CORE Metadata, citation and similar papers at core.ac.uk Provided by Springer - Publisher Connector Huempfner-Hierl et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:35 DOI 10.1186/s13049-015-0117-z ORIGINAL RESEARCH Open Access Maxillofacial fractures and craniocerebral injuries – stress propagation from face to neurocranium in a finite element analysis Heike Huempfner-Hierl*, Andreas Schaller and Thomas Hierl Abstract Background: Severe facial trauma is often associated with intracerebral injuries. So it seemed to be of interest to study stress propagation from face to neurocranium after a fistlike impact on the facial skull in a finite element analysis. Methods: A finite element model of the human skull without mandible consisting of nearly 740,000 tetrahedrons was built. Fistlike impacts on the infraorbital rim, the nasoorbitoethmoid region, and the supraorbital arch were simulated and stress propagations were depicted in a time-dependent display. Results: Finite element simulation revealed von Mises stresses beyond the yield criterion of facial bone at the site of impacts and propagation of stresses in considerable amount towards skull base in the scenario of the fistlike impact on the infraorbital rim and on the nasoorbitoethmoid region. When impact was given on the supraorbital arch stresses seemed to be absorbed. Conclusions: As patients presenting with facial fractures have a risk for craniocerebral injuries attention should be paid to this and the indication for a CT-scan should be put widely. Efforts have to be made to generate more precise finite element models for a better comprehension of craniofacial and brain injury. Keywords: Facial fractures, Finite element analysis, Craniocerebral injuries, Stress propagation Abstract Hintergrund: Frakturen des Gesichtsschädels gehen häufig mit intrakraniellen Verletzungen einher. Deshalb erschien es interessant, die Weiterleitung und Verteilung von Spannungen, wie sie bei einem Faustschlag auftreten, vom Gesichtsschädel zum Hirnschädel in einer Finite Elemente Analyse zu untersuchen. Methoden: Ein Finite Elemente Modell des menschlichen Schädels ohne Unterkiefer, welches aus zirka 740,000 tetraedrischen Volumeneinheiten bestand, wurde entwickelt. Die Einwirkung einer Kraft, die einem Faustschlag entsprach, auf den Infraorbitalrand, die Nasoorbitoethmoidregion und den supraorbitalen Bogen wurden simuliert. Die Weiterleitung der Spannungen wurde in einem zeitlichen Verlauf dargestellt. Ergebnisse: Die Finite Elemente Simulation zeigte von Mises-Spannungen oberhalb des Wertes, ab dem Gesichtsschädelknochen frakturieren, im Bereich der Krafteinleitung und Fortleitung von Spannungen in Richtung auf die Schädelbasis in beachtlicher Höhe bei Auftreffen des Impaktors auf den Infraorbitalrand oder die Nasoorbitoethmoidregion. Bei Auftreffen der Kraft supraorbital scheinen die Spannungen absorbiert zu werden. (Continued on next page) * Correspondence: [email protected] Department of Oral and Maxillofacial Plastic Surgery, Leipzig University, Liebigstrasse 12, 04103 Leipzig, Germany © 2015 Huempfner-Hierl et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Huempfner-Hierl et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:35 Page 2 of 9 (Continued from previous page) Schlussfolgerungen: Da Patienten mit Gesichtsschädelfrakturen ein Risiko für Schädel-Hirn-Traumata aufweisen, sollte eine entsprechende Überwachung erfolgen. Die Indikation für CT-Untersuchungen sollte großzügig gestellt werden. Genauere Finite Elemente-Modelle sind zum besseren Verständnis kraniofazialer Frakturen und Hirnverletzungen notwendig. Background segmentation, triangulated (VWorks 4.0® Cybermed, Severe facial trauma is often associated with intracere- Korea) and exported to ANSYS ICEM CFD 12.0.1® bral injuries. McLean described inertial loading and head (ANSYS Inc., Canonsburg, PA, U.S.A.) [10]. One of the acceleration as a cause of brain injury [1]. It is obvious specific characteristics of the model was to assign individ- that impact on the facial skeleton results in head acceler- ual bone material parameters to each element by trans- ation. Many studies report on statistical analyses con- forming grey scale values of the CT Hounsfield scale cerning patterns of facial fractures and probability of intoinformationaboutbonedensity.ByusingaBone- intracranial haemorrhage. Bellamy et al. reported on Mat script Young’s moduli for each element were com- 3,291 patients with midfacial fractures and found that putated [11,12]. 21.3% of them had intracranial injuries, 6.3% died. Here Regarding the impact simulating a punch of fist, a vir- the cumulative incidence of intracranial injury of simple tual brass impactor (weight of 412 grams, density of 8.4 midface fractures was 6.3% and that of complex midface grams per cubic centimetre, Young’s modulus of 100,000 fractures was 11.9% [2,3]. In their study on 6,117 pa- megapascal, Poisson ratio of 0.37) was modelled in ac- tients who were admitted for blunt trauma Plaisier et al. cordance with the experiments of Waterhouse et al. found that 48% of patients who died of neurologic injury [13]. Impact velocity was set to six meters per second. showed midfacial fractures [4]. A potential mechanism is Because of time dependency of interaction between ruptures of intracranial vessels [5]. In a further large skull bone and impactor a transient mode of simulation study Salentijn et al. reported on 579 trauma patients was applied, which in contrast to static finite element with facial fractures, 8.1% of them had also intracranial analysis reflects the gradient impact, which seems more injuries [6,7]. realistic in fast phenomena. In patients suffering from high velocity impacts like The model was fixed at the occipital condyles in all de- car accidents the mechanisms of brain injury seem obvi- grees of freedom. For the yield criterion of skull bone ous, and the patients have to undergo a cranial CT scan von Mises stresses of 150 megapascal are accepted [14]. to detect intracranial haemorrhage. But question arises Three different areas of impact were chosen. In the concerning impairment in patients with smaller impacts. first the impactor hit the facial bone in the medial third Severalauthors[5,8]reportonahighpercentageof of the infraorbital rim, in the second in the junction area intracerebral injuries in patients presenting with facial between nasal bone, maxillary nasal process and lacrimal fractures without any neurological impairment and bone, in the third on the supraorbital arch (see Figure 1, recommend a wider indication for cranial CT scan A, B, C). Impact was identical concerning the three sites. than has been previously published [9]. So it seemed to Stress propagation is depicted in a time-dependent dis- be of interest to simulate fistlike impacts on the mid- play for each scenario. face and the upper face in a finite element analysis to According to the regulations of our institutional re- gain information about the dispersion of stresses and view board no approval of this investigation has been to investigate the aetiopathogenesis of craniocerebral necessary. injuries after blunt facial skull trauma. Results Finite element simulation revealed von Mises stresses Methods beyond the yield criterion of facial bone, which corre- To conduct finite element analyses corresponding with a lates with fractures at the site of impact [15]. traumatic scenario of fistlike impacts on the midface and In this study main attention shall be paid to stress the upper face a finite element model (FE model) of the propagation towards cranium and skull base caused by an skull without mandible was generated. The model con- impact, which would lead to rather simple facial fractures. sisted of 736,934 tetrahedral shaped 10-node elements and was based on the CT-dataset of a 34 years old white Caucasian male without any pathologies (Siemens Volume Impact on the infraorbital rim Zoom Plus, 1 mm contiguous slicing). This CT-dataset Time-dependent stress propagation caused by a fistlike was exported into VRML data format after manual impact on the medial third of the infraorbital rim causes Huempfner-Hierl et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:35 Page 3 of 9 Figure 1 Site of impact by virtual impactors: A) Impact on the medial orbital rim (green); B) Impact on the nasoorbitoethmoid region (blue); C) Impact on the supraorbital arch (red). first maximum stress on the site of impact. Here the Impact on the supraorbital arch threshold for bone is exceeded, which stands for bone Fistlike impact on the supraorbital arch produces max- fracture in this area. Then stresses propagate in an imum stresses at the site of impact. Then stress propagates anterior-posterior direction over skull base with proces- into the orbit in direction to the optic canal and to the oc- sus styloidei and zygomatic arch to the occipital bone. cipital bone. Stresses in the occipital bone caused by im- Considerable stress propagation is seen in the zygomatic