J Oral Maxillofac Surg 50:21&222. 1992

A Review of 100 Closed Head Injuries Associated With Facial Fractures RICHARD H. HAUG, DDS,* JAMES D. SAVAGE, DDS,t MATT J. LIKAVEC, MD,* AND PHILIP J. CONFORTI, DDS§ One hundred closed head injuries associated with facial fractures treated over a 78-month period at a level I trauma center in Northeast Ohio were reviewed. The incidence of closed head injury in patients with facial fractures was 17.5%. Males suffered closed head injuries four times more often than females, and sustained severe intracranial injuries eight times as often. The 16- to 30-year age group predominated (59%). Although motor vehicle accidents were the most frequent cause of injury (61%), motorcycle accidents were associated with the most severe head injury. The mandible/midface fracture ratio (1.3:1) was almost half that of the non-head-injured population (2.1:1). Facial fracture complications were found to have a similar incidence (14%) as in the non-head-injured population, but were associated with more severe intracranial injuries.

The incidence of neurologic injury associated with facial fractures has been reported to be as high as 76%.lF6Yet, the relationship of closed head injury to facial fractures has not been firmly established in the oral and maxillofacial surgical literature. The purpose of this study was to identify the population characteristics of patients with both closed head injuries and facial fractures and to determine the relationships between them.

injuries were identified. This required a review of 570 patients suffering 444 mandible fractures, 143 zygoma fractures, and 68 maxillary fractures treated during the 78 months between March 1984 and August 1990. These 100 patients were reviewed for type of closed head injury, type of facial fracture, age, sex, cause of injury, brain injury index, Glasgow coma scale, and presence of complications with facial fractures. The definition and classification of closed head injuries were according to the systems described by Davidoff and coworkers and Lee and coinvestigators7,* The brain injury index was according to the system described by Bennet and coauthors (grade I, loss of consciousness to grade IV, brain death).’ The Glasgow coma scale was the system reported by Teasdale and Jennett (15 the best prognosis and 3 the worst).” Complications of facial fractures identified were nonunion, malunion, malocclusion, osteomyelitis, or deep space infection. The data were recorded and the age, sex, and cause of injury were related to the type and severity of closed head injury. The types of facial fractures were then related to the type and severity of closed head injury. Finally, complications of facial fractures were related to the type and severity of closed head injury.

Materials and Methods This investigation was performed at the MetroHealth Medical Center of Cleveland, a level I trauma center and county facility serving a population of 3.4 million in Northeast Ohio. Hospital charts for all patients with facial fractures treated by the Division of Oral and Maxillofacial Surgery were reviewed retrospectively from July 1990 until 100 patients with closed head * Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center and the Case Western Reserve University, Cleveland. t Resident, Division of Oral and Maxillofacial Surgery, MetroHealth Medical Center, Cleveland. $ Assistant Professor of Neurosurgery, MetroHealth Medical Center and the Case Western Reserve University, Cleveland. 8 In private practice, Hamden, CT, Attending, Department of Oral and Maxillofacial Surgery, St Raphael’s Hospital, New Haven, CT. Address correspondence and reprint requests to Dr Haug: Division of Oraland MaxtiofacialSurgery,MetroHealthMedicalCenter,3395 Scranton Rd, Cleveland,OH 44109.

Results SEX, AGE, AND ETIOLOGY RELATED TO CLOSED HEAD INJURY

0 1992 American Association of Oral and Maxillofacial Surgeons

Males having closed head injuries associated with facial fractures predominated 4: 1 (Table 1). Males also

027%2397/92/5003-0003$3.00/0

218

219

HAUG ET AL

Table 1. Types of Closed Head Injury and Sex Distribution Total

Male

Female

Loss of consciousness Subdural hematoma Epidural hematoma lntracerebral hematoma Pneumoencephalus Subarachnoid hemorrhage Midline shifts Hemorrhagic contusion Transtentorial hemiation Edema Intraventricular hemorrhage

43

15 1

1

2

3

Total

80

20

100

3

58 8 3

5 4

5 4

1

1 3

1

2 3

8

1

9

FACIAL FRACTURE COMPLICATIONS AND CLOSED HEAD INJURY

0 5

tended to have more severe diagnoses by a ratio of 8: 1 (Table 1). The 16- to 30-year age group was most frequently affected (59%) (Table 2). Motor vehicle accidents were the most common cause of head injury in patients with facial fractures (61%) (Table 3), but motorcycle accidents caused the most severe intracranial injuries (Tables 3, 4). FACIAL FRACTURES

Discussion

Types of Closed Head Injury and Age Distribution

Ageh) Loss of consciousness Subdural hematoma Epidural hematoma Intracerebral hematoma Pneumoencephalus Subarachnoid hemorrhage Midline shifts Hemorrhagic contusion Transtentorial herniation Edema Intraventricular hemorrhage Total

Only 14% of the patients had complications associated with their facial fractures. There were 13 complications associated with mandibular fractures: 6 infections, 5 nonunions, and 2 delayed unions. There was necrosis of one hemimaxillary fracture. These patients were equally distributed between a simple loss of consciousness and a more severe diagnosis (Table 7). However, patients with facial fracture complications tended to have a slightly higher brain injury index (Table 8) and lower Glasgow coma score (Table 9) than the remainder of the population studied (Table 6).

Closed head injury, as defined by Davidoff and coworkers, is a “documented loss of consciousness and/ or posttraumatic amnesia.“7 Lee and coauthors included 10 additional computed tomographic findings in their classification of closed head injury (Table 1).8

AND CLOSED HEAD INJURY

The closed head injury most frequently encountered with facial fractures was the simple loss of conscious-

Table 2.

ness (58), followed distantly by the hemorrhagic contusion (9), subdural hematoma (8), intracranial hematoma (5), edema (5), and others (15) (Table 5). Patients with mandible fractures were most frequently affected (45), and patients with isolated maxillary fractures were least frequently affected (2) (Table 5). The patients with the most severe intracranial injuries were those with combination mandible/zygoma fractures or combination maxilla/zygoma fractures (Table 6). The least severe closed head injuries were associated with isolated maxillary fractures.

O-5

6-10

lo-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

I

3

9

13

12

7

4

4

2

1

1

4

1

1

1 1

I

I

1

I 3

1

2

5

18

24

1

2

1

1

1

3

1

1

4

2

1

1

I

1

66-70

1

1 1 1

1

61-65

1

1

1

56-60

17

9

1

8

5

3

2

I

1

2

220 Table 3.

A REVIEW OF 100 CLOSED HEAD INJURIES

Types of Closed Head lniurv and Cause of lnhv MVA

of consciousness Subdural hematoma Epidural hematoma Intracerebral hematoma Pneumoencephalus Subarachnoid hemorrhage Midline shifts Hemorrhagic contusion Transtentorial hemiation Edema Intraventricular hemorrhage

33 7

Total

Lass

MCA 3 1 1 1

4 4

Assault

SPOrtS

Occupation

Home

Total

18

2

1

1

58 8 3 5 4 2 3 9 0 5 3

2

1

1

100

2

2 3 4

4

4 2

1 1

61

14

1

21

Abbreviations: MCA, motorcycle accident; MVA, motor vehicle accident.

Table 4.

Cause of Injury and Severity of Head Injury (Mean -+ SD) MVA (n = 61)

Brain injury index

2.0 (k0.8)

Glasgow coma scale

11.1 (14.3)

MCA (n = 14)

Assault (n=21)

sports (n = 2)

Occupation (n = 1)

1.2 (kO.6) 10.4 (+3.9

14.0 (k2.5)

Home (n= 1)

1.0 (kO.0) 10.5 (k6.3)

15.0 (kO.0)

15.0 (kO.0)

Abbreviations: MCA, motorcycle accident; MVA, motor vehicle accident.

Table 5.

Types of Closed Head Injury and Concomitant Facial Fractures

Mandible

Zygoma

Maxilla

Mandible/ Maxilla

Loss of consciousness Subdural hematoma Epidural hematoma Intracerebral hematoma Pneumoencephalus Subarachnoid hemorrhage Midline shifts Hemorrhagic contusion Transtentorial hemiation Edema Intraventricular hemorrhage

28 1

11

2

2

Total

45

Mandible/ Zygoma 3 3

4 3 2

1

2

1 3 1

Maxilla/ Zygoma

1

1

Mandible/ Maxilla/ Zygoma 8 1

58 8 3

1

5 4

1

2 3

1

9

3 1

3

2

2

Total

0

1

2

2

5 3

3 12

2

4

11

13

13

100

221

HAUG ET AL

Table 6. Number of Complications and Brain Injury Index (Mean Index, 2.3 f 0.6)

Table 6. Facial Fractures and Severity of Head Injury (Mean + SD)

Brain Injury Index

Glasgow Coma Scale

Mandible (n = 45) Zygoma (n = 12) Maxilla (n = 2) Mandible/maxilla (n = 4) Mandible/zygoma (n = 1 I) Maxillalzygoma (n = 13) Mandible/maxilla/zygoma (n = 13)

1.9 -I 0.9 1.3 +_0.7 1.0 + 0.0 1.5 k 0.6 2.3 + 1.0 2.0 + 0.9 1.5 k 0.7

11.2 f 4.3 14.2 +_ 1.0 (5.0 t 0.0 12.8 f 3.3 8.7 + 4.5 10.5 f 3.4 12.9 f 3.0

Total

1.8 k 0.9

11.5k4.1

these guidelines, we were able to identify 100 patients with closed head injuries from 570 patients with facial fractures treated during the 78 months between March 1984 and August 1990. This was a 17.5% incidence in the population studied. Patients between the ages of 16 to 30 were the group most frequently affected with both closed head injury and facial fractures (59%). Males in this population predominated by a ratio of 4:l. Each of these distributions were similar to the non-head-injured facial fracture population treated in our facility.6 Females were found to have a simple loss of consciousness 75% of the time, whereas this occurred in males only 50% of the time. This may be owing to the greater number of females assaulted than involved in motor vehicle or motorcycle accidents in the population studied.6 Motor vehicle accidents were the predominant cause of injury in our study (61%), and produced an equal distribution between simple loss of consciousness and more severe intracranial injury. Motorcycle accidents, however, caused a disproportionately high rate of severe intracranial injury (78.6%), as well as a higher brain injury index and lower Glasgow coma score than any other cause. This may be partially attributed to the lack of a helmet law in our state. Of the patients with Using

Table 7. Type of Head Injury and Number of Complications Loss of consciousness Subdural bematoma Epidural bematoma Intracerebral hematoma Pneumoencephalus Subarachnoid hemorrhage Midline shifts Hemorrhagic contusion Transtentorial herniation Edema lntraventricular hemorrhage Total

I

1

I 14

Grade Grade Grade Grade

1 II III IV

3 4 7 0

more severe intracranial injuries in the assault group, two were subjected to bludgeoning with a baseball bat, and the third was the victim of a gunshot. If these were eliminated, assault, sport, occupational, and home injuries were limited to simple loss of consciousness. This indicates that the more severe intracranial injuries are related to high-energy impacts. Patients with mandible fractures and closed head injury were the largest group in our series. However, the mandible/midface fracture ratio in patients with closed head injury (1.3: 1) was lower than in the nonhead-injured facial fracture population treated at our institution (2.1: 1) by a factor of almost two.6 This indicates that midface fractures have a more frequent association with closed head injuries than mandible fractures and tends to refute theories that the midface is developed to absorb impact and protect intracranial structures.8 Combinations of fractured facial bones tended to be associated with more severe intracranial injury as indicated by the Glasgow coma scale and brain injury index than when individual bones were fractured (Table 6). Kaufman and coinvestigators in 1984 stated that neurologically injured patients have a higher facial fracture complication rate.” This statement was not supported by our study. Only 14% of the patients identified in our study had a problem. This was well within the range of reported complication rates for both mandibular and midfacial fractures. ‘*-I5It was noted. how-

Table 9. Number of Complications and Glasgow Coma Score (Mean Score, 6.7 +: 4.4)

Coma Score 3 4 5 6 7 8 9 10 11 12 13 14 15

No. of Complications

1 2

1 3

222 ever, that facial fracture complications were more frequently associated with severe intracranial injuries as determined by a lower Glasgow coma score and higher brain injury index. References 1. Olson RA, Fonseca RJ, Zeitler DL, et al: Fractures of the mandible. J Oral Surg 40:23, 1982 2. Morgan BDG, Madan DK, Bergerot JPC: Fractures of the middle third of the face: A review of 300 cases. Br J Plast Surg 25: 147, 1972 3. Adekeye EO: The pattern of fractures of the facial skeleton in Kaduna, Nigeria. Oral Surg Oral Med Oral Path01 49:491, 1980 4. Turvey TA: Midface fractures: A retrospective analysis of 593 cases. J Oral Surg 35:887, 1977 5. Murray JF, Hall HC: Fractures of the mandible in motor vehicle accidents. Clin Plast Surg 2: 13 1, 1975 6. Haug RH, Prather J, Indresano AT: An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 48:926, 1990

A REVIEW OF 100 CLOSED HEAD INJURIES

7. Davidoff G, Jakubowski M, Thomas D, et al: The spectrum of closed-head injuries in facial trauma victims: Incidence and impact. Ann Emerg Med 17:6, 1988 8. Lee KF. Waaner LK. Lee YE. et al: The imnact-absorbing effects of facial f;actures’in closed-head injury: J Neurosurg 166542, 1987 9. Becker DP, Miller JD, Young HF, et al: Diagnosis and treatment of head injuries in adults, in Youman JR (ed): Neurological Surgery (ed 2). Philadelphia, PA, Saunders, 1986, p 2016 10. Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 1:81, 1974 11. Kaufman MS, Marciani RD, Thomson SF, et al: Treatment of facial fractures in neurologically injured patients. J Oral Maxillofac Surg 42:250, 1984 12. Wagner WF, Neal DC, Alpert B: Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 37197, 1979 13. Zallen RD, Curry JT: A study of antibiotic usage in compound mandibular fractures. J Oral Surg 33:43 1, 1975 14. Steidler NE, Cook RM, Reade PC: Residual complications in patients with major middle third facial injuries. Int J Oral Surg 9:259, 1980 15. Heimgartner-Candinas B, Heimgartner M, Jonutis A: Results of treatment of midfacial fractures. J Maxillofac Surg 6293, 1978

A review of 100 closed head injuries associated with facial fractures.

One hundred closed head injuries associated with facial fractures treated over a 78-month period at a level I trauma center in Northeast Ohio were rev...
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