Brain Injuries and Facial Fractures: A Prospective Study of Incidence of Head Injury Associated with Maxillofacial Trauma

Concomitant head or neck injury increases risk of traumatic brain injury in facial fracture patients

Concomitant traumatic brain injury (TBI) is common in facial fracture patients and prompt intervention is crucially important to minimise the risk of potential long-term sequalae. In order to achieve rapid diagnosis, clinicians need to be aware of the risk factors associated with concomitant TBI and facial fractures. Previous literature suggests that a facial fracture can be considered a significant indicator of TBI. Nevertheless, a large data gap remains on specific injury patterns of facial fractures and associated TBI. Therefore, the objective of this study was to estimate and compare the frequency of and risk factors for TBI in patients with and without different types of additional injuries. The retrospective cohort study included 1836 facial fracture patients aged at least 18 years. The outcome variable was TBI with radiological findings in computed tomography or magnetic resonance imaging. The primary predictor variables were associated injury outside the head and neck, associated cranial fracture and associated neck injury. Based on this study, associated cranial fracture increased the risk of TBI 4.7-fold. Patients with associated neck injury had a 2.1-fold risk of TBI. In addition, significant predictors for TBI were increasing age (p = 0.0004), high energy of injury (p < 0.0001) and anticoagulant medication (p = 0.0003). Facial fracture patients with associated injuries in the head and neck region are at significant risk of TBI. In clinical work, multiprofessional evaluation of facial fracture patients should be routine and repeated survey should be targeted especially at high-risk patients to identify TBIs.

Acute hydrocephalus triggered by isolated traumatic subarachnoid hemorrhage in the posterior fossa following mandibular fracture in a toddler: a rare case report

INTRODUCTION

Facial bone fractures triggered by low-height falls are rare in toddlers, while severe intracranial injuries resulting from minor trauma are extremely rare.

CASE

Herein, we report the case of a 2-year-old girl who fell from a baby chair, striking her chin, who rapidly developed impaired consciousness 3 h later. The patient subsequently presented with a mandibular fracture and acute obstructive hydrocephalus due to a traumatic isolated subarachnoid hemorrhage in the posterior cranial fossa. She was successfully treated with ventricular drainage, which achieved a favorable outcome.

CONCLUSION

Maxillofacial trauma and head injuries are closely associated. Even in minor cases of maxillofacial trauma, vigilant monitoring and prompt intervention are crucial to prevent fatal outcomes in toddlers.

Traumatic Brain Injury in Patients With Frontal Sinus Fractures

Traumatic brain injury (TBI) is an insult to the brain from an external mechanical force that may lead to short or long-term impairment. Traumatic brain injury has been reported in up to 83% of craniofacial fractures involving the frontal sinus. However, the risk factors for TBI at presentation and persistent neurological sequelae in patients with frontal sinus fractures remain largely unstudied. The authors aim to evaluate the prevalence and risk factors associated with TBI on presentation and neurological sequelae in these patients. The authors retrospectively reviewed patients who presented with traumatic frontal sinus fractures in 2019. The authors' primary outcome was the prevalence of concomitant TBI on presentation, which authors defined as any patient with neurological symptoms/signs on presentation and/or patients with a Glasgow Coma Scale <15 with no acute drug or alcohol intoxication or history of dementia or other neurocognitive disorder. The authors' secondary outcome was the incidence of neurological sequelae after 1 month of injury. Bivariate analysis and multivariate logistic regression were performed. A total of 56 patients with frontal sinus fractures were included. Their median (interquartile range) age was 47 (31-59) years, and the median (interquartile range) follow-up was 7.3 (1.3-76.5) weeks. The majority were males [n = 48 (85.7%)] and non-Hispanic whites [n = 35 (62.5%)]. Fall was the most common mechanism of injury [n = 15 (26.8%)]. Of the 56 patients, 46 (82.1%) had concomitant TBI on presentation. All patients who had combined anterior and posterior table frontal sinus fractures [n = 37 (66.1%)] had TBI on presentation. These patients had 13 times the odds of concomitant TBI on presentation [adjusted odds ratio (95% CI): 12.7 (2.3-69.0)] as compared with patients with isolated anterior or posterior table fractures. Of 34 patients who were followed up more than 1 month after injury, 24 patients (70.6%) had persistent neurological sequelae, most commonly headache [n = 16 (28.6%)]. Patients who had concomitant orbital roof fractures had 32 times the odds of neurological sequelae after 1 month of injury [adjusted odds ratio (95% CI): 32 (2.4->100)]. Emergency physicians and referring providers should maintain a high degree of suspicion of TBI in patients with frontal sinus fractures. Head computed tomography at presentation and close neurological follow-up are recommended for patients with frontal sinus fracture with combined anterior and posterior table fractures, as well as those with concomitant orbital roof fractures.

World trends in publication for maxillofacial and dental trauma in the elderly

Aging may increase the risk of maxillofacial and dentoalveolar trauma (MDT). This review assessed global trends in scientific publications on MDT in the elderly. Six databases were searched. Studies about MDT in the elderly (≥60 years old) were included in two text mining stages (S1 and S2). In S1, all studies with elderly subjects were included, while in S2 only studies in which the elderly were assessed in a separate set of data or in a subanalysis by age groups were included. In S1, relevant data were mined using VantagePoint™ software. In S2, data were descriptively analyzed. There were 2265 studies at S1 and 110 at S2. The publication dates spanned from 1963 to 2023. In S1, the most cited keywords and terms were aged (n = 1872), male (n = 1839), female (n = 1777), "mandible fracture" (n = 460), "orbit fracture" (n = 362), and "maxilla fracture" (n = 118). Thirty authors published 10 or more articles with visible collaboration networks. There was a progressive increase in publications, especially in Europe (n = 150). In S2, most studies were case reports/case series (n = 62). The primary etiology was accidental falls (n = 84), the most affected region was the middle third of the face (n = 65), and dental trauma was rarely reported (n = 15). Cone Beam computed tomography was the most used diagnostic tool (n = 67). Of the 81 articles that addressed therapy, 52 opted for surgical treatment. Although there has been an increase in the number of articles on MDT over the years, studies with the elderly population as a specific study group are still needed. Accidental falls were the most reported etiology, while the middle third of the face and the mandible were the anatomic region and bone most affected, respectively. The high number of case reports indicates the need for improvement in the available scientific evidence about MDT in the elderly.

The association between head injury and facial fracture treatment: an observational study of hospitalized bicyclists from a level 1 trauma centre

PURPOSE

To compare the types of facial fractures and their treatment in bicyclists admitted to a level 1 trauma centre with major and minor-moderate head injury.

METHODS

Retrospective analysis of data from bicycle-related injuries in the period 2005-2016 extracted from the Oslo University Hospital trauma registry.

RESULTS

A total of 967 bicyclists with head injuries classified according to the Abbreviated Injury Scale (AIS) were included. The group suffering minor-moderate head injury (AIS Head 1-2) included 518 bicyclists, while 449 bicyclists had major head injury (AIS Head 3-6). The mean patient age was 40.2 years (range 3-91 years) and 701 patients (72%) were men. A total of 521 facial fractures were registered in 262 patients (on average 2 facial fractures per bicyclist). Bicyclists with major head injury exhibited increased odds for facial fractures compared to bicyclists with minor-moderate head injury (sex and age adjusted odds ratio (OR) 2.75, 95% confidence interval (CI) 2.03-3.72, p < 0.001. More specifically, there was increased odds for all midface fractures, but no difference for mandible fractures. There was also increased odds for orbital reconstruction in cyclist with major head injury compared to bicyclist with minor-moderate head injury (adjusted OR 3.34, 95% CI 1.30-8.60, p = 0.012).

CONCLUSION

Bicyclists with more severe head injuries had increased odds for midface fractures and surgical correction of orbital fractures. During trauma triage, the head and the face should be considered as one unit.

Development of AI-Based Diagnostic Algorithm for Nasal Bone Fracture Using Deep Learning

Facial bone fractures are relatively common, with the nasal bone the most frequently fractured facial bone. Computed tomography is the gold standard for diagnosing such fractures. Most nasal bone fractures can be treated using a closed reduction. However, delayed diagnosis may cause nasal deformity or other complications that are difficult and expensive to treat. In this study, the authors developed an algorithm for diagnosing nasal fractures by learning computed tomography images of facial bones with artificial intelligence through deep learning. A significant concordance with human doctors' reading results of 100% sensitivity and 77% specificity was achieved. Herein, the authors report the results of a pilot study on the first stage of developing an algorithm for analyzing fractures in the facial bone.

The importance of the oral and maxillofacial surgery and traumatology team in the diagnosis of a cavernous carotid fistula: Case report

Due to the anatomical proximity between the skull and the face, maxillofacial trauma can often cause injuries to cranial structures. Among these complications are carotid-cavernous fistulas (CCF), which are rare in maxillofacial trauma, although their etiology is usually traumatic. They are described as an atypical communication between the internal carotid artery and the cavernous sinus, which can generate a sudden change in the direction and distribution of blood flow between the brain and orbit. This paper aims to report a case of craniomaxillofacial trauma in which the patient evolved with diplopia, palpebral ptosis, and ophthalmoplegia of the left eye, diagnosed as traumatic CCF. The oral and maxillofacial surgery and traumatology team of the University Hospital of Western Paraná was observed these symptoms for the first time during post-operative follow-up after one day of surgery to repair mandibular fractures of the patient in question. With the identifying the signs and symptoms, a neurosurgery was requested for assessment and management. After clinical evaluation and imaging tests, they diagnosed the condition as CCF 5 days after the mandibular fractures and the patient was referred for treatment. Surgery was performed, in the same day, to resolve the CCF with the endovascularly by embolization with micromoles. The CCF was resolved and the patient continued on outpatient follow-up, progressing without sequelae from the CCF or mandibular fractures.

Traumatic brain injuries and maxillofacial fractures: a systematic review and meta-analysis

Traumatic brain injuries (TBIs) associated with maxillofacial fractures (MFFs) are a public health concern worldwide, especially among adult-aged males. There is an urgent need for early detection of associated TBIs in patients with MFFs during the initial assessment and treatment stage to reduce morbidity and mortality. The objective of the present study was to systematically review the literature to determine specific MFF situations associated with TBIs and to identify the factors associated with TBIs in patients with MFFs. The protocol was developed in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and was registered to the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42020155912. Overall, of 26,774 patients recorded, 13,667 patients (51.04%) sustained MFFs with an associated TBI. The male to female ratio was 4.8:1. RTA was the most common cause. The most common TBIs were concussions, contusions, and closed brain injuries. Within the limits of this study, it was concluded that TBI-related MFFs should be suspected whenever maxillary or mandibular bone fractures occur, especially among adults, males, and people with injuries caused by RTAs and assaults. There is a need to increase the awareness of maxillofacial surgeons on the possible associations of combined maxillofacial trauma and brain injuries.

Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma

Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8 h, 21.5 versus 63.5 ( P = 0.002); 8-16 h, 4.9 versus 20.6 ( P = 0.02); 16-24 h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8 h, 7.7 versus 8.1; 8-16 h, 4.4 versus 8.0; 16-24 h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.

Traumatic maxillofacial injuries: Patterns, outcomes, and long-term follow-up of a military cohort

BACKGROUND/AIMS

Maxillofacial trauma poses a distinct challenge on the modern battlefield, and data on its long-term implications are scarce. The aim of this study was to investigate maxillofacial injury characteristics, outcomes, and complications along the continuum of care among hospitalized military personnel from the pre-hospital setting through long-term rehabilitation.

MATERIALS AND METHODS

A registry-based study was undertaken of three national trauma and rehabilitation registries: The Israel Defense Forces Trauma Registry (IDF-TR), which records pre-hospital data. The Israeli National Trauma Registry for in-hospital data and the Israel Ministry of Defense Rehabilitation Department (MOD-RD) registry contain long-term disability data. The cohort comprised IDF soldiers who suffered maxillofacial injuries between 1997 and 2020.

RESULTS

A total of 672 patients with maxillofacial injuries were included in the study, and 6.4% of all trauma admissions were related to maxillofacial injuries. Of these, 366 (54%) were injured in non-military (NMC) circumstances, and 306 (46%) were wounded in military circumstances (MC). The mechanisms of injury were mainly traffic-related among the NMC group compared with an explosion in the MC group. Maxillofacial fractures were frequently associated with traumatic brain injuries with higher rates in the NMC group than in the MC group (55% vs. 30%, p < .001). In a multivariate analysis, zygomatic and orbital fractures were associated with higher odds of concomitant head injury. The most common categories of long-term disability included central nervous system disorders, skull injuries, epilepsy, hearing impairment, ophthalmologic conditions, and post-traumatic stress disorder.

CONCLUSIONS

Maxillofacial injuries are often associated with concomitant traumatic brain injury. Long-term disabilities associated with these injuries included the central nervous system, hearing, ophthalmologic impairments, and post-traumatic stress disorder.

Facial Fractures and Their Relation to Head and Cervical Spine Injuries in Hospitalized Bicyclists

Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.

Pattern of associated brain injury in maxillofacial trauma: a retrospective study from a high-volume centre

The incidence of head injury in maxillofacial trauma patients varies widely in the literature. A good understanding of the patterns of association between these injuries would aid in efficient multidisciplinary treatment. The aim of this study therefore was to understand the associations between head injury and facial trauma by retrospectively analysing the records of patients seen at a tertiary care trauma centre. Demographic data were also described. Records of 4350 facial trauma patients over a five-year period were reviewed. A total of 3564 (81.9%) patients were victims of motor vehicle accidents (MVA). Male patients predominated, comprising 3711 (85.3%), and 36.6% were in the third decade of life. Facial fractures were seen in 2120 (48.7%), the most common being zygomatic fractures (60%). At the time of trauma, 2383 (57.3%) patients were under the influence of alcohol, and 2821 (87.8%) victims of two-wheeler MVAs were not using their helmet. Of all patients, 29.75% sustained a traumatic brain injury (TBI). Midface fractures were strongly associated with TBI. Maxillofacial injury may be considered a risk factor for TBI, and as such should immediately be suspected and investigated in all patients. Prompt recognition and management can improve outcomes in these patients.

Role of the Maxillofacial Surgeon in Identifying the Correlation Between Facial Bone Fractures and Traumatic Brain Injury - A Prospective Study

Introduction

Maxillofacial trauma accounts for a high percentage of patients reporting to the emergency medicine department and being admitted in the hospital. The purpose of this study was to form a direct association between maxillofacial fractures and traumatic brain injury (TBI).

Methods

Ninety patients with maxillofacial fractures that reported to/were referred to the Department of Oral and Maxillofacial Surgery were observed for features indicative of TBI based on clinical presentation and radiological interpretations. Parameters such as loss of consciousness, vomiting, dizziness, headache, seizures and the requirement for intubation, cerebrospinal fluid rhinorrhoea and otorrhoea were also assessed. Appropriate radiographs for the diagnosis of the fracture were taken followed by a computed tomography (CT) scan when indicated in accordance to the Canadian CT Head Rule. These scans were then assessed for contusion, extradural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage, pneumocephalus and cranial bone fracture.

Results

A total of 90 patients were evaluated, of which 91.1% were males and 8.9% were females. Association between the occurrence of head injury and different maxillofacial bone fractures using the Chi-square test showed a statistical significance of <0.001 in patients with naso-orbito-ethmoid as well as frontal bone fractures. There was a clear association between fractures present in the upper as well as the middle third of the face and traumatic head injury (P ≤ 0.001).

Discussion

Patients with the frontal bone and zygomatic bone fractures have a high prevalence of TBI. Patients with the upper and middle third of the face injury are more prone to traumatic head injury and importance should be given to patients with the same and prevent poor prognosis.

Facial Fractures: Independent Prediction of Neurosurgical Intervention

Context  Over half of patients with facial fractures have associated traumatic brain injury (TBI). Based on force dynamic cadaveric studies, Le Fort type 2 and 3 fractures are associated with severe injury. Correlation to neurosurgical intervention is not well characterized.

Aims  This study characterizes fracture pattern types in patients requiring neurosurgical intervention and assesses whether this is different from those not requiring intervention.

Settings and Design  Retrospective data was collected from the trauma registry from 2010 to 2019.

Methods and Materials  Patients over 18 years, with confirmed facial fracture, reported TBI, available neuroimaging, and hospital admission were included.

Statistical Analysis  Retrospective contingency analysis with fraction of total comparison was used with chi-square analysis for demographic and injury characteristic data.

Results  Note that 1,001 patients required no neurosurgical intervention and 171 required intervention. The intervention group had a significantly greater number of patients with Glasgow Coma Scale (GCS) < 8 compared with the nonintervention group. Subset analysis revealed a twofold increase in Le Fort type 2 fractures and notable increase in Le Fort type 3 and panfacial fractures in the intervention group. Patients requiring craniectomy, craniotomy, or burr holes were much more likely to have Le Fort type 2 or 3 fractures compared with those only requiring external ventricular drains or intracranial pressure monitoring. Subset analysis accounting for GCS supported these results.

Conclusion  Le Fort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm to improve patient care.

Comprehensive facial injury (CFI) score as a predictor of surgical time, length of hospital stay, and head injury? Our experience at level I trauma center

Purpose:

The present study aimed to evaluate the statistical significance of comprehensive facial injury (CFI) score concerning total surgical time (ST), length of hospital stay (LHS), and head injury in maxillofacial trauma patients.

Methods:

This retrospective observational study included 288 patients having maxillofacial injuries with or without associated head injury. CFI score was calculated for each of them. One-way ANOVA and Kruskal–Wallis H-test were used to compare ST (minutes), LHS (days), and Glasgow Coma Scale (GCS) score among the CFI score clusters. Head injury among the CFI score clusters was compared using Fisher's exact test. The level of statistical significance was set at P < 0.05.

Results:

Of total 288 cases (males: 83.68%, females: 16.31%, mean age: 30 ± 15.92 years), road traffic accidents accounted for 76.0% of admissions. A definitive approach (open reduction and internal fixation) was used in 26.38% of cases. Statistically significant association of CFI score was obtained with ST and LHS in high-dependency unit (P < 0.001). Posttraumatic head injury was seen in 21.25% of cases. A significant association of CFI score with GCS score (P = 0.032) and with head injury (P = 0.019) was found.

Conclusion:

CFI score is a comprehensive yet simple scale to assess ST and LHS. A strong correlation established between CFI score and these variables further validate its reliability as a perfect tool for communication of the maxillofacial morbidity and in making a treatment protocol, although its predictive ability for associated head injuries needs to be studied further.

Football-related maxillofacial injuries

Maxillofacial injuries sustained playing sports are becoming increasingly common, and in the UK where football is the most popular team sport, associated maxillofacial injuries are a regular occurrence. This study retrospectively examined data on patients who were referred with facial injuries sustained playing football between 2007 and 2019 (n = 265). Demographics, mechanism of injury, diagnosis, and treatment received were analysed. The mean (SD) age was 25 (11.0) years (range 3-85) and there was a strong male predominance (n = 256, 97% male). Facial fractures were diagnosed in 143 (54%) patients. The most common injury was a midface fracture and the most common mechanism of injury was a clash of heads. Patients with a facial fracture were significantly more likely to have sustained a concurrent head injury (p = 0.006). Those who were elbowed or punched were significantly more likely to have a facial fracture than a soft tissue or dentoalveolar injury (p ≤ 0.05). Players who clashed heads were significantly more likely to have a midface fracture (p ≤ 0.001). In conclusion, football-related maxillofacial injuries predominantly affect young adult males following a clash of heads. An elbow or punch to the face carries a significant risk of facial fracture and concurrent head injury. Therefore, to reduce the percentage of maxillofacial injuries seen in this sport, observed intentional contact between players, using an elbow or fist to the face in particular, must continue to carry the highest sanction.

Facial Fractures: Independent Prediction of Neurosurgical Intervention

CONTEXT

Over half of patients with facial fractures have associated traumatic brain injury (TBI). Based on force dynamic cadaveric studies, Lefort type 2 and 3 fractures are associated with severe injury. Correlation to neurosurgical intervention is not well characterized.

AIMS

This study characterizes fracture pattern types in patients requiring neurosurgical intervention and assesses whether this is different from those not requiring intervention.

SETTINGS AND DESIGN

Retrospective data were collected from the trauma registry from 2010 to 2019.

SUBJECTS AND METHODS

Patients over 18, with confirmed facial fracture, reported TBI, available neuroimaging, and hospital admission were included.

STATISTICAL ANALYSIS USED

Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-square analysis for demographic and injury characteristic data.

RESULTS

One thousand and one patients required no neurosurgical intervention and 171 required intervention. The intervention group had a significantly greater number of patients with Glasgow Coma Scale (GCS) <8 compared to the nonintervention group. Subset analysis revealed a twofold increase in Lefort type 2 fractures and notable increase in Lefort type 3 and panfacial fractures in the intervention group. Patients requiring craniectomy, craniotomy, or burr holes were much more likely to have Lefort type 2 or 3 fractures compared to those only requiring external ventricular drains or intracranial pressure monitoring. Subset analysis accounting for GCS supported these results.

CONCLUSIONS

Lefort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm to improve patient care.

Numerical simulation and analysis of midfacial impacts and traumatic brain injuries

Backgrounds

The maxillofacial region is the exposed part of the human body and is susceptible to injury due to the limited protective equipment. Due to anatomic proximity of the maxillofacial skeleton and cranium, the force can be transmitted directly to the brain in case of maxillofacial impact, maxillofacial injuries are often accompanied with craniocerebral trauma. Therefore, it is necessary to study the biomechanical response mechanism of trauma to improve prevention of traumatic brain injury (TBI).

Methods

To investigate the biomechanical mechanism between the two injuries, a finite element (FE) head model including skull, midfacial bones and detailed anatomical intracranial features was successfully developed based on CT/MRI data. The model was validated by comparing it with one classical cadaver experiment. During the simulations, three different load forces were used to simulate common causes of injury seen in the clinic including boxing-type impact injury and car accident-type impact injury, and four locations on the model were considered as common injury sites in the midface.

Results

Twelve common impact scenarios were reproduced by FE simulation successfully. Simulations showed that there was a linear relationship between the severity of TBI and the collision energy. The location of TBI was directly related to the location of the impact site, and a lateral impact was more injurious to the brain than an anterior-posterior impact. The relative movement between the skull and brain could cause physical damage to the brain. The study indicated that the midfacial bones acted as a structure capable of absorbing energy and protecting the brain from impact.

Conclusions

This biomechanical information may assist surgeons better understand and diagnose brain injuries accompanied by midfacial fractures.

Combined trauma in craniomaxillofacial and orthopedic-traumatological patients: the need for proper interdisciplinary care in trauma units

Aim

The primary aim of this study was to analyze frequency and characteristics of combined facial and peripheral trauma with consecutive hospitalization and treatment.

Materials and methods

The study included all patients with concomitant orthopedic-traumatolgical (OT) and craniomaxillofacial (CMF) injuries admitted to our level I trauma center in 2018. The data were collected by analysis of the institution’s database and radiological reviews and included age, sex, injury type, weekday and time of presentation. All patients were examined and treated by a team of surgeons specialized in OT and CMF directly after presentation.

Results

A total number of 1040 combined OT and CMF patients were identified. Mean age was 33.0 ± 26.2 years. 67.3% (n = 700) were male patients. Primary presentation happened most frequently on Sundays (n = 199) and between 7 and 8 pm (n = 74). 193 OT fractures were documented, where cervical spine injuries were most frequent (n = 30). 365 facial and skull fractures were recorded. 10.8% of the 204 patients with fractures of the viscerocranium presented with at least one fracture of the extremity, 7.8% (16/204) with cervical spine fractures, 33.3% (68/204) with signs of closed brain trauma and 9.8% (20/204) with intracranial hemorrhage.

Discussion

The study shows a high frequency of combined facial with OT-injuries and brain damage in a predominantly young and male cohort. Attendance by interdisciplinary teams of both CMF and OT surgeons specialized in cervical spine trauma surgery is highly advisable for adequate treatment.

Conclusion

Diagnostics and treatment should be performed by a highly specialized OT and CMF team, with a consulting neurosurgeon in a level-1 trauma center to avoid missed diagnoses and keep mortality low.

Facial fractures and associated injuries in high- versus low-energy trauma: all are not created equal

Introduction

Facial fractures (FFs) occur after high- and low-energy trauma; differences in associated injuries and outcomes have not been well articulated.

Objective

To compare the epidemiology, management, and outcomes of patients suffering FFs from high-energy and low-energy mechanisms.

Methods

We conducted a 6-year retrospective local trauma registry analysis of adults aged 18–55 years old that suffered a FF treated at the Santa Barbara Cottage Hospital. Fracture patterns, concomitant injuries, procedures, and outcomes were compared between patients that suffered a high-energy mechanism (HEM: motor vehicle crash, bicycle crash, auto versus pedestrian, falls from height > 20 feet) and those that suffered a low-energy mechanism (LEM: assault, ground-level falls) of injury.

Results

FFs occurred in 123 patients, 25 from an HEM and 98 from an LEM. Rates of Le Fort (HEM 12% vs. LEM 3%, P = 0.10), mandible (HEM 20% vs. LEM 38%, P = 0.11), midface (HEM 84% vs. LEM 67%, P = 0.14), and upper face (HEM 24% vs. LEM 13%, P = 0.217) fractures did not significantly differ between the HEM and LEM groups, nor did facial operative rates (HEM 28% vs. LEM 40%, P = 0.36). FFs after an HEM event were associated with increased Injury Severity Scores (HEM 16.8 vs. LEM 7.5, P <0.001), ICU admittance (HEM 60% vs. LEM 13.3%, P <0.001), intracranial hemorrhage (ICH) (HEM 52% vs. LEM 15%, P <0.001), cervical spine fractures (HEM 12% vs. LEM 0%, P = 0.008), truncal/lower extremity injuries (HEM 60% vs. LEM 6%, P <0.001), neurosurgical procedures for the management of ICH (HEM 54% vs. LEM 36%, P = 0.003), and decreased Glasgow Coma Score on arrival (HEM 11.7 vs. LEM 14.2, P <0.001).

Conclusion

FFs after HEM events were associated with severe and multifocal injuries. FFs after LEM events were associated with ICH, concussions, and cervical spine fractures. Mechanism-based screening strategies will allow for the appropriate detection and management of injuries that occur concomitant to FFs.

Type of study

Retrospective cohort study.

Level of evidence

Level III.

Anesthetic considerations for extracranial injuries in patients with associated brain trauma

Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

The Characteristics and Cost of Le Fort Fractures: A Review of 519 Cases From a Nationwide Sample

PURPOSE

The aims were to report the characteristics of Le Fort fractures and to quantify the associated hospital costs.

MATERIALS AND METHODS

From October 2015 to December 2016, the National Inpatient Sample was searched for patients admitted with a primary diagnosis of a Le Fort fracture. Predictor variables were drawn from demographic, admission, and injury characteristics. The outcome variable was hospital cost. Summary statistics were calculated and compared among Le Fort patterns. Univariate comparisons and multivariate regression analyses were conducted to determine predictors associated with cost.

RESULTS

A total of 519 patients were identified in this cohort. Associated injuries included skull fractures (28%), intracranial hemorrhage (13%), cervical spine injury (9.8%), and concussion (9.1%). Seventy-three percent of patients received open reduction and internal fixation (ORIF) for their facial fractures during their admission, 13% received a tracheostomy, and 10% were mechanically ventilated for at least 1 day. The ventilation (P < .01) and tracheostomy (P < .01) rates increased with Le Fort complexity, as did length of stay (LOS; P < .01), costs (P < .01), and charges (P < .01). The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS.

CONCLUSIONS

The prevalence of head injuries and the need for respiratory support substantially increased with Le Fort complexity. Hospital costs were not markedly influenced by the diagnosis and management of associated injuries. Instead, costs were predominantly driven by fracture complexity and the need for necessary procedures, such as ORIF, tracheostomy, and mechanical ventilation.