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Introduction: To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI)., Materials and Methods: This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale <9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS < 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were < 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality., Results: A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group., Conclusions: This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries., Competing Interests: Declaration of Competing Interest Nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: We aim to describe morphological structures of skull fractures and relevant factors in motorcycle accident victims in Vietnam. This work represents a retrospective cross-sectional study based on forensic reports of fatal motorcycle accident victims. Between January 2013 and August 2019, a total of 226 fatal motorcycle accident patients with skull fracture diagnoses were enrolled. Linear and depressed fractures were the common patterns (46.0% and 37.2% of cases, respectively), whereas stellate (11.5%) fractures were rare. Fractures of the temporal bone (68.6% of cases) and basilar skull (60.6%) were the most common, whereas fractures of the parietal bone were the least common (9.7%). Two or more patterns of skull fracture were recorded in 25.5% of cases, and 2 or more fracture locations were recorded in 76.6% of cases. Fractures of the parietal bone were associated with victims not wearing a helmet. In addition, fractures of the basilar skull were more likely to occur among victims with alcohol consumption. We found the common pattern of skull fractures was linear and depressed fractures, and the common location of skull fractures was temporal and basilar bone. Further studies that include larger sample sizes and collect more information should be conducted to better understand relationships between skull fractures and related factors., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Traumatic injuries are significant sources of morbidity and mortality in the pediatric population. Using a national database, this study aims to characterize pediatric facial fracture management and the effect of health care policy changes on populations receiving treatment., Methods: A retrospective cohort study was performed using Healthcare Cost and Utilization Project Kids' Inpatient Database databases from 2000 to 2016. Pediatric patients admitted with a facial fracture diagnosis were included. Clinical outcomes include mortality, reduction of fracture during hospital stay, and open fracture reduction. The impact of the Affordable Care Act on patient demographics and management was assessed., Results: Between 2000 and 2016, 82,414 patients were managed for facial fractures, 8.3 percent of whom were managed after implementation of the Affordable Care Act (n = 6841). Mean age was 15.2 years, and the male-to-female ratio was 2.9:1. Significant racial disparities were identified before the Affordable Care Act: African American and Native American patients had decreased odds of having facial fracture reduction during the initial hospital stay (OR, 0.84 and 0.86, respectively), and identifying as either Hispanic or Native American was associated with higher odds of mortality (OR, 1.4 or 2.4, respectively). Race was not contributory to patient mortality after the Affordable Care Act. Before Affordable Care Act implementation, patients receiving care with no charge (including charity care/charity research) had lower odds of having an open reduction or any reduction; insurance status was not contributory to management after the Affordable Care Act., Conclusion: Although the Affordable Care Act may have increased access to care for certain populations, race- and sex-associated differences in mortality rate and fracture management should be further investigated to ensure a national standard of equitable patient care., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes., Methods: Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition., Results: 19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001)., Conclusions: Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The objective of our study was to assess the reliability of the estimation of posttraumatic survival time (PTST) in forensic cases based on microCT and histology of putrefied/dry bone samples with comparison of initial macroscopic fracture classification performed during autopsy. Macroscopic morphological patterns of bone fracture are routinely used in forensic pathology and anthropology to distinguish between antemortem, perimortem and postmortem injuries. Based on macroscopic and microscopic analysis of six craniofacial fractures, our study results illustrate the need to complete macroscopical findings and initial fracture classification with microscopic analysis to avoid any inaccuracy. MicroCT has become a powerful technique to identify early bone healing signs but histology remains the gold standard to estimate the PTST and determine vital fracture based on hemorrhage marker. Raman microspectroscopy can identify a blood clot in the fracture line., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

The detection of intracranial gas (ICG) in people who died due to trauma became possible once postmortem computed tomography (PMCT) became available in addition to traditional post-mortem examinations. The aim of this study was to determine the importance of ICG in the context of medico-legal opinions. We assessed 159 cases of trauma-induced death. Cadavers with pronounced signs of decomposition, open skull fractures, and after neurosurgical operations were excluded. Both PMCT findings and data from autopsy reports were analyzed. ICG was found in 38.99% (n = 62) of the cadavers, 96.77% (n = 60) of which presented with pneumocephalus (PNC) and 40.23% (n = 25) with intravascular gas (IVG). There was a strong correlation between ICG and skull fractures/brain injuries, as well as chest injuries, especially lung injuries. In 13 cases, ICG presented without skull fractures; three of these cases died as a result of stab and incised wounds to the neck and chest. The mean time between trauma and death was significantly longer in the non-ICG group than the ICG group at 2.94 days (0-48 days) and 0.01 day (0-1 day), respectively (p < 0.0001). The presence of ICG is a result of severe neck and chest injuries, including stab and incised wounds. The victims die in a very short amount of time after suffering trauma resulting in ICG. The ability to demonstrate ICG on PMCT scans can be of significance in forming medico-legal opinions.

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients. Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates. Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup. Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P  = 0.007) and older age groups ( P  = 0.017). Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.

Fatal head trauma (FHT) represents one of the most frequent causes of death diagnosed in forensic pathology. However, profound statistic autopsy data on FHT is still sparse. Therefore, the purpose of this study was to investigate the circumstances and injury patterns of FHT with particular focus on age and sex, and additionally, to describe a recent risk profile of FHT. To this end, the forensic autopsy records of each FHT case at a large German university hospital during a 10-year period (2006-2015) were analyzed retrospectively (n = 372). The male-female ratio was 2.6:1. Regarding median age, females were 12.5 years older than males. Traffic-associated FHT represents the major mechanism of death, followed by fall-associated FHT. While accident was the major manner of death and presented a similar distribution of age and sex, homicides were the only subgroup with a significantly lower ratio between males and females. Skull fractures occurred in 78.2% and intracranial hemorrhages in 80.6% of all cases. In summary and partly in contrast to clinical data on head trauma, FHT still occurs predominantly in male individuals under the age of 45 years, in the context of traffic accidents and affected by alcohol intake. Improvements in traffic security as well as continuing surveillance of the incidence of FHT by forensic autopsies are necessary to further reduce the incidence of FHT.

Background: In automotive events, head injuries (skull fractures and/or brain injuries) are associated with head contact loading. While the widely-used head injury criterion is based on frontal bone fracture and linear accelerations, injury risk curves were not developed from original datasets., Objectives: Develop skull fracture-based risk curves for using previously published data and apply resampling techniques to assess their qualities., Methods: Force, deflection, energy, and stiffness data from thirteen human cadaver head impact tests were used to develop risk curves using parametric survival analysis. Injuries occurred to all specimens. Data points were treated as uncensored. Variables were ranked, and the variable best explaining the underlying fracture response was determined using the Brier Score Metric (BSM). The qualities of the risk curves were determined using normalized confidence interval sizes. Statistical resampling methods were used to assess the quality of the risk curves and the impact of the sample size by conducting 2000 simulations. Sample sizes ranged from 13 to 26., Findings: The Weibull distribution was optimal for all the response variables, except deflection (log-logistic). The quality of the risk curves was the highest for deflection. This variable best explained the underlying head injury response, based on BSM. Improvements in the quality of the risk curves were achieved with additional samples of force and deflection (<13), while energy and stiffness variables required more size. Individual risk curves are given., Interpretation: These probability curves from head contact loading add to the understanding skull fractures and can be used to improve safety in injury producing environments., (Published by Elsevier Ltd.)

Background: Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH., Methods: We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model., Results: A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55-76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9-15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%-23.3%). A large posterior fossa SDH (>30 cm 3 ; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46-13.9), 0.82 (95% CI, 0.73-0.92), and 4.59 (95% CI, 1.52-13.9), respectively., Conclusions: Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Fatal falls are frequent and seem to be an increasing problem in the elderly. Especially ground level falls (GLFs) and falls on or from stairs and steps (stairs falls) are worth examining for forensic classification and in order to improve the development of preventive measures. We retrospectively analyzed 261 fatal falls of elderly age 65 + years, which were autopsied at the Institute of Legal Medicine in Munich between 2008 and 2014. After careful screening, the sub-set of all 77 GLFs and 39 stairs falls were analyzed towards socio-demographic characteristics, fall circumstances, injuries, and circumstances of death. A subsequent analysis of GLF cases regarding the presence of proximal femur fractures (PFF) was performed. The injury pattern of the GLFs and the stairs falls clearly differ with a higher share of injuries to the lower extremities in the GLFs. However, the most severely injured body region was the head in both groups (62% of the stairs cases, 49% of the GLF cases). Alcohol as contributing to the fall was seen more frequently in the stairs falls. PFF were not seen in the stairs falls, but then in 18 GLF cases. Yet, for 17 among them (22% of 77), their hip fracture was the only serious injury leading to hospitalization and death. Only one GLF case was already found dead. This finding indicates a potential of avoiding up to 22% of the GLF fatalities by preventing hip fractures by optimized hip protectors or other measures, especially for the elderly aged 75 + years.

A 45-year-old male was autopsied. He had fallen backwards from a two-stairs height to the ground and passed away. A skull fracture was detected in the left occipital area, extending up to the left side of the skull base. The patient's death occurred due to the very low thickness of the calvarial bones, which led to the aforementioned fracture, and in turn resulted in subarachnoid hemorrhage and death. The cortical thickness was measured and compared with average values at standardized points. Uniform bone thinning was confirmed rather than localized. Calvarial thinning may result from various conditions. In the present case study, however, the exact mechanism which led to the low thickness of the calvarial bones of the patient is undetermined. Death due to the susceptible structure and fracture of calvarial bones has rarely been reported throughout relevant literature., (Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.)

Objectives: Blunt cerebrovascular injury (BCVI) is a known sequela of high-energy craniomaxillofacial (CMF) trauma and can result in stroke or death. The objective of this systematic review is to 1) identify CMF trauma patients who may benefit from BCVI screening and 2) describe the optimal diagnostic and treatment modalities., Study Design: Systematic review of the literature (1946-2013)., Methods: An a priori study protocol was created using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The authors conducted a search of Ovid/Medline, PubMed, and Cochrane databases for articles related to BCVI and CMF fractures. All abstracts were reviewed, and data was extracted to determine the incidence of BCVI in the setting of CMF trauma. Individual fracture patterns were analyzed using descriptive statistics., Results: Twenty-one studies met inclusion criteria. The overall incidence of CMF fracture-associated BCVI was 0.45%. The majority of patients (86.6%) sustained BCVI in the setting of high-energy trauma. The distribution of CMF fractures among BCVI patients was the mandible (12.5%), followed by the maxilla (11.8%). Computed tomographic angiography (CTA) was the most common diagnostic modality. A total of 63.1% of patients with BCVI were managed medically. The mortality among CMF patients with BCVI was 23.9%, and stroke rate was 47.1%., Conclusion: Blunt cerebrovascular injury is a rare but devastating complication of blunt trauma. The recommended screening modality is CTA, and the most common treatment is antiplatelet/anticoagulant medication. Mandibular and LeFort fractures were the most common isolated CMF injury associated with BCVI, highlighting the need for prospective trials to expand current screening criteria., Level of Evidence: N/A. Laryngoscope, 127:79-86, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: There are several studies about M1 type vehicle-pedestrian collision injury pattern, and based on them, there has been several changes in automobiles for pedestrian protection. However, the lack of sufficient studies about injury pattern in motorbikes-pedestrian collisions leads to a lack of optimization design of these vehicles. The objective of this research is to study the injury pattern of pedestrians involved in collisions with motorized two-wheeled vehicles., Methods: A retrospective descriptive study of pedestrian's deaths after collisions with motorcycles in an urban area, like Barcelona was performed. The cases were collected from the Forensic Pathology Service database of the Institute of Legal Medicine of Catalonia. The selected cases were categorized as pedestrian-motorcycle collision, between January 1st, 2005 and December 31st, 2014. Data were collected from the autopsy, medical, and police report. The collected information was then analyzed using Microsoft Excel statistical functions., Results: Traumatic Brain Injury is the main cause of death in pedestrian hit by motorized two-wheeled vehicles (62.85%). The most frequent injury was the subarachnoid hemorrhage, in 71.4% of cases, followed by cerebral contusions and skull base fractures (65.7%). By contrast, pelvic fractures and tibia fractures only appeared in 28.6%., Conclusions: The study characterizes the injury pattern of pedestrians involved in a collision with motorized two-wheeled vehicles in an urban area, like Barcelona, which has been found to be different from other vehicle-pedestrian collisions, with a higher incidence of brain injuries and minor frequency of lower extremities fractures in pelvis, tibia and fibula., (Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Purpose: It is hypothesized that facial trauma-associated injuries (AIs) are more frequent and severe in elderly than in younger adult patients. The purpose of this study was to determine the occurrence of, reasons for, and severity of AI in geriatric facial fractures and to compare the differences between geriatric and younger adult patients., Materials and Methods: Two patient cohorts were included in this cross-sectional retrospective study. Geriatric patients were at least 65 years old (n = 117) and younger controls were 20 to 50 years old (n = 136). The main predictor was age, the primary outcome was AI, and secondary outcomes were affected organ system, multiple AIs, polytrauma, and mortality during hospitalization. The other explanatory variables were gender, trauma mechanism, and type of facial fracture. Statistical methods included χ(2) tests, risk analyses with 2 × 2 table, and logistic regression analyses., Results: AIs were significantly more common in geriatric patients (44.0%) than in younger controls (25.0%; P < .001). Also, multiple AIs (P = .003), polytrauma (P = .039), mortality (P = .008), limb injuries (P = .005), and spine injuries (P = .041) were significantly more common in the elderly. In the risk analyses, geriatric patients had a 1.8-fold risk for AI, a 2.6-fold risk for multiple AIs, and a 2.2-fold risk for polytrauma., Conclusions: AIs are much more frequent and severe in geriatric patients, and the elderly die more often of their injuries. The results emphasize that elderly patients require specific attention and multi-professional collaboration in the diagnosis and sequencing of trauma treatment., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The National Confidential Enquiry describes the epidemiology of children admitted to hospital with head injury., Method: Children (<15 years old) who died or were admitted for >4 h with head injury were identified from 216 UK hospitals (1 September 2009 to 28 February 2010). Data were collected using standard proformas and entered on to a database. A descriptive analysis of the causal mechanisms, child demographics, neurological impairment, CT findings, and outcome at 72 h are provided., Results: Details of 5700 children, median age 4 years (range 0-14.9 years), were analysed; 1093 (19.2%) were <1 year old, 3500 (61.4%) were boys. There was a significant association of head injury with social deprivation 39.7/100 000 (95% CI 37.0 to 42.6) in the least deprived first quintile vs. 55.1 (95% CI 52.1 to 58.2) in the most deprived fifth quintile (p<0.01). Twenty-four children died (0.4%). Most children were admitted for one night or less; 4522 (79%) had a Glasgow Coma Scale score of 15 or were Alert (on AVPU (Alert, Voice, Pain, Unresponsive)). The most common causes of head injury were falls (3537 (62.1%); children <5 years), sports-related incidents (783 (13.7%); median age 12.4 years), or motor vehicle accidents (MVAs) (401 (7.1%); primary-school-aged children). CT scans were performed in 1734 (30.4%) children; 536 (30.9%) were abnormal (skull fracture and/or intracranial injury or abnormality): 269 (7.6%) were falls, 82 (10.5%) sports related and 100 (25%). A total of 357 (6.2%) children were referred to social care because of child protection concerns (median age 9 months (range 0-14.9 years))., Conclusions: The data described highlight priorities for targeted age-specific head injury prevention and have the potential to provide a baseline to evaluate the effects of regional trauma networks (2012) and National Institute of Health and Care Excellence (NICE) head injury guidelines (2014), which were revised after the study was completed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: Head trauma takes place among the leading causes of mortality in children. This study aimed to determine the risk factors of head trauma-related deaths among children younger than 5 years in Istanbul, Turkey., Material and Methods: This study was conducted using the records of the Morgue Department of the Council of Forensic Medicine in Istanbul. The records of cases autopsied between 2008 and 2012 were retrospectively investigated. Of all preschool children deaths, 203 head trauma-related deaths were included in the study., Results: Of all, 117 (57.6%) were males and 86 (42.4%) were females. Most cases (107, 52.70%) were between the ages of 12 and 36 months. The most common mechanism of injury was "fall from a height" with 97 cases (47.78%), followed by "traffic accidents" (67, 33%) and "hit by falling objects" (19, 9.35%). Skull fracture was detected in 176 cases (86.69%), of which 81 (46.02%) were characterized with linear fracture. Furthermore, skull fracture was accompanied by 1 or more skeletal bone fracture in 64 cases. Retinal hemorrhage was investigated in 5 cases of suspected physical abuse and only 2 of them showed retinal hemorrhage findings., Conclusions: Obtained findings revealed that fall from a height was the leading cause of death among unnatural deaths in children younger than 5 years. Domestic accident was found to be a significant risk factor in childhood deaths. Traffic fatalities were among leading causes of death in childhood in our country, likewise in all around the world. Children were found to be more vulnerable to traumas when they start to move around with incomplete motor skills. Therefore, education of parents in terms of child supervision and installing safety precautions toward preschool children will be helpful in preventing such injuries. On the contrary to some findings in the literature, more severe lesions were also prominent even in case of short-range falls from a height.

Objective: A retrospective cross-sectional analysis was undertaken to determine the impact of race and insurance status on trauma outcomes in patients admitted to a Level I trauma center following head and neck fractures., Study Design: Putative predictive factors, including injury mechanism, hemorrhagic shock, injury severity score (ISS), race, gender, and insurance status, were used in a multivariate outcome analysis to determine their influence on length of hospital stay, number of procedures performed, discharge status, and mortality; P < .05 was significant., Results: Proportionately more male patients (76.5%) sustained head and neck fractures compared with females (23.5%). Blacks and Hispanics sustained proportionately more gunshot wounds (GSWs) compared with Whites, 16:1 and 7:1, respectively. There were no significant differences in length of hospital stay and mortality based on race or insurance status. Mortality was related to age, GSW as a mechanism of injury, increasing ISS, and shock on admission., Conclusions: Minority race and insurance status did not correlate with worse outcomes. Treatment biases in the acutely injured patient with head and neck injuries may be less prevalent than thought, if we consider mortality and utilization of care as primary outcome measures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures., Methods: A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL)., Results: A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death., Conclusions: Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.

To date, no estimates of the long-term effect of cranial vault fractures on the risk of dying have been generated from historical or prehistoric skeletons. Excess mortality provides a perspective on the efficacy of modern treatment, as well as the human cost of cranial injuries largely related to interpersonal violence in past populations. Three medieval to early modern Danish skeletal samples are used to estimate the effect of selective mortality on males with cranial vault injuries who survived long enough for bones to heal. The risk of dying for these men was 6.2 times higher than it was for their uninjured counterparts, estimated through a simulation study based on skeletal observations. That is about twice the increased risk of dying experienced by modern people with traumatic brain injuries. The mortality data indicate the initial trauma was probably often accompanied by brain injury. Although the latter cannot be directly observed in skeletal remains, it can be inferred through the relative risks of dying. The ability to identify the effects of selective mortality in this skeletal sample indicates it must be taken into account in paleopathological research. The problem is analogous to extrapolating from death register data to modern communities, so epidemiological studies based on mortality data have the same inherent possibility of biases as analyses of ancient skeletons.

Background: Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome., Methods: We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques., Results: SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969)., Conclusion: SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.

Purpose: The aim of this study was to analyze the occurrence and characteristics of orbital roof fractures, periorbital hematoma, conjunctival hemorrhage, orbital roof discoloration, and concomitant head injuries in falls from a standing height., Methods: A prospective autopsy study was performed over a 4-year period (from 2010 to 2013). Subjects who had died due to traumatic brain injury caused by falls from a standing height were included in the study., Results: Fifty cases of ground level falls were recorded. This group consisted of 39 men and 11 women, with an average age of 67.3 ± 13.6 years, and median age of 70 years. Skull fractures originating in the proximity of impact site were found in 47 of 50 individuals, and 22 had isolated orbital roof fractures not connected to the fracture line. Bluish discoloration of the orbital roof was noted in 19 subjects, 14 had periorbital hematomas, and 12 had blotchy or purpura-like conjunctival hemorrhages., Conclusions: Isolated orbital roof fractures in falls from a standing height are easily detected using a standard autopsy technique, with special regard to careful removal of the dura in the anterior cranial fossa. Our study shows that orbital roof fractures can occur in accidental falls from a standing height and may not be associated with concomitant skull fractures and brain injuries.

Background: Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit., Materials and Methods: Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover., Results: Of 185 patients treated 172 (93%) were male. Mean age was 31±11.4 years. Mean GCS on admission was 13±2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1-145). The median GOS at discharge was 5 (range 1-5). Twelve patients died within the same admission (6.5%)., Conclusion: Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Object: To assess the impact that injury severity has on complications in patients who have had a decompressive craniectomy for severe traumatic brain injury (TBI)., Methods: This prospective observational cohort study included all patients who underwent a decompressive craniectomy following severe TBI at the two major trauma hospitals in Western Australia from 2004 to 2012. All complications were recorded during this period. The clinical and radiological data of the patients on initial presentation were entered into a web-based model prognostic model, the CRASH (Corticosteroid Randomization After Significant Head injury) collaborators prediction model, to obtain the predicted risk of an unfavourable outcome which was used as a measure of injury severity., Results: Complications after decompressive craniectomy for severe TBI were common. The predicted risk of unfavourable outcome was strongly associated with the development of neurological complications such as herniation of the brain outside the skull bone defects (median predicted risk of unfavourable outcome for herniation 72% vs. 57% without herniation, p=0.001), subdural effusion (median predicted risk of unfavourable outcome 67% with an effusion vs. 57% for those without an effusion, p=0.03), hydrocephalus requiring ventriculo-peritoneal shunt (median predicted risk of unfavourable outcome 86% for those with hydrocephalus vs. 59% for those without hydrocephalus, p=0.001), but not infection (p=0.251) or resorption of bone flap (p=0.697) and seizures (0.987). We did not observe any associations between timing of cranioplasty and risk of infection or resorption of bone flap after cranioplasty., Conclusions: Mechanical complications after decompressive craniectomy including herniation of the brain outside the skull bone defects, subdural effusion, and hydrocephalus requiring ventriculo-peritoneal shunt were more common in patients with a more severe form of TBI when quantified by the CRASH predicted risk of unfavourable outcome. The CRASH predicted risk of unfavourable outcome represents a useful baseline characteristic of patients in observational and interventional trials involving patients with severe TBI requiring decompressive craniectomy., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Importance: Firearm injuries (FAIs) play a major role in unintentional injuries, suicides, and homicides. It is important that policy makers, public health authorities, physicians, and the public are kept abreast of current trends in FAIs so that preventive programs can be tailored to the needs of cohorts that are at highest risk for such injuries., Objectives: To provide nationally representative longitudinal estimates of outcomes associated with hospitalizations attributed to FAIs in all age groups in the United States during the years 2003 to 2010; to obtain prevalence estimates of skull and/or facial fractures and intracranial injuries among those hospitalized owing to firearm injuries; and to examine the association between the occurrence of skull and/or facial fractures and/or intracranial injuries and in-hospital mortality., Design, Setting, and Participants: In this retrospective analysis of the largest all-payer hospitalization data set in the United States, we evaluate a Nationwide Inpatient Sample of patients hospitalized for FAIs during the years 2003 to 2010., Exposures: Face and/or skull fracture and/or intracranial injuries due to firearm injuries., Main Outcomes and Measures: The main outcome of interest was in-hospital mortality. The primary independent variables included occurrence of face and/or skull fracture and/or intracranial injuries. RESULTS During the study period, 252,181 visits were attributed to FAIs. Adolescents and young adults accounted for nearly 80% of all hospitalizations, with more than half of these in the 18- to 29-year-old, high-risk group. Male patients consistently accounted for 89% of the hospitalizations. The uninsured population accounted for nearly a third of hospitalizations. A total of 214,221 FAI hospitalizations did not involve facial and/or skull fractures or intracranial injuries; 13,090 involved a facial and/or skull fracture without a concomitant intracranial injury; 20,453 involved an intracranial injury without a concomitant facial and/or skull fracture; and 4417 involved both a facial and/or skull fracture and intracranial injury. Those with intracranial injuries without concomitant facial and/or skull fractures (odds ratio [OR], 58.40; 95% CI, 50.08-68.11) (P < .001) and those with both facial and/or skull fractures and intracranial injuries (OR, 17.45; 95% CI, 13.98-21.79) (P < .001) were associated with higher odds of in-hospital mortality than those without these injuries. Teaching hospitals were associated with higher odds of in-hospital mortality than nonteaching hospitals (OR, 1.31; 95% CI, 1.14-1.49) (P < .001). Teaching hospitals also tended to treat a higher proportion of complex cases. The uninsured had higher odds of in-hospital mortality than those with private insurance (OR, 1.55; 95% CI, 1.35-1.78)., Conclusions: AND RELEVANCE Occurrence of intracranial injuries was an independent risk factor for poor outcomes. Teaching hospitals had higher mortality rates but also treated more complex cases than nonteaching hospitals.

Purpose: The purpose of this study was to compare and characterize 2 cohorts of patients with maxillofacial fractures within the same institution over 2 6-year time frames 20 years apart., Materials and Methods: A retrospective review of patients with maxillofacial fractures at the authors' institution from 2004 to 2010 was performed, and a comparison was made with the authors' experience from 1984 to 1990., Results: The 1990 study showed 458 maxillofacial fractures (152 midface and 306 mandibular fractures). In the 2010 study, there were 1,731 maxillofacial fractures (1,313 midface and 418 mandibular fractures). There were significant differences in the mechanism of injury between the 1990 and 2010 studies: assaults decreased from 48.8% to 29.7%, motor vehicle collisions decreased from 39.1% to 29.6%, and falls increased from 3.6% to 22.1%. Comparison by age categories showed major changes in the following groups: maxillofacial fractures in patients 21 to 40 years old decreased from 61.7% to 35.3%, those in patients 41 to 65 years old increased from 13.1% to 35.4%, and those in patients at least 66 years old (elderly) increased from 0.2% to 14.5%. All these changes were statistically significant (P < .0001)., Conclusion: Maxillofacial trauma has changed significantly over the past 2 decades in the authors' institution. A decrease in assault-related injuries in the younger populations and an increase in the incidence of falls in the elderly were the main differences. There was a significant increase in elderly patients with maxillofacial trauma. This change emphasizes the need for adequate prevention programs and appropriate maxillofacial surgery teams to manage these injuries in the older patient., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Fatal falls often involve a head impact, which are in turn associated with a fracture of the skull or cervical spine. Prior authors have noted that the degree of inversion of the victim at the time of impact is an important predictor of the distribution of skull fractures, with skull base fractures more common than skull vault fractures in falls with a high degree of inversion. The majority of fatal fall publications have focused on skull fractures, and no research has described the association between fall circumstances and the distribution of fractures in the skull and neck. In the present study, we accessed data regarding head and neck fractures resulting from fatal falls from a Swedish autopsy database for the years 1992-2010, for the purposes of examining the relationships between skull and cervical spine fracture distribution and the circumstances of the fatal fall. Out of 102,310 medico-legal autopsies performed there were 1008 cases of falls associated with skull or cervical spine fractures. The circumstances of the falls were grouped in 3 statistically homogenous categories; falls occurring at ground level, falls from a height of <3 m or down stairs, and falls from ≥3 m. Only head and neck injuries and fractures that were associated with the fatal CNS injuries were included for study, and categorized as skull vault and skull base fractures, upper cervical injuries (C0-C1 dislocation, C1 and C2 fractures), and lower cervical fractures. Logistic regression modeling revealed increased odds of skull base and lower cervical fracture in the middle and upper fall severity groups, relative to ground level falls (lower cervical <3 m falls, OR = 2.55 [1.32, 4.92]; lower cervical ≥3 m falls, OR = 2.23 [0.98, 5.08]; skull base <3 m falls, OR = 1.82 [1.32, 2.50]; skull base ≥3 m falls, OR = 2.30 [1.55, 3.40]). C0-C1 dislocations were strongly related to fall height, with an OR of 8.3 for ≥3 m falls versus ground level. The findings of increased odds of skull base and lower cervical spine fracture in falls from a height are consistent with prior observations that the risk of such injuries is related to the degree of victim inversion at impact. The finding that C0-C1 dislocations are most common in falls from more than 3 m is unique, an indication that the injuries likely result from high energy shear forces rather than pure tension, as previously thought., (Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

It is important to improve the medical care system and treatment of victims, introduce new methods of treatment and attract the multidisciplinary specialists in the cases of multitrauma. An integrated approach is required for the identification of different character and severity of multiple craniofacial injuries and the development of rational surgical strategy on this base. Different scales such as AIS, CRIS, ISS, PTS, TRISS, TRISSCAN, CRAMS et.al, were created abroad. Another approach to medical strategy was developed in the department of military surgery of Kirov Military Academy in the late nineties. It was based on investigating of possibilities of surgical strategy optimization by application of objective evaluation of the severity of injuries (military surgery--SP, SG, SS). Given treatment strategy of victims with multiple craniofacial trauma resulted in double reduction of quantity of suppurative and septic complications (from 10.5% to 4.1%). It gave the possibility to reduce the lethality from 6.4% to 4.0%. At the same time a hospital stay was shortened and the strategy allowed obtaining satisfactory functional results of treatment and avoiding reinterventions for removal of posttraumatic facial deformations.

Purpose of the Study: To estimate the odds of death associated with documented unintentional falls and acute care hospitalization among older adults in the United States., Design and Method: Data were abstracted from the 2005 Nationwide Inpatient Sample (NIS) and odds of death were modeled using logistic regression., Results: The age 65 and older fall rate per 1,000 discharges was 53.0 while the mortality rate for those who fell was 33.2. Older-old (odds ration [OR] = 2.93; confidence interval [CI] = [2.50, 3.43]), men (OR = 1.64, CI = [1.54, 1.75]), and non-White (OR = 1.09; CI = [1.01, 1.19]) had higher odds of death compared to younger-old, women, and Whites. Additional comorbidity (OR = 3.41, CI = [3.05, 3.82]), dehydration (OR = 1.14; CI = [1.05, 1.25]) and intracranial fractures (OR = 4.46; CI = [4.02, 4.95]) resulted in greater odds of death., Implications: Among older adults who experienced a fall and hospitalization, odds of mortality appear influenced by factors beyond injury severity related to falling. Additional research is necessary to delineate the mechanisms behind these phenomena to inform the public about falls-prevention programs.

Purpose: The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma., Methods: Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression., Results: Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P < 0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P < 0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face., Conclusions: The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

Purpose: To investigate whether complex midface fractures have a greater association with death and intracranial injury than simple midface fractures., Materials and Methods: A retrospective chart review was performed for patients with blunt-mechanism midface fractures who had presented to an urban trauma center from 1998 to 2010. The survival and intracranial injury status was evaluated for patients with simple and complex midface fractures, including Le Fort, naso-orbitoethmoid, and/or zygomaticomaxillary fractures. Intracranial injury included hemorrhage and brainstem injury. Patients with upper face fractures were excluded to minimize confounding. Adjusted relative risk estimates were obtained using multivariate regression analysis., Results: Of 3,291 patients with midface fractures, 213 (6.3%) died and 693 (21.3%) had an intracranial injury. The cumulative mortality reached 11.6% in patients with complex midface fractures and 5.1% in those with simple midface fractures (P < .001). Patients with complex midface fractures were 57% more likely to die (relative risk = 1.57; P < .005). Specifically, Le Fort II fractures independently conferred a 94% increased risk of death (relative risk = 1.94; P < .01), but Le Fort I and III fractures were not significantly associated with death. Among patients presenting without neurologic impairment, those with Le Fort II and III fractures remained 2.88-fold (P < .01) and 2.54-fold (P < .001) more likely to have an underlying intracranial injury, respectively., Conclusions: Le Fort II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures are associated with serious intracranial injury, even in the absence of alterations in consciousness. These patients should be monitored with heightened vigilance and followed up closely during hospitalization, regardless of the presenting clinical findings., (Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Pontomedullary lacerations (PMLs) have often been reported in car occupants and pedestrians, are less frequently described in motorcyclists, and are very rarely described in bicyclists. The aim of this study was to determine the frequency of brainstem PMLs among fatally injured motorcyclists and bicyclists as well as the frequency of concomitant cranial, facial, and cervical spine injuries in such cases. A possible underlying mechanism of PML in fatally injured motorcyclists and bicyclists might thus be established. Of 443 cases of fatally injured motorcyclists and bicyclists, a sample of 381 cases of fatally injured motorcyclists and bicyclists with head injury of Abbreviated Injury Scale score of 3 or greater was formed and further analyzed. This group was composed of 345 men and 36 women. The average age was 48.8 ± 20.8 years (range, 15-99 years). In the analyzed sample group, there were 158 motorcyclists and 223 bicyclists. Partial PMLs were present in 44 cases (12%) within the sample of 381 head injuries, which breaks down to 40 men and 4 women. In our study, the impact area on the head and the specific skull base fracture type were good predictors of either PML occurrence or absence (B = -2.036, Wald = 161.312, P < 0.01, for the whole model). Impact to the chin, with or without a skull base fracture, most often led to this fatal injury due to impact force transmission, either through jawbone or vertebral column. Also, lateral head impact, the most frequent in bicyclists, with subsequent hinge fracture, PML, and frontoposterior hyperextension of the head that is associated with upper spine fracture, could be possible mechanisms of brainstem injury in fatally injured motorcyclists or bicyclists. Our study showed that the jawbone, as well as other facial bones, could act as shock absorbers, and their fracture could diminish energy transfer toward the skull and protect the brain and brainstem from injury.

This study aimed to evaluate the occurrence of injuries to the head and face in adolescent and teenager victims of non-natural deaths. A retrospective study was undertaken by the analysis of medical forensic reports obtained from medical forensic examinations performed at the Department of Forensic Medicine of the city of Campina Grande, PB, Brazil, between January 2003 and December 2007. From a total of 607 reports issued during this time span, the study sample consisted of 423 reports (69.6%) referring to adolescents and teenagers of both genders, aged 12 to 18 years, who were confirmed to have died from external causes. The causes of death were encoded according to the Chapter XX of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The majority of victims were 17 year old males (25.8%). Firearms (33.3%) and transport accidents (32.2%) were the most common causes of death, with boys showing a 3.7 times greater likelihood of getting killed by firearms than girls. There was statistically significant relationship between the occurrence of transport accidents and gender. The majority of victims (71.6%) presented with multiple injuries throughout the body. There was statistically significant relationship between the occurrence of transport accidents and the presence of multiple injuries. A high percentage of the victims presented with injuries to the head and face. There was statistically significant relationship between the occurrence of transport accidents and the presence of injury to the head. Fatal gunshot wounds and transport accidents were the main causes of death of male adolescents and teenagers. The victims presented with multiple injuries, especially to the head and face, and the mandible was the most frequently injured facial bone. .

Objective: To study the relationship pattern of intracranial hemorrhage in cases of traumatic petrous temporal bone fracture., Methods: All head injury cases admitted to the Emergency Department, Hospital Tengku Ampuan Afzan, Pahang, Malaysia in 2008 were assessed. Computerized tomography (CT) scan of the skull base was performed in indicated cases. Patients with a petrous temporal bone fracture were included in the study. Subsequent magnetic resonance imaging (MRI) was performed. Intracranial hemorrhages incidence, management and outcome were recorded., Results: From 1421 cases of head injury, 49(3.4%) patients were diagnosed to have a petrous bone fracture from the CT scan. Only 46 cases underwent MRI scan and were included in this study. Of these, 36(78.3%) cases had associated intracranial hemorrhages (p<0.01). Intracranial hemorrhage was associated with the longitudinal types of petrous fracture (p<0.05). Subdural hematoma was the most prevalent type of bleed (55.6%). There was no association between the types of intracranial bleeding (extradural, subdural, subarachnoid or intracerebral hemorrhage) and the types of petrous bone fracture (longitudinal, oblique or transverse). The mortality rate was 17.4%. The mortality cases were associated with the presence of other skull bone fractures (p<0.05)., Conclusions: Petrous fracture is significantly associated with intracranial hemorrhage. There was no association between the types of petrous fracture and the types of intracranial hemorrhages in our material., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Craniomaxillofacial trauma is associated with severe injuries and disability. There are no recent reports analyzing the demographics of facial trauma in elderly patients. Our objective was to review the demographics, outcomes, and risk factors associated with death in elderly patients with facial fractures in a single-institution level I trauma center., Methods: We performed a retrospective review of the University of Pittsburgh Medical Center Trauma Registry from January 1999 to December 2008 in an institutional review board-approved protocol. The search query included all types of craniofacial trauma using International Classification of Diseases, Ninth Revision coding. A χ test was used for analyzing categorical data. Continuous data were analyzed using unpaired t-test or analysis of variance. Logistic regressions were done to determine odds ratio (OR) for death. P = 0.05 was deemed significant., Results: A total of 16,528 patients with facial trauma were identified. Of these, 4536 patients had falls. Among the falls, 1020 patients had facial fractures. Finally, 460 patients were younger than 65 years, and 560 were older than 65 years. The variable with the highest odds for mortality in patients with facial fractures was intensive care unit admission (OR, 13.1), followed by acute renal failure (OR, 10.3), medical history of myocardial infarction (OR, 5.1), coagulopathy (OR, 4.78), age older than 65 years (OR, 4.13), acute respiratory failure (OR, 3.55), Abbreviated Injury Scale score greater than 3 at the head (OR, 3.5), congestive heart failure (OR, 2.64), history of cardiac surgery (OR, 2.4), and vault skull fracture (OR, 2.35)., Conclusions: Craniofacial trauma is a serious condition in the elderly. Associated injuries are demonstrated to have a deleterious effect on survival. Recognition of these risk factors is likely to promote the development of preventive measurements to decrease fatal outcomes.

Purpose: Prospective investigation of incidence and outcome of occipital condyle fractures (OCF) in a level 1 trauma centre., Methods: Over a period of 5 years, we prospectively recorded all cases of OCF, and performed a 1-year post-injury radiological and clinical follow-up using CT imaging, SF-36 and Neck Disability Index, respectively., Results: A total of 31 patients with OCF were identified. Based on a total of 2,616 CT scans that had been performed during this period, the incidence was 1.19%. There were 27 unilateral and 4 bilateral OCFs. Furthermore, 3 out of 31 patients (9.7%) were additionally diagnosed with atlanto-occipital dislocation (AOD), one of which was dorsally stabilised in a surgical procedure. All other patients were treated conservatively. 5 out of 31 patients (16.1%) died due to the severity of associated injuries. 22 out of 31 patients (70.9%) were prospectively followed-up for 1 year after trauma. During this period, CT imaging showed bony consolidation of fractures in all cases except for one, with no evidence of secondary dislocation or nonunion. Evaluation of the Neck Disability Index showed moderate disability. The SF-36 questionnaire showed an impaired quality of life in all areas; however, these were determined by associated injuries and independent of the type of fracture., Conclusions: Both unilateral and bilateral OCFs represent a stable injury regardless of the type of fracture. If AOD has been diagnosed in addition, it requires surgical stabilisation-independent of the OCF-and it is a significant predictor for poor outcomes. The patients quality of life 1 year after trauma has not been affected by the OCF, but by the overall pattern of the injury and by comorbidities. Based on our results, we introduce a new, simple and practical classification for OCFs.

Investigation of unexpected mortality in caged layer chickens led to the discovery of a consistent traumatic injury to the heads of affected hens. Initial post-mortem examination found linear skin lacerations and associated fractures in the dorsal cranium of all birds examined, and 5 to 10 mm deep trauma in the underlying brain tissue. Post-mortem multidetector computed tomography (CT) scanning of two affected birds demonstrated similar obliquely orientated, linear, depressed fractures of the skulls consistent with a single, severe impact force to the head. Both skull fractures had a pattern of rounded, rostral expansion measuring approximately 3 mm in width. On inspection of the cages during a farm visit, this CT pattern corresponded with the size and shape of sheet metal lugs holding feed troughs onto the cages (on which blood stains were subsequently observed). Based on this analysis and hypothesizing that hunger was a triggering factor, a recommendation was made to reverse the shed "lights on" and feed hopper operation times with instant reduction in mortality. This case highlights the value of post-mortem CT imaging in bird death investigation where trauma is a postulated cause.

Background: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data., Methods: This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status., Results: A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ≤ 0.001)., Conclusions: Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics.

Concealment of pregnancy and newborn infant abandonment are closely associated with neonaticide, the killing of an infant within the first 24 h of life or less than 28-30 days depending on the jurisdiction. Abandonment of newborn infants occurs throughout the world and often the outcome for the infant is death. Together with neonaticide it is felt to be one of the least preventable crimes. In this retrospective study we present all forensically known Danish cases of abandoned newborn infant corpses, covering the period from 1997 to 2008. Eleven newborn infant corpses were found; we registered characteristics of the newborn infants and the circumstances of the cases based on autopsy reports. One further newborn infant was included, dating back to 1992, as it was found to be connected with one of the later cases. The mean age of the women who abandoned their newborn infants was 22 years, and five of the autopsied newborn infants were probably alive when abandoned. In two cases the newborn infants were half siblings and abandoned by the same mother. The time span from abandonment to when the newborn infant was found ranged from hours to 7 years. Two-thirds of the newborn infants were girls (66.6%). The most common means of disposal was in a plastic bag (~60%); only one newborn infant was wearing clothes when found. Causes of death were usually given as asphyxia, brain injury or simply undetermined. Two-thirds of the newborn infants showed signs of violence. None of the newborn infants had congenital malformations.

Background and Purpose: The scope of trainee misinterpretations on pediatric neuroimaging studies has been incompletely assessed. Our aim was to evaluate the frequency of trainee misinterpretations on neuroimaging exams in children, describe a useful classification system, and assess related patient management or outcome changes., Materials and Methods: Pediatric neuroimaging examinations with trainee-dictated reports performed without initial attending radiologist assessment were evaluated for discrepant trainee interpretations by using a search of the RIS. The frequency of discrepant trainee interpretations was calculated and classified on the basis of the type of examination on which the error occurred, the specific type and severity of the discrepancy, and the effect on patient management and outcome. Differences relating to examination type and level of training were also assessed., Results: There were 143 discrepancies on 3496 trainee-read examinations for a discrepancy rate of 4.1%. Most occurred on CT examinations (131; 92%). Most discrepancies (75) were minor but were related to the clinical presentation. Six were major and potentially life-threatening. Thirty-seven were overcalls. Most had no effect on clinical management (97, 68%) or resulted simply in clinical reassessment or imaging follow-up (43, 30%). There was no permanent morbidity or mortality related to the misinterpretations. The most common misinterpretations were related to fractures (28) and ICH (23). CT examinations of the face, orbits, and neck had the highest discrepancy rate (9.4%). Third- and fourth-year residents had a larger discrepancy rate than fellows., Conclusions: Trainee misinterpretations occur in 4.1% of pediatric neuroimaging examinations with only a small number being life-threatening (0.17%). Detailed analysis of the types of misinterpretations can be used to inform proactive trainee education.

Background: The indications for immediate intubation in trauma are not controversial, but some patients who initially appear stable later deteriorate and require intubation. We postulated that initially stable, moderately injured trauma patients who experienced delayed intubation have higher mortality than those intubated earlier., Methods: Medical records of trauma patients intubated within 3 h of arrival in the emergency department at our university-based trauma center were reviewed. Moderately injured patients were defined as an ISS < 20. Early intubation was defined as patients intubated from 10-24 min of arrival. Delayed intubation was defined as patients intubated ≥25 min after arrival. Patients requiring immediate intubation, within 10 min of arrival, were excluded., Results: From February 2006 to December 2007, 279 trauma patients were intubated in the emergency department. In moderately injured patients, mortality was higher with delayed intubation than with early intubation, 11.8% versus 1.8% (P = 0.045). Patients with delayed intubations had greater frequency of rib fractures than their early intubation counterparts, 23.5% versus 3.6% (P = 0.004). Patients in the delayed intubation group had lower rates of cervical gunshot wounds than the early intubation group, 0% versus 10.7% (P = 0.048) and a trend toward fewer of skull fractures 2.9% versus 16.1%, (P = 0.054)., Conclusions: These findings suggest that delayed intubation is associated with increased mortality in moderately injured patients who are initially stable but later require intubation and can be predicted by the presence of rib fractures., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Object: Helmet use has been associated with fewer hospital visits among injured skiers and snowboarders, but there remains no evidence that helmets alter the intracranial injury patterns. The authors hypothesized that helmet use among skiers and snowboarders reduces the incidence of head injury as defined by findings on head CT scans., Methods: The authors performed a retrospective review of head-injured skiers and snowboarders at 2 Level I trauma centers in New England over a 6-year period. The primary outcome of interest was intracranial injury evident on CT scans. Secondary outcomes included the following: need for a neurosurgical procedure, presence of spine injury, need for ICU admission, length of stay, discharge location, and death., Results: Of the 57 children identified who sustained a head injury while skiing or snowboarding, 33.3% were wearing a helmet at the time of injury. Of the helmeted patients, 5.3% sustained a calvarial fracture compared with 36.8% of the unhelmeted patients (p = 0.009). Although there was a favorable trend, there was no significant difference in the incidence of epidural hematoma, subdural hematoma, intraparenchymal hemorrhage, subarachnoid hemorrhage, or contusion in helmeted and unhelmeted patients. With regard to secondary outcomes, there were no significant differences between the 2 groups in percentage of patients requiring neurosurgical intervention, percentage requiring admission to an ICU, total length of stay, or percentage discharged home. There was no difference in the incidence of cervical spine injury. There was 1 death in an unhelmeted patient, and there were no deaths among helmeted patients., Conclusions: Among hospitalized children who sustained a head injury while skiing or snowboarding, a significantly lower number of patients suffered a skull fracture if they were wearing helmets at the time of the injury.

Aim: The aim of this study is to evaluate the changes between the initial and late cranial CT scans in patients with mild-to-moderate head trauma. MATERIAL and, Methods: Of the two thousand six hundred and forty-four patients hospitalized for head trauma within a two-year period, 112 (4.24%) patients scored 8 or above in the Glasgow coma scale and there were changes between initial and late head CT., Results: Of these, 103 had worsening CT findings. Neurological status deteriorated in 30% of these cases. Forty-six patients required surgery based on findings seen on the delayed scans. Neurological status was stable in 50% of the cases. All the eight patients who expired had abnormal CT scans initially and had progression in their late scans., Conclusion: In patients with mild-to-moderate head trauma, serial CT scanning may independently modify treatment decisions in a subgroup of patients. Judgment for delayed scans should be made on an individual basis by taking the risk factors into account.

Background: The global incidence of fatal head injuries as the result of assault is greater than the number of non-fatal cases. The important factors that determine the outcome in terms of survival of such head injury cases include the type of weapon used, type and site of skull fracture, intra cranial haemorrhage and the brain injury. The present study aims to highlight the role of skull fractures as an indirect indicator of force of impact and the intra cranial haemorrhage by a comparative study of assault victims with fatal and nonfatal head injuries., Methods: 91 head injury cases resulting from assault were studied in the Department of Forensic Medicine, IMS, BHU Varanasi over a period of 2 years from which 18 patients survived and 73 cases had a lethal outcome. Details of the fatal cases were obtained from the police inquest and an autopsy while examination of the surviving patients was done after obtaining an informed consent. The data so obtained were analyzed and presented in the study., Results: Assault with firearms often led to fatality whereas with assault involving blunt weapons the survival rate was higher. Multiple cranial bones were involved in 69.3% cases while comminuted fracture of the skull was common among the fatal cases. Fracture of the base of the skull was noted only in the fatal cases and a combination of subdural and subarachnoid haemorrhage was found in the majority of the fatal cases., Conclusions: The present study shows skull fractures to be an important indicator of severity of trauma in attacks to the head. Multiple bone fracture, comminuted fracture and base fractures may be considered as high risk factors in attempted homicide cases. ‎

Frontal airbag deployment may cause severe fetal injury and loss without maternal injury.

Object: Occipital condyle fractures (OCFs) are rare injuries and their treatment remains controversial. Several classification systems have been proposed, first by Anderson and Montesano and more recently by Tuli and colleagues and Hanson and associates, who sought to stratify these fractures in a manner that would guide treatment that has typically ranged from semirigid collar immobilization to halo fixation or occipitocervical fusion. It has been the authors' impression, based on experience with OCFs at their institution, that classification is cumbersome and contributes little to the clinical decision-making process, while the identification of craniocervical misalignment and neural element compromise is paramount, and sufficient, for the planning of treatment., Methods: The authors performed a retrospective review of 24,745 consecutive trauma presentations to a single Level I trauma center (UPMC Presbyterian Hospital) over a 6-year period, identifying 100 patients with 106 OCFs. All patients were evaluated by the spine trauma service and underwent imaging of the craniocervical junction using reconstructed CT scans. Patient characteristics, fracture characteristics (including fracture classification according to the 2 major classification systems), initial management, and status at follow-up were recorded., Results: The incidence of OCF in this trauma population was 0.4%. Two patients had evidence of craniocervical misalignment on reconstructed CT imaging at the time of admission; both patients underwent occipitocervical fusion. One patient underwent occipitocervical fusion for unrelated C1-2 fractures. The remainder of those surviving to discharge, whose fractures represented all fracture subtypes, received treatment with a rigid cervical collar or counseling alone. No patients, including 4 patients with bilateral OCFs, were found to have developed delayed craniocervical instability or misalignment on follow-up, or to require further neurosurgical intervention for an OCF. Neural element compression was not identified in any of the patients, and there were no cases of delayed cranial neuropathy., Conclusions: Beyond the identification of craniocervical misalignment on reconstructed CT scans at admission, further classification of OCFs is unnecessary. Management should consist of up-front occipitocervical fusion or halo fixation in cases demonstrating occipitocervical misalignment, or of immobilization in a rigid cervical collar followed by delayed clinical and radiographic evaluation in a spine trauma clinic if misalignment is not present.

Background: Although cerebral venous sinus occlusion (CVSO) is reported to be associated with intracranial hypertension, its incidence or significance in head trauma is not clear. This study investigated with CT venography the incidence of posttraumatic CVSO, its clinical course, and relation to intracranial hypertension., Patients: This study comprised 97 consecutive patients admitted to our Trauma Center from 2002 through 2008 with skull fracture of the petrous portion of the temporal bone or that crossed the dural sinus. Patients with CVSO were examined with CT venography and followed up with CT venography or magnetic resonance imaging. The relation of CVSO to patient outcome and incidence of "talk and deteriorate" was also investigated., Results: CVSO was observed in 22 of 97 patients (22.4%). Mortality was significantly higher in the CVSO group versus no-CVSO group (50.0% vs. 9.3%, p < 0.001). Incidence of lethal intracranial hypertension was higher in the CVSO versus no-CVSO group (40.9% vs. 5.3%, p < 0.001), although there was no difference in Glasgow Coma Scale score at admission between the two groups (CVSO group, 8 +/- 5 vs. no-CVSO group, 10 +/- 4). Recanalization without treatment for CVSO occurred by 6 months in 9 of the 11 survivors (81.8%) who could be followed up., Conclusion: CVSO incidence after head injury was much higher than ever thought. It was associated with mortality and lethal intracranial hypertension, indicating that CVSO may induce acute increase in intracranial pressure in some cases. Early recognition of CVSO may be important to predict deterioration after admission and for starting immediate treatment.

Objective: The aim of the study was to identify risk factors for mortality in patients brought to the emergency department (ED) after blunt traumatic brain injury (TBI)., Methods: The medical records of such patients who visited the ED from June 2004 to May 2005 were retrospectively reviewed. Data (age, gender, initial Glasgow coma scale (GCS) scores, initial vital signs, brain computed tomography scan findings and cause of trauma) were collected from the records of 204 TBI patients, who were treated at the ED and needed intensive care. Among these patients, 48 died in the intensive care unit (ICU) of the hospital. Logistic regression was used to assess factors affecting mortality after trauma., Results: Age (odds ratio (OR) 1.04; 95% CI 1.01 to approximately 1.07), GCS score less than 9 (OR 19.29; 95% CI 5.04 to approximately 73.82) and skull bone fracture (OR 10.44; 95% CI 3.59 to approximately 30.38) were identified as possible risk factors of mortality in TBI patients., Conclusion: These predictors appear to be clinically relevant and may help improve ED triage of TBI patients in need of ICU care.

The aim of this paper is to provide a methodology to facilitate consequence analysis for vapour cloud explosions (VCE). Firstly, the main PROBIT equations to evaluate direct damage on humans from those accidents (eardrum rupture, death due to skull fracture, death due to whole body impact and lung damage) are discussed and the most suitable ones are selected. Secondly, a new methodology is developed to relate characteristic overpressure-impulse-distance curves for VCE, obtained in a previous paper (F. Diaz Alonso et al., Characteristic overpressure-impulse-distance curves for vapour cloud explosions using the TNO Multi-Energy model, J. Hazard. Mater. A137 (2006) 734-741) with the selected PROBIT equations. This methodology allows the determination of damage as a function of distance to the accident's origin in only one step, using explosion energy and VCE Multi-Energy charge strength as input parameters.

Objective: To minimize overall mortality and optimise reconstructive and cosmetic outcome in severely injured patients with maxillofacial injuries the interdisciplinary coordination of several surgical disciplines is required. It is still discussed controversy whether patients with maxillofacial fractures benefit from early fracture repair or if delayed operative management also yields in good results., Methods: Herein we analysed the data of 1252 severely injured patients between May 1998 through June 2002 in our trauma department regarding fractures of the maxillofacial region, injury severity, length of ICU stay and postoperative complications in patients with either early (within 72 hours) or delayed ( > 3 days) facial fracture repair., Results: 147 patients had severe facial fractures. Average age was 39.8 years (3-87 years), mean ICU was 25 (+/- 16) and the overall mortality 12% (n = 18). The most common cause for the injuries were traffic accidents in 45%. 78 patients (53%) underwent surgical repair of the maxillofacial fractures; 18 patients had early fracture repair and 60 patients had delayed operative repair. We found 4 complications (22%) in the early repair group and 13 local complications (21%) in the group with delayed surgical repair., Conclusion: Delayed repair of maxillofacial injuries in severely injured patients is feasible and yields in good results compared to early fracture repair.