics which may be associated with post-operative complications.

Methods

We performed a retrospective cohort analysis of the National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. All patients included in this study sample must have (a) been ≥18 years old and (b) underwent surgical repair of a facial fracture during the study period by a plastic surgeon or otolaryngologist. Adverse outcomes at 30 days were characterized into four groups: superficial surgical site infection (SSI), deep SSI, organ space infection, and wound disruption.

Results

In total, 2481 patients met the primary outcome of facial fracture. Among the four fracture types assessed, 1090 fractures (43.9%) were mandibular, 721 were zygomatic (29.1%), 638 were orbital (25.7%), and 32 (1.3%) were Lefort. Of the entire cohort, 25 patients (1.01%) experienced a superficial SSI, 14 patients (.56%) presented with a deep SSI, 25 fractures (1.01%) returned with an organ space infection, and 23 patients (.93%) experienced some type of wound disruption. Smokers had a significantly higher risk of superficial SSIs (P < .05) and organ space infections (P < .05).

Conclusions

The majority of facial fracture patients do not experience post-operative complications. However, smokers and patients with diabetes mellitus were shown to be at an elevated risk of developing complications. Future research should further investigate this relationship and focus on developing interventions to improve post-operative outcomes.

Initial Assessment of the Facial Trauma Patient

The initial evaluation of the craniofacial trauma patient must be systematic, thorough, and consistent to ensure that injuries are not missed. Life-threatening conditions are first identified using ATLS principles, and focused head and neck examination conducted by a specialist then follows. Imaging is used to guide operative planning, as many craniofacial injuries ultimately benefit from repair to prevent permanent cosmetic or functional deformity. Peri-operative care is often multi-disciplinary in nature, and specialist consultation should be performed in an efficient fashion. Finally, it should be noted that surgeons operating in the maxillofacial region are at high risk for transmission of COVID-19, and risk of COVID-19 sequelae must be balanced with risks associated with the delay of treatment of craniofacial injury.

General Overview of the Facial Trauma Evaluation

The initial evaluation of maxillofacial trauma in athletes should first focus on the management of life-threatening injuries that require emergent care. Airway, breathing, and circulation are the 3 areas to be addressed first and foremost, as set forth by Advanced Trauma Life Support (ATLS) guidelines. Following the stabilization of the patient, a thorough physical examination and systematic review of any relevant imaging studies are imperative to ensure that injuries are not missed. Ultimately, management by the facial plastic surgeon should balance the goals of facial trauma restoration with the overall needs of the patient.

Automated 3D Analysis of Zygomaticomaxillary Fracture Rotation and Displacement

Background

The zygomaticomaxillary complex (ZMC) can experience a multitude of deforming forces. There is limited understanding on which deformities alter patient outcomes. This study utilized an automated, three-dimensional analysis to elucidate which fracture patterns and rotational deformities are most prevalent and associated with postoperative complications.

Methods

This study was a 7-year retrospective review of patients with unilateral ZMC fractures who underwent surgical intervention. Patient demographics, injury mechanisms, presenting symptoms, and postoperative outcomes were collected. Segmentation was completed using Mimics software. The lateral-medial, superior-inferior, and anterior-posterior axes were manually identified on the zygoma and then displacement, rotational direction, and rotational degrees were automatically calculated using Geomagic software. Total displacement score was generated by summation of individual displacement scores at each of the five sutures.

Results

Eighty-one patients satisfied inclusion criteria. The most prevalent rotational pattern of the zygoma was medially-superiorly-posteriorly (P < 0.001). When comparing rotation along the three axes, the zygoma had the greatest rotation along the lateral-medial axis compared with the superior-inferior (P = 0.003) and anterior-posterior (P < 0.001) axes. Within each axis, the zygoma was more likely to rotate medially than laterally (P = 0.003) and posteriorly than anteriorly (P = 0.01). Multivariate analysis identified total displacement scores and degrees rotated along the lateral-medial axis as significant predictors of facial complications and reoperation.

Conclusions

This study suggests that patients with unilateral ZMC fractures who undergo surgical intervention are at an increased risk for adverse outcomes with greater rotation along the lateral-medial axis and higher total displacement scores. Additionally, the automated analysis method described can provide objective data to better characterize ZMC fractures.

The use of interosseous dental wires and sutures for internal fixation in a patient with multiple comminuted middle facial fractures and facial nerve injury: A demonstrative case report

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We report on a case of multiple comminuted middle facial fractures.

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There was concurrent facial nerve injury.

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Fracture fixation was done with wires which is considered obsolete.

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Wire fixation was preferred to protect the facial nerve repair.

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The outcome was satisfactory.

Introduction

The use of plates and screws for facial fractures is considered the gold standard; providing accurate reduction and rigid fixation.

Case report

We report on a case with multiple comminuted middle facial fractures and concurrent facial nerve injury. The fractures were fixed with a combination of interosseous dental wires and polypropylene sutures with a satisfactory outcome.

Discussion

We aim to demonstrate two main advantages of wire/suture fixation in such cases when compared to plates and screws. Wire/suture fixation does not require periosteal dissection for fixation; and hence there is more preservation of the blood supply of the bony fragments. Furthermore, in the setting of concurrent facial nerve repair, the use of plates may risk re-injury of the repaired nerve during the late removal of the hardware. Interosseous wires/sutures do not require late removal and this is another advantage in these cases.

Conclusion

Interosseous dental wires and polypropylene sutures may be considered for fixation of multiple comminuted middle facial fractures and concurrent facial nerve injury.

Validation of the "Wisconsin Criteria" for Obtaining Dedicated Facial Imaging and Its Financial Impact at a Level 1 Trauma Center

Introduction

According to national trauma databases, 25% of all people injured have some type of facial injury. The gold standard for diagnosing bony trauma of the facial skeleton has been computed tomography (CT) scan. In 2011, the "Wisconsin criteria" were established and subsequently validated as a method to predict which patients truly have a facial fracture and warrant further imaging. The purpose of this study is to externally validate these criteria and determine the economic impact they might have on avoiding unnecessary CT scans.

Methods

This was a retrospective chart review. We collected 1000 patients who had undergone facial CT related to trauma and retrospectively applied the "Wisconsin criteria" based on physical exam documentation.

Results

Of the 1000 facial CT scans obtained, we identified 408 fractures, 12% of which required operative intervention. The "Wisconsin criteria" applied to our patient population had a sensitivity of 90% and a negative predictive value of 93%. Using these criteria resulted in a missed fracture rate of 2.8%. Finally, had these criteria been used to determine when a facial CT scan was indicated, our institution could be saving over US$300 000 annually.

Conclusion

The "Wisconsin criteria" are a reliable method to screen for facial fracture in trauma patients. Using a validated instrument tool to guide decision-making, we can avoid obtaining low-value imaging studies. This can have a large economic impact while maintaining safety and reliability in accurate diagnosis.

Considerations in Orbital Reconstruction for the Oncologic Surgeon: Critical versus Optimal Objectives

Background Orbital reconstruction following oncologic midface resection is uniquely challenging, and makes critical contributions to patient aesthetics, function, and identity. Approach is largely dependent on surgeon and patient preferences, and there exists no consensus on defect characterization. Objective The goal of the study is to provide a mental framework for the reconstructive oncologic surgeon to use as a foundation during his or her approach to the orbit. Design The design of the study is based on the review of current literature and expert opinion. Conclusions Critical versus optimal objectives must be set in orbital reconstruction, and a systematic approach should be followed. We approach orbital reconstruction by first deciding whether globe-sparing surgery is possible, or if orbital exenteration will be necessary. We then set critical and optimal objectives for our chosen pathway. Critical goals in globe-sparing reconstruction include maintaining orbital volume and preserving visual function, and an optimal goal includes preservation of the nasolacrimal system. Critical goals in orbital exenteration include obliterating the defect, sealing the skull base and nasal cavities, and allowing eye protection to be worn over the contralateral eye postoperatively. Optimal goals in exenteration include preparation for prosthetics, volume and bony replacement, eyelid-sparing technique, and consideration of postoperative radiation.

Postoperative CT of the Mandible Following Trauma: Review of Normal Appearances and Common Complications

RATIONALE AND OBJECTIVES

Surgeons aim to restore occlusion and jaw function to baseline status for patients with mandibular fractures using either closed treatment or reduction and fixation.

MATERIALS AND METHODS

Occlusion is defined as the relationship between the maxillary and mandibular teeth as they approach each other.

RESULTS

Radiologists should be familiar with the goals of repair to help identify which treatment is adequate as well as to diagnose potential complications. Some of the more common complications encountered are infection, nonunion or malunion, and malocclusion.

CONCLUSION

We provide a comprehensive review of both the desired and untoward CT findings after surgical repair of traumatic mandibular injuries.

Custom-made facemask as a coadjuvant in the postoperative treatment of sport-related facial trauma: Case report

Maxillofacial injuries are a regular consequence of sport activities that can force athletes to take a long time off from training and competitions. One way to decrease the time that the athlete needs to get back to his or her training exercises after surgery is to use a custom facemask as a coadjuvant in the postoperative recovery phase. This case report describes the case of a 16-year-old male athlete who suffered facial trauma (orbitozygomatic fractures) during a soccer game. After surgery, a facemask was used during the postoperative phase. He returned to his regular physical activities only 3 weeks after surgery. This simple and very efficient procedure is a good option for athletes who suffer facial injuries.

Blindness after facial trauma: epidemiology, incidence and risk factors: a 27-year cohort study of 5708 patients

OBJECTIVES

This was a 27-year study of a cohort of 5708 patients who had sustained maxillofacial fractures. Our purpose was to present the etiology, mechanism of trauma, site, and concomitant injuries that led to visual loss. We hypothesize that fractures caused by high-energy impact of the midface may be associated with blindness. A discussion of the treatment approaches is also included.

STUDY DESIGN

The study included 5708 patients who had sustained a maxillofacial fracture during the years 1985-2012. Patients' records were reviewed for gender, age, fracture site, etiology of trauma, concomitant injuries, method of treatment, length of hospital stay, and cause of blindness. The relationship of the above variables to blindness was investigated.

RESULTS

The incidence of loss of vision was 0.34%. A very strong association between firearm injuries and blindness was observed (P < .001). These patients spent much longer time in hospital (P < .01) and suffered serious concomitant injuries involving the brain.

CONCLUSIONS

Retrobullbar hemorrhage should be treated with lateral canthotomy, whereas in traumatic optic neuropathy, observation seems to be the safest thing to do. In patients with penetrating injuries of the globe, the immediate involvement of an ophthalmic surgeon is of paramount importance.

Postoperative CT of the Midfacial Skeleton After Trauma: Review of Normal Appearances and Common Complications

OBJECTIVE

The objective of this article is to describe the CT appearance of the midfacial skeleton after surgical repair of posttraumatic Le Fort, nasoorbitoethmoidal (NOE), and frontal sinus fractures. Several of the more commonly encountered complications will also be described.

CONCLUSION

Surgery after midfacial trauma is aimed at restoring both form and function. Knowledge of the principal tenets of Le Fort, NOE, and frontal sinus fracture repair is vital for radiologists to accurately assess the adequacy of treatment on postoperative CT and provide meaningful reports for the surgeon.

Trauma of the Frontal Region Is Influenced by the Volume of Frontal Sinuses. A Finite Element Study

Anatomy of frontal sinuses varies individually, from differences in volume and shape to a rare case when the sinuses are absent. However, there are scarce data related to influence of these variations on impact generated fracture pattern. Therefore, the aim of this study was to analyse the influence of frontal sinus volume on the stress distribution and fracture pattern in the frontal region. The study included four representative Finite Element models of the skull. Reference model was built on the basis of computed tomography scans of a human head with normally developed frontal sinuses. By modifying the reference model, three additional models were generated: a model without sinuses, with hypoplasic, and with hyperplasic sinuses. A 7.7 kN force was applied perpendicularly to the forehead of each model, in order to simulate a frontal impact. The results demonstrated that the distribution of impact stress in frontal region depends on the frontal sinus volume. The anterior sinus wall showed the highest fragility in case with hyperplasic sinuses, whereas posterior wall/inner plate showed more fragility in cases with hypoplasic and undeveloped sinuses. Well-developed frontal sinuses might, through absorption of the impact energy by anterior wall, protect the posterior wall and intracranial contents.

Frontal Sinus Fractures

The frontal bone serves a protective role, representing the transition between the facial skeleton and the cranium. Within its enclosure, the frontal sinus lies adjacent to many important intracranial structures, and injury to this region has severe complications if not properly managed. Historically, the goals of frontal sinus fracture management have been to best prevent intracranial complications with invasive procedures, but a recent shift favoring conservative management now aims to preserve the form and function of the frontal sinus and its outflow tract. With the advancement of endoscopic techniques and the development of new technologies, many alternatives to aggressive surgical management are available.

Managing a grossly comminuted and infected mandibular fracture using a maxillary extra-oral distractor as stabilizing agent: A clinical case report

Facial fracture management dates as early as Hippocratic era. Comminuted mandibular fractures are one of the challenging clinical condition requiring high surgical expertise to achieve a good functional and esthetic outcome. In presence of infection and other facial fractures managing comminuted mandibular fracture becomes more challenging.

Here we present a case of grossly comminuted and infected mandibular fracture with delayed presentation managed by using maxillary distractor as stabilizing agent. Using a maxillary distractor for managing a fractured mandible has been seldom reported in literature. Current case report gives idea to practicing clinician about the possibility of treatment beyond the established principles.

Treatment Outcomes following Traumatic Optic Neuropathy

BACKGROUND

Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision.

METHODS

Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion.

RESULTS

A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 ± 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15).

CONCLUSIONS

The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Prognostic Value of Ocular Trauma Scores in Patients With Combined Open Globe Injuries and Facial Fractures

PURPOSE

To assess the prognostic value of the Ocular Trauma Score in patients with combined open globe injuries and facial fractures.

DESIGN

Retrospective cohort study.

METHODS

A comprehensive chart review was conducted on 25 patients (28 eyes) identified from the Elmhurst City Hospital Trauma Registry between January 1, 2000 and June 30, 2012. Elmhurst City Hospital is a level 1 trauma center located in Elmhurst, New York, USA.

RESULTS

Average age was 52 (range 18-88) and patients were predominantly male (84%). The majority of patients had an Ocular Trauma Score of 1 (87.5%), and of these patients, 76% and 14% had final visual acuities of no light perception (NLP) and light perception/hand motion (LP/HM), respectively. These corresponded to 74% and 15% predicted by the original Ocular Trauma Score guidelines (100% sensitive and 100% specific). Ocular Trauma Score of 1 was associated with zone 3 eye wound location (P = .02). Independent of Ocular Trauma Score, initial visual acuity and frontal bone fractures were predictive of NLP (P = .006 and P = .047). Nonblindness was associated with nasal bone fractures (P = .047).

CONCLUSION

This study validates the use of the Ocular Trauma Score in patients with combined facial fracture and open globe injury. The presence of facial fractures does not appear to influence visual prognosis for open globe injuries with an Ocular Trauma Score of 1. In the absence of data to calculate a full Ocular Trauma Score, initial visual acuity was the strongest predictor of final visual outcome.

Mirror-Imaged Rapid Prototype Skull Model and Pre-Molded Synthetic Scaffold to Achieve Optimal Orbital Cavity Reconstruction

PURPOSE

Reconstruction of traumatic orbital wall defects has evolved to restore the original complex anatomy with the rapidly growing use of computer-aided design and prototyping. This study evaluated a mirror-imaged rapid prototype skull model and a pre-molded synthetic scaffold for traumatic orbital wall reconstruction.

PATIENTS AND METHODS

A single-center retrospective review was performed of patients who underwent orbital wall reconstruction after trauma from 2012 to 2014. Patients were included by admission through the emergency department after facial trauma or by a tertiary referral for post-traumatic orbital deformity. Three-dimensional (3D) computed tomogram-based mirror-imaged reconstruction images of the orbit and an individually manufactured rapid prototype skull model by a 3D printing technique were obtained for each case. Synthetic scaffolds were anatomically pre-molded using the skull model as guide and inserted at the individual orbital defect. Postoperative complications were assessed and 3D volumetric measurements of the orbital cavity were performed. Paired samples t test was used for statistical analysis.

RESULTS

One hundred four patients with immediate orbital defect reconstructions and 23 post-traumatic orbital deformity reconstructions were included in this study. All reconstructions were successful without immediate postoperative complications, although there were 10 cases with mild enophthalmos and 2 cases with persistent diplopia. Reoperations were performed for 2 cases of persistent diplopia and secondary touchup procedures were performed to contour soft tissue in 4 cases. Postoperative volumetric measurement of the orbital cavity showed nonsignificant volume differences between the damaged orbit and the reconstructed orbit (21.35 ± 1.93 vs 20.93 ± 2.07 cm(2); P = .98). This protocol was extended to severe cases in which more than 40% of the orbital frame was lost and combined with extensive soft tissue defects.

CONCLUSION

Traumatic orbital reconstruction can be optimized and successful using an individually manufactured rapid prototype skull model and a pre-molded synthetic scaffold by computer-aid design and manufacturing.

Emergency radiology: Maxillofacial and skull-base trauma

Craniofacial trauma is common following road-traffic accidents, assaults and falls and may occur in isolation or associated with other body injuries. Due to the complexity of the maxillofacial and skull-base region, initial diagnosis may be inaccurate or delayed, leading to significant morbidity. Multidetector computed tomography is the modality of choice following high-energy blunt or penetrating trauma. It allows accurate evaluation of the fracture patterns and associated soft tissue complications and aids the appropriate medical and surgical treatment. In this article, we review and classify the most common traumatic injuries to the maxillofacial and skull-base region and outline the role of imaging in establishing complications and prognosis.

Wire internal fixation: an obsolete, yet valuable method for surgical management of facial fractures

In some developing countries wire is still widely used in facial fractures internal fixation. This study presents the effectiveness and complications of wire osteosynthesis in a university teaching hospital in Burkina Faso and discusses some of its other benefits and disadvantages. Notes of 227 patients with facial fractures treated by wire internal fixation at department of stomatology and maxillofacial surgery of CHU Souro Sanou, Burkina Faso between 2006 and 2010 are reviewed retrospectively. A satisfactory treatment outcome was recorded in 91.2% of the 227 patients. Complications occurred in 8.8% of the patients who had operative site infection (3.1%), malocclusion (1.8%), sensory disturbance (1.8), facial asymmetry (1.3%), delayed bone union (0.9%) or enophtalmos (0.4%). The overall complications rate was 7.4% after mandibular osteosynthesis, 6.9% after Le Fort osteosynthesis and 6.5% after zygoma osteosynthesis. Post operative infections occurred irrespective to the surgical site. The other complications were more specific to the surgical site. Wire internal fixation may be a reasonable alternative for the surgical treatment of non-comminuted facial fractures and those without bone substance loss, in the setting of limited resources.

Spectrum of critical imaging findings in complex facial skeletal trauma

Multidetector computed tomography (CT) is the modality of choice for the evaluation of facial trauma because it helps accurately identify and characterize fractures and associated complications, thereby aiding timely clinical management and surgical planning. In particular, CT clearly depicts clinically relevant fractures in the eight osseous struts or buttresses that function as an underlying scaffold for facial structures. Information about the involvement of specific facial buttresses in a complex fracture is helpful for determining the type of fracture present and for identifying associated soft-tissue injuries that may require urgent care or surgery. Various kinds of complications can be expected to occur in Le Fort fractures, which affect the full thickness of the pterygoid plates, with resultant dissociation of part or all of the maxilla from the skull base; naso-orbitoethmoid complex fractures, which involve the medial orbital wall, nasal bone, ethmoid sinuses, and, often, the attachment site of the medial canthal tendon; zygomaticomaxillary complex fractures, which disrupt all four zygomatic sutures and may lead to enophthalmos due to increased orbital volume because of angulation of the lateral orbital wall; orbital "blowout" fractures, which may result in extraocular muscle herniation or entrapment and injuries to the globe or the infraorbital nerve; and fractures of the alveolar process, which are treated as open fractures because of their extension through the gingiva to the oral cavity and their resultant vulnerability to infection. Similarly, extension of a frontal sinus fracture through the posterior sinus wall creates a portal to the anterior cranial fossa and may lead to cerebrospinal fluid leakage, intracranial hemorrhage, or intracranial infection.

[Maxillofacial fractures: midface and internal orbit. Part 2: therapeutic options]

While the state of the art of clinical assessment and imaging techniques were described in Part 1, this contribution presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments and advances are characterized by limited versus extended surgical approaches, by standardization of osteosynthesis principles with regard to three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intraoperative and postoperative imaging. Newly developed resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension in order to reduce ptosis effects in the cheeks and nasolabial area to achieve facial aesthetics similar to those prior to the injury.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes

INTRODUCTION

Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010.

METHODS

We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes.

RESULTS

Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively.

CONCLUSIONS

Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

Cholesteryl group- and acryloyl group-bearing pullulan nanogel to deliver BMP2 and FGF18 for bone tissue engineering

To create a drug delivery system that allows the controlled release of proteins, such as growth factors, over a long-term period, cholesteryl group- and acryloyl group-bearing pullulan (CHPOA) nanogels were aggregated to form fast-degradable hydrogels (CHPOA/hydrogels) by cross-linking with thiol-bearing polyethylene glycol. The gold standard of clinical bone reconstruction therapy with a physiologically active material is treatment with recombinant human bone morphogenetic protein 2 (BMP2); however, this approach has limitations, such as inflammation, poor cost-efficiency, and varying interindividual susceptibility. In this study, two distinct growth factors, BMP2 and recombinant human fibroblast growth factor 18 (FGF18), were applied to a critical-size skull bone defect for bone repair by the CHPOA/hydrogel system. The CHPOA-FGF18/hydrogel displayed identical results to the control CHPOA-PBS/hydrogel, and the CHPOA-BMP2/hydrogel treatment imperfectly induced bone repair. By contrast, the CHPOA-FGF18 + BMP2/hydrogel treatment strongly enhanced and stabilized the BMP2-dependent bone repair, inducing osteoprogenitor cell infiltration inside and around the hydrogel. This report indicates that the CHPOA/hydrogel system can successfully deliver two different proteins to the bone defect to induce effective bone repair. The combination of the CHPOA/hydrogel system with the growth factors FGF18 and BMP2 might be a step towards efficient bone tissue engineering.

Oral and maxillofacial trauma and the use of telemedicine in the grampian region of Scotland: a retrospective study

Objectives

To evaluate the amount and nature of adult facial trauma in Aberdeen, Scotland's third largest city, that requires referral to Aberdeen Royal Infirmary oral and maxillofacial surgery department by the Emergency Department and Grampian's telemedicine service over a six month period.

Material and Methods

A retrospective audit using oral and maxillofacial surgery trauma clinic and theatre records to identify Emergency Department (ED) notes for those patients presenting with facial trauma. ED notes were examined to extract demographic data on each patient as well as information on the nature and outcomes of the facial trauma. This data was compared with previously published national and international statistics.

Results

137 patients were identified with a mean age of 33.7 years with a standard deviation of 16.7. 83.2% of facial trauma victims were male and 62% of facial injuries were caused by alleged assault. Only 1 patient was referred to Aberdeen Royal Infirmary by telemedicine.

Conclusions

Aberdeen has a high number of injuries caused by interpersonal violence. Telemedicine is an underused resource in the referral and review of facial trauma at Aberdeen Royal Infirmary.