Trauma-Associated Tension Pneumocephalus with Characteristic Mount Fuji Sign—Case Report

Tension pneumocephalus is a rare and life-threatening neurosurgical emergency in the setting of blunt or penetrating head trauma, especially in those with craniofacial fractures, which emergency physicians should be aware about. Early identification and appropriate treatment measures including supine positioning, 100% oxygen via mask, early neurosurgery consultation and, if required, operative intervention are paramount to optimal neurological and survival outcome. Definitive diagnosis requires imaging usually in the form of computed tomography (CT) head and serial monitoring of neurological status, optic nerve sheath diameter measurement and repeat imaging, essential to identify patients who might have features of increased pressure on brain matter, which could lead to adverse neurological and clinical outcomes. We present two cases of tension pneumocephalus with the characteristic Mount Fuji sign on CT head, who were managed nonoperatively with optimal neurological outcome. In patients with severe head or maxillofacial trauma presenting to emergency department, CT should be evaluated for signs of tension pneumocephalus, and such patients need to be closely observed for complications of pressure effect on brain matter to ensure optimal neurological and survival outcomes.

Characterizing Firearms-Related Injuries and Craniofacial Fractures: A TQIP Study

Background: Interest in firearm injuries (FAIs), from medical and public health perspectives continues to grow. Few studies have analyzed the relationship of FAIs, craniofacial fractures, and traumatic brain injuries (TBIs). Methods: FAIs were isolated from national data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) 2014 to 2016 using external cause encodings. Pertinent demographic, injury, and hospital characteristics were extracted to characterize trends and statistically significant outcomes. Results: Thirty-two thousand eight hundred ninety-three (out of 829 805 cases) FAIs were captured, with a majority of patients being male and non-Hispanic/Latino Black. Multivariate linear regression revealed that race/ethnicity, age, hospital size, hospital region, intent of injury, and ISS significantly contributed to risk of mortality, increased hospital length of stay (LOS), and intensive care unit (ICU) duration. Five thousand nine hundred ten (18.0%) FAIs had at least 1 craniofacial fracture, and among these 75.1% (4441) incurred a traumatic brain injury (TBI). Mortality rate among patients with craniofacial FAI was 43.8% (2586/5910), compared to 9.7% (2618/26 983) without. Delayed surgical repair significantly increased hospital LOS ( P < .01), but not mortality ( P = .09). Conclusion: FAIs with craniofacial injury have significantly higher mortality rates than those without craniofacial injury. FAI-associated craniofacial injuries are frequently associated with TBI which is associated with significant morbidity and mortality. Such findings pose important public health and economic implications.

Nasal and Naso-orbito-ethmoid Fractures

Craniofacial fractures are common among trauma patients. Nasal fractures are the most common craniofacial fracture. Understanding how to evaluate and manage craniofacial fractures is important for the craniofacial trauma consultant. This manuscript describes the appropriate workup and management of nasal and naso-orbito-ethmoid fractures.

Computed Tomography Study of the Mummy of King Seqenenre Taa II: New Insights Into His Violent Death

Seqenenre-Taa-II, The Brave, (c.1558–1553 BC) ruled Southern Egypt during the occupation of Egypt by the Hyksos. The mummy was physically examined and X-rayed in the 1960s, which showed severe head wounds that have prompted various theories about the circumstances of his death. We postulated that Computed Tomography (CT) study of Seqenenre-Taa-II's mummy would give insights into the circumstances of his death. We examined Seqenenre's mummy using CT and compared the findings with the archaeological literature as well as with five Asian weapons found in Tell-el-Dabaa. CT findings indicate that Seqenenre died in his forties. The mummies deformed hands suggest that the King was likely imprisoned with his hands tied. CT images provided detailed analysis of Seqenenre's previously reported injuries to the forehead, right supra-orbital, nose-right orbit, left chick, and skull base. This study revealed additional craniofacial fractures in the right lateral side of the skull that had been concealed by the embalmers beneath layers of material. Analysis of the morphology of the injuries enabled a better understanding of the mechanism of trauma, possible number of the attackers, and their relative position to the King. The size and shape of the fractures correlated well with the studied Hyksos weapons. The lethal attack was aimed at the King's face, likely in an attempt to disgrace him. Mummification of Seqenenre's body was limited to evisceration without brain removal. The desiccated brain is shifted to the left side of the skull. This may indicate that the King's dead body stayed on its left side for some time—long enough for decomposition start before the mummification began. This suggests that the King likely died at a location distant from the funeral place, possibly on a battlefield. The embalmers attempted to conceal the King's injuries; the methods used suggest that the mummification took place in a royal mummification workshop rather than in a poorly equipped location. CT findings of Seqenenre's mummy helped us to better understand the circumstances of his violent death. His death motivated his successors to continue the fight to unify Egypt and start The New Kingdom.

Trends in Craniofacial Injuries Associated with the Introduction of Electric Scooter Sharing Services

Electric scooters are an increasingly common and convenient mode of transportation worldwide and have effectively revolutionized the shared micromobility industry. As electric scooter sharing companies have increased in popularity there has been a concomitant increase in the frequency of all electric scooter-related injuries. The purpose of this study is to describe the most up-to-date trends in craniofacial fractures and lacerations related to electric scooter use among all age groups. We queried the National Electronic Injury Surveillance System (NEISS) for craniofacial fractures and lacerations related to e-scooters between 2010 and 2019. We then compared injury trends over time and between time periods before and after 2017 when electric scooter share apps revolutionized micromobility. We compared incidence of injury overall and by day of the week, patient demographics, and case severity based on clinical disposition. We identified an increase in the frequency of craniofacial lacerations and fractures in the 3 years following the introduction of electric scooter share services in 2017 (2017 and 2019), compared to the 3 years before this time (2014-2016). Young adults (18-39 years) were the age group with the greatest interval increase in craniofacial injuries. There was also an increase in number of craniofacial injuries occurring on Mondays and a decrease number occurring on Fridays in the later time period. Finally, patients who presented with electric scooter-related craniofacial injuries in this later time period showed a higher frequency of overnight observation and hospital admission for their injuries. The number of craniofacial injuries secondary to electric scooter use has increased dramatically since the introduction of share services. Craniofacial fractures and lacerations are a common reason for craniofacial or maxillofacial surgery consultation and understanding these patterns of injury will help prepare surgeons for patient care, preventative education, and public advocacy.

The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland

Study Design: Retrospective, quasi-experimental difference-in-differences investigation. Objective: Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland’s All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. Methods: Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid’s Inpatient Database (Healthcare Cost and Utilization Project). Results: Between 2009–2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals ( p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: −1.1 fewer admissions, 95% confidence interval: −2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. Conclusions: Maryland’s APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.