Age and Number of Surgeries Increase Risk for Complications in Polytrauma Patients with Operative Maxillofacial Fractures

Fracture heat map of the facial skull demonstrates a danger zone of concomitant cervical spine injuries

Concomitant maxillofacial and cervical spine injuries occur in 0.8-12% of the cases. We examined the relation of injury localization and the probability of cervical spine fracture. A retrospective study was conducted on patients that have been treated at Dortmund General Hospital for injuries both to the maxillofacial region and to the cervical spine between January 1st, 2007 and December 31th, 2017. Descriptive statistical methods were used to describe the correlation of cervical spine injuries with gender, age as well as maxillofacial injury localization. 7708 patients were hospitalized with maxillofacial injury, among them 173 were identified with cervical spine injury. The average ages for both genders lie remarkably above the average of all maxillofacial trauma patients (36.2 y.o. in male and 50.9 y.o. in female). In the group of men, most injuries were found between the ages of 50 and 65. Whereas most injuries among women occurred after the age of 80. The relative ratio of cervical spine injuries (CSI) varies between 1.1 and 5.26% of the maxillofacial injuries (MFI), being highest in the soft tissue injury group, patients with forehead fractures (3.12%) and patients with panfacial fractures (2.52%). Further, nasal, Le Fort I and II, zygomatic complex and mandibular condyle fractures are often associated with CSI. Fractures next to the Frankfurt horizontal plane represent 87.7% of all MFI with concomitant CSI. Patients in critical age groups with a high-energy injury are more likely to suffer both, MFI and CSI injuries. Our findings help to avoid missing the diagnosis of cervical spine injury in maxillofacial trauma patients.

Inpatient Versus Outpatient Operative Management of Isolated Facial Fractures

BACKGROUND

Patients with isolated facial fractures requiring operative fixation can be managed on an inpatient or outpatient basis. The goal of this study was to compare the safety of each approach using a large multi-institutional database.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Project was reviewed for facial fractures between 2005 and 2018. Groups were identified using inpatient and outpatient status as designated in the database. Patients who required additional procedures, concurrent procedures, or other emergency procedures were excluded. Descriptive statistics were used for group comparisons and logistic regression models were used to identify risk factors for complications.

RESULTS

We identified 3350 patients who underwent operative fixation of isolated facial fractures. The majority of these cases (70.3%) were done on an outpatient basis. Compared to those in the outpatient group, patients in the inpatient group were older, had more medical comorbidities, had higher wound class, and had higher American Society of Anesthesiologists class. Complication (6.3% versus 2.3%), reoperation (4.3% versus 1.7%), and readmission (6.9% versus 2.5%) rates were all higher in the inpatient group (P < 0.01). By logistic regression analysis, the odds ratios for complications, reoperation, and readmission were higher in the inpatient group. After adjusting for imbalanced preoperative patient characteristics, the increased risk of complications in the inpatient group persisted [odds ratio (OR) = 1.9, confidence interval (CI) 1.2-3.0, P = 0.01] while the risk of reoperation (OR = 1.7, CI 1.0-2.9, P = 0.08) and risk of readmission (OR = 1.4, CI 0.7-2.6, P = 0.33) no longer showed statistical significance between the inpatient and outpatient groups.

CONCLUSIONS

Inpatient operative management of isolated facial fractures is associated with an almost 2-fold increased risk of complications, though no increased risk of reoperation or readmission.

Cervical spine injuries in facial fracture patients - injury mechanism and fracture type matter

Evidence supports the notion that craniofacial fractures are significant predictors of cervical spine injuries (CSIs), but some debate remains on the injury mechanism of co-existing CSIs in craniofacial fractures and the relationship between CSI and specific facial fractures. In this retrospective study, we aim to assess the incidence rates of specific facial fracture types as well as other important variables and their relationship with CSIs. The primary outcome variable, CSI, and several predictor variables, including facial fracture type, were evaluated with logistic regression analyses. Of 2919 patients, the total CSI incidence rate was 3.0%. Rates of CSI in patients with isolated mandibular fractures (OR 0.26 CI 0.10, 0.63; p = 0.006) were lower than those previously reported, whereas isolated nasal fractures were strongly associated with CSI (OR 2.67 CI 1.36, 5.22; p = 0.004). Patients with concomitant cranial injuries were twice as likely to have CSI (OR 2.00, CI 1.22, 3.27; p = 0.006). Even though there is a strong occurrence rate of CSIs in patients with cranial injuries, clinicians should be aware that patients presenting with isolated facial fractures are at significant risk for sustaining CSIs also.

Successful Treatment of Well-Developed Accessory Lower Limb Associated with Spinal Dysraphism

Accessory lower limb with spinal dysraphism are amongst the rarest known anomalies. We successfully managed a 5-months old female infant with surgical ablation of the accessory lower limb and repair of the associated large lipomyelomeningocele. A comprehensive review of the relevant literature was undertaken and presented herein. A classification system for accessory lower limb is also proposed.

Implications of Facial Fracture in Airway Management of the Adult Population: What Is the Most Effective Management Strategy?

PURPOSE

Facial fractures are a harbinger when it comes to airway management. Facial fractures can cause airway obstruction or preclude the use of intubation. We aim to examine the etiologies, types of facial fractures, and the risk factors that may lead to requirement of an advance airway.

METHODS

A retrospective chart review was performed of all facial fractures in the adult population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and course of hospital stay.

RESULTS

During the period examined, 2626 patients were identified as 18 years or older and with facial fracture. Among these patients, 443 received airway management. Mean age was 34.21 years (range, 18-95 years), with a male predominance of 91.9%. One hundred nineteen patients were intubated on, or before, arrival to the trauma bay. One hundred three patients required surgical airways on arrival to the trauma bay, and 91 of these patients were also reported to have been intubated before arrival. There were a total of 741 fractures identified on radiologic imaging. The most common fractures observed were orbital fractures, frontal sinus fractures, and nasal fractures. Mean Glasgow Coma Scale score on arrival was 9.45 (range, 3-15). Gunshot wound was also the most common etiology among those who were intubated and those who received a surgical airway. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Forty-one patients died, most of which were intubated during their hospital course.

CONCLUSIONS

There is a dearth of literature detailing standardization of airway management for patients who present with facial fractures. The difference between intubation and surgical airway is often a subjective judgment call, but the authors believe that a more streamlined process can be elucidated after analyzing previous trends as well as variabilities in patient survival and prognosis.