Maxillofacial Fracture Patterns in Road Traffic Accidents

Off-Label Use of an External Hand Fixator for Craniomaxillofacial Fractures-An Anatomical Feasibility Study

BACKGROUND

The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Therefore, Barton bandages and/or interdental wiring are considered in these regions. Fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles.

MATERIALS AND METHODS

An AO hand fixator was used. CMF of types Le Fort 1-3 with split fractures of the hard palate were treated with EFF on 13 anatomical specimens. Fractures were created using a chisel, and pins were placed in specific anatomical regions. The maximal pull-out force [N] of pins was analysed by a tensile force gauge, and Fmax of the mandibular pins was evaluated. Computer tomography scans were performed on the healthy, fractured and EFF-treated skulls.

RESULTS

The pull-out forces for the single pins were mandibular pins (n = 15, median 488.0 N), supraorbital pins (n = 15, median 455.0 N), zygomatic pins (n = 14, median 269.1 N), medial hard palate pins (n = 12, median 208.4 N) and lateral hard palate pins (n = 8, median 49.6 N).

CONCLUSIONS

The results indicate that the operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can safely be inserted into the described areas with good reduction results. Using EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC.

Stability and Clinical Outcomes of Angle Fracture Fixation Using Sagittal Split Plate (SSOP) Versus Two Miniplates: Randomized Clinical Trial

The aim of this study was to compare the stability and clinical outcomes between the two miniplates and sagittal split plate (SSOP) in angle fracture fixation. Thirty-eight patients with a mandibular angle fracture were selected and divided randomly into two groups. Intervention was treated with SSOP, and the control group was treated with conventional two miniplates. Clinical evaluation included occlusion, edema, nerve affection, wound dehiscence and mouth opening. Radiographic parameters included the measurement of inter-ramus distance, inter-mental distance and bone density. All clinical parameters were evaluated at one week, one month and three months intervals. Radiographic parameters were evaluated immediately postoperative, and after three months. Results showed that SSOP had less postoperative complications (10.50%) than the two miniplates (31.60%). It can be concluded that both methods offered high performance in management of mandibular angle fractures. However, SSOP group had a significantly shorter operating time, increased bone density and less edema. Clinical trial registration number: NCT03839368.

Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures-A NSQIP Study

INTRODUCTION

Le Fort fractures comprise a pattern of complex midfacial fractures that arise secondarily to craniofacial trauma. Although management of these fractures has been detailed within the literature, there is a paucity of research examining postoperative outcomes after surgical repair. The primary aim of this study is to assess patient outcomes after operative management of Le Fort fractures, and examine factors influencing the risk for developing postoperative complications, through utilization of the ACS-NSQIP database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases recorded between 2012 and 2019 with International Classification of Disease (ICD)-9 and ICD-10 codes corresponding to Le Fort fractures. Patient demographics, clinical variables, and postoperative variables were recorded. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications.

RESULTS

Identification of cases with appropriate ICD codes, and exclusion of those with missing data, yielded 562 patients for analysis. There were no cases of minor complications and 14 cases of severe complications (3 cases of wound dehiscence, 3 cases of transfusion requirement, 1 case of failure to wean from the ventilator for more than 48 h, 1 pulmonary embolism, and 8 cases of reoperation), corresponding to an overall complication rate of 2.49%. Logistic regression analysis revealed steroid use as an independent predictor of severe postoperative complications (OR =13.73, 95% CI: 1.08-128.02, P =0.02).

CONCLUSION

The present study is the first to conduct a risk factor analysis of patients with Le Fort fractures using the ACS-NSQIP national database. The overall postoperative complication rate was 2.49%, with 14 cases of complications recorded in 8 years. Although this may suggest that surgical management of Le Fort fractures is generally well-tolerated, it should be noted that this problem is frequently associated with other severe injuries of the head and neck that may influence patient prognosis. Given this, further analysis would benefit from a larger patient cohort and longer postoperative data as the ACS-NSQIP database only records outcomes within 30 days.

Classification of unusual fracture patterns of the mandible: A retrospective study

The aim of this study is to devise and summarize a classification of fracture patterns involving multiple anatomical sites of the mandible. A retrospective study was conducted by reviewing clinical case records, imaging records, and the surgical management of patients presenting with mandibular fracture. Demographic data were collected and causes of the fractures were studied. Following radiological evaluations based on the courses of fracture lines, these fractures were categorized into three components: horizontal (H), vertical (V), and sagittal (S). In case of horizontal components, the mandibular canal was used as a reference. For vertical components, the fracture lines were classified according to where they terminated. With sagittal components, the direction of the bicortical split at the base of mandible was used as a reference. Out of a total of 893 mandibular trauma patients, 30 unusual fractures were identified (21 in males and nine in females), which do not fit into existing classifications. These were mainly due to road traffic accidents. Horizontal components of fractures were classified as H-I, H-II, and H-III, and vertical components as V-I, V-II, and V-III. For sagittal components, two types were identified - S-I and S-II - resulting in a bicortical split of the mandible. This classification is proposed to help understanding the complex fractures and to allow standardized communication among clinicians. Moreover, it is designed in such a way that aids in the choice of fixation technique. Further studies are needed to establish standardized treatment algorithms for efficient management of these unusual fractures.

Mandibular Fracture Patterns in a Rural Setup: A 7-Year Retrospective Study

Aim

This study is designed to outline the probable patterns of mandibular fracture based on patient demographics and mechanism of injury in a rural setup.

Materials and Methods

The data from the record section in our unit belonging to patients who sustained fractures in the maxillofacial skeleton and were treated in our unit between the period June 2012-May 2019 were collected and analyzed. The variables analyzed for the study were etiology, gender, age, and type of fracture. All cases were treated by open reduction and rigid internal fixation.

Results

A total of 224 patients with maxillofacial fractures were diagnosed, of which 195 were male and 29 were female. The ages ranged from 7 to 70 years. Road traffic accidents are noted to be the most common cause of mandibular fractures. The maximum cases were in the age group of 21-30 years with 85 (38%) patients. In a total of 224 patients, there were 278 mandibular fractures. The maximum incidence of fractures was in the mandibular parasymphysis region with 90 fractures accounting for 32.3% of the mandibular fractures. Males were more susceptible to mandibular fractures. Majority of them sustained mandibular fracture at more than one anatomical area.

Conclusion

It can be concluded that mandibular fractures are seen predominantly in the second and third decades of life due to road traffic accidents with high-speed vehicles and lack of protective safety accessories. Mandible when it fractured, it usually involved more than one anatomical location.

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.

Off-Label Treatment for Severe Craniomaxillofacial Fractures in Low-Income Countries-A Novel Operation Method with the External Face Fixator

Introduction: Craniomaxillofacial fractures (CMF) are common in low-income countries (LIC). Due to limited resources, treatment of these fractures usually consists of interdental wiring or immobilization with a Barton bandage to maintain the reduction by permanent occlusion. These non-surgical treatment methods often lead to unsatisfactory results, such as a disturbed dental occlusion and lockjaw. The aim of this study is to present an off-label treatment option for CMF by applying a hand fixator as external face fixator (EFF) and to demonstrate the surgical method in detail. Materials and Methods: The feasibility and postoperative outcomes of this new off-label operation technique were evaluated by analyzing patients with CMF (n = 13) treated at an NGO hospital in Sierra Leone between 2015 and 2019. Results: The application of the EFF was feasible. The biggest advantage compared to the conventional non-operative methods was, that a dynamic occlusion was still possible during the 6 weeks healing period. Hence, patients could eat and drink almost normally and perform dental hygiene with the EFF in place. We did not discover pintrack infections or other complications. Three patients developed an oronasal fistula due to traumatic a palatal bone loss of about 7–8 mm which was treated by a palatal mucoperiosteal flap 15–20 days after the first operation. Discussion and Conclusions: In LIC, where plate osteosynthesis for CMF cannot be performed due to limited resources the application of an EFF is a promising alternative for a better outcome and an improved quality of life for the patients.

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.

Mandible Fractures Associated With the Introduction of an E-Scooter-Sharing System

ABSTRACT

With the introduction of an e-scooter-sharing system in Germany, standing electric scooters became popular modes of transportation in many urban areas. But the increase in popularity has resulted in an increase in traumatic injuries associated with e-scooter accidents. The purpose of this investigation was to determine the common fracture pattern of patients with mandible fractures as a result of an electric scooter accident. The authors performed a retrospective investigation of 52 patients who were admitted to the trauma unit of an oral and maxillofacial department from June until November 2019 with a fracture of the mandible. Our study investigated the first 6 months of e-scooter sharing system in a major city with more than 1 million inhabitants. Our cohort consists of 52 patients, 38 males, and 14 females with a mean age of 37 years. E-scooter related mandible fractures were with 21% the third biggest group, after physical assault and falls. 45% of these patients were intoxicated by alcohol. Furthermore, the majority of e-scooter patients presented more than one fracture of the mandible (73%). For our cohort, a typical combination of a symphysis or body fracture and bilateral affected ramus and/or condyle was the prevalent recorded fracture combination (55%) of e-scooter related traumata. Small scooter wheels, a speed of 15 miles or 20 kilometers per hour and the individual clinging to the handlebar falling predestinate these vehicles for accidents with craniofacial trauma. Among all cranio-facial traumas mandible fractures were mostly documented for e-scooter accidents. The severity of e-scooter related mandible fractures and their fracture pattern should be recognized by trauma units.