Surgical Management of a Firearm Injury in the Infraorbital Area / Manejo quirúrgico de una herida por arma de fuego en el área infraorbitaria

Abstract The surgical management of firearm injuries to the zygomaticomaxillary complex is a topic that needs to be addressed with much care. The complications that can arise during treatment, as well as the potential residual problems that can appear, lead to the need of recognizing these injuries as a maxillofacial treatment challenge. The infraorbital zone is the second most common area of injury in the face, accounting for up to 45% of midfacial fractures. The case presented is of a 54 year old man affected by the backward firing of a gun rifle that caused an oblique impaction towards the posterior lateral inferior side of the infraorbital complex. He was rapidly stabilized with an antibiotic and analgesic scheme, yet presented the following: a comminute fracture of the orbit floor with consequent communication towards the maxillary sinus, a non-displacing fracture of the frontomalar suture, a non-displacing fracture of the zygomatic arch and a lesion with loss of osseous tissue in the petrous region of the temporal bone. Rigid fixation followed stabilization, and the area was covered with a titanium mesh. Occasional tinnitus and photopsia were reported by the patient upon return, yet all other evaluated factors were in order. There have been different forms of management described in the literature, and it is recognized that each patient has different needs, therefore each case must be closely evaluated, so it is approached in the most appropriate manner.

Resumen El manejo quirúrgico de las lesiones por armas de fuego al complejo cigomaticomaxilar representa una situación compleja en la práctica maxilofacial que debe ser abordada con extrema cautela, debido a las complicaciones que pueden surgir durante el tratamiento y los potenciales problemas residuales. La zona infraorbitaria es la segunda área más común de lesiones en la cara, representando hasta 45% de las fracturas mediocraneales. El presente caso es de un masculino de 54 años de edad, que sufrió trauma ocasionado por la parte trasera de un rifle de caza que causó un impacto en sentido oblicuo hacia el lado lateral inferior del complejo infraorbitario. El paciente fue estabilizado con esquema antibiótico y analgésico, el diagnóstico fue: fractura cominuta del piso de la órbita, con consecuente comunicación al seno maxilar, fractura no desplazada de la sutura frontomalar, fractura no desplazada del arco cigomático, y lesión con pérdida de tejido óseo en la región petrosa del hueso temporal. El tratamiento quirúrgico consistió en reducción de las fracturas y fijación rígida de las estructuras. Al control post operatorio el paciente refirió acufenos y fotopsia ocasional, no presentando otras alteraciones. Se ha descrito en la literatura diferentes abordajes para el manejo de estos traumatismos, sin embargo cada caso debe ser individualizado y evaluado de forma minuciosa para que éste, sea el adecuado.

Fractura evolutiva: colocación de sistema derivativo cisto-peritoneal y corrección diferida: a propósito de un caso / Growing skull fracture: positioning system cisto-peritoneal derivative and correction deferred: report of a case

Describimos el caso de una paciente femenina de 5 años de edad, con antecedente de fractura craneal asociado a trauma directo en su segundo día de vida, posteriormente se diagnostica quistes porencefálico y aracnoideo frontoparietal izquierdo a los 3 meses de edad. Fue tratada en un primer momento con la colocación de sistema derivativo cistoperitoneal, y se le realizaron estudios de imágenes de seguimiento. A los 5 años de edad es traída a consulta de nuestro servicio de neurocirugía, por presentar deformidad calvarial en la superficie frontoparietal izquierda. El seguimiento con tomografía de cráneo demostró un cese relativo en la progresión en las dimensiones del quiste porencefálico y aumento del espacio entre los bordes óseos de la fractura. La paciente fue llevada a mesa operatoria, en la cual se realizó un abordaje hemicoronal izquierdo con resección de tejido gliótico, duroplastia con pericráneo y colocación de craneoplastía con tejido óseo craneal autólogo. El seguimiento al mes de la intervención correctiva mostró evolución satisfactoria y sin complicaciones. La cirugía correctiva de la fractura evolutiva, debe realizarse en el momento del diagnóstico para evitar su expansión. En concordancia con la teoría de Moss, se observa aumento del espacio entre los bordes de la fractura, aún con la disminución de la presión intracraneal al derivar el líquido cefalorraquídeo. En este caso, la intervención correctiva de la fractura, determinó una evolución satisfactoria, en ausencia de hidrocefalia o crisis convulsiva, posiblemente debida a la presión disminuida del quiste porencefálico sobre el parénquima subyacente.

We describe the case of a female patient of five years old, with a history of a skull fracture associated with direct trauma on his second day of life, then porencephalic left frontoparietal arachnoid cysts was diagnosed at 3 months of age. She was iniatially treated by plaing cystoeritoneal derivative system and follow-up imaging studies was performed. At 5 years of age is brought to clinic in our departmen of neurosurgery, for presenting calvarial deformity in the left frontoparietal area. The follow-p scan of the head showed a cease progression relative dimensions porencephalic cyst an increased space between the bone edges of the fracture. The patient was transferred to operating table, on which a hemicoronal left gliotico approach with resection of tissue was performed with dural graft placement craneoplasty bone tissue. Monitoring the month showed satisfactory corrective intervention and hassle evolution was performed with dural graft placement craneoplasty scalp and skull with autologous bone tissue. Corrective surgery of evolutionary fracture should be performed at the time of diagnosis to prevent its expansion. In agreement with the Moss theory, increasing the space between the edges of the fracture even with decreasing intracranial pressure deriving the cerebrospinal fluid was observed. In this case corrective intervention of the fracture produced a satisfactory outcome in the absence of hydrocephalus or seizure, possibly due to decreased pressure of porencephalic cyst on the underlying parenchyma.

Occipital Condyle Fractures in Traumatic Brain Injury­A Review / Fraturas de côndilo occipital no trauma cranioencefálico ­ uma revisão

É bem estabelecido que o diagnóstico da fratura de côndilo occipital tem aumentado nas últimas décadas, provavelmente devido à disponibilidade e ao uso comum da tomografia computadorizada durante a investigação do trauma craniano, além da maior gravidade dos mecanismos de trauma. Por causa da baixa especificidade da apresentação clínica, e também pelo pouco conhecimento sobre o mecanismo de lesão, o diagnóstico desta condição é um desafio para neurocirurgiões. A abordagem terapêutica destes pacientes é baseada em estudos com baixa casuística e em relatos de caso. Uma revisão sobre este tema foi realizada a fim de discutir alguns aspectos controversos sobre o manejo da fratura de côndilo occipital. As fraturas de côndilo occipital são eventos raros, entretanto podem relacionar-se à alta morbidade em pacientes que sofreram trauma encefálico. Alguns sintomas, como intensa dor cervical, podem estar associados com esta fratura; portanto, paciente com suspeita de fratura de côndilo occipital deve ser submetido a investigação radiológica detalhada da região. O diagnóstico precoce desta fratura permite investigação apropriada, minimizando a chance de sequelas.

It is well established that diagnoses of occipital condyle fracture have increased in past decades, probably because of the availability and common use of computed tomography for investigating traumatic brain injuries, as well as themajor seriousness of trauma mechanism. Because of the low specificity of clinical presentation besides the lesion mechanism not well known, this condition is a diagnostic challenge for neurosurgeons. Therapeutic approaches of these patients are based on studies with low samples and case reports. A review of this theme was performed objecting to discuss some controversial topics about management of occipital condyle fracture. The occipital condyle fracture is a rare event, and it, however, could be related to high morbidity in patients who suffered traumatic brain injury. Some symptoms such as severe neck pain are related with this fracture, and thus patients suspicious of this fracture should undergo detailed radiologic investigation of this region. Early diagnosis of this fracture allows appropriate investigation, thus minimizing the risk of sequelae.

Fracturas del tercio superior facial. Experiencia en el Servicio de Cirugía de Cabeza, Cuello y Máxilo-Facial del Hospital Nacional Dos de Mayo, 1999 û 2009 / Superior third facial fractures at Dos de Mayo National Hospital Head, Neck and Maxillo-Facial Surgery Service, 1999 - 2009

Introducción: Las fracturas del tercio superior facial corresponden a una patología importante pero poco frecuente en la especialidad de cabeza, cuello y máxilo-facial, consecuencia de traumatismos severos; determinarlas por edad, sexo y agente causal ayudará para su manejo. Objetivos: Determinar la presentación de fracturas del tercio superior facial por edad, sexo, agente causal y clasificación. Diseño: Estudio observacional descriptivo. Lugar: Servicio de Cirugía de Cabeza, Cuello y Máxilo-Facial del Hospital Nacional Dos de Mayo, Lima-Perú. Participantes: Pacientes con fractura del tercio superior facial. Métodos: Recolección de datos registrados en las historias clínicas, entre junio 1999 y mayo 2009. Principales medidas de resultados: Edad, sexo, agente causal y clasificación. Resultados: Se encontró 49 pacientes, 90 por ciento de sexo masculino, 67,5 por ciento entre 21 y 40 años de edad, 55 por ciento por accidentes de tránsito y 23 por ciento por robos; 41 por ciento eran solamente fracturas del tercio superior y 59 por ciento acompañadas del tercio medio facial. Conclusiones: Las fracturas del tercio superior facial son importantes en la región de la cara. El diagnóstico clínico depende de la estructura afectada. Se debe actuar oportunamente para evitar secuelas y complicaciones. Los accidentes de tránsito y robos son causas que van en aumento. Se espera que este trabajo ayude a elaborar protocolos de atención en servicios de emergencia...

Introduction: Superior third facial fractures represent an important but rare pathology in the specialty of head, neck and maxillofacial surgery, and result from severe trauma. Objectives: To determine the presentation of superior third facial fractures by age, sex, causal agent and classification. Design: Observational descriptive study. Setting: Head, Neck and Maxillofacial Surgery Service, Dos de Mayo National Hospital, Lima, Peru. Participants: Patients with superior third facial fracture. Methods: Medical records data between June 1999 and May 2009 were captured. Main outcome measures: Age, sex, causing agent and classification. Results: Forty nine patients were included. Ninety per cent were male, about two thirds (67.5 per cent) were between 21 and 40 years old. More than half of the lesions (55 per cent) resulted from traffic accidents and 23 per cent from robberies; more than 40 per cent had superior third fractures only and 59 per cent were accompanied by midface fractures. Conclusions: Superior third facial fractures are important in the facial region. Clinical diagnosis depends on the affected structure. Treatment should be timely to prevent sequelae and complications. Traffic injuries and robberies are increasingly important causes. This study may contribute to developing treatment protocols in emergency services...

Fractura compuesta de cráneo: reporte de casos y revisión de la literatura / Compound fracture of skull: case report and literature review

Introducción: Las fracturas son generalmente clasificados como simples (cerrada) o compuesta (abierta). En el caso de las fracturas de cráneo, pueden ser fracturas lineales, elevados, o triturado con la depresión. Fractura de cráneo compuesta rara vez se ha reportado en la literatura médica y cursa con una alta morbilidad y mortalidad. Los autores presentan seis casos de fracturas múltiples del cráneo, hablan sobre el tratamiento y pronóstico. Pacientes y métodos: Se analizaron seis casos de fractura compuesta del cráneo. Analizado por sexo, causa, localización, diagnóstico, tratamiento y pronóstico. Resultados: El sexo 5M / 1F. La edad media fue de 22 a. Las causas fueron: tres por agresión física, dos por accidente de coche y uno por explosión de neumático. Todos los pacientes fueron sometidos a TC. GCS medio al ingreso fue de 8. El tratamiento quirúrgico fue instituido en todos los casos. Tres pacientes desarrollaron infecciones (meningitis 2, empiema 1). Las secuelas fueron tres convulsiones, trastornos de la conducta 2. Hubo una muerte. Conclusión: La fractura compuesta del cráneo es rara y depende de la superficie del objeto y energía cinética. Las fracturas compuestas del cráneo con fragmentos de la depresión, son más frecuentes debido a la fuerza que se aplica hacia el cráneo. Su tratamiento inicial es quirúrgico y frecuentemente evoluciona con un mal pronóstico.

Introduction: Fractures are usually classified as simple (closed) or compound (open). In the case of skull fractures, they may be linear, high, or comminuted fracture with subsidence. The compound skull fracture has been rarely reported in medical literature and courses with high morbidity and mortality. The authors present six cases of compound fractures of the skull, discuss the treatment and prognosis. Patients and methods: We reviewed six cases of compound fracture of the skull. Analyzed according to gender, causes, location, diagnostic, treatment and prognosis. Results: The gender 5M / 1F. The mean age was 22 a. The two causes were physical aggression 3, car accident 2 and explosion of a tire 1. All patients underwent CT. Average score on ECG in admission 8. Surgical treatment was instituted all cases. Sequels were seizures 3 and behavioral disorders 2. There is one death. Conclusion: The compound fracture of the skull is rare and depends on the surface of blunt object and kinetic energy. The compound skull fractures with fragments of depression are more common, due to the force that is applied toward the skull. The initial treatment is surgical, and usually evolves with poor prognosis.

Original research paper patterns of head injuries in fatal road traffic accidents in a rural district of Maharashtra- autopsy based study.

Road traffic accidents are the major causes of death worldwide. Head injury is the single most common cause of mortality in road traffic accidents; head being the most vulnerable part of the body. The present study was undertaken on 138 victims of road traffic accidents, died due to head injury to find out the patterns of head injuries, their age and sex distribution and site distribution of different types of fractures. The highest incidence was seen in age group of 21-30 years and males clearly outnumbered females. In the present study, most of the incidents occurred between 1200 to 1800 hours. The maximum number of victims (39.57%) died while on the way to hospital. The motor-cyclists were the commonest group of victims and trucks being the commonest offending vehicles. Intracranial haemorrhages were seen in 113 cases, skull fractures were found in 95 cases and injury to brain in 51 cases. Linear fracture of skull with basal fracture was the commonest type and temporo-parietal region was involved predominantly. Subdural haemorrhage was the commonest haemorrhage observed.

Understanding temporal bone fractures

The temporal bone is the most complex bone in the human body and a tremendous force is required to fracture the temporal bone. Temporal bone fractures secondary to blunt trauma typically occur along structurally weakened points and can injure many vital structures, including the cochlear and vestibular end organs and the facial nerve, carotid artery, and jugular vein either alone or in combination. With the advent of advanced imaging techniques there has been better understanding of the temporal bone fractures. One should remember that temporal bone fractures are one of the serious conditions after head injury and can be associated with devastating complication if not identified and managed properly

Traumatic Entrapment of the Vertebrobasilar Junction Due to a Longitudinal Clival Fracture: A Case Report

Vertebrobasilar junction entrapment due to a clivus fracture is a rare clinical observation. The present case report describes a 54-yr-old man who sustained a major craniofacial injury. The patient displayed a stuporous mental state (Glasgow Coma Scale [GCS]=8) and left hemiparesis (Grade 3). The initial computed tomography (CT) scan revealed a right subdural hemorrhage in the frontotemporal region, with a midline shift and longitudinal clival fracture. A decompressive craniectomy with removal of the hematoma was performed. Two days after surgery, a follow-up CT scan showed cerebellar and brain stem infarction, and a CT angiogram revealed occlusion of the left vertebral artery and entrapment of vertebrobasilar junction by the clival fracture. A decompressive suboccipital craniectomy was performed and the patient gradually recovered. This appears to be a rare case of traumatic vertebrobasilar junction entrapment due to a longitudinal clival fracture, including a cerebellar infarction caused by a left vertebral artery occlusion. A literature review is provided.

Superior sagittal sinus and torcula thrombosis in minor head injury.

A 27-year-old man suffered a relatively minor trauma. He developed signs of raised intracranial pressure three days after injury. Investigations revealed superior sagittal sinus and torcular thrombosis.

Quiste leptomeningeo: hallazgos en TC y RM / Leptomeningeal cyst: findings in CT and MR

El quiste leptomeníngeo es una complicación de las fracturas craneales que ocurre mayoritariamente en población pediátrica. La existencia del mismo en adultos es rara. Presentamos el caso de un varón de 47 años que mostró un cuadro de acorchamiento en miembro superior derecho y desviación de la comisura bucal del que se recuperó en una hora. Los estudios de neuroimagen mostraron una destrucción irregular del hueso temporal derecho y una hipodensidad del tejido cerebral subyacente. La cirugía y el estudio histológico del hueso resecado mostraron que se trataba de un quiste leptomeníngeo asociado a un infarto cerebral.

Posterior fossa extradural hematoma.

OBJECTIVE: To review the clinical profile, radiology and treatment of Pediatric posterior fossa extradural hematoma (PPFEDH) and evaluate the outcome. METHODS: Posterior fossa extradural hematoma (PFEDH) is an uncommon trauma sequel and in pediatric age group is still rare. This article discusses 18 cases of PPFEDH seen over a period of 8 years and review the pertinent medical literature. Only a few studies discuss PPFEDH and in most of them outcome has been good. Trauma has been subtle and fracture of occipital bone is seen in majority of cases. Treatment has been operative in majority of the cases. RESULTS: Most of the patients were diagnosed only on high index of suspicion with a history of trauma on the occipit, fracture of the occipital bone and persistent symptoms suggestive of increasing intracranial pressure and posterior fossa space occupying lesion. CT scanning was done liberally to confirm the suspicion and the patients with hematoma were treated aggressively by surgical evacuation with good recovery in most of them. CONCLUSION: Authors suggest an aggressive approach in the event of PPFEDH. However some patients can be managed conservatively but they should be closely observed for clinical manifestation and CT scan routinely to evaluate the progress of hematoma radiologically. A strict criterion should be followed in choosing such patients for conservative treatment as highlighted in the study.

Diplopia in facial fractures.

A prospective study was made on facial fracture patients who received treatment in Siriraj Hospital from 1 Jan 1997 to 31 Dec 1998. We recorded the types of fractures which involved the orbit, diplopia, operations and results. From the 675 facial fracture patients in this period, there were 256 cases that involved the orbit. Diplopia was found in 17 cases; Orbital floor fracture 8, Zygomatic fracture 4, Le Fort fracture 4, and Medial aspect fracture of maxilla 1. Ten cases were recent fractures and seven cases were old fractures. The floor of the orbits were explored in all cases and repaired with silastic sheath, except 2 severe enophthalmos cases whose medial wall and the floor of the orbits were repaired with titanium mesh. Diplopia disappeared after operation in 14 cases. Three cases still had minimal diplopia in the upward-gaze position and all of them were old fracture cases. The authors concluded that diplopia was found in 6.64 per cent of orbital fractures. Fracture of the floor of the orbit was the most common cause. An early operation will give a better result than late repair.

Fraturas em crescimento do crânio / Growing skull fractures

Fratura em crescimento do crânio é uma complicaçäo rara que pode ocorrer na infância, como conseqüência de laceraçäo dural a partir de uma fratura linear. Apresentamos 9 casos operados e enfatizamos nova técnica, onde utilizamos a própria gálea aderida aos tecidos subjacentes à fratura para a reparaçäo do defeito dural.

Achados otoneurológicos em um caso de fratura do osso temporal / Otoneurologic findings in temporal bone fracture

Fratura de osso temporal é um achado freqüente em traumatismos cranianos. A linha de fratura pode ser paralela ou perpendicular ao maior eixo da pirâmide petrosa, caracterizando assim dois tipos de fraturas: longitudinal e transversal. Distúrbios cocleares e da funçao vestibular sao as complicaçoes tardias mais freqüentemente encontradas nos traumatismos caranianos. O objetivo deste trabalho é descrever resultados das avaliaçoes audiológica e vestibular de um paciente de 55 anos de idade, vítima de traumatismo crânio-encefálico pós-acidente automobilístico com fratura de osso temporal.

Cisto leptomeníngeo traumático: relato de caso / Traumatic leptomeningeal cyst: report of case

Os autores relatam um caso de cisto leptomeníngeo em um paciente do sexo masculino de 1 ano de idade, seis meses após trauma craniano. Tais cistos sao caracterizados pelo crescimento da fratura com laceraçao ou ruptura da dura-máter e herniaçao do conteúdo intracraniano, através da progressiva separaçao das bordas da fratura, sendo mais comum em crianças abaixo dos 3 anos. Exames clínicos e radiológicos do crânio devem ser feitos até a consolidaçao da fratura, para que o diagnóstico seja feito antes que se desenvolvam sintomas neurológicos graves.

Posterior fossa extradural haematoma.

Seventeen patients with posterior fossa extradural haematoma are presented. While 7 patients had acute course, 6 had subacute and 4 had chronic course. All patients had evidence of occipital injury. Two patients did not have any fracture in the occipital bone. Concomitant lesions included cerebellar contusion in 3 cases, cerebral contusion in 4 patients, supratentorial extradural haematoma in 2 and hydrocephalus in 2 patients. All but one patient were treated surgically. None of the supratentorial lesions were operated upon. All patients with subacute and chronic course had good outcome while 43% with acute course succumbed to death. Besides the initial clinical status the co-existing lesions signifying the increased severity of injury have influenced the mortality and quality of outcome. In presence of occipital fracture a careful observation and timely intervention are warranted.

Ar em hematomas extradurais: relato de dois casos / Air in extradural hematomas: report of 2 cases

Os autores relatam dois casos de presença de ar livre em hematoma extradural agudo. Trata-se de achado radiológico näo incomúm, mas que tem sido relatado infrequentemente na literatura

Fraturas craniofaciais e fístulas liquóricas / Craniofacial fractures and and liquoric fistulas

Lesöes combinadas do complexo craniofacial e da base do crânio säo comumente vistas como o resultado de acidentes de alta velocidade. Levando-se em conta a gravidade destes pacientes e o risco de lesöes associadas, um tratamento inicial por uma equipe multidisciplinar é requerido. Ao neurocirurgiäo e ao cirurgiäo craniofacial, cabe o cuidado a ser dispensado no sentido de uma correta definiçäo das lesöes, levando-se em consideraçäo o risco de severas complicaçöes, se uma lesäo dural for negligenciada. A relativa falta de sintomas na fase aguda, se compara com a severidade do politrauma, contrasta com o trágico futuro que pode ser observado. Uma avaliaçäo sistemática e precisa da regiäo afetada e a determinaçäo de critérios para uma intervençäo se apresentam como a chave para um correto manuseio das fraturas craniofaciais. O propósito do presente trabalho é apresentar dados referentes ao diagnóstico clínico e radiológico e estabelecer critérios para uma indicaçäo cirúrgica destas lesöes