Sustained Facial Fractures Research Articles

Necrotizing soft tissue infection of the chest wall.

A 53-year-old man with hypertension, anxiety, and active alcohol abuse presented to the emergency room with increasing lethargy and shortness of breath. He reported a 9-day history of left-sided chest pain and erythema, which had worsened over the 4 days prior to admission. Review of systems was positive for fever, chills, fatigue, cough, chest tightness, and malaise. Notably, 12 days prior to his presentation, he was admitted after an assault and sustained facial fractures and lacerations; physical examination and CT of the chest/abdomen/pelvis at that time were negative for other injuries. On re-presentation, he was tachycardic and normotensive. His left chest wall was warm, erythematous, and diffusely tender with crepitus that extended into the axilla. Initial laboratory data demonstrated hyponatremia (serum sodium 130 mEq/L (135–145 mEq/L)), an anion gap of 20 mEq/L (3–11 mEq/L), and hypovolemia, with a blood urea nitrogen (BUN) of 42 mg/dL (7–20 mg/dL) and a creatinine of 0.9 mg/dL (0.5–1.2 mg/dL). He had a leukocytosis of 17 500 cells/μL (4500–10 000 cells/μL) with a marked left shift (15% bands, 56% neutrophils). Blood cultures were collected. A CT of the chest/abdomen/pelvis was obtained and demonstrated a 23 cm×10 cm×18 cm collection of air and fluid in the left chest wall …

Q&A: Rating Facial Numbness

QUESTION: A man fell and sustained facial fractures that required surgery. He was left without residual deformity, disfigurement, scar, or other ratable conditions. Per the AMA Guides Sixth Edition, Chapter 11, Ear, Nose, Throat and Related Structures, there is no ratable impairment. However, he does have a residual small area of numbness over his right upper lip noticed occasionally when touching the spot or chewing. There is no interference with activities of daily living (ADLs) and no facial neuralgia. Would I rate him per Table 13-20, Criteria for Rating Miscellaneous Peripheral Nerves (6th ed, 344) as class 1 with “sensory loss only in an anatomic distribution” and 1% whole person permanent impairment? However, the trigeminal nerve is not listed in Table 13-20.ANSWER: Table 13-20 does not list the trigeminal nerve; however you could consider this by analogy. You could reference Table 13-19, Criteria for Rating Trigeminal or Glossopharyngeal Neuralgia (6th ed, 343) which states if there is “no neuralgia” the rating is 0%. Section 13.11b, Trigeminal and Glossopharyngeal Neuralgia (6th ed, 343) states “Both atypical, episodic facial pain and typical, neuralgic pain may be evaluated (Table 13-19) if they have occurred for months and interfere with ADLs.” However, he does not have interference with ADLs therefore technically this would not be ratable. Section 13.11b does state you should evaluate by “pain, temperature, and touch” and therefore you could rate by analogy at the low end of class 1 in Table 13-19 at 1% whole person permanent impairment. Even if the sensory loss were not present, some people may complain minimally of discomfort when outdoors in cold weather.You need to use good judgment and determine whether it is more appropriate to conclude there is no ratable impairment or 1% whole person permanent impairment and in the latter case rate by analogy.

Intimate partner violence: an underappreciated etiology of orbital floor fractures.

To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence-associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non-IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Facial Fractures in the Aging Population

INTRODUCTION: The elderly population will more than double between now and 2050. With the advancing age, trauma centers will need to adapt to their needs. However, there is a paucity of literature evaluating facial fractures in the elderly. METHODS: A retrospective review of adult patients at a level one trauma center was performed to evaluate age related differences in facial fractures. Elderly patients were defined as 65 years or older and younger patients less than 65 years. Descriptive statistics were used to compare fracture number and type, etiology of injury, management, and adverse events between the age cohorts. Logistic regression was used to evaluate the effect of age on fracture type while controlling for potential confounding variables. RESULTS: 2023 patients sustained facial fractures at Duke University Medical Center from 2001 to 2011. 209 were elderly (mean age=76.9) and 1814 were younger (mean age=34.7). Gender and race differed between the ages such that elderly females and younger males were more likely than elderly males and younger females to sustain a facial fracture (p<0.0001). The incidence of facial fractures was higher in white compared to non-white elderly patients and higher in non-white compared to white younger patients (p<0.0001). Elderly patients were more likely to fall and younger patients were more likely to sustain assaults and MVCs (p<0.0001; Figure 1).Figure 1: Etiology of Injury.Logistic regression revealed that elderly patients were 2 times more likely to experience a maxillary and orbital floor fracture and 1.67 less likely to sustain a mandible fracture compared to the younger population (Table 1). Elderly patients required less surgical intervention (p<0.0001) and were significantly less likely to experience adverse events with their care (p=0.0162).Table 1: Multivariate Regression Analysis Evaluating the Effect of Age on Fracture TypeCONCLUSION: Elderly patients tend to suffer from less severe facial fractures requiring less need for operative intervention likely secondary to low-energy mechanisms of injury.

Dental Injuries in Pediatric Patients With Facial Fractures Are Frequent and Severe

This study was carried out to identify the occurrence, type, location, and severity of dental injuries (DIs), as well as predictors for DIs, in pediatric patients with facial fractures. This study examined the files of patients aged 16 years or less who had sustained facial fractures during a 12-year period. The outcome variable was DI. The explanatory variables included gender, age, trauma mechanism, and type of facial fracture. Data analysis was carried out with the χ(2) test and logistic regression analysis. A total of 200 patients, 119 (59.5%) of whom were boys, met the inclusion criteria. The mean age was 12.6 years. A total of 45 patients (22.5%) had DIs. Crown fracture, the most common type of DI, occurred in 59.9% of all DIs. The most common location of crown fractures was in the premolars (37.4% of all crown fractures). Multiple DIs occurred in 71.1% of those with DIs and severe DI in 66.7%. DIs were significantly associated with motor vehicle collision (MVC) (P = .02) and mandibular fracture (P = .03). DIs are common in pediatric patients with facial fracture, often being both multiple and severe. In association with pediatric facial fracture, facial surgeons should be especially alert for crown fractures in the lateral parts of the jaws.

Occurrence and Severity of Concomitant Injuries in Other Areas Than the Face in Children With Mandibular and Midfacial Fractures

To clarify the occurrence, causes, severity, and predictors of concomitant injuries in pediatric patients with facial fractures. Files of 339 pediatric patients who had sustained facial fractures at age 15 years or younger were reviewed. Outcome variables were injured organ systems other than the face, types of injuries in areas other than the face, and severity of injuries in areas other than the face. Explanatory variables were gender, age, mechanism of trauma, and type of facial fracture. Concomitant injuries in organ systems other than the face were observed in 11.0%. Limb injuries occurred in 9.1%, head and neck injuries in 5.6%, and chest injuries in 1.8%. The most common injury types were upper limb injury (8.0%), brain injury (3.2%), and lower limb injury (2.9%). Severe head and neck injuries occurred in 3.5% and severe chest injuries in 1.2%. Concomitant injuries occurred more frequently after motor vehicle accidents and falls from height compared with other etiologies (P < .001) and more frequently in association with combined mandibular and midfacial fractures than in association with other fracture types (P < .001). Concomitant injuries in areas other than the face should be expected first and foremost after high-speed trauma mechanisms and in association with severe facial fractures. Concomitant injuries in general occur most frequently in the limbs, with severe concomitant injuries in particular occurring most often in the head and neck region and chest, emphasizing the importance of multiprofessional teamwork in the diagnosis of pediatric patients who have sustained facial fractures.

Occurrence and Types of Associated Injuries in Patients With Fractures of the Facial Bones

To identify the occurrence, types, and severity of associated injuries outside the facial region among patients diagnosed with facial fractures, and to analyze whether there are any factors related to associated injuries. This was a cross-sectional study of 401 patients diagnosed with facial fractures during the 2-year period from 2003 to 2004. Associated injuries were observed in 101 patients (25.2%). The most common type of injury was a limb injury (13.5%), followed by brain (11.0%), chest (5.5%), spine (2.7%), and abdominal (0.8%) injuries. Multiple associated injuries were observed in 10% and polytrauma in 7.5%. The mortality rate was 0.2%. The occurrence of associated injury correlated significantly with trauma mechanism and fracture type; high-speed accidents and severe facial fractures were significant predictors of associated injury. Associated injuries are frequent among patients who have sustained facial fractures. The results underscore the importance of multiprofessional collaboration in diagnosis and sequencing of treatment, but also the importance of arranging appropriate clinical rotations for maxillofacial residents in training.

Masticatory Diplopia

We report a case of diplopia that was exacerbated by chewing in a patient who had sustained facial fractures in a motorcycle crash. The diplopia was corrected surgically 1 year following the accident. To the best of our knowledge, masticatory diplopia as a result of adhesion of the temporalis muscle to the periorbita secondary to facial trauma has not been previously reported.

Utilization of Tracheostomy in Craniomaxillofacial Trauma at a Level-1 Trauma Center

The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy. All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis. A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group. Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

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.

Does the face protect the brain? A case-control study of traumatic brain injury and facial fractures.

The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury. To examine the association between facial fractures and traumatic brain injuries. Case-control study. Subjects were recruited from the emergency departments of 7 hospitals in the Seattle, Wash, area. Three thousand eight hundred forty-nine injured bicyclists and 5 scene deaths were identified from March 1, 1992, to August 31, 1994, with complete data available on 3388 bicyclists. None. The study group was composed of 1602 cases with injuries to the head, face, or brain and 1540 control subjects. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. The odds ratio for the risk of intracranial injury associated with facial fractures after adjustment for significant confounders was 9.9 (95% confidence interval, 5.1-19.3). The effect was less strong but still present when all traumatic brain injuries including concussions were considered (odds ratio, 2; 95% confidence interval, 1.1-3.7). No association was found for concussion only. This study demonstrates no evidence that facial fractures help prevent traumatic brain injury. Data indicate that facial fractures are markers for increased risk of brain injury.