Injuries associated with mandible fractures sustained in motor vehicle collisions

Motor vehicle collisions are second only to altercations as the most common cause of mandible fractures. This article details in a retrospectively studied group the incidence of isolated mandible fractures and associated injuries in patients who were involved in motor vehicle collisions. This group consisted of 148 patients with mandible fractures listed in the University of Mississippi's trauma registry during the past 5 years. In almost all patients, associated injuries occurred with mandible fractures that were caused by motor vehicle collisions, with an incidence of 99.3 percent. Facial and head lacerations and facial fractures were the leading associated injuries, occurring in more than half of the patients who had a mandible fracture. Closed head injury is the major life-threatening associated injury and cause of mortality. The life-threatening injuries occurred in 64.8 percent of patients in this study. The mortality rate in this group of patients was 8.1 percent. These data suggest that mandible fractures from motor vehicle collisions should never be viewed as an isolated injury but rather as part of a spectrum of significant and sometimes life-threatening injuries that require thorough trauma evaluation at the time of presentation.     

Facial fractures from dog bite injuries

Dog bites are commonly associated with soft-tissue injury to the face but rarely result in facial fractures. This article reports six new cases of facial fractures associated with dog bites and reviews additional cases reported in the literature. The demographics of the patients attacked, the location of facial fractures, and the characteristics of associated soft-tissue injuries or complications developing from the dog bite are described. With six new cases and 10 from the literature, this article reviewed a total of 16 cases involving 27 facial fractures. Eighty-seven percent of the cases involved children less than 16 years of age. The periorbital or nasal bones were involved in 69 percent of the cases. Lacerations were the most frequently associated soft-tissue injury. Additional injuries included facial nerve damage, lacrimal duct damage requiring stenting and reconstruction, ptosis from levator transection, and blood loss requiring transfusion. Although facial fractures are not commonly considered to be associated with dog bite injuries, the index of suspicion for a fracture should be raised when the injury occurs in a child, particularly when injury occurs near the orbit, nose, and cheek.     

Patterns of maxillofacial injuries in powered watercraft collisions

Because of the widespread popularity of water sports, plastic and reconstructive surgeons can expect to manage an increasing number of injuries associated with these activities, particularly those related to powered watercraft vehicles. Although seat belts for motorists and helmets for motorcyclists may be efficacious, such devices currently do not serve a similar role in powered watercraft sports. In this study, a retrospective chart review of 194 consecutive patients who presented to the University of Miami/Jackson Memorial Hospital (Level I trauma center) as a result of powered watercraft collisions is presented. The purpose of this investigation was to assess the incidence, cause, demographics, and available management options for head and neck injuries secondary to powered watercraft. Identified were 194 patients who presented because of watersports-related injuries during the period January 1, 1991, through December 31, 1996. From this group, 81 patients (41.8 percent) sustained injuries directly attributable to powered watercraft collisions, including 41 personal watercraft collisions (50.6 percent), 39 boat collisions (48.1 percent), and 1 airboat collision (1.2 percent). The patient population, as expected, tended to be young and male with an average age of 29 years (range, 8 to 64 years old). Interestingly, 41 of the patients (50.6 percent) who presented to this trauma center as a result of powered watercraft collisions also sustained associated head and neck trauma. Of 74 injuries 24 were facial fractures (32.4 percent), 18 were facial lacerations (24.3 percent), 14 were closed head injuries (18.9 percent), 8 were skull fractures (10.8 percent), 4 were scalp lacerations (5.4 percent), 4 were C-spine fractures (5.4 percent), 1 was an ear laceration (1.4 percent), and 1 was a fatality (1.4 percent). Le Fort fractures were the most commonly identified facial fracture in this series. The number of these injuries seen in hospital emergency rooms will most likely increase in the future as the popularity of water-related recreational activities becomes even more widespread. Based on these findings, it is strongly recommended that future efforts be directed toward the prevention of these injuries through patient education and the eventual development of efficacious and safe protective equipment.     

Maxillofacial fractures in the elderly: a comparative study

Previous maxillofacial trauma research has dealt primarily with facial bone fractures in the general population. Very few studies have specifically addressed maxillofacial fractures in the elderly. We compared 45 elderly (65 years of age or older) and 201 younger adult (16 to 64 years of age) patients admitted to our hospital with maxillofacial fractures. The percentage of patients admitted with nasal bone fractures was much greater in the elderly population, while mandibular fractures were more common in the adult group. Motor vehicle accidents accounted for over half the injuries in both groups, while falls were more prevalent in the elderly. Management of the elderly patient may be complicated by their associated injuries or underlying medical problems, perhaps partially accounting for their longer median length of hospital stay. The elderly are a unique subpopulation of maxillofacial fracture patients and deserve further study regarding their injuries and optimal methods for treatment.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center.

This study characterizes the surgically treated patient population suffering from orbital floor fractures by use of current data from a large series consisting of 199 cases taken from a nonurban setting. Data were gathered through a retrospective chart review of patients surgically treated for orbital floor fractures at the University of Michigan Health System, collected over a 10-year period. Data regarding patient demographics, signs and symptoms of presentation, cause of injury, nature of injury, associated facial fractures, ocular injury, and associated nonfacial skeleton trauma were collected. In total, there were 199 cases of orbital floor fractures among 189 patients. Male patients outnumbered female patients by a 2:1 ratio and were found to engage in a wider range of behaviors that resulted in orbital floor fractures. Motor vehicle accidents were the leading cause of orbital floor fractures, followed by physical assault and sports-related mechanisms. The ratio of impure to pure orbital floor fracture was 3:1. The most common signs and symptoms associated with orbital floor fractures, in descending order, were periorbital ecchymosis, diplopia, subconjunctival hemorrhage, and enophthalmos. Associated facial fractures were found in 77.2 percent of patients, the most prevalent of which was the zygoma-malar fracture. Serious ocular injury occurred in 19.6 percent of patients, with globe rupture being the most prevalent, accounting for 40.5 percent of those injuries. There was a 38.1 percent occurrence of associated nonfacial skeletal trauma; skull fracture and intracranial injury were the most prevalent manifestations. Associated cervical-spine fractures were rare (0.5 percent). Statistical examination, using odds ratios and chi-squared analysis, demonstrated significant associations that have not previously been reported. Impure and pure orbital floor fractures revealed striking differences in several demographic aspects, including mechanism of injury, signs and symptoms of presentation, spectrum of associated trauma, and the severity of concomitant trauma.     

Orbital roof fractures in the pediatric population

Twenty-three patients aged 3.3 +/- 1.6 years (mean +/- SD) presented between January of 1984 and September of 1987 with fronto-orbital trauma resulting in fractures of one (N = 20) or both (N = 3) orbital roofs. All patients had computed tomography (CT) with axial and coronal sections that revealed three fracture patterns of the orbital roof (nondisplaced, superiorly displaced, and inferiorly displaced fractures). Orbital dystopia was exhibited in 35 percent (N = 8) of the patients. Exophthalmos was noted in 61 percent (N = 14) of the patients. Only 30 percent of the patients (N = 7) sustained associated maxillofacial fractures. Eight percent of fractures exhibited orbital encephaloceles. All patients lacked frontal sinus pneumatization. The majority of children with orbital roof fractures do not exhibit concomitant facial fractures. CT utilizing both axial and coronal sections is valuable in defining the extent and pattern of the fracture as well as in identifying associated neurologic injuries. Large, displaced orbital roof fractures, which occurred in 3 of 13 patients with displaced fractures in our series, should undergo early reduction to avoid late development of encephalocele.     

Risk factors contributing to symptomatic plate removal in maxillofacial trauma patients

This study analyzed the fate of plates used to correct maxillofacial injuries and defined risk factors that eventually resulted in plate removal. The outpatient clinic files of 108 patients treated with rigid internal fixation after maxillofacial trauma were reviewed. Study variables included age, sex, trauma circumstances, diagnosis, type of fracture, approach to the facial skeleton, presence of teeth in the line of fracture, plate material, site of plates, and reasons for plate removal. Of 204 plates used for fixation, 44 plates (22 percent) were removed. When all factors were considered together, only fracture diagnosis (mandibular body and angle) and plate location (mandibular body and angle) were statistically significant. Only when each factor was considered separately, the approach to the facial skeleton (intraoral) and the type of fracture (comminuted and compound fractures) were statistically associated with plate removal. Selection of favorable plate location, the extraoral approach, and vigilant infection control may reduce plate removal in patients with maxillofacial injuries. Special attention should be given to compound and comminuted fractures of the mandibular body and angle.     

Influence of restraining devices on patterns of pediatric facial trauma in motor vehicle collisions

In the Commonwealth of Pennsylvania, it is required that all children under the age of 4 years be restrained by an infant seat or car seat appropriate for their age and weight. Furthermore, all individuals riding in the front seat must be restrained by a seatbelt. This study examined the relationship between patterns of facial injuries and the use of restraining devices in the pediatric population. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the Intensive Care Unit, those who died during hospitalization, those who were hospitalized for more than 72 hours, or those who were transferred in or out of the receiving hospital. A subset of 412 pediatric patients, 15 years of age or younger, was analyzed for patterns of facial injury and the presence or absence of restraining devices. Restraining devices were categorized as a car seat or a seatbelt. Statistical analysis was performed using chi-square and Fisher's exact tests. Of the 412 pediatric patients, only 17 children were restrained with a car seat and 121 were wearing a seatbelt. A total of 30 children sustained facial fractures, and 50 children suffered facial lacerations. There was a statistically significant increase in the incidence of facial fractures with increasing age of the child (p < 0.001). Of children with facial fractures, 70 percent of those 5 to 12 years old and 90 percent of those 13 to 15 years old were unrestrained (p = 0.166). In conclusion, despite legislation mandating the use of restraints, a large proportion of children involved in motor vehicle collisions were unrestrained. Furthermore, there seems to be a direct relationship between the age of a child and the incidence of facial fractures sustained in motor vehicle collisions.     

The management of orbitozygomatic fractures

Orbitozygomatic injuries are among the most common fractures encountered by the plastic surgeon. Appropriate management depends on an accurate diagnosis, focusing on the physical examination and data from computed tomography scans. One must pay particular attention to the orbital component of this injury, as it is from this that so much of the morbidity relating to these fractures is incurred. As with all facial fractures, accurate reduction is paramount to a successful outcome. As many buttresses as are necessary should be visualized to ensure an anatomic reduction. The amount and location of fixation depend on the fracture anatomy.A successful outcome may be expected if these basic principles are followed.     

Craniofacial trauma: an assessment of risk related to timing of surgery

Following the retrospective analysis of approximately 4000 head-injury patients, 49 were identified with a combination of displaced facial fractures and significant cerebral trauma. The purpose of this study was to define clinical and radiographic features in these patients that are associated with a poor prognosis, which in turn might influence the timing of facial fracture repair. The presence of an upper-level facial fracture, low Glasgow coma score, intracranial hemorrhage, displacement of normally midline cerebral structures, and multisystem trauma was associated with a statistically significant poorer prognosis. Additionally, in demographically similar groups of patients (age, sex, concomitant injury) preselected for intracranial pressures of less than 15 mmHg at the time of surgery, no significant difference in survival was appreciated in patients who underwent early (0 to 3 days), middle (4 to 7 days), or late (greater than 7 days) surgical repair. Early surgical repair of facial fractures in these circumstances does not appear to have a negative impact on recovery.     

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified.Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records.Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent).When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms.The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance.Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.     

The influence of airbag and restraining devices on the patterns of facial trauma in motor vehicle collisions

According to the National Highway Traffic Safety Administration (1990), there were more than 3 million motor vehicle collisions severe enough to lead to significant injury or fatality. Airbags may prevent brain and facial injury caused by these accidents. To date, however, no study has focused primarily on the correlation between facial injuries and the use of airbags and restraining devices. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission to the database included admission to the intensive care unit, death during hospitalization, hospitalization for >72 hours, or transfer to or from the receiving hospital. There were 15,450 patients who sustained facial trauma (identified by ICD-9 codes) and were analyzed for patterns of injury and the presence or absence of protective devices. Protective devices were categorized into four groups: airbag alone, airbag with seatbelt, seatbelt or car seat without airbag, and no restraining devices. Statistical analysis was performed using chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. There were 9408 male and 6042 female subjects, with a mean age of 38 years (range, 3 to 98 years). There were 11,672 drivers and 3778 passengers. Airbags were deployed in 429 instances. In 276 of these cases, additional restraint was provided with a seatbelt. Airbags were not deployed in 4866 cases when a seatbelt or a car seat was used. In 10,155 cases, no restraining device was employed. There was significantly more facial trauma in patients without protective devices (p < 0.001). Drivers sustained significantly fewer facial fractures when airbags were used, either alone or in combination with a seatbelt (p < 0.001); however, there was no difference in the number of facial lacerations. Among passengers, airbags provided protection from lacerations (p < 0.001) but had no impact on the incidence of facial fractures. In collisions in which airbags were deployed, the use of a seatbelt provided no additional protection from facial fractures or lacerations. In summary, the use of any protective device decreased the incidence of facial fractures and lacerations sustained in motor vehicle collisions (p < 0.001). Airbags provided the best protection of all currently available devices.     

The causes and consequences of maxillofacial injuries in elderly people

Objective: The occurrence of trauma in older people is well‐documented; however the incidence of maxillofacial trauma is scarcely reported. Therefore, the objective of this study is to determine the causes and consequences of maxillofacial trauma in older people. Design: A five‐year (March 95 ‐ March 2000) retrospective study was earned out of all patients over the age of 65 years with facial trauma presenting to Accident and Emergency Department (A&E). The information was collected using the medical notes and discharge summaries. Setting: The Departments of A&E and Maxillofacial Surgery. Subjects: A total of 42 patients' records were examined for study related data. Results: A total of 42 patients were seen during the study period. Thirty‐six gave a history of a fall, of which 15 had tripped, 5 had slipped, 3 resulted from a Transient Ischaemic Attack (TIA), 1 as a result of alcohol abuse, in 1 a prosthetic knee gave way and 11 gave no cause for the fall. Of the remaining 6 patients. 5 were assaulted and 1 had a wardrobe fall on top of him. The majority of the falls occurred during the winter months. Maxillofacial injuries were noted in 27 of the 42 patients. Sixteen patients had cheekbone fractures, 8 mandibular fractures, 2 midface and 1 orbital complex fracture. Twenty‐five percent of cheekbone fractures and 50% of mandibular fractures were treated surgically. Medical history was noted in 27 patients. Conclusions: This study clearly demonstrates the majority of the facial trauma in the older people can be treated conservatively unless the patients complain of functional problems.     

Facial fractures

Fractures of the facial skeleton can result in the loss of an aesthetically pleasing appearance and basic function, and many cases subsequently require an operative intervention. The surgeon managing these facial fractures must, at the same time, be cognizant of concomitant injuries, including neurologic, ophthalmologic, and cervical spine issues. For most situations, early stabilization in anatomical position using rigid fixation will give the most accurate reduction for the optimal return of preoperative appearance and function, while reducing long-term soft-tissue contracture.     

Midface fractures: advantages of immediate extended open reduction and bone grafting

Experience with 240 midface (Le Fort and zygoma) fractures in multiple trauma patients has emphasized that superior aesthetic results are obtained by immediate extended open reduction with primary bone grafting. Internal fixation of 110 zygomatic and 130 Le Fort fractures was performed in the lower midface (zygomaticomaxillary and nasomaxillary buttresses). Open reduction of the condyle was employed in five concomitant Le Fort and subcondylar fractures with a loss of ramus height to prevent superior and posterior displacement of the middle and lower face. Bone grafts were utilized in 74 patients. They were most frequently employed in the orbit and less frequently in the lower midface. Bone graft survival paralleled that observed under elective conditions, and a slightly higher infection rate was observed. Extended open reduction and immediate bone grafting adds a new dimension to the aesthetic results obtained from facial fracture treatment. Structural bony integrity and pre-injury facial architecture may be restored in the absence of soft-tissue contracture. Restoration of the pre-injury facial architecture (the essence of facial fracture treatment) is more accurately accomplished when these techniques are utilized.     

Laryngeal Trauma

Laryngeal trauma may be obscured by associated injuries of the face and chest. An early assessment of these injuries should be made. Many cases may require observation only. In patients with severe laryngeal fractures, preservation of the airway and control of hemorrhage must first be assured. Following this, splinting by external or internal means should be carried out. Three severe laryngeal injuries were splinted with open and closed plastic moulds, with satisfactory results. It is proposed that early recognition and proper management of severe cases of this nature would shorten the treatment and achieve the best results.     

Infraorbital nerve injury associated with zygoma fractures: documentation with neurosensory testing

Persistent sensibility abnormalities after correction of zygoma fractures indicate injury to the infraorbital nerve and may produce pain. To investigate this, a retrospective study of 25 patients who had undergone surgical correction of a zygoma fracture was performed. Bilateral neurosensory measurements were obtained with the Pressure-Specified Sensory Device (Sensory Management Services, Baltimore, Md.). Seven of the 25 patients had required orbital floor reconstruction. Each patient had undergone fracture correction at least 6 months earlier and was interviewed, at the time of sensibility testing, regarding symptoms related to the fracture. The data were evaluated by a blinded examiner, from a separate clinical facility, who attempted to predict the side of the fracture and the degree of zygoma displacement on the basis of measurements of sensibility of the paranasal, upper lip, and zygomaticotemporal areas. Seventy-six percent of patients demonstrated abnormal sensibility on the side of the zygoma fracture, compared with the contralateral side. Sensibility was abnormal for 100 percent of the patients who required orbital floor reconstruction. Seventy-four percent of patients with abnormal sensibility reported symptoms related to the fracture. Eighty percent of the zygoma fractures were correctly identified, with respect to the side of the fracture, by the blinded examiner on the basis of the neurosensory measurements alone (p < 0.005). Predictions proved correct for 91 percent of the patients with widely displaced fractures and none of the patients with nondisplaced fractures. The results of this study suggest that neurosensory testing is an important clinical adjunct for the evaluation of patients with facial pain or dysesthesia after facial fracture reconstruction. The results suggest the need to develop algorithms for the diagnosis and treatment of trigeminal nerve injuries after craniofacial trauma. This approach could also be applicable to dysesthesia or pain after aesthetic facial surgical procedures.     

Serious head injury in sport.

Of 1900 head injuries serious enough to be admitted to the neurosurgical unit in Glasgow over a five year period, 52 (2.7%) were due to "sport." Golf, horse-riding, and Association football were the sports most commonly linked with serious head injury. Golfing injuries were all compound depressed fractures, and all these patients made a good recovery; horse-riding produced more severe injuries, three of the eight patients being left with residual disability. Much attention has been directed to preventing repeated minor head injury in boxing, but this study emphasises the need for preventing both the primary head injury and secondary complications associated with other sports.     

Septal fracture in simple nasal bone fracture

SUMMARY: Nasal bone fractures are the most common type of facial fractures. Previous studies have shown that most nasal fractures involve the septum, which can provide an obstacle to the successful reduction of nasal bone fractures. In particular, septal fractures in combination with simple nasal bone fractures are usually unrecognized and untreated at the time of injury. Furthermore, systemized treatment protocols and diagnostic tools for septal fractures in the case of simple nasal bone fracture have not previously been presented. In this study, the clinical findings of septal fractures in cases of simple nasal bone fracture were correlated with symptoms, signs, and computed tomography findings and assessed statistically. The patterns of septal fractures in simple nasal bone fractures were assessed by direct vision via hemitransfixion incision. Of the 52 patients with simple nasal bone fracture who presented over a 3-year period and were included in this study, 10 were female and 42 were male, with an average age of 33.8 years (age range, 18 to 61 years). Fifty of these patients (96.2 percent) showed septal fractures, and septoplasty or submucosal resection was performed on 41 patients (78.8 percent) who manifested severe septal fractures of perioperative septal grade 3 or higher. Closed reduction of the nasal bone fracture only was performed on the remaining 11 patients. Among the signs evident at physical examination, mucosal tearing was found to be statistically significant for septal fracture. Computed tomography was found to be very helpful in diagnosing septal fracture but could not predict its severity accurately (Spearman correlation coefficient between computed tomography septal grading and perioperative septal grading, 33.5 percent). Therefore, computed tomography could not be used as a definitive diagnostic modality for septal fractures in terms of deciding whether septoplasty or submucous resection was needed. It is evident that septal fractures are frequent in simple nasal bone fractures that are not combined with other facial bone fractures. This study confirms that there are differences between radiologic findings and perioperative findings. To reduce the incidence of posttraumatic nasal deformity, meticulous physical examinations with subsequent septoplasty or submucosal resection are needed in the treatment of simple nasal bone fracture.