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Weitzman RE, Subramanian T, Zhao K, Shomorony A, Sclafani AP. Trends in Management and Cost Burden of Facial Fractures: A 14-Year Analysis. Laryngoscope 2024; 134:3120-3126. [PMID: 38294281 DOI: 10.1002/lary.31299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/31/2023] [Accepted: 01/03/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE To discuss patient demographics and management and better understand the economic impact associated with the treatment of facial fractures at a major metropolitan level 1 trauma center. STUDY DESIGN Retrospective chart review. METHODS We identified 5088 facial fractures in 2479 patients who presented from 2008 to 2022. Patient demographics, mechanism of injury, associated injuries, treatment information, and hospital charges were collected and analyzed to determine factors associated with surgical management and increased cost burden. RESULTS Our 14-year experience identified 1628 males and 851 females with a mean age of 45.7 years. Orbital fractures were most common (41.2%), followed by maxilla fractures (20.8%). The most common mechanism was fall (43.0%). Surgical management was recommended for 41% of patients. The odds of surgical management was significantly lower in female patients, patients age 65 and older, and patients who presented after the onset of the COVID-19 pandemic. The odds of surgical management was significantly higher for patients who had a mandible fracture or greater than 1 fracture. The average cost of management was highest for naso-orbito-ethmoidal fractures ($37,997.74 ± 52,850.88), followed by LeFort and frontal fractures ($29.814.41 ± 42,155.73 and $27,613.44 ± 39.178.53, respectively). The highest contributor to the total average cost of management was intensive care unit-related costs for every fracture type, except for mandible fractures for which the highest contributor was operating room (OR)-related costs. CONCLUSIONS This study represents one of the largest comprehensive databases of facial fractures and one of the first to provide a descriptive cost analysis of facial trauma management. LEVEL OF EVIDENCE 4 Laryngoscope, 134:3120-3126, 2024.
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Affiliation(s)
- Rachel E Weitzman
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Tejas Subramanian
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Karena Zhao
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Andre Shomorony
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Anthony P Sclafani
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
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Rangarajan S, Chen EW, Nguyen XM, Lakshmipathy D, Sethi K, Bailey J. Epidemiology of Craniomaxillofacial Fractures Over a 5-year Period at a Midwestern Level 1 Trauma Center Serving a Large Rural Population. J Oral Maxillofac Surg 2024; 82:663-670. [PMID: 38527728 DOI: 10.1016/j.joms.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/02/2024] [Accepted: 03/03/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Though the epidemiology of craniomaxillofacial (CMF) fractures has been well documented at urban hospitals, the characteristics of these fractures in rural hospitals have not been well studied. PURPOSE The purpose of this study is to report on the epidemiology of CMF fractures at a regional Level 1 trauma center serving a large rural population in central Illinois. STUDY DESIGN, SETTING, SAMPLE This is a retrospective cohort study at a community-based regional tertiary referral center that serves a predominantly rural population. Inclusion criteria comprised patients with radiologically confirmed CMF fractures between 2015 and 2019. Patients with incomplete medical records were excluded. PREDICTOR VARIABLE Predictor variables included demographics (age, admission source, race, and sex) and etiology of CMF fracture (assault/domestic violence, all-terrain vehicle/off-road, falls, farm-related, motor vehicle collisions, gunshot wound, and others). MAIN OUTCOME VARIABLE The primary outcome variable was the CMF anatomic location including nasal bone, orbit, mandible, malar/maxillary, and other CMF fractures. COVARIATES The covariates are not applicable. ANALYSES Descriptive statistics were used to summarize a sample of the population characteristics. Wilcoxon ranked sign tests and χ2 tests of independence were used to assess for statistically significant associations between select variables of interest. Statistical significance was defined as P < .05. RESULTS Between 2015 and 2019, a total of 2,334 patients presented to the emergency department with a CMF fracture. After applying the inclusion/exclusion criteria, the final sample was composed of 1,844 patients for the management of 2,405 CMF fractures. The majority of patients were male(62.0%) and young adults (aged 18-39) had the highest number of CMF fractures (819) relative to all other age groups. The most common fracture etiology was fall(37.3%), and nasal bone fractures represented the most common fracture location(41.6%). χ2 analyses revealed statistically significant associations between the anatomic location of CMF fracture incurred, and differing categories of age, admission source, race, sex, and etiology. CONCLUSION AND RELEVANCE Our study shows that patients seen at our Midwestern Level 1 trauma center are more likely to present with nasal bone and malar/maxillary fractures due to falls. In studies based in urban centers, patients are likely to present with orbital and mandibular fractures due to falls and assault.
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Affiliation(s)
- Shreya Rangarajan
- Medical Student, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Urbana, IL.
| | - Ethan W Chen
- Radiology Resident, Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA
| | - Xuan-Mai Nguyen
- Medical Student, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Urbana, IL
| | - Deepak Lakshmipathy
- Medical Student, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Urbana, IL
| | - Knika Sethi
- Oral and Maxillofacial Surgery Resident, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Urbana, IL; Oral and Maxillofacial Surgery Resident, Department of Oral and Maxillofacial Surgery, Carle Foundation Hospital, Urbana, IL
| | - Jonathan Bailey
- Oral and Maxillofacial Surgeon and Faculty, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Urbana, IL; Oral and Maxillofacial Surgeon and Faculty, Department of Oral and Maxillofacial Surgery, Carle Foundation Hospital, Urbana, IL
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de Sousa Lima A, Câmara JVF, Pierote JJA, Santos LA, Ferrari CR, de Almeida Lopes MC, Fialho ACV. Repercussions of the COVID-19 pandemic on the epidemiology of facial fractures: a retrospective cohort study. Oral Maxillofac Surg 2024; 28:945-955. [PMID: 38057681 PMCID: PMC11144671 DOI: 10.1007/s10006-023-01200-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/26/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Artur de Sousa Lima
- Department of Pathology and Dental Clinic, Health Sciences Center, Federal University of Piauí, Campus Universitário Ministro Petrônio Portella, Teresina, PI, 64049-550, Brazil
| | - João Victor Frazão Câmara
- Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University Hospital, Saarland University, Kirrberger Str. 100, Building 73, 66421, Homburg, Saar, Germany.
| | | | - Lethycia Almeida Santos
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil
| | - Carolina Ruis Ferrari
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil
| | - Maria Cândida de Almeida Lopes
- Department of Pathology and Dental Clinic, Health Sciences Center, Federal University of Piauí, Campus Universitário Ministro Petrônio Portella, Teresina, PI, 64049-550, Brazil
| | - Ana Cristina Vasconcelos Fialho
- Department of Pathology and Dental Clinic, Health Sciences Center, Federal University of Piauí, Campus Universitário Ministro Petrônio Portella, Teresina, PI, 64049-550, Brazil
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Benassi CM, de Assis Santos VP, Spagnol G, Ferraz EP, Luz JGC. The profile of patients with maxillofacial trauma due to interpersonal violence treated in a hospital emergency room. Dent Traumatol 2024; 40:35-43. [PMID: 37694974 DOI: 10.1111/edt.12886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023]
Abstract
AIM This study evaluated records of patients with maxillofacial trauma due to interpersonal violence (IPV) being treated in the emergency room of a level I trauma center hospital in São Paulo, Brazil. MATERIAL AND METHODS Data of patients with maxillofacial trauma due to IPV recorded between January 2019 and December 2019 were retrospectively examined. Personal data, days on which they experienced IPV, and the type of maxillofacial trauma sustained were extracted and statistically analyzed (p < .050). RESULTS During the analysis, 1034 patients with maxillofacial trauma were identified; of these patients, 292 (28.2%) who experienced trauma due to IPV were included in this study. There was a mean age of 32.6 years and the most common type of trauma was soft tissue injuries (38.7%). Mandible and nose fractures were more prevalent in males and females, respectively. Our data, when compared with other studies on maxillofacial trauma due to IPV, showed a lower prevalence and male-to-female ratio, and a higher presence of dentoalveolar trauma. Additionally, our data when compared with studies on maxillofacial trauma due to other causes showed lower mean age and male-to-female ratios, and a higher occurrence of nose fractures differing from the predominance of mandibular fractures. CONCLUSION Oral and maxillofacial surgeons must be able to suspect and identify cases due to IPV among their patients with trauma. With our results, although each case has its individuality, we can suggest that cases of maxillofacial trauma in young, female, and nasal fracture patients may be suspicious for IPV.
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Affiliation(s)
- Camila Maciel Benassi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Vinícius Paes de Assis Santos
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, São Paulo, Brazil
- Department of Oral and Maxillofacial Surgery, Hospital M. Dr. Arthur R. de Saboya, São Paulo, Brazil
| | - Guilherme Spagnol
- Department of Oral and Maxillofacial Surgery, Hospital M. Dr. Arthur R. de Saboya, São Paulo, Brazil
| | - Emanuela Prado Ferraz
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - João Gualberto C Luz
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of São Paulo, São Paulo, Brazil
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Gokharman FD, Kadirhan O, Celik Aydin O, Yalcin AG, Kosar P, Aydin S. A Comprehensive Look at Maxillofacial Traumas: On the Basis of Orbital Involvement. Diagnostics (Basel) 2023; 13:3429. [PMID: 37998566 PMCID: PMC10670346 DOI: 10.3390/diagnostics13223429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/28/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Orbital wall fractures that may develop in maxillofacial traumas (MFTs) may cause ophthalmic complications (OCs). The aim of this study is to determine the frequency of orbital fractures (OFs) accompanying MFTs and findings suspicious for orbital traumatic involvement. MATERIALS AND METHODS Computed tomography (CT) images of 887 patients who presented to the emergency department within a 1-year period with a history of MFT were retrospectively scanned. During the examination, patients with orbital wall fractures, craniofacial bone fractures, and posttraumatic soft tissue changes were recorded. RESULTS OF was observed in 47 (5.3%) of the patients admitted for MFT. In cases with OFs, accompanying nasal (25.5%), ethmoid (2.1%), frontal (19.1%), maxillary (38%), and zygomatic bone fracture (10.6%), sphenoid (4.3%), and soft tissue damage (55.3%) were observed. It was observed that the pathologies mentioned at these levels were significantly higher than in patients without orbital involvement (p < 0.05). In our study, mild (48.9%) and moderate-severe (2.12-4.25%) OCs accompanying OFs were observed after MFT. CONCLUSIONS The frequency of MFT varies depending on various factors, and such studies are needed to take preventive measures. Knowing the risk and frequency of orbital damage accompanying MFTs may help reduce complications by allowing rapid and accurate diagnosis.
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Affiliation(s)
- Fatma Dilek Gokharman
- Department of Radiology, SBU Ankara Education and Research Hospital, Ankara 06660, Turkey; (A.G.Y.); (P.K.)
| | - Ozlem Kadirhan
- Department of Radiology, Erzincan University, Erzincan 24100, Turkey; (O.K.); (S.A.)
| | - Ozlem Celik Aydin
- Department of Pharmacology, Erzincan University, Erzincan 24100, Turkey;
| | - Arzu Gulsah Yalcin
- Department of Radiology, SBU Ankara Education and Research Hospital, Ankara 06660, Turkey; (A.G.Y.); (P.K.)
| | - Pınar Kosar
- Department of Radiology, SBU Ankara Education and Research Hospital, Ankara 06660, Turkey; (A.G.Y.); (P.K.)
| | - Sonay Aydin
- Department of Radiology, Erzincan University, Erzincan 24100, Turkey; (O.K.); (S.A.)
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Juncar M, Tent PA, Juncar RI, Harangus A, Mircea R. An epidemiological analysis of maxillofacial fractures: a 10-year cross-sectional cohort retrospective study of 1007 patients. BMC Oral Health 2021; 21:128. [PMID: 33731083 PMCID: PMC7968332 DOI: 10.1186/s12903-021-01503-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Epidemiological data is providing vital indicators for organizing the financial resources related to a particular type of trauma, estimating expenses and training of dental practioners and ambulatory medical staff for collaboration with a certain pattern of patients. Knowing the etiology and epidemiology of a certain pathology is significant for approaching its means of prevention.
Methods
A 10-year retrospective statistical analysis of 1007 patients with maxillofacial fractures treated in a University Clinic of Oral and Maxillofacial Surgery in Romania was performed. The data were extracted from patients’ medical records. Statistical analysis was performed. A value of p < 0.05 was considered statistically significant. Results The incidence of maxillofacial fractures was high among patients in the 20–29 age group (35.9%). Male patients (90.57%, M:F = 9.6:1), having a low level of education (46.60%) and living in urban areas (53.50%) were more affected. The main cause of maxillofacial fractures was interpersonal violence (59.37%), both in the mandibular and midface topographic regions (p = 0.001, p = 0.002). In urban areas, fractures caused by interpersonal violence and road traffic accidents were predominant, while in rural areas, most of the fractures were due to interpersonal violence, domestic accidents, work accidents and animal attacks (p = 0.001). Conclusions Interpersonal violence is the main cause of maxillofacial fractures having epidemic proportions. Male patients aged 20–29 years with a low level of education represent the major risk category. Considering the wide area of interpersonal aggression, both the medical staff in the hospital and in the dental offices must be educated in order to collaborate with possible violent patients. Dentists must be prepared to work on a post-traumatic dento-periodontal field. Taking all measures to prevent inter-human aggression is imperative and will lead to a major decrease in maxillofacial fractures and an overall increase of oral health in a population. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-021-01503-5.
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Affiliation(s)
- Mihai Juncar
- Department of Oral and Maxillofacial Surgery, University of Oradea, Romania, Str. Piața 1 Decembrie, no.10, 410073, Oradea, Romania
| | - Paul Andrei Tent
- Department of Oral and Maxillofacial Surgery, University of Oradea, Romania, Str. Piața 1 Decembrie, no.10, 410073, Oradea, Romania.
| | - Raluca Iulia Juncar
- Department of Oral and Maxillofacial Surgery, University of Oradea, Romania, Str. Piața 1 Decembrie, no.10, 410073, Oradea, Romania
| | - Antonia Harangus
- Research Center for Functional Genomics, Biomedicine and Translational Medicine, Iuliu Hatieganu" University of Medicine and Pharmacy, 400337, Cluj-Napoca, Romania
| | - Rivis Mircea
- Discipline of Oral Surgery, 2nd Department of Dental Medicine, "Victor Babeş" University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041, Timisoara, Romania
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Long S, Spielman DB, Losenegger T, Obayemi AA, Neuner R, Cosiano MF, Reeve G, Kacker A, Stewart MG, Sclafani AP. Patterns of Facial Fractures in a Major Metropolitan Level 1 Trauma Center: A 10-year Experience. Laryngoscope 2021; 131:E2176-E2180. [PMID: 33433012 DOI: 10.1002/lary.29397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/13/2020] [Accepted: 01/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE/HYPOTHESIS To report characteristics and management of facial fractures in a major metropolitan center within the United States. STUDY DESIGN Retrospective chart review. METHODS Retrospective review at a level 1 trauma academic medical center of 3,946 facial fractures in 1,914 patients who presented from 2008 to 2017. Demographics, injury mechanism, associated injuries, and treatment information were collected. Logistic regression analyses were performed to determine factors associated with management. RESULTS There were 1,280 males and 630 females with a median age of 42 years. Orbital fractures were the most common (41.4%) followed by maxilla fractures (21.9%). The most common mechanism was fall (43.6%). Surgical management was recommended for 38% of patients. The odds of surgical management were less for females (OR 0.59, 95% CI 0.48-0.73). Patients over 70 years were significantly less likely to undergo surgery compared to other age groups (OR 0.15-0.36, P < .001). The odds of surgical management were 1.69 times greater for patients with more than three fractures than for a single fracture (95% CI 1.18-2.42) and 2.23 times greater for traffic injuries compared to injuries from activities of daily living (95% CI 1.42-3.5). CONCLUSIONS This represents one of the largest comprehensive databases of facial fractures. Our patients were most frequently injured during activities of daily living, most commonly from falls. The majority of patients were managed conservatively. Gender, age, fracture number, and mechanism of injury were independently associated with the decision to treat surgically. Our data are in stark contrast to that from other populations in which assault or motor vehicle accidents predominate. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2176-E2180, 2021.
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Affiliation(s)
- Sallie Long
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Daniel B Spielman
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Tasher Losenegger
- Department of Otorhinolaryngology Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adetokunbo A Obayemi
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Romy Neuner
- Department of General Surgery, Spital Uster, Uster, Switzerland
| | - Michael F Cosiano
- Department of Medicine, Duke University Hospital, Durham, North Carolina, U.S.A
| | - Gwendolyn Reeve
- Division of Dentistry, Oral and Maxillofacial Surgery, New York-Presbyterian Hospital/Weill, Cornell Medical Center, New York, New York, U.S.A
| | - Ashutosh Kacker
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Michael G Stewart
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
| | - Anthony P Sclafani
- Department of Otolaryngology Head and Neck Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, U.S.A
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Nissen NJ, Okhah ZI, Basta MN, Hsieh S, Crozier JW, Jehle CC, Rao V, Woo AS. Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury. Plast Reconstr Surg 2020; 145:1001-1008. [PMID: 32221221 DOI: 10.1097/prs.0000000000006626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. METHODS The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. RESULTS The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). CONCLUSIONS These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.
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Affiliation(s)
- Nicholas J Nissen
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Zachary I Okhah
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Marten N Basta
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Sun Hsieh
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Joseph W Crozier
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Charles C Jehle
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Vinay Rao
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| | - Albert S Woo
- From the Warren Alpert Medical School of Brown University and the Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
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