Temporal bone fractures in children.

Fifty children with temporal bone fractures were treated during a 40-month period. The diagnosis and management of temporal bone fractures in children is reviewed. The author's cases are classified as to longitudinal and transverse fractures, and the figures are presented for age distribution, sex, cause, loss of consciousness, CSF otorrhea, hearing loss, permanent tympanic membrane perforations, and facial nerve involvement. The author has followed a conservative method of management. Permanent impairment was not frequent, although all the patients with transverse fractures suffered total loss of hearing in the involved ear.     

Cadaveric Dissections Based on Observations of Injuries to the Temporal Bone Structures following Head Trauma

One hundred temporal bones obtained from forensic autopsies were dissected to expose injured structures. Longitudinal fractures were present in 82%, transverse fractures in 11%, and mixed fractures in 7% of the cases. Facial canal injuries were present in almost half of the bones with longitudinal fractures (36/82), although cuts of the facial nerve stem were rarely encountered. Damages to the facial canal associated with longitudinal fractures were most frequently seen in the region of the geniculum. However, transverse fractures with facial canal involvement (7/11) most frequently occurred in the labyrinthine portion, causing a complete cut of the facial nerve. Injuries to the jugular bulb were also common (21/100) and associated with all types of temporal bone fractures. Observed damages to the auditory ossicles included disconnection of their joints or fractures of the malleus or stapes. Fractures of the incus were not observed. Injuries to the carotid canal were common (52/100), although an injury to the arterial wall was observed in only one specimen. The frequency and nature of damage in temporal bone fractures strictly reflect the type of fracture, especially in terms of facial nerve disorders: the most serious damage is observed with fractures that involve the otic capsule.     

Severity of injuries associated with femoral fractures as a result of motor vehicle collisions

Introduction: Femoral fractures are often the result of high-velocity injuries, and the early identification of associated injuries is important. The purpose of this study was to review the associated injuries present in a current UK series of patients who sustain femoral fractures as a result of motor vehicle accidents. Materials and methods: All cases of femoral fractures were extracted from the UK co-operative crash injury study (CCIS) database, from 1998 to 2002. Associated injuries, skeletal and non-skeletal, were identified by body region and severity (according to the abbreviated injury scale and injury severity scale). Results: A total of 5,841 crashes were investigated in that time period, and there were 365 car occupants who sustained a femoral fracture. The 16–35 age group accounted for nearly half of all cases. A total of 313 patients (85.2%) had at least one other concomitant significant injury, of which 84 (23.0%) had skeletal injury only, 45 (12.3%) had non-skeletal injury only, and 184 (50.4%) had both. The opposite lower limb was the most common skeletal injury, and thoracic injuries were the most common visceral injuries. Thoracic injuries also accounted for the most serious injuries (AIS 4–6). The overall mortality was 40.5% in our series. Conclusion: Concomitant injuries are to be expected in the majority of cases of femoral fractures sustained as a result of MVCs. There should be a low threshold for involving a general surgical team in the management of these cases.     

Adult spontaneous CSF otorrhea: correlation with radiographic empty sella.

OBJECTIVE: To determine the prevalence of radiographic empty sella in patients with spontaneous cerebrospinal fluid (CSF) otorrhea. STUDY DESIGN AND SETTING: Retrospective case series of adult patients with CSF otorhinorrhea at an academic tertiary medical center. Patients with history of skull base surgery, trauma, tumor, or chronic ear disease were excluded. Available imaging studies were reviewed with attention to the sella turcica. RESULTS: Eight patients were diagnosed with spontaneous CSF otorrhea. Five of seven patients with adequate imaging studies (71%) had a radiographic empty sella. Seven of eight patients were clinically obese, with a body mass index BMI>30 kg/m2. CONCLUSIONS: Empty sella is a common radiologic finding in patients with spontaneous CSF otorrhea. This supports the theory that increased intracranial pressure contributes to development of spontaneous CSF otorrhea. SIGNIFICANCE: Radiographic empty sella predicts elevated intracranial pressure, which may require further evaluation and treatment in patients with spontaneous CSF otorrhea. EBM rating: C-4.     

下肢长骨骨折并发同侧膝关节损伤

作者统计４２０例下肢长骨骨折，３１例经影像学检查或手术证实并发同侧膝关节损伤。在此类损伤中高能量伤占９３．５％，其中交通伤（包括井下）占５１．６％。长骨骨折多为不稳定型，而且骨折越靠近膝关节越易并发膝关节损伤。在并发的膝关节损伤中韧带伤明显多于其它伤，其中内侧副韧带伤占韧带伤的６３．６％。膝关节损伤极易漏诊，其中交叉韧带伤漏诊最多；而股骨、胫骨均有骨折者其膝关节损伤最易漏诊。为防止漏诊，对下肢长骨骨折并发膝关节肿胀、积液者应运用稳定试验、Ｘ线平片、麻醉下或手术固定长骨骨折后稳定试验、Ｂ超和关节镜等手段查明膝关节损伤的类型。我们对长骨骨折及有手术指征的膝关节损伤行早期手术治疗，效果较为满意。     

Gunshot injuries of the temporal bone

Concurrent with the increase in handgun crime in the United States is a rising incidence of gunshot wounds to the temporal bone. These injuries present challenging diagnostic and management problems to the otolaryngologist. A timely multicenter review of this entity revealed 22 cases evaluated and treated by the authors between 1975 and 1984. A wide variety of injuries were encountered, involving anatomic structures within or contiguous with the temporal bone. These included: eight intracranial injuries; 11 traumatized facial nerves; seven vascular wounds; 19 mastoid, middle, or inner ear injuries; and 11 cases of damage to the external auditory canals. A rational scheme for immediate and long-term management of each type of injury is outlined. Illustrative cases representing vascular, neural, temporal bone, and central nervous system injury are presented.     

Pediatric temporal bone fractures in a rural population.

OBJECTIVE: To examine pediatric temporal bone fractures in a rural population. STUDY DESIGN AND SETTING: A retrospective chart review of pediatric temporal bone fractures between January 1, 1996, and December 31, 2000, at a rural academic medical center. RESULTS: A total of 108 patients were identified. Common etiologies include falls, bicycle-related injuries, and motor vehicle accidents. Animal-related injuries were identified primarily in patients under 5. Facial nerve injuries were noted in 7%, hearing loss in 16%, additional skull base fractures in 65%, and intracranial injuries in 75%. CONCLUSIONS: Temporal bone fracture etiology in the rural pediatric population is associated with age. Young children may suffer fractures secondary to animal-related accidents. Patterns of injury differ little between rural and urban settings. SIGNIFICANCE: Animal-related accidents may be a significant cause of temporal bone trauma in rural young children. Our data remain unique in that we report additional skull base fractures as well as intracranial injuries in this population.     

Childhood fractures requiring inpatient management

INTRODUCTION: Fractures account for significant morbidity during childhood. Children requiring inpatient management for their fractures represent the most serious injuries. The aim of this study was to identify injury patterns in childhood fractures requiring inpatient management at a regional trauma centre. METHODS: Three thousand and forty two consecutive injured children were admitted to our orthopaedic centre over a 4-year period. Data was prospectively collected by independent audit clerks and entered onto a database. Data recorded included type of injury, mechanism of injury and place of injury. This was then used to assess injury patterns and trends. RESULTS: Upper limb and lower limb fractures accounted for 51% (n=1,565) and 21% (n=637) of all emergency admissions, respectively. Other causes included soft tissue injury, Infections, Polytrauma and Dislocations. Twice as many males were admitted with upper or lower limb fractures compared to females (67% versus 33%) (P<0.001). Males were more likely to be older (P<0.001) compared to females. Distal radial fractures accounted for 60% of upper limb fractures. Distal and midshaft tibial fractures accounted for 52% of lower limb fractures. Sports injuries were responsible for the majority of lower limb fractures with falls accounting for the majority of upper limb fractures. Fracture incidence peaked during summer months. CONCLUSION: Males are twice as likely to require inpatient management for fractures as females. Male adolescents are particularly at risk. Distal radial fractures following falls and distal tibial fractures following sports injuries are the most common fractures requiring admission. Identifying ways of minimising risk of these injuries would reduce childhood morbidity.     

Patterns of osseous injuries and psychosocial factors affecting victims of child abuse

The aim of this paper is to document experience in the management of cases of child abuse with suspected osseous injury, at the Adelaide Children's Hospital, during the period January 1974-December 1986. The study is a retrospective review of the casenotes, radiographs and radiologists' report of 108 consecutive cases with suspected osseous injuries. Information regarding the osseous injuries sustained and the pyschosocial environment surrounding the circumstances of the patients admitted was recorded. Of 108 cases of suspected osseous injuries, 90% had confirmed osseous injury, of whom 56 cases (52%) had multiple fractures. Twenty of the 41 cases of single osseous injury were due to skull fractures. In children less than 12 months of age, long bone injuries were the most common form of presentation, and in 83% of these the injuries were multiple. Metaphyseal injury in association with other fractures was present in 14% of cases, and 8% of cases showed evidence of periosteal reaction to injury. There were two deaths during the period of this study, as a direct consequence of abuse. The main cause of death in both of these cases was the combination of cerebral haemorrhage and liver trauma. There were 10 other deaths not associated with fracture during this period. The analysis of psychosocial factors demonstrated that 48% of the children were first-born and 67% of parents were unemployed. Of the alleged abuser, the mother was known to be responsible in 50% of cases. In 10% of cases, the parent responsible for the injury admitted to the offence at the time of presentation at the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of cerebrospinal fluid otorrhea 6 years after temporal bone fracture

A 16 year-old female was admitted to our hospital because of left temporal bone fracture and brain contusion in the left temporal lobe. CSF otorrhea was also present for a week. Four years later, when she was 20 years old, she was noticed to have a white mass in the left external auditory canal. One and a half year later, left CSF otorrhea reappeared, and she was readmitted to our hospital. High resolution coronal CT revealed that the left temporal bone fracture had opened widely and brain tissue had herniated into the left external auditory canal. Metrizamide CT cisternography showed that CSF was leaking around the mass. Operative findings have shown that there were two dural defects, both of which were 2 cm in diameter, and brain tissue surrounded by arachnoid membrane had herniated through these defect. The herniated brain tissue was removed, and both dural- and osteo-plasty were successfully carried out. This case indicates that dissociation of temporal bone fracture and laceration of dura mater may cause herniation of brain tissue and CSF otorrhea years later.     

Causes of infections and management results in penetrating craniocerebral injuries

From February 1992 to December 1994, 148 patients with penetrating craniocerebral injuries were treated surgically with primary and secondary debridement including repair of dural defects and removal of retained intracranial bone and metal fragments. Dural defects were closed primarily or with temporalis fascia, pericranium, and cadaver graft. Cerebrospinal fluid fistulas were observed in 11(7.3 %) patients; 7 of these were infected. Central nervous system (CNS) infection was seen in 2 patients without CSF fistula. Excluding those 11 patients with CSF fistula, CNS infection was shown in 2 of the 137 cases (1.5 %). All patients underwent CT scans periodically. In 51 (34 %) of 148 patients, bone and metal fragments were determined on control CT scans. During this time, 12 patients died (8 %). Most of deaths were caused by the direct effect of brain injury and occured within the first month after injury. Fragments retained after first debridement were followed periodically by CT scan. Surgery was not performed until infection developed. Retained fragments did not increase the infection risk, but high rates of infection did occur in cases with CSF fistula.     

Vertebral fractures and abdominal trauma. A retrospective study based on 415 documented vertebral fractures]

415 spinal fractures were analysed retrospectively. A simultaneous occurrence of vertebral fracture and abdominal trauma was found in 14 patients (3.4%). The mechanism of injury was a fall from a considerable height in 9 cases, a car accident in 3 and a motorcycle accident in 2. Isolated fractures of the transverse processes and rotational injuries of the spine were found to be associated particularly frequently with an abdominal trauma (3 of 14 isolated fractures of the transverse processes = 22%, 5 of 61 rotational injuries = 8.2%), while compression injuries only showed such a simultaneous abdominal injury in 2% of the 300 fractures of this type. We never encountered the combination of distraction injury/abdominal trauma. This is probably because two-point lap-type seat belts are only rarely used in our country. In 2 patients with rotational injuries neurological deficits were observed. The abdominal injuries encountered in our patients were: massive concussion of the kidney (6 cases), rupture of the spleen (3 cases), rupture of the liver (2 cases), rupture of the mesocolon (2 cases), rupture of the caecum (1 case), rupture of a pre-existent aneurysm of the aorta (1 case), rupture of a renal artery (1 case), massive retroperitoneal haematoma (1 case). Other injuries were present in 12 of the 14 patients: 3 craniocerebral injuries, 7 fractures of the long bones, 6 injuries to the thorax and 3 to the pelvis. In conclusion, a simultaneous finding of vertebral fracture and abdominal trauma is rare in our patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

HRCT和增强MRI诊断面神经损伤

目的探讨HRCT、增强MR扫描诊断面神经损伤的价值。方法对18例面神经损伤患者行HRCT及增强MR扫描。在Philips EBW工作站行面神经管、面神经CPR,观察颞骨骨折部位、类型、面神经管、面神经受累及走行。采用GE AW 4.5工作站,与健侧相比,观察患侧面神经受累位置、粗细及信号变化。结果 18例中,纵行骨折8例、横行骨折5例、混合型骨折5例。HRCT轴位及CPR显示颞骨骨折18例,其中面神经骨管迷路段受累1例,膝状神经窝受累2例,鼓室段受累4例,膝状神经窝、鼓室段同时受累并发中耳腔积血2例,面神经管鼓室段与中耳腔积血关系密切3例,面神经管骨壁无明显骨折6例。增强MRI及CPR显示面神经损伤18例,其中内听道段受累12例,迷路段受累14例,膝状神经节受累18例,鼓室段受累16例,乳突段受累15例。患侧面神经内听道段、迷路段、膝状神经节、鼓室段、乳突段信号强度比值均高于健侧(P均0.001)。结论 HRCT、增强MRI可评价不同节段面神经损伤,CPR可直观显示颞骨内面神经及骨管损伤。     

膝关节后交叉韧带损伤的临床流行病学分析

目的:研究膝关节后交叉韧带损伤的临床特点及其分布规律.方法:回顾性分析2006年1月至2013年6月确诊的326例膝关节后交叉韧带损伤患者临床资料,将病例按损伤类型分组,对性别、侧别、年龄、受伤原因、受伤至就诊时间、合并损伤等因素进行分析,同时比较不同类型后交叉韧带损伤的个体化因素及合并损伤情况.结果:后交叉韧带损伤患者男性占73％,30～50岁是发病高峰(59％),患者多于伤后1个月内就诊(62.6％);受伤原因以交通伤为主(59％);合并损伤中前交叉韧带损伤最多(46.9％),其次为内侧副韧带(29.8％)和后外侧角(26.1％);后交叉韧带实质部损伤较止点撕脱骨折多,发生合并损伤的概率也较后者高(P＜0.05),受伤原因差异也具有统计学意义(P＜0.05);单纯止点撕脱骨折与单纯实质部损伤在发生率和就诊时间方面差异具有统计学意义(P＜0.05).结论:后交叉韧带损伤以实质部损伤为主,合并损伤率较高,以ACL损伤最常见;止点撕脱骨折以胫骨侧为主,多由低能量暴力导致,合并损伤较少;实质部损伤多由高能量暴力所致,多有合并损伤;单纯止点撕脱骨折发病率较单纯实质部损伤高.     

Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations

OBJECTIVE: To assess the practicality and utility of the traditional classification system for temporal bone fracture (transverse vs. longitudinal) in the modern Level I trauma setting and to determine whether a newer system of designation (otic capsule sparing vs. otic capsule violating fracture) is practical from a clinical and radiographic standpoint. METHODS: The University of Massachusetts Medical Center Trauma Registry was reviewed for the years 1995 to 1997. Patients identified as sustaining closed head injury were reviewed for basilar skull fracture and temporal bone fracture. Clinical and radiographic records were evaluated by using the two classification schemes. RESULTS: A total of 2,977 patients were treated at the trauma center during this time. Ninety (3%) patients sustained a temporal bone fracture. The classic characterization of transverse versus longitudinal fracture (20% vs. 80%, respectively) was unable to be determined in this group; therefore, clinical correlation to complications using that paradigm was not possible. By using the otic capsule violating versus sparing designation, an important difference in clinical sequelae and intracranial complications became apparent. Compared with otic capsule sparing fractures, patients with otic capsule violating fractures were approximately two times more likely to develop facial paralysis, four times more likely to develop CSF leak, and seven times more likely to experience profound hearing loss, as well as more likely to sustain intracranial complications including epidural hematoma and subarachnoid hemorrhage. CONCLUSION: The use of a classification system for temporal bone fractures that emphasizes violation or lack of violation of the otic capsule seems to offer the advantage of radiographic utility and stratification of clinical severity, including severity of Glasgow Coma Scale scores and intracranial complications such as subarachnoid hemorrhage and epidural hematoma.     

Physical therapy within the scope of fracture treatment in children. Recommendations of the Traumatology in Childhood Study Group

Physiotherapeutic follow-up treatment is required only in exceptional cases of fractures in childhood. Physiotherapeutic indications are justified for fractures with months of immobilisation, multiple fractures, fractures accompanied by soft-tissue defects and nerve injuries, vertebral fractures, fractures and craniocerebral trauma, and fractures entailing the risk of bone necrosis. Passive exercises are not at all indicated.     

Otologic surgery following ear trauma.

OBJECTIVES: To investigate common presentations and expected outcomes in patients with traumatically induced otologic dysfunction. STUDY DESIGN: Retrospective case review of patients who underwent otologic surgery for sequelae of otologic trauma over a 28-year period. Patients were stratified into major and minor trauma cohorts. Major trauma was designated as closed head injury with or without temporal bone fracture; lower-energy insults comprised the minor trauma group. Preoperative and postoperative audiograms were obtained and correlated with extent of injury. SETTING: Tertiary referral center. RESULTS: Major trauma accounted for 44.9 percent of all patients. The remaining 55.1 percent suffered minor trauma, of which simple traumatic tympanic membrane perforation was the most common insult (33.6%). Two hundred twenty-seven cases were performed on 214 patients. Pure tone averages improved a significant 20.8 dB to essentially normal levels postoperatively. CONCLUSION: Regardless of injury extent, surgical rehabilitation of conductive losses attains excellent hearing results that surpass those historically reported for the chronic ear population.     

Temporal bone fracture: Evaluation in the era of modern computed tomography

BackgroundTemporal bone fractures (TBFs) are harbingers of high energy head trauma that can result in a variety of significant complications of the auditory, vestibular, nervous, and vascular systems. Multiple cohort studies have identified the incidence and proper evaluation of these fractures. We hypothesize that these have changed with the advent of modern high resolution computer tomography (CT) imaging.MethodsWe performed a retrospective review of all TBFs admitted to an urban level one trauma center between June 1, 2011 and May 31, 2015. A database was compiled including demographics, physical exam findings, imaging performed and results, morphology and directionality of fracture as well as outcomes and follow-up.ResultsOne hundred thirteen patients were identified, representing 4.7% of skull fractures and 35.9% of skull base fractures. Most were subsequent to falls (41.6%) followed by pedestrian vehicular trauma (19.5%). The majority of TBF patients (67.3%) had additional fractures of the skull and 77.9% of TBF patients also had some kind of intracranial hemorrhage. The morphology of TBF and the overall mortality (7.9%) was consistent with previous reports. The incidence of facial nerve paralysis (1.6%), CSF leak (1.7%), and hearing loss (18.6%) were all lower than previously reported. Trauma imaging was able to identify 98.6% of TBF, calling the utility of routine temporal bone CT imaging into question.ConclusionTBFs are less common than they once were and though they still carry a mortality rate similar to previously reported cohorts, the incidence of complications among survivors has dramatically improved. Additionally, modern CT imaging is very capable of identifying these injuries and dedicated temporal bone CT may only be of utility in cases where facial nerve injury or vascular injury is suspected.Level of evidenceEpidemiologic study, Level III.     

Clinical analysis of craniocerebral trauma complicated wiht thoracoabdominal injuries in 2 165 cases

OBJECTIVE: To explore the optimal treatment for craniocerebral trauma complicated with thoraco-abdominal injuries. METHODS: A total of 2165 cases of craniocerebral trauma complicated with thoraco-abdominal injuries admitted to our hospital between July 1993 and June 2003 were retrospectively studied. Among them, 382 cases sustained severe craniocerebral trauma (in which 167 were complicated with shock), 733 thoracic injuries, 645 abdominal injuries and 787 thoraco-abdominal injuries. On admittance, 294 cases had developed shock. With the prime goal of saving life, respiratory and circulatory systems and encephalothilipsis were especially treated and monitored. Priority in management was directed to severe or open injures rather than to moderate or closed injures. For cases with cerebral hernia due to intracranial hematoma and severe shock due to blood loss, cerebral hernia and shock were treated concurrently. RESULTS: After treatment, 2024 (93.49%) cases survived and the other 141 (6.51%) died. Among patients who had severe craniocerebral injury with shock and those without, 78 (46.71%) and 53 (24.56%) died, respectively. For patients who had underwent craniocerebral and thoraco-abdominal operations concurrently and those who had not, the death rates were 58.49%-65.96% and 28.57% respectively, indicating a significant difference (P<0.05). CONCLUSIONS: Treatment for hematoma hernia, shock and disturbed respiration is the key in the management of multiple trauma of craniocerebral, thoracic or abdominal injuries, especially when two or three conditions occurred simultaneously. Unless it is necessary, operations at two different parts at the same time is not recommended. It is preferred to start two concurrent operations at different time.     

Positive predictive values of selected clinical signs associated with skull base fractures

BACKGROUND: The goal of this study was to determinate the positive predictive values of selected clinical signs for skull base fractures and associated intracranial lesions. METHODS: EXPERIMENTAL DESIGN: Clinical and radiological data were collected prospectively for all patients with selected clinical signs of skull base fractures, and their admission criteria were: 1) recent head injury story; 2) presence of one or more of following clinical signs: unilateral or bilateral blepharohaematoma, bloody otorrhea, and Battle's sign. SETTING: Emergency service of a institutional hospital. PATIENTS: One hundred forty two patients with the selected clinical signs for skull base fracture. RESULTS: Frontal bone fractures were the most frequent in patients with selected clinical signs. Battle's sign (100%) and unilateral blepharohaematoma (90%) were the signs with higher positive predictive values for skull base fractures; bilateral blepharohaematoma (70%) and bloody otorrhea (70%) were those with less values. The positive predictive values of the selected signs for intracranial lesions (acute extradural haematoma, pneumocephalus, brain contusion, brain sweLling, and acute subdural haematoma) were: unilateral and bilateral blepharohaematoma with positive predictive values of 85% and 68%, respectively; Battle's sign was 66%; and bloody otorrhea was 46%. For patients at admission on the 13-15 Glasgow Coma Scale only, the positive predictive values for that intracranial lesions were: blepharohaematoma=78%; Battle's sign=66%; and bloody otorrhea=41%. CONCLUSIONS: Our data demonstrated that the selected signs of skull base fractures have high positive predictive values for the presence of skull fracture and intracranial lesions, even in those patients classified in the Glasgow Coma Scale between 13 and 15. This indicates that all patients with the selected clinical signs should be submitted to computerized tomography of skull and with bone window, with the aim to detect associated lesions.