Automatic detection of midfacial fractures in facial bone CT images using deep learning-based object detection models

BACKGROUND

Midfacial fractures are among the most frequent facial fractures. Surgery is recommended within 2 weeks of injury, but this time frame is often extended because the fracture is missed on diagnostic imaging in the busy emergency medicine setting. Using deep learning technology, which has progressed markedly in various fields, we attempted to develop a system for the automatic detection of midfacial fractures. The purpose of this study was to use this system to diagnose fractures accurately and rapidly, with the intention of benefiting both patients and emergency room physicians.

METHODS

One hundred computed tomography images that included midfacial fractures (e.g., maxillary, zygomatic, nasal, and orbital fractures) were prepared. In each axial image, the fracture area was surrounded by a rectangular region to create the annotation data. Eighty images were randomly classified as the training dataset (3736 slices) and 20 as the validation dataset (883 slices). Training and validation were performed using Single Shot MultiBox Detector (SSD) and version 8 of You Only Look Once (YOLOv8), which are object detection algorithms.

RESULTS

The performance indicators for SSD and YOLOv8 were respectively: precision, 0.872 and 0.871; recall, 0.823 and 0.775; F1 score, 0.846 and 0.82; average precision, 0.899 and 0.769.

CONCLUSIONS

The use of deep learning techniques allowed the automatic detection of midfacial fractures with good accuracy and high speed. The system developed in this study is promising for automated detection of midfacial fractures and may provide a quick and accurate solution for emergency medical care and other settings.

Pediatric Craniomaxillofacial Fractures: A Review

Pediatric facial fractures constitute a small portion of all facial fractures. The frequency of pediatric facial fractures by location, and mechanism of injury, changes over time associated with craniofacial growth and activity. Pediatric patients have protective anatomic features, such as increased soft tissue, excess adipose tissue, and more flexible bone. Conservative management is often sufficient. Surgical intervention can often be conservative. Follow-up monitoring is valuable for concerns of growth disruption from either the trauma itself or surgical interventions. Older teenage patients may often be treated similar to adults. Postoperative management varies by fracture type without a defined long-term follow-up course.

Pediatric Facial Fracture in Garhwal Himalayan Region of Uttarakhand State: A Retrospective Study

Background

Pediatric facial fractures are fairly uncommon injuries and comprise less than 15% of all facial fractures in the literature.

Objectives

To analyze the pattern of pediatric facial fractures and compare the results with similar studies performed in India and the rest of the world.

Materials and Methods

A total of 231 patients were admitted for the treatment of maxillofacial fractures. Data on etiology, anatomical location, mode of treatment, duration of stay, and X-ray advice were recorded.

Results

Pediatric trauma comprised 27% of the total population. The most common cause of injury was road traffic accident (RTA), that is, 28 (43.8%) patients.

Conclusion

The incidence of pediatric facial trauma is high in the hilly Garhwal-Himalayan region of Uttarakhand state in India as compared to other states of India.

Head & Neck Trauma in the Geriatric Population

Craniofacial trauma in the geriatric population is increasing as our population ages. Due to loss of bone quality and medical comorbidities, injuries for minor trauma can be severe. A more extensive medical evaluation is usually warranted in this population before proceeding with surgery. In addition, unique surgical considerations exist in the repair of atrophic and edentulous bony fractures. Some quality improvement measures have already been undertaken but more is needed to help standardize care in this vulnerable population.

Fractures in professional footballers: 7-years data from 106 team seasons in the Middle East

Epidemiological studies on fractures in European professional football (soccer) are in abundance. However, such data are lacking in Middle Eastern professional footballers and information on fracture treatment is scarce. The aim of this study is to describe the epidemiology of fractures across seven seasons in Qatar Stars League (QSL) footballers. A prospective study of fractures in professional male footballers over 7 consecutive seasons (2013 to 2020), involving 3255 players and 106 team' seasons. Time loss and injuries and illnesses were recorded using standardised digital tools in accordance with international consensus procedures. Fractures were recorded according to onset mechanism, location, diagnoses, treatment and return to play. A total of 108 players sustained fractures during 638,247 hours of player exposure (88.9% training and 11.1% matches), representing 2.7% of all time-loss injuries. The incidence was 0.17 fractures per 1000 h of exposure (match and training incidence of 0.9 and 0.07 fractures / 1000 h, respectively), equivalent to an average of one fracture per team per season. Fractures mostly occurred in the feet (28.2%), hands (21.1%), shoulders (11.3%) and head (i.e., face) (9.9%). Mean (median) absence was 71 (47 days), with 4.6% refractures. Only 34.3% of the fractures required surgery and nearly all players (98.1%) returned to play at the professional level. Almost all professional football players with fractures return to play at the same competitive level after an average of 10 weeks of absence (mean absence was 71 ± 81 (median: 47, Inter Quartile Range [14-93]) days). One in ten continue to play with symptoms and one in twenty may refracture. Long-term effects of fractures are still unknown.

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients' daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.

Epidemiology of Maxillofacial Traumatisms in French Alps Metropole (Grenoble) Specificity for the mountain sports and evolution in the last 40 years

INTRODUCTION

Over the years, several studies have been carried in the Teaching Hospital of Grenoble, analysing the epidemiology of facial injuries. The aim of this study was to gather and compare the previous works, focusing on the injuries caused by mountains sports. The evolution of mountain sports trauma in the last 40 years was studied, and observations on the protective action on the face and facial bones of the helmet were made.

MATERIALS AND METHODS

The data from all facial injuries treated in the years 2016 and 2017 were collected, and a retrospective study was performed. It was supplemented by the data of 3 articles (1981, 1992, 2006) and a thesis (1985).

RESULTS

Localizations of the fractures, when not discriminated according to causes, were consistently the same in our study than in previous works, with 66% of upper 2/3 of the face fractures, and 22% of lower 1/3 fractures. When filtering only mountain sports traumatisms, a significant decrease of upper 2/3 facial injuries was observed in the current study compared to the 1981, 1985 and 2006 data. This drop tallies with the period where the use of the helmet generalized. The evolution of mountain sports practices, the improvement of protective personal equipment and of the security on sport sites triggered a real diminution of mid and upper face traumatisms.

Zygomaticomaxillary Fractures

Fractures of the zygomaticomaxillary complex and zygomatic arch are common athletic injuries. Fracture displacement can lead to midfacial retrusion and widening, causing noticeable deformity. Associated signs and symptoms include hypoesthesia of the infraorbital nerve distribution, trismus, and subjective malocclusion. Operative treatment is indicated in cases of significant displacement or functional disturbance. The approach and details of osteosynthesis are catered to the specific characteristics of the fracture. Technology, such as virtual surgical planning, intraoperative navigation, and intraoperative imaging, has the potential to improve accuracy of treating challenging fractures.

Pattern of maxillofacial fractures in a Tertiary Referral Centre in Central Kerala - A comparison between the Pre-COVID and COVID periods

Our aim was to observe if there was any appreciable difference in the etiology and pattern of maxillofacial fractures during the pre-COVID-19 and COVID-19 periods in Central Kerala, South India. This retrospective study was conducted with data over a period of two years from the central database registry of our hospital. Age, sex, etiology, date of injury, and site of facial fractures were recorded and compared between both the time periods. Increase in facial fractures due to fall at home (p value < 0.01) and decrease in mass casualty cases (p value < 0.01) were observed during the COVID-19 period. Pedestrians involved were significantly more in the pre-COVID-19 period (p value < 0.01) and heavy vehicle accidents producing facial fractures were significantly more in the COVID-19 period (p value < 0.01). Frontal bone (p value = 0.008), nasal bone (p value < 0.001) and zygomatico-maxillary complex fractures (p value < 0.001) occurred significantly more in the COVID-19 time period whereas naso-orbito-ethmoidal (p value = 0.003), mandibular (p value = 0.011) and dentoalveolar fractures (p value < 0.001) were seen significantly more in the pre-COVID-19 period. There was decrease in the total number of maxillofacial cases during the COVID-19 period. However, this was not significant when only the number of facial fractures were compared between the two periods. This study provided an insight on the differences in etiology and pattern of maxillofacial fractures during the pre-COVID-19 and COVID-19 periods. Road traffic accidents involving two wheelers predominate during the COVID-19 period also, prompting further critical exploration of the reasons behind this finding.

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.

The impact of COVID-19 on the injury pattern for maxillofacial fracture in Daegu city, South Korea

Background

This study aimed to analyze the impact of COVID-19 on oral and maxillofacial fracture in Daegu by comparing the demographic data in 2019 and 2020, retrospectively. We collected data from all patients having trauma who visited the emergency room for oral and maxillofacial fractures.

Methods

This retrospective study was based on chart review of patients who visited the emergency department of Kyungpook National University Hospital in Daegu, South Korea from January 1, 2019, to December 31, 2020. We conducted a comparative study for patients who presented with maxillofacial fractures with occlusal instability during pre-COVID-19 era (2019) and COVID-19 era (2000) with demographics and pattern of injuries.

Results

After the outbreak of COVID-19, the number of monthly oral and maxillofacial fractures, especially sports-related oral and maxillofacial fractures, decreased significantly. Also, the number of alcohol-related fractures increased significantly. In addition, as the number of monthly confirmed cases of COVID-19 increases, the incidence of fracture among these cases tends to decrease.

Conclusions

The COVID-19 pandemic has changed the daily life in Korea. Identifying the characteristics of patients having trauma can provide a good lead to understand this long-lasting infectious disease and prepare for future outbreaks.

Classifying the causes of morbidity and error following treatment of facial fractures

Analysing morbidity and using this to improve the quality of patient care is an important component of clinical governance. Several methods of data collection and clinical analysis have been suggested, but to date none have been widely adopted. All adult patients sustaining facial fractures were prospectively identified between 01 March 2019 and 28 February 2020, and matched to those who required a return to theatre for surgical complications. Morbidity resulting in a return to theatre was determined using the Clavien-Dindo classification and the Northwestern University error ascribing method. During this period, return to theatre occurred for 33/285 (11.6%) procedures and 23/173 (13.3%) of patients being treated for facial fractures. According to the 27 procedures discussed, Clavien-Dindo Grade IIIb was most commonly found (20/27). Error in judgement (13/35) and nature of disease (12/35) were ascribed as the most common causes of error. Presence of a consultant was associated with increased odds of a return to theatre (p = 0.014). Standardised national data collection of morbidity and error is required for comparisons of outcomes within a single institution or between institutions. To the best of our knowledge, this is the first paper to utilise these widely used methods of morbidity analysis for facial fracture surgery. We would recommend further development of an error analysis method that is more specific to complications from facial fracture surgery.

Maxillofacial trauma in children: Association between age and mandibular fracture site

PURPOSE

To describe the association between age and location of facial fractures in the pediatric population.

MATERIALS AND METHODS

A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) from the 2016 Kids' Inpatient Database (KID) in children aged ≤18 years was conducted. International Statistical Classification of Diseases, 10th Revision (ICD-10) codes were used to extract facial fracture diagnoses. Logistic regression was used to evaluate and compare the contribution of various demographic factors among patients who had different types of facial fractures.

RESULTS

A total of 5568 admitted patients were identified who sustained any type of facial bone fracture. Patients who had facial fractures were significantly more likely to be male (68.2% versus 31.8%; p<0.001) and were older with a mean age of 12.86 years (95% confidence interval [CI]: 12.72-12.99). Approximately one-third of patients with a facial fracture had a concomitant skull base or vault fracture. Maxillary fractures were seen in 30.9% of the cohort while mandibular fractures occurred in 36.9% of patients. The most common mandibular fracture site was the symphysis (N=574, 27.9% of all mandibular fractures). Condylar fractures were more common in younger children while angle fractures were more common in teenagers. Regression analysis found that age was the only significant contributor to the presence of a mandibular fracture (β=0.027, p<0.001) and race was the only significant contributor to maxillary fractures (β=-0.090, p<0.001).

CONCLUSIONS

Facial fractures increase in frequency with increasing age in children. The mandible was the most commonly fractured facial bone, with an age-related pattern in fracture location.

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.

Surgical planning using facial fracture 3D models: The role of cyanoacrylate glue and miniplating for anatomical reduction

Background

In comminuted facial fractures, peri-operative use of 3D-printed life size models is increasingly a useful adjunct. It allows for preoperative surgical rehearsal and plate bending, to achieve anatomical reduction with reduced operative time and cost. One problem encountered is difficulty contouring the fixation plate whilst maintaining the relative spatial orientation of comminuted fragments. This paper shares an effective method of overcoming this problem.

Methods

All comminuted facial fracture patients underwent counselling for 3D printing. Pre-printing thresholding and segmentation of each fragment (as directed by the surgeon) were done by the radiologist and the engineering team, using the multi-slice CT Face DICOM data. Life-size 3D-resin models of the fractures were printed. Fast-acting medium consistency cyanoacrylate glue (Zap-A-Gap^Ⓡ) and miniplates were used to assemble the printed model segments in ‘anatomic reduction’. Aerosolized alcohol accelerator facilitated immediate glue curing, providing a stable model. The plates were adapted over this restored neonative 3D construct with bending inserts, sterilized and used intraoperatively. The 3D model was used to guide the operative sequence. Intraoperative CT was used in select cases to confirm anatomic reduction.

Results/Complications

All patients (n = 5) had comminuted fractures in at least one of the bony units (mandible, maxilla or orbits) and one was a pan-facial fracture case. 3D printed models aided fracture reduction and fixation, whilst avoiding the guesswork in ascertaining the contour of the mandibular arch. In addition, the pre-contoured mandible plates restored premorbid occlusion and projection, without the need for long-term archbars in all cases. Operative time was estimated to be reduced by 0.5–1 h. Resident teaching was enhanced by this approach.

Conclusion

The application of medium consistency fast-acting cyanoacrylate glue and miniplates facilitated the creation of the premorbid facial skeletal model and allowed pre-bending of the plates, thus saving operative time and cost.

Complications of craniofacial surgery using the ultrasonic-assisted pinned resorbable system: A prospective report with a minimum follow-up of 30 months

Several resorbable fixation systems are used for osteosynthesis in craniofacial surgery. Recently, ultrasonic-assisted pinned resorbable systems have been introduced; however, few studies have described the associated complications during the long-term follow-up until complete resorption. In this study, we investigated the complications of craniofacial surgery using the ultrasonic-assisted pinned resorbable system with a follow-up of at least 30 months. Among patients who underwent craniofacial surgery using a commercially available ultrasonic-assisted pinned resorbable system between 2014 and 2016, those with follow-up visits for at least 30 months were included in this study. We investigated the development of complications such as local infection, exposure of the device, and reoperation related to the implant. Twenty-four patients aged 6 months to 69.4 years (median: 3.5 years) were followed up for more than 30 months. None of the patients required reoperation regardless of implants. Further, no infection or device exposure was seen among all patients. However, two patients aged 6 and 22 months who underwent cranioplasty for craniosynostosis and another patient aged 148 months who underwent cranioplasty for cranial defect exhibited plate-related bulging in the scalp during the course of resorption between 7 and 12 months of follow-up. The bulges were characterized by swelling without pain or redness and resolved spontaneously within 18 months of follow-up, which was considered to occur after complete absorption of the plate. In conclusion, subcutaneous swelling is related to resorbable plates and has a benign clinical course. We recommend that patients be informed of this phenomenon preoperatively to relieve their anxiety.

The relationship between the status and position of third molars and the presence of mandibular angle and condylar fractures

INTRODUCTION

The aim of this study was to assess the relationship between the status and position of third molars, and the presence of mandibular angle and/or condylar fractures, in a group of patients treated for mandibular fractures, thus hoping to contribute to the knowledge of potential predictors of these fractures.

METHODS

A retrospective study was designated to include all the patients who were diagnosed and treated with open reduction and internal fixation for isolated mandibular angle fractures or isolated mandibular condylar fractures between 1st of January 2012 and 31st of December 2018. The following data were collected for each included patient: gender, age, etiology, site and side of the fracture, and presence and eruption state of third molars in the fracture side.

RESULTS

Seventy patients were diagnosed with a condylar fracture, 48 with an angle fracture. No statistically significant difference was observed as for etiology and gender distribution between angle fracture and condyle fracture patients (p > 0.05). Angle fractures were statistically associated with the presence of third molars, whereas condylar fractures with the absence of third molars (p < 0.000005). The presence of completely erupted 3Ms was associated with condylar fractures (p < 0.05), and partially impacted 3Ms were associated with angle fractures (p < 0.0005).

CONCLUSIONS

Mandibular angle fractures and third molar presence are associated in patients who present with mandibular fractures, especially if the third molar is incompletely erupted. This information should be kept in consideration as for the diagnosis and management of patients with mandibular fractures.

An assessment of histological margins and recurrence of completely excised cutaneous SCC

There is a paucity of data relating to histological margins of cutaneous squamous cell carcinoma (cSCC) and local recurrence. Retrospective data were collected for 721 patients with cSCC treated at Queen Victoria Hospital, UK, and followed up for five years. The local recurrence rate was 6.1%, the mean time to recurrence was 12.61 months and 93% of recurrences occurred within two years. Sixty-six per cent of recurrences had a deep margin of 2.5 mm or less (p 0.041). The Pearson's correlation coefficient showed a strong correlation with tumour grade (r=0.82, p, 0.05), lymphovascular invasion (r=0.73. p<0.05), medium correlation with deep histological margin(r= -0.55, p<0.05), a weak correlation with male sex (r= 0.31, p<0.05) and the anatomical site of head and neck (r=0.31, p<0.05).The multiple regression analysis model using the 5 variables generated an r value of 0.71 and adjusted r square of 0.7. In conclusion, our findings are consistent with previously mentioned prognostic indicators and also demonstrate that deep histological margin is a significant predictor of local recurrence of cSCC. We recommend larger multi-institutional studies to confirm the above results to subsequently guide the specialist skin multidisciplinary teams' recommendations.

Oral health-related quality of life of patients undergoing different treatment of facial fractures: The OHIP-14 questionnaire

Background

The choice of surgical approach can affect the quality of life in patients with a facial fracture.

Objective

The aim of this study was to assess the quality of life in surgically treated patients with facial fractures, and to determine the potential difference in the quality of life related to different surgical approaches.

Materials and Methods

Ninety facial fracture cases were analyzed. They were divided into three groups: operated by skin incision, mucosal incision, and treated conservatively. To examine the quality of life of patients, a questionnaire on the quality of oral health Oral Health Impact Profile (OHIP)-14 questionnaire was used.

Results

In the first days after the injury, patients with transcutaneous approach showed a poorer quality of life in comparison to patients with transmucosal and conservative treatment. The presence of severe posttraumatic pain is significantly more prevalent in patients with transcutaneous surgical approach than in other treatment types.

Conclusion

During the immediate posttraumatic period, the quality of life is poorer in patients who have undergone transcutaneous approach. There are no differences in the quality of life 1 month or 3 months after the injury.

Discussion

Assessment of complaints in the first days after the injury shows statistically significant differences across various therapeutical methods in variables such as pain, discomfort when eating certain foods, aesthetic appeal, nervousness, and relaxation. There is not sufficient evidence related to the differences in these outcomes regarding different surgical approaches for facial fractures.

Early return to sport post maxillofacial fracture injury in the professional athlete: A systematic review

INTRODUCTION

To summarize the current literature on return to sport times post-maxillofacial fracture injury in the professional athlete.

MATERIALS AND METHODS

A literature search on six databases for articles relating to maxillofacial fractures, professional athletes, and return to sport times. Study design, clinical data, and author recommendations were analysed.

RESULTS

17 studies were retrieved. One prospective study returned 17 athletes to competitive rugby union and soccer at 3 weeks post injury without complication. Two large retrospective studies (n = 278) returned patients to sport at approximately 7 weeks without complication. 64% (n = 7) of patients from case based studies returned to sport at 3-14 days, 4 of which utilized protective facemasks. Athletes generally returned to competition earlier for lower grade (3-10 days) compared to higher grade contact sport (21 days at least). 2 articles recommended a 3 months recovery period for combat sports. 8 articles supported the utility of protective facemasks.

CONCLUSION

Early return to sport (<6 weeks) in the professional athlete post maxillofacial fracture injury is achievable. The optimal clinical approach may be to grade the sport according to its impact forces, discuss an early return with reference to the available literature, the potential utility of facemasks, risks of refracture and its operative implications.

The use of teleradiology for triaging of maxillofacial trauma

PURPOSE

The aim of this study was to assess and discuss our experience with a teleradiology technique applied to facial trauma patients referred to an oral and maxillofacial surgery hub center.

MATERIALS AND METHODS

All trauma patients with maxillofacial fractures from the hospitals of Vercelli, Biella, Borgosesia, Borgomanero, Verbania, and Domodossola who were referred between July 2014 and September 2018 to the hub maxillofacial center of Novara were reviewed. The following data were recorded for each patient: sex, age, referral hospital, etiology, etiology mechanisms, site of facial fractures, date of injury, indications for surgery according to teleradiology consultation, indications for surgery following clinical maxillofacial assessment, date of eventual surgery, timing of surgery from trauma, type of surgical intervention.

RESULTS

A total of 467 patients with a total of 605 fractures were triaged and managed by the Tempore telemedicine system. The most frequent cause of maxillofacial injury was fall. The most frequently observed fracture involved the zygoma. Following remote computed tomography assessment, surgical indications were suggested in 68 patients; 223 patients were not considered suitable candidates for surgery; and 176 patients needed a clinical assessment for the establishment of definitive eventual indications for surgery. Following clinical assessment, the absence and presence of surgical indications was confirmed in all 223 and 68 patients, respectively. Within the 176 patients with "possible" surgical indications, only 27 patients were referred for surgery.

CONCLUSION

Teleradiology may be helpful for an appropriate triaging of trauma patients from peripheral hospitals for the correct referral to a maxillofacial trauma hub center.

Water balloon-induced orbital fracture in an aviator

BACKGROUND

Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature.

CASE PRESENTATION

A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status.

CONCLUSIONS

Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Prospective analysis of mid-facial fractures in a single-center pediatric-adolescent cohort

BACKGROUND

The complex architecture of the midface renders diagnosing and treating fractures challenging, especially for young patients who present the additional risk of suffering growth and development deficiencies, which is to be avoided at all costs.

OBJECTIVES

This study sought to characterize pediatric mid-facial fractures considering the possible complications.

METHODS

Between September 2008 and September 2018, data was collected on inpatients aged <18 years, treated for mid-facial fractures at the Halle University Hospital. Evaluated parameters were age, gender, cause and type of fracture, associated injuries, treatment, and complications.

RESULTS

In total, 31 patients were examined; 20 were boys. The most common cause of injury was road traffic accident (41.9%). Orbital floor fracture was the most common type of injury (58.1%). In 54.8% of cases, surgery was performed.

CONCLUSION

The incidence of complications associated with mid-facial fractures was low (n = 7), requiring treatment in only three cases (orthodontic, ophthalmological).

Relation between facial fractures and socioeconomic deprivation in the north east of England

Patients with a low socioeconomic status suffer disproportionately from trauma, and have a high incidence of mandibular fractures. To explore how deprivation affects the incidence of facial fractures in the north east of England, we reviewed 1096 patients who were admitted to the oral and maxillofacial surgical (OMFS) unit at Sunderland Royal Hospital for treatment of a facial fracture between December 2013 and December 2017. Levels of socioeconomic deprivation, which were obtained from postcodes and the UK Government Open Data Communities database, were compared with a random sample of deprivation data from the catchment area of our hospital. Patients with nasal and mandibular fractures were more likely to be socioeconomically deprived than those in the catchment area of our hospital (p = 0.006 and p < 0.001, respectively), but this was not the case in those with malar/maxillary or orbital floor fractures (p = 0.184 and p = 0.641, respectively). The incidence of fractures that were caused by assault was not associated with increased socioeconomic deprivation (p = 0.241). Patients of low socioeconomic status were more likely to have been under the influence of a substance when the injury occurred (p = 0.014). There is a strong association between socioeconomic deprivation and facial fractures. OMFS departments should therefore be as accessible as possible to patients from more disadvantaged backgrounds, given their greater risk of injury.

The "European zygomatic fracture" research project: The epidemiological results from a multicenter European collaboration

PURPOSE

Fractures of the zygomaticomaxillary complex (ZMC) are common injuries that may lead to loss of an aesthetically pleasing appearance and functional impairment. The aim of this study was to analyze the demographics, causes, characteristics, and outcomes of zygomatic fractures managed at several European departments of oral and maxillofacial surgery.

MATERIALS AND METHODS

This study is based on a multicenter systematic database that allowed the recording of all patients with ZMC fractures between 1 January 2013 and 31 December 2017. The following data were recorded: gender, age, personal medical history, etiology, side of zygomatic fracture, classification of ZMC fracture, associated maxillofacial fractures, symptoms at diagnosis, type of performed treatment, and sequelae/complications.

RESULTS

A total of 1406 patients (1172 males, 234 females) were included in the study. Statistically significant correlations were found between assault-related ZMC fractures and the A3 class (p < .0000005) and between Infraorbital Nerve (ION) anesthesia and B class (p < .00000005).

CONCLUSION

The most frequent cause of ZMC fractures was assault, followed by falls. The most frequently involved decade of age was between 20 and 29 years. The decision and type of surgical treatment of ZMC fractures depends on several issues that need to be considered on a case by case basis.

Coincidence of craniocerebral and craniofacial injuries

PURPOSE

To determine the incidence of craniocerebral injuries in patients who experienced upper facial or midfacial traumas associated with the disorders of consciousness. To find which types of craniofacial traumas predisposed to craniocerebral injuries. To analyze a relationship between the site of the force application and the type of resultant craniocerebral injury.

MATERIALS AND METHODS

The study included 3,481 patients with upper facial and midfacial traumas. All 425 patients with craniofacial traumas and disorders of consciousness at the time of the event or hospital admission, were qualified for computed tomography (CT) of the head.

RESULTS

In 85/425 patients (20%), 70 men and 15 women (age 14-71 years), craniofacial trauma coincided with a craniocerebral injury. Upper facial dislocation and zygomatic-orbital-maxillary complex fracture significantly more often co-existed with skull, dura mater or cranial nerve injuries, and zygomatico-orbital fracture with the injuries of the brain. Application of force both centrally and laterally to the horizontal plane predisposed to skull, dura mater and cranial nerve injuries.

CONCLUSION

The recommendation to perform head CT in each patient with craniofacial trauma who experienced the disorders of consciousness is as simple as possible, yet provides high diagnostic sensitivity, facilitating proper management at initial stages post-injury.

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

BACKGROUND

Poly-trauma patients often sustain complex head/neck injuries requiring prolonged hospitalizations and multiple operations. Few studies have evaluated the associated injury patterns and risk factors for poor clinical outcomes.

METHODS

Consecutive poly-trauma patients with operative maxillofacial fractures treated at a level 1 trauma medical center between 1995 and 2013 were evaluated. Concomitant head/neck injuries to identify potential injury patterns were numerated. Lastly, a multivariate analysis was performed to determine independent risk factors for complications during the acute hospitalization period.

RESULTS

Totally, 232 poly-trauma patients presented with operative maxillofacial fractures, while 38.8% of patients had a secondary maxillofacial fracture, 16.4% had intracranial hemorrhage, 23.7% had skull fractures, and 12.1% had spinal fractures. The rate of complication during admission was 28.3%. Multivariate analysis revealed advanced patient age and increased number of operations to predict the rate of complication. Patients requiring more than one operation had a 1.8-fold increase in complication rate (p<0.01) and older patients had a 4.5% increase in complication rate (p<0.05) for every year of increased age.

CONCLUSION

Poly-trauma patients have a high incidence of secondary maxillofacial fractures, concomitant head/neck injury, and inpatient complication rate. Knowledge of associated injury patterns can help increased awareness and can guide physician decision-making to avoid missed/delayed injuries.

Behavior of C-reactive protein in association with surgery of facial fracture and the influence of dexamethasone

PURPOSE

To clarify pre- and postoperative C-reactive protein (CRP) levels in patients with facial fractures and to investigate the influence of perioperatively administered dexamethasone on postoperative CRP levels.

PATIENTS AND METHODS

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone (Oradexon®), whereas patients in the control group received no glucocorticoid. The analysis included patients who had CRP measured pre- and postoperatively.

RESULTS

A total of 73 adult patients with facial fractures were included in the final analysis. Mean CRP level was elevated preoperatively and the level increased further after surgery. However, postoperative CRP rise was significantly impeded by dexamethasone (p < 0.001), regardless of gender, age, treatment delay, site of fracture, surgical approach, and duration of surgery. CRP rise halved on the 1st postoperative day when dexamethasone was used. In addition, dexamethasone resulted in a CRP decrease on the 2nd postoperative day, whereas the CRP rise continued in the control group.

CONCLUSIONS

CRP rise is a normal body response after facial fracture and surgery that can be markedly reduced with dexamethasone. CRP changes should be considered with caution if perioperative dexamethasone is used.

Retrobulbar hematoma: A systematic review of factors related to outcomes

INTRODUCTION

Retrobulbar hematoma (RBH), a rare but serious condition, can result in permanent vision loss. Although it is a known complication following trauma or facial fracture reduction, sinus surgery, or blepharoplasty, factors related to patient outcomes are not well-defined. A systematic review was performed to determine the relation of patient/treatment factors to outcomes.

METHODS

Articles retrieved from a PubMed search (1989-2017) were reviewed. Demographic information, etiology, symptoms, and final vision outcomes were analyzed using Fisher's exact tests, single and multiple predictor logistic regression.

RESULTS

Of 429 articles identified, 16 were included in the study. 93 cases of retrobulbar hematoma were included. 74% occurred after trauma, while 26% occurred postoperatively. Onset of symptoms occurred after approximately 24 hours. 28% received treatment within 1 hour, 54% within 1-24 hours, and 18% after 24 hours. 51% had complete visual recovery, while 27% had partial recovery, and 22% developed blindness. Older patients and patients who sustained trauma were less likely to have a full recovery (p = 0.029, p = 0.023). Increasing number of symptoms trended towards a prediction of blindness (p = 0.092). Surgical decompression and shorter time to treatment were each highly predictive of full recovery (p = 0.024, p = 0.003) and decreased likelihood of blindness (p = 0.037, p = 0.045); use of steroids was not found to be significant.

DISCUSSION

Retrobulbar hematoma is a diagnostic and therapeutic emergency. Factors associated with improved outcomes include younger age, decreased number of total symptoms, surgical decompression, and shorter time to treatment. If recognized and treated early with surgical decompression, recovery of vision is possible.

Modified closed cap splint: Conservative method for minimally displaced pediatric mandibular fracture

Mandibular fracture in younger children is the most common facial fracture among all the facial fracture in the sequence of condyles followed by symphysis/parasymphysis and body of the mandible. Symphysis/Parasymphysis fracture of mandible can be minimally displaced or severely displaced depending upon the severity of the injury. This case report highlights the simple, reliable method of minimally displaced fracture i.e. modified closed cap splint for stability of the fracture segments in pediatric patients.

Patterns of facial trauma before and after legalization of marijuana in Denver, Colorado: A joint study between two Denver hospitals

INTRODUCTION

The effect of marijuana on human health has been studied extensively. Marijuana intoxication has been shown to affect performance, attention span, and reaction time. The public health relationship between trauma and cannabis use has also been studied, with mixed conclusions. In this report, the effect of marijuana legalization on many aspects of facial trauma at two hospitals in Denver, Colorado is examined.

METHODS

A retrospective review of the electronic medical records was undertaken. Mann-Whitney U tests were used to compare age of patients before and after legalization, and chi squared analyses were used to compare mechanism of injury, and fracture types before and after recreational marijuana legalization in Denver, Colorado. Geographical location of patients was also considered.

RESULTS

No significant increase was found in race before and after marijuana legalization (p=0.19). A significant increase in age was found before (M=39.54,SD=16.37), and after (M=41.38,SD=16.66) legalization (p<0.01). Maxillary and skull base fracture proportions significantly increased following legalization (p<0.001 and p<0.001respectively). No significant differences were seen in the proportion of patients who lived in urban and rural counties before and after legalization (p>0.05).

CONCLUSION

Public health efforts should be directed towards educating residents and visitors of Colorado on the effects and toxicology of marijuana. More epidemiologic studies are needed for further assessment of the long-term effects of the legalization of marijuana on the population.

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

INTRODUCTION

Patients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.

METHODS

From January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.

RESULTS

In our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p<0.001), a Glasgow coma scale of 8 or less (p<0.001), moderate or severe degrees of head injury severity scale (p<0.001), positive physical examination findings (p<0.001), and positive CT cranial abnormalities (p<0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p<0.001) and orbital fractures (p=0.019).

CONCLUSIONS

TBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.

Postoperative leukocyte changes in facial fracture patients: a randomized prospective study with short-term dexamethasone

PURPOSE

We investigated leukocyte changes in facial fracture patients undergoing surgery. Of specific interest was the effect of perioperative dexamethasone on leukocyte changes.

METHODS

Facial fracture patients were randomized to receive perioperatively a total dose of 30 mg of dexamethasone, whereas patients in the control group received no glucocorticoid. All patients received antibiotics until postoperative days 7-10. Leukocyte count was measured on postoperative days 1 and 2. Clinical infections were observed during the follow-up.

RESULTS

A total of 110 adult patients were included in the study. Postoperative leukocytosis was found in 91.2% of patients receiving dexamethasone and in 67.9% of controls. Dexamethasone was associated strongly with leukocyte rise (p < 0.001) on both postoperative days. Transoral surgery and younger age (≤40 years) showed significant associations with leukocytosis on the first postoperative day (p = 0.002). In regression analyses, dexamethasone associated with leukocytosis most significantly (p < 0.001). No association was found with infections.

CONCLUSIONS

Dexamethasone use was the most significant predictor of leukocyte rise. As a drug response, perioperative dexamethasone caused sixfold postoperative leukocytosis. High-dose dexamethasone-induced leukocytosis may confuse the clinical decision-making especially in assessment of early infections.

C-spine injury and mandibular fractures: lifesaver broken in two spots

BACKGROUND

Trauma is a leading cause of injury and mortality and may involve mandibular fractures and cervical spine injuries. Manipulation of the spine during trauma protocols and operative treatment has the potential to cause serious spinal cord injuries. The purpose of this study was to identify risk factors associated with cervical spine injury (CSI) in patients with mandibular fractures.

METHODS

The National Trauma Databank (2007-2010) was used to identify patients with mandibular fractures.

RESULTS

A total of 59,028 patients were identified and separated into adult and pediatric cohorts. There were 50,711 adults (86%) and 8317 children (14%). There were statistically significant lower rates of associated CSI in pediatric patients than adults (3.5% versus 7.3%, P < 0.01). Predictors of associated CSI in mandible fractures for both adults and children were older age, lower Glasgow Coma Scale, thoracic injuries, firearm or motor vehicle accident mechanisms, and symphyseal fractures. In the pediatric cohort, body, ramus, and subcondylar fractures were significantly associated with CSI. In adults, female gender, and upper extremity, abdominopelvic, and head injuries were also significantly associated with CSI.

CONCLUSIONS

Multiple mandibular fractures were inversely correlated with CSI. One possibility is that energy dissipation in the mandible with multiple fractures is protective of the C-spine leading to fewer fractures. Children and adults had different associations in the pattern of mandible fractures concomitant with CSI. This has implications in management, imaging, and workup of trauma patients.

A chilling reminder: Pediatric facial trauma from recreational winter activities

BACKGROUND

Winter activities offer children and adolescents an outdoor recreational opportunity during the coldest months. Our objectives were to estimate the national incidence of facial injury associated with recreational winter activities. Furthermore, we analyze demographic trends and clinical characteristics of patients presenting to emergency departments (EDs).

METHODS

The National Electronic Injury Surveillance System (NEISS), a population-based resource, was evaluated for ED visits from 2010 to 2014 for children injured from "active" winter -undertakings (snowboarding, skiing, ice skating) and sledding/tubing. Entry narratives were evaluated for demographics, diagnoses, and other clinical factors.

RESULTS

841 entries amounting to an estimated 27,618 patients were evaluated. The most common injuries were lacerations (69.4%), contusions/abrasions (19.5%), and fractures (5.5%), with the most common fracture sites being the nose (60.9%), orbit (15.2%), and mandible (10.9%). Median age was 9 years (IQR 5-12), and 65.8% were male. A greater proportion of adolescents sustained fractures than younger children (8.1% vs. 4.0%). The majority of fractures were to the nose.

CONCLUSION

With nearly 30,000 ED visits over five years, participation in winter sports can be perilous. Adolescents harbor a greater risk of sustaining serious injuries than younger children, and patients injured sledding/tubing had a greater fracture risk compared to those participating in more "active" winter activities. As upper/mid-face fractures occurred in only 1.4%, these findings reinforce a very limited role for CT. These findings suggest a need for greater use of facial protection and closer supervision of older children participating in these activities.

Bicycle helmets work when it matters the most

BACKGROUND

Helmets are known to reduce the incidence of traumatic brain injury (TBI) after bicycle-related accidents. The aim of this study was to assess the association of helmets with severity of TBI and facial fractures after bicycle-related accidents.

METHODS

We performed an analysis of the 2012 National Trauma Data Bank abstracted information of all patients with an intracranial hemorrhage after bicycle-related accidents. Regression analysis was also performed.

RESULTS

A total of 6,267 patients were included. About 25.1% (n = 1,573) of bicycle riders were helmeted. Overall, 52.4% (n = 3,284) of the patients had severe TBI, and the mortality rate was 2.8% (n = 176). Helmeted bicycle riders had 51% reduced odds of severe TBI (odds ratio [OR] .49, 95% confidence interval [CI] .43 to .55, P < .001) and 44% reduced odds of mortality (OR .56, 95% CI .34 to .78, P = .010). Helmet use also reduced the odds of facial fractures by 31% (OR .69, 95% CI .58 to .81, P < .001).

CONCLUSION

Bicycle helmet use provides protection against severe TBI, reduces facial fractures, and saves lives even after sustaining an intracranial hemorrhage.

Maxillofacial trauma scoring systems

The changing complexity of maxillofacial fractures in recent years has created a situation where classical systems of classification of maxillofacial injuries fall short of defining trauma particularly that observed with high-velocity collisions where more than one region of the maxillofacial skeleton is affected. Trauma scoring systems designed specifically for the maxillofacial region are aimed to provide a more accurate assessment of the injury, its prognosis, the possible treatment outcomes, economics, length of hospital stay, and triage. The evolution and logic of such systems along with their merits and demerits are discussed. The author also proposes a new system to aid users in quickly and methodically choosing the system best suited to their needs without having to study a plethora of literature available in order to isolate their choice.

Epidemiology and cause-specific outcomes of facial fracture in hospitalized children

PURPOSE

Facial fractures in the pediatric population have a significant impact on public health. Although some demographic data exists regarding the overall epidemiology of facial fractures, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma.

MATERIAL AND METHODS

The Kids' Inpatient Database 2000-2009 was utilized to analyze pediatric facial fractures. A total of 21,533 patients were identified. Associations of patient characteristics with outcomes of interest were assessed.

RESULTS

The top three etiologies were motor vehicle accident (MVA), intentional trauma (IT), and falls. There was a decrease in the incidence of facial fractures due to MVAs and an increase in injuries due to IT and falls. Concomitant injuries were present in 58.8% and the mortality rate was 2%. The rate of concomitant injuries increased during study period. Age was significantly associated with concomitant injury, mortality, and LOS.

CONCLUSION

The increasing rate of IT and falls with concomitant injury warrants special consideration to reduce undiagnosed accompanying injuries. Further programs should be put in place to protect children younger than 5 years of age, who have increased risk of concomitant injury and mortality following intentional trauma.

Significance of post-traumatic maxillary sinus fluid, or lack of fluid, in a level II trauma population

Our goal was to test the predictive value of high-attenuation material within the maxillary sinus for adjacent facial bone fracture. After IRB approval, all blunt trauma facial CTs performed over a 5-month period at a level II trauma center were reviewed in consensus by three radiologists for the presence of facial fractures or high attenuation maxillary sinus opacity (≥30HU, ≥40HU, or ≥50HU). Three classes of fractures were analyzed: any fracture, any fracture contiguous with the maxillary sinus, and only fractures not contiguous with the maxillary sinus. Statistics were calculated using two-by-two tables. A total of 844 cases were reviewed with 273 patients having any fracture. There were 402 hemi-faces with any fracture and 62 hemi-faces with fracture contiguous with the maxillary sinus. Sensitivity, specificity, positive predictive value, and negative predictive value for any fracture (using the ≥40HU threshold) were 13, 99, 85, and 78 % respectively; for fracture contiguous with the sinus, these were 71, 99, 72, and 99 % respectively; and for only non-contiguous fractures, these were 2.3, 96, 13, and 80 %, respectively. We conclude that in this level II trauma population, lack of high attenuation maxillary sinus material nearly ruled out fractures in contiguity with the sinus. High-attenuation sinus material is only moderately predictive of a fracture contiguous with the maxillary sinus. Therefore, if after careful review a fracture is not identified, the radiologist should not be overly concerned that a fracture is being missed. High-attenuation sinus material is a poor marker for fractures not contiguous with the maxillary sinus.

Facial fracture management in northwest Nigeria

Background:

Facial fracture is gradually become a public health problem in our community due to the attendant morbidity and mortality. Hence, the aim of this study was to determine the pattern of facial fracture in Dental and Maxillofacial Surgery Department of Usmanu Danfodiyo University Teaching Hospital. This cross-sectional study was undertaken to provide information regarding gender, age, etiology, and diagnosis of patients with maxillofacial fractures.

Materials and Methods:

A 1-year review of patients diagnosed and treated for facial fractures in Usmanu Danfodiyo University Teaching Hospital between January 2011 and December 2011. The diagnosis was based on radiographic data and clinical examination. The main analysis outcome measures were etiology, age, gender, site, and treatment. Data were organized and presented by means of descriptive statistics and Pearson's Chi-square test. The level of significance adopted was 5%.

Results:

A total of 40 patients were treated in this period. Over 95% were male, 81% were caused by road traffic crash (RTC) and 86.4% were in the 21-30 years group. Most patients (52%) had mandibular fractures, and the most common site was the body. Most patients with midfacial fractures had fractures of the zygomaticomaxillary region (36%), while fractures of the parasymphyseal region were more common in the mandible 156 (31%). The most common treatment for jaw fractures was mandibulomaxillary fixation (MMF). Stable zygomatic complex fractures were reduced (elevated) intraorally, and unstable ones were supported by antral packs.

Conclusions:

This study highlights facial fractures secondary to RTC as a serious public health problem in our environment. Preventive strategies remain the cheapest way to reduce direct and indirect costs of the sequelae of RTC. It also bring to the fore the necessity to shift to open reduction and internal fixation (ORIF) of fractures.

Wire internal fixation: an obsolete, yet valuable method for surgical management of facial fractures

In some developing countries wire is still widely used in facial fractures internal fixation. This study presents the effectiveness and complications of wire osteosynthesis in a university teaching hospital in Burkina Faso and discusses some of its other benefits and disadvantages. Notes of 227 patients with facial fractures treated by wire internal fixation at department of stomatology and maxillofacial surgery of CHU Souro Sanou, Burkina Faso between 2006 and 2010 are reviewed retrospectively. A satisfactory treatment outcome was recorded in 91.2% of the 227 patients. Complications occurred in 8.8% of the patients who had operative site infection (3.1%), malocclusion (1.8%), sensory disturbance (1.8), facial asymmetry (1.3%), delayed bone union (0.9%) or enophtalmos (0.4%). The overall complications rate was 7.4% after mandibular osteosynthesis, 6.9% after Le Fort osteosynthesis and 6.5% after zygoma osteosynthesis. Post operative infections occurred irrespective to the surgical site. The other complications were more specific to the surgical site. Wire internal fixation may be a reasonable alternative for the surgical treatment of non-comminuted facial fractures and those without bone substance loss, in the setting of limited resources.

Associated injuries in patients with facial fractures: a review of 604 patients

Facial fractures may be associated with concomitant lesions of other parts of body with some of these injuries being life-threatening. This retrospective study reports the types of associated injury and the factors influencing their occurrence, in patients with facial fractures. In 18.2% of 604 patients, one associated injury at least was recorded. The most common associated injury was cranial trauma (9.9%), followed by limbs fractures (9.1%), chest trauma (2%), spine injury (0.5%) and eye ball rupture (0.5%). A poly trauma was recorded in 3.2% of the patients who had sustained a cerebral trauma, a spinal injury or a thoracic trauma. Death occurred in two patients (0.3%) who had respectively a spinal injury and a chest trauma. The occurrence of associated injuries correlated significantly with the fracture type with solitary mandibular fracture being a significant predictor of associated injuries. Although not statistically significant, multiple facial fractures and violence were more associated with concomitant injuries. The findings of this study recall the need for initial full examination of the trauma patients particularly victims of violence, patients presenting with multiple facial fractures or single facial bone fracture involving the mandible, the trauma patients? multidisciplinary management as well as trauma prevention.

Equine-associated maxillofacial injuries: retrospective 5-year analysis

We explored the relation between the causes of facial injuries in equestrians and the presence or absence of associated injuries. Over a 5-year period we retrospectively reviewed all patients who presented to the John Hunter Hospital, New South Wales, with facial injuries that had resulted from activity with horses. We analysed the rates of hard and soft tissue injuries, and of associated injuries by sex and mechanism. A total of 85 patients were included (50 female and 35 male) with an age range of 2-88 years. There was a significant difference in the rate of maxillofacial and associated injuries when groups were analysed for sex and mechanism of injury. Facial injuries caused by falling from a horse were more often associated with other injuries in men than in women (p<0.05), and men were 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1 to 14) We also found significant differences in the rates of facial fracture. Women who had been kicked by a horse were more likely to sustain bony injuries than men (p<0.05). Our data confirm the association between kicks and facial fracture, and this may provide an impetus for the development of appropriate protective equipment. Patients who sustain facial injuries when falling from a horse often present with associated injuries and this has practical implications for clinicians involved in their management.

Surgical treatment of facial fracture by using unsintered hydroxyapatite particles/poly l-lactide composite device (OSTEOTRANS MX(®)): a clinical study on 17 cases

BACKGROUND

In Japan we currently use absorption properties for facial fractures. OSTEOTRANS MX(®) (Takiron co., ltd, Japan) is an absorption device, which is called Super FIXSORB MX(®) in Japan. This absorbable osteosynthetic device constitutes unsintered hydroxyapatite particles/poly l-lactide (u-HA/PLLA) composites. This study focuses on reporting clinical cases of using OSTEOTRANS MX(®).

MATERIALS AND METHODS

Seventeen patients (16 men and 1 woman) aged 10-80 years (mean: 39.9 years, SD: ±20.7) with 86 fracture sites were treated. In all cases we used 1.0 mm plates and 5 mm or 7 mm screws. The postoperative observation period was 6-60 months (mean: 21.8 months, SD: ±14.5).

RESULTS

The fracture site recovered in all cases. Complications included one bone excess on the forehead and one foreign-body reaction on the frontozygomatic suture, but the fracture sites were recovered and had no problems. In the case with the longest observation time 60 months, the plate was almost fully absorbed. However, in other cases the plate was not fully absorbed because of a shorter observation time.

CONCLUSION

OSTEOTRANS MX(®) is a useful device because of its suitable intensity, thinness, radiopaque, and few complications. A longer observation time is required for a plate to be absorbed completely.

Facial fractures - association with ocular injuries: A 13-year review of one practice in a tertiary care centre

BACKGROUND

The incidence of ocular injury associated with facial fractures has been reported to be between 0.8% and 30%.

OBJECTIVE

Because of this wide range of incidences, a system to stratify the risk of ocular injury by type of facial fracture was sought.

METHODS

The present study reviewed 266 patients with facial fractures to determine the risk factors for ocular injury. The anatomy of each facial fracture was classified using an orbit-centred approach according to the number of orbital walls fractured. Patients were then grouped using this classification system. Charts documenting follow-up for each patient over a minimum of one year were examined and initial emergency room presentations of patients with subsequent visual impairment were recorded.

RESULTS

The incidence of severe visual impairment and blindness was 4.5% overall. Although all facial fractures (including isolated fractures of the mandible) had a notable incidence of ocular injury, an increased number of orbital wall fractures were correlated with an increased incidence of permanent visual disability. One of 147 (0.68%) patients without an orbital wall fracture sustained permanent severe ocular injury or blindness, while 13.5% (five of 37) of three-wall orbital fracture patients and 25% (four of 16) of four-wall orbital fracture patients sustained the same injury.

CONCLUSIONS

The risk of ocular injury in complex facial fractures can be stratified by the degree of orbital wall involvement. However, because all patients with persistent visual impairment had ocular findings on initial examination, it is proposed that oculovisual testing is a more sensitive indicator of lasting ocular injuries than the type of facial fracture.