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Maxillofacial Injuries in Severely Injured Patients Max J Scheyerer et al. Journal of Trauma Management & Outcomes (2015) 9:4 DOI 10.1186/s13032-015-0025-2 RESEARCH Open Access Maxillofacial injuries in severely injured patients Max J. Scheyerer1*†, Robert Döring1†, Nina Fuchs1, Philipp Metzler2, Kai Sprengel1, Clement M. L. Werner1, Hans-Peter Simmen1, Klaus Grätz2 and Guido A. Wanner1 Abstract Background: A significant proportion of patients admitted to hospital with multiple traumas exhibit facial injuries. The aim of this study is to evaluate the incidence and cause of facial injuries in severely injured patients and to examine the role of plastic and maxillofacial surgeons in treatment of this patient collective. Methods: A total of 67 patients, who were assigned to our trauma room with maxillofacial injuries between January 2009 and December 2010, were enrolled in the present study and evaluated. Results: The majority of the patients were male (82 %) with a mean age of 44 years. The predominant mechanism of injury was fall from lower levels (<5 m) and occurred in 25 (37 %) cases. The median ISS was 25, with intracranial bleeding found as the most common concomitant injury in 48 cases (72 %). Thirty-one patients (46 %) required interdisciplinary management in the trauma room; maxillofacial surgeons were involved in 27 cases. A total of 35 (52 %) patients were treated surgically, 7 in emergency surgery, thereof. Conclusion: Maxillofacial injuries are often associated with a risk of other serious concomitant injuries, in particular traumatic brain injuries. Even though emergency operations are only necessary in rare cases, diagnosis and treatment of such concomitant injuries have the potential to be overlooked or delayed in severely injured patients. Keywords: Maxillofacial injury, Trauma, Head injury Background To reduce morbidity and mortality, early recognition Facial injuries, in particular soft tissue injuries and frac- of severe head trauma and concomitant injuries remains tures of the facial bones, are frequently occurring as a an important part of the initial assessment and treat- result of motor vehicle crashes, falls, violent assaults, ment plan of severely injured patients. Understanding and crashes during recreational activities such as bicyc- the cause, severity, and distribution of facial trauma and ling and skiing [1, 2]. the concomitant injuries can help in the optimization of While they occasionally occur as isolated lesions, they the initial clinical treatment and definition of the right are more commonly associated with other serious injur- time to involve oral surgeon. In this context, it has re- ies [3]. Previous studies demonstrate that the rate of cently become more commonly recognized that patients concomitant head injuries in cases of facial fracture is as with sustained multiple injuries benefit from an early high as 50- 80 %- depending on the location of the multidisciplinary management in a specialized trauma fracture [4]. While intracranial injuries occur most often center (Fig. 3) [3]. in cases of fractures of the bones of the upper face and The majority of the existing studies on facial injuries maxilla, they are less frequently associated with lesions focused on a single type of concomitant injury like of the mandible [4–6]. Besides involvement of the head, brain or cervical spine [9–11]. Others broach the issue other concomitant injuries include the cervical spine of concomitant injuries with a particular type of facial and other body parts (Figs. 1, 2) [3, 7, 8]. fracture [12, 13]. The aim of the present study is to present a compre- hensive view on facial and associated injuries in severely * Correspondence: [email protected] injured patients. Additionally, the role of plastic and max- † Equal contributors illofacial surgeons in the management of this collective of 1Department of Surgery, Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, 8091 Zürich, Switzerland patients is to be evaluated. Full list of author information is available at the end of the article © 2015 Scheyerer et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Scheyerer et al. Journal of Trauma Management & Outcomes (2015) 9:4 Page 2 of 9 Fig. 1 A 37-years-old patient who was hit by a pipe through the car windscreen. As a result, the patient suffered, beside a fracture of the mandibular, severe cervical (destruction of the larynx, cervical spine fractures, thyroid gland and esophagus lesion), and chest trauma (serial rib fracture, lung contusion, clavicles fracture, soft tissue emphysema). The initial treatment of the mandibular fracture within the trauma room included provisional bony stabilization. Definitive treatment was carried out after stabilization of the patient three days after trauma (Fig. 2) Methods dual source CT; 120 kV, 210 mAs, slice thickness 3 mm). Severely injured patients with facial fractures and who Fracture classification was conducted by a radiologist, were admitted to the trauma division were included in neuro-radiologist, trauma surgeon and in case of involve- the present retrospective study. The observation period ment by a plastic or cranio-maxillo-facial surgeon. was two years. All trauma patients aged 16 years and The following parameters were collected and examined older with an injury severity score (ISS) of ≥ 17, a thresh- retrospectively: gender, age at time of injury, circumstances old commonly used to define severely injured patients, regarding the mechanism of injury, abbreviated injury scale were routinely entered into the trauma database. Patients (AIS) as well as ISS, and concomitant injuries and treat- with an age lower than 16 were directly admitted to the ment thereof. Concomitant injuries were defined as any children’s hospital and were therefore not included in major injury outside the facial region and were identified this study. according to body region and severity. Furthermore, we All patients underwent a whole body computed tom- analyzed vital parameters, laboratory parameters, length of ography performed with contrast at admission (Soma- hospital stay, length of intensive care unit (ICU) stay, over- tom Definition, Siemens, Munich, Germany; 128-slice all mortality rates, and finally cause of death. Fig. 2 Definitive treatment of the abovementioned mandibular fracture of a 37-years-old patient three days later Scheyerer et al. Journal of Trauma Management & Outcomes (2015) 9:4 Page 3 of 9 Fig. 3 A 24-years-old patient with epidural hematoma and fracture of the orbital floor, lateral orbital wall, fracture of the sinus maxillaris, and zygoma fracture. A haematoma compression of the optical nerve resulted that was decompressed by a maxillofacial surgeon in collaboration with an ophthalmologists in the trauma room With regard to facial injury, the observed fractures Results were divided into isolated fractures and complex frac- Within the study period, 487 severely injured patients tures involving the respective bone. with an ISS of 17 or greater were admitted to our emer- Before the final statistical analysis, the data was pre- gency room. Fourteen per cent had concomitant maxillo- checked in order to ensure the necessary data quality. facial injuries (n = 67). Fifty-five (82 %) of these patients Mean values for interval variables and median values for were male and 12 (18 %) were female, resulting in a ratio ordinal variables were calculated. Correlations between of almost 5:1 (Fig. 4). The age ranged from 16 to 91 years ordinal variables were tested using Spearman’s Rho. For with a mean age of 44. correlations between ordinal and interval variables the The most common cause of injury were falls (37 %, n = Kruskal-Wallis-Test was performed. Differences in AIS 25), in most cases from a level below 5 meters (24 %, n = face between particular groups were analyzed using the 16), followed by motor vehicle collisions (MVC) (21 %, Pearson Chi-Square Test and confidence intervals. n = 14) and bicycle accidents (19 %, n = 13). Almost all A probability value of < 0.05 was considered statisti- patients involved in MVCs were driving the vehicles cally significant. All statistical analysis was performed themselves (93 %, n = 13). Other causes of injury were using IBM SPSS Statistics software (Version 21.0; IBM pedestrian-car-accidents and assaults. Penetrating injuries Corp., Armonk, NY). appeared in 6 cases (9 %). Prior to data acquisition, the ethics committee approved A large fraction of the patients suffering facial trauma of the study. was injured during late afternoon and evening, between Scheyerer et al. Journal of Trauma Management & Outcomes (2015) 9:4 Page 4 of 9 Fig. 4 Distribution of age and sex at the time of injury 16:00 and 24:00 (31 %, n = 21). Almost half of the injur- AIS Face (Spearman’s rho prehosp.: p = 0,94; 17 cases ies occurred on weekends including Fridays (48 %, n = missing; ER.: p = 0,43; 4 cases missing) was identified. 32). Regarding the monthly distribution, a higher num- Hence, correlation between the GCS in ER and the AIS ber of injuries occurred during the summer months Face could be observed (Spearman’s rho p = 0.02; 4 cases (June to August, 33 %, n = 22). missing) (Fig. 6). Compared to self-breathing patients, A median ISS of 25 (range 17-57) was identified. The patients who arrived intubated did not have a more se- most common injuries associated with facial fractures vere facial fracture pattern (Pearson Chi-Square, p = 0.4). were intracranial bleeding (72 %, n = 48), injuries of A positive blood alcohol level at admission was found extremities (58 %, n = 39), and the chest (49 %, n = 33) in 11 cases (Mean level: 29.4 mmol/l, range 9.7 – (Table 1). More severe facial injuries were associated 51.1 mmol/l).
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