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

What Is the Relationship Between Maxillofacial Injury Location and Associated Injuries?

BACKGROUND

Patients sustaining maxillofacial fractures are at risk for associated injuries (AIs) to other body regions. The incidence of AIs is reported to be from 20 to 35%. AIs may be life-threatening and play a key role in considering first-line management at the emergency department, as well as planning the definitive treatment of maxillofacial fractures.

PURPOSE

The study aimed to determine the frequency and risk factors for AIs in patients with maxillofacial fractures.

STUDY DESIGN, SETTING, SAMPLE

The investigators designed and implemented a retrospective cohort study of patients with facial fractures treated at Central Hospital (Lahti, Finland) from January 1, 2009 through December 31, 2019. All adult patients with verified maxillofacial fractures were included. Patients under 18 years of age were excluded from the study.

PREDICTOR VARIABLE

The predictor variable was the location of the maxillofacial fractures grouped into three categories: mandible alone, midface alone, and both midface and mandible.

MAIN OUTCOME VARIABLE(S)

The primary outcome variable was associated body region injuries coded as present or absent. The secondary outcome variable was the location of the AI categorized as skull, neck, thorax, pelvis, or extremity injuries.

COVARIATES

Other study variables included demographic data (age, sex, alcohol use), Glasgow Coma Scale, and etiology (fall, traffic- and bicycle accident, assault, pedestrian hit by motor vehicle, work-related, or sports/free-time injuries).

ANALYSES

Continuous variables were analyzed for normal distribution using the Shapiro-Wilks test and compared with categorical variables using the Mann-Whitney test. The univariate analyses of categorical variables were analyzed by the χ2 test (P ≤ .05 was considered statistically significant).

RESULTS

During the study period, 443 adult (≥18) patients had maxillofacial fractures. AIs were present in 88 subjects (20%). The mean age was 47.6 years (range 18-91); 52 years with AIs (range 19-91), and 47 years (range 18-92) without AIs (P = .03). Subjects with midface and mandible + midface fractures had greater risk to AIs compared to mandibular fractures (relative risk 2.0, P = .002, relative risk 2.8, P = .009).

CONCLUSION AND RELEVANCE

Every fifth maxillofacial trauma patient had an associated injury. Trauma patients should be evaluated in institutions with trauma protocols and imaging modalities before determining and executing the treatment plan for maxillofacial fractures.

Clinical Significance of Diplopia and the Orthoptic Examination in Zygomatic Maxillary Complex Fractures

Literature describes variable rates of diplopia of associated with zygomatic maxillary complex (ZMC) fractures (6% to 40%). The aim of this study was to retrospectively assess the prevalence of diplopia in ZMC fracture patients, the usefulness of the orthoptic evaluation compared with the clinical finger-tracking examination, and to seek possible relations of this symptom with clinical parameters. Data of patients attending the Maxillofacial Surgery Units of the University of Messina and University of Naples "Federico II", between January 2012 and December 2022 were retrieved. Statistical analysis of positive versus negative diplopia at both the clinical examination and the orthoptic evaluation and subgroup analysis were performed. 320 patients were included in the analysis. 50 (15.6%) patients reported diplopia at the clinical examination, whereas 70 (21.9%) resulted positive at the orthoptic evaluation. Statistical analysis for every determinant and subgroup did not show statistical significance ( P >0.05). Performing routine preoperative orthoptic evaluation allowed an increase of 6.3% in positive reports. Although it seems that no basic clinical parameter can predict diplopia, results suggest that the orthoptic evaluation is superior in the assessment of this symptom. Clinical analysis was shown to be a moderate/low efficient test and should not be used as a decisional standard.

Trends in Management and Cost Burden of Facial Fractures: A 14-Year Analysis

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.

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.

Associated Injuries Related to Patients With Facial Fractures

Study Design: Retrospective Study. Objective: To find out the incidence, type, and severity of injuries in other parts of the body in patients diagnosed with facial fractures. The study also analyzed any correlation between these injuries and facial fractures. Methods: A retrospective study of 991 patients with facial fractures during the period of 2006-2016. Results: 111 patients reported associated injuries (11.1%). The most common type of injury was limb injury (33.33%), followed by head injury (22.5%), clavicle fracture (14.7%), rib fracture (10.9%), cervical spine injury (5.4%), and other injuries constituted (13.2%). Multiple associated injuries were observed in 14% of patients. Conclusion: The findings show that facial fracture management is a multidisciplinary approach. Prompt diagnosis and proper management are important to reduce the mortality rate and improve the prognosis of the patient.

Sensory change and recovery of infraorbital area after zygomaticomaxillary and orbital floor fractures

BACKGROUND

To compare the sensory change and recovery of infraorbital area associated with zygomaticomaxillary and orbital floor fractures and their recoveries and investigate the factors that affect them.

METHODS

We retrospectively reviewed 652 patients diagnosed with zygomaticomaxillary (n= 430) or orbital floor (n= 222) fractures in a single center between January 2016 and January 2021. Patient data, including age, sex, medical history, injury mechanism, Knight and North classification (in zygomaticomaxillary fracture cases), injury indication for surgery (in orbital floor cases), combined injury, sensory change, and recovery period, were reviewed. The chi-square test was used for statistical analysis.

RESULTS

Orbital floor fractures occurred more frequently in younger patients than zygomaticomaxillary fractures (p< 0.001). High-energy injuries were more likely to be associated with zygomaticomaxillary fractures (p< 0.001), whereas low-energy injuries were more likely to be associated with orbital floor fractures (p< 0.001). The sensory changes associated with orbital floor and zygomaticomaxillary fractures were not significantly different (p= 0.773). Sensory recovery was more rapid and better after orbital floor than after zygomaticomaxillary fractures; however, the difference was not significantly different. Additionally, the low-energy group showed a higher incidence of sensory changes than the high-energy group, but the difference was not statistically significant (p= 0.512). Permanent sensory changes were more frequent in the high-energy group, the difference was statistically significant (p= 0.043).

CONCLUSION

The study found no significant difference in the incidence of sensory changes associated with orbital floor and zygomaticomaxillary fractures. In case of orbital floor fractures and high-energy injuries, the risk of permanent sensory impairment should be considered.

Factors affecting mortality of hospitalized facial trauma patients in Al-Ain City, United Arab Emirates

BACKGROUND

Facial injuries affect one-third of severely injured patients. These injuries have devastating long-term negative impacts on quality of life. We aimed to study the epidemiology of facial injuries and factors affecting the mortality of hospitalized facial trauma patients in Al-Ain City, United Arab Emirates.

METHODOLOGY

This is a retrospective analysis of prospectively collected data from Al-Ain Hospital Trauma Registry. All patients with facial injury who were hospitalized for more than 24 hours or who died after arrival at the hospital during the period from January 2014 to December 2017 were studied. Two sample data analysis was used to compare patients who died and those who survived. Significant factors were then entered into a backward logistic regression model to define factors affecting mortality.

RESULTS

408 patients having a mean age of 31.9 years were studied, 87.3% were males. The main mechanisms of injury were road traffic collisions (52.2%) and fall from height (11.3%). 289 (70.8%) patients had associated injuries which were mainly in the head and chest. The backward logistic regression model showed that the Glasgow Coma Scale (GCS) was the only factor that predicted mortality, p<0.0001 with the best cut-off point of 7.5, having a sensitivity of 0.972 and a specificity of 0.8. The ROC had an area under the curve of 0.924.

CONCLUSION

The majority of facial injury patients in our setting are young males who were involved in road traffic collisions or falls from height. The most important factor predicting the mortality of these patients was the low GCS. Those having a GCS of 8 and more had a better chance of survival. This information is very important when counseling patients or their relatives for facial surgery.

Does mechanism of injury impact the outcome of operative fixation of geriatric proximal humerus fractures

BACKGROUND

The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population.

METHODS

Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments.

RESULTS

Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group.

CONCLUSIONS

Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

Multiple ways for the same destination: bone regeneration

The regeneration of the bone is a challenging topic for maxillofacial plastic and reconstructive surgeons. For successful bone regeneration, timely providing of essential components is prerequisite. They are cellular components (osteoblasts, osteoclasts, and immune cells), extracellular matrix, and inorganic components (calcium and phosphate). Any deficient component can be provided from outside as a graft. Accordingly, there are many ways for successful bone regeneration. Selection of appropriate methods in an individualized situation is important.

Patterns of Facial Fractures in a Major Metropolitan Level 1 Trauma Center: A 10-year Experience

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.