ORIGINAL ARTICLE

Changing Trends in Adult Facial Trauma Epidemiology Zachary P. VandeGriend, MD,* Araz Hashemi, MA,† and Mahdi Shkoukani, MD* Objective: The aim of this study was to determine whether the incidence of facial fractures has changed in the United States since 1990. Study Design: This study is a retrospective review of all nonpediatric inpatient and outpatient facilities of the Detroit Medical Center from 1990 to 2011 and weighted national inpatient estimates from 1993 to 2010 using the National Inpatient Survey. Methods: Facial fractures and surgical repairs were grouped according to fracture site and scaled to annual populations. Chow testing determined the year with the most significant change in trend, and regressions were performed before and after the break point. Results: Chow testing showed the year 2000 as the most significant break point across all data sets. National inpatient and institutional data showed a significant decrease in total fractures and most subsites during the 1990s and an increase since 2000. Since 1990, the rate of fracture repairs decreased at our institution and during inpatient stays in the United States. Motor vehicle–related injuries have decreased since the early 1990s. Assault rates have fallen nationally but increased slightly in Detroit. Conclusions: Evidence from the largest institutional series of adult facial fractures and the largest national inpatient database supports a decrease in fractures and repairs during the 1990s and an increase in fractures despite no change in repairs since 2000. These trends are likely related to increasing use of computed tomographic imaging, decreasing severity of facial injuries, and changing incidences of the major etiologies of facial fractures. Key Words: Facial trauma, epidemiology

to evaluate this question.3 This has likely been due to a lack of easily searchable databases until recently. The most common causes of facial fractures for ER visits nationally in 2007 were assaults (37%), falls (25%), and motor vehicle collisions (MVCs) (12%).1 Motor vehicle collisions have historically been a major cause of facial fractures. Increasing regulations have been imposed on the automotive industry and vehicle occupants to improve safety. In 1989, the US government required new cars to have driver's-side air bags or automatic seat belts. In 1998, dual front air bags were mandated by the National Highway Traffic Safety Administration. New York was the first to pass mandatory seat belt laws in 1984. Other states followed until 49 states had similar mandatory seat belt laws by 1994. However, a lag effect exists because oldermodel cars not subject to these regulations continue to be driven. Several studies have demonstrated evidence that increasing use of vehicle safety equipment has changed the likelihood of sustaining facial fractures after MVCs,4–7 and newer car models have been shown to decrease the likelihood of facial injuries in MVCs.7 Detroit has historically been one of the highest-volume trauma cities in the United States. The Detroit Medical Center (DMC) treats the majority of the trauma in the city of Detroit and has a large trauma database. Use of electronic medical records and national data collection has allowed for increasing longitudinal analysis of epidemiologic trends, including facial trauma. Most of these electronic databases start in the early 1990s. With the use of 2 large data sets from both local and national sources, we sought to determine whether the incidence of site-specific and total facial fractures has changed in the United States during the last 20 years. We hypothesized that, because of increasing safety measures primarily related to motor vehicles, rates of facial fractures have decreased.

(J Craniofac Surg 2015;26: 108–112)

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acial trauma is a significant cause of morbidity in the United States. Estimated annual costs due to emergency department (ED) visits alone approach $1 billion per year.1 Despite this, few studies have looked longitudinally at trends of facial fractures in the United States. Most studies to date have looked at either singleinstitutional data, often outside the United States,2 or isolated years From the *Department of Otolaryngology-Head and Neck Surgery, School of Medicine, and †Department of Mathematics, Wayne State University, Detroit, Michigan. Received January 14, 2014. Accepted for publication August 19, 2014. Address correspondence and reprint requests to Zachary P. VandeGriend, MD, Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, 4201 St. Antoine St 5E-UHC, Detroit, MI 48201; E-mail: [email protected] Supported in part by the Department of Otolaryngology, Wayne State University. Presented at the American Academy of Facial Plastic and Reconstructive Surgery Spring Meeting at Combined Otolaryngological Spring Meeting, April 14, 2013, Orlando, FL. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001299

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METHODS Description of Database The National Inpatient Survey (NIS) is a database of the Healthcare Cost and Utilization Project (HCUP). The HCUP is sponsored by the Agency for Healthcare Research and Quality. The NIS is a 20% stratified sample of hospital inpatient stays relying on discharges for diagnosis codes. Data are provided by participating states and weighted. National estimates of diagnoses and procedures are calculated along with SEs. The NIS contains a free online query system for health professionals and researchers to perform secondary data analysis. The first author completed the data user agreement with the HCUP regarding use of the NIS data set.

Data Collection After institutional review board approval was obtained from Wayne State University, electronic medical records from the DMC were searched from 1990 to 2011. Data were collected according to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for facial fractures. They were grouped as nasal (802.0 and 802.1), mandible (802.2x and 802.3x), malar/maxillary (802.4x and 802.5x), orbital floor (802.6x and 802.7x), and other (802.8x and 802.9x). For patients with multiple fractures, each fracture was recorded separately.

The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

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The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

TABLE 1. Detroit Facial Fracture Trends Year

Nasal

Orbital Floor

1990–2011 β = 0.81 β = 0.23 P = 0.01 P = 0.14 1990–2000 β = −1.07 β = −1.15 P = 0.01 P = 0.001 2000–2011 β = 3.00 β = 0.92 P < 0.001 P = 0.01

TABLE 2. Detroit Facial Fracture Repair Trends

MalarMaxillary

Mandible

Year

β = 0.04 P = 0.74 β = −0.63 P = 0.02 β = 1.07 P = 0.001

β = 0.15 β = 0.73 P = 0.31 P < 0.001 β = −0.21 β = 0.27 P = 0.39 P = 0.32 β = 0.99 β = 1.11 P = 0.03 P < 0.001

Other

Total β = 1.51 P = 0.04 β = −2.79 P = 0.02 β = 7.09 P < 0.001

β indicates the regression coefficient (slope) per population of 10,000.

Because the population of Detroit has changed significantly during the past 20 years, we used the 3 nonpediatric DMC hospitals located in Detroit. Demographic data of all ED visits at these hospitals were searched by zip code for their home residence. Every year since 1990 at these 3 hospitals, a range from 75% to 85% of patients seen in these ERs lived in the city of Detroit. This allowed for a reasonably controlled group to scale data using city of Detroit statistics. All hospital-affiliated facilities were used including inpatient hospitals, outpatient surgical centers, and EDs. With the use of the free publicly available online query system,8 data were searched by all ICD-9-CM codes applicable to the previously mentioned facial fractures. Procedural codes of the ICD-9-CM were used for facial fracture repairs. The HCUP database identifies patients upon discharge with diagnosis and procedural codes. Multiple procedural codes may be listed on each stay. They were grouped as follows: malar/zygomatic (76.71 and 76.72); maxillary (76.73 and 76.74), which includes LeFort fractures; mandible (76.75 and 76.76); facial fracture NEC (76.78 and 76.79), which includes orbital floor and other fractures; and nasal (21.71 and 21.72). For simplification, malar/zygomatic repairs will be referred to as “malar” and facial fracture NEC will be referred to as “other.” Open and closed fractures as well as repairs were grouped together for both data sets.

Statistical Analysis Each of the Detroit data sets, including total and site-specific data for both fractures and repairs, was scaled by the Detroit population.9 Annual Detroit aggravated assaults9 and motor vehicle– related injuries were scaled as well.10 National inpatient data were analyzed in a scaled and unscaled manner.9,11,12 National data shown in figures and tables are unscaled.

FIGURE 1. DMC fractures.

Adult Facial Trauma Epidemiology

Nasal

1990–2011 β = −0.01 P = 0.94 1990–2000 β = 0.07 P = 0.71 2000–2011 β = −0.29 P = 0.09

Malar

Maxillary Mandible

Other

β = −0.29 β = −0.03 β = −0.08 β = −0.34 P < 0.001 P = 0.23 P = 0.28 P < 0.001 β = −0.54 β = 0.03 β = −0.09 β = −0.43 P = 0.001 P = 0.67 P = 0.60 P = 0.09 β = −0.06 β = −0.10 β = 0.02 β = −0.01 P = 0.44 P = 0.07 P = 0.93 P = 0.24

Total β = −0.75 P < 0.001 β = −0.96 P = 0.14 β = −0.53 P = 0.24

β indicates the regression coefficient (slope) per population of 10,000.

Visual inspection of scatter plots suggested a nonlinear trend. To assess for a statistically significant break point (change in trend), Chow tests were used. The Chow test (commonly applied for economic research) tests whether the coefficients from 2 linear regressions on different sets of data are equal. In our case, the Chow test is assessing the constancy of linear regression coefficients before and after a break point. Chow tests were applied to each data set to test the significance of all available years as a break point for each type of fracture/repair for the 4 primary data sets (DMC fractures, DMC repairs, national fractures, and national repairs). Regression coefficients (β) were calculated, representing the slope for an increasing or decreasing trend, along with corresponding P values for all available years and before and after the break point. Because numbers from the Agency for Healthcare Research and Quality were estimates, SEs were incorporated into regression analysis for national data.

RESULTS Chow testing showed that the year 2000 was generally the most significant break point (P < 0.02) across all 4 primary data sets. Although several years in the late 1990s and early 2000s were also statistically significant break points, the year 2000 was the most significant. From 1990 to 2011, a total of 30,260 adult facial fractures were identified in DMC records. These included nasal (30.1%), mandible (22.7%), malar/maxillary (15.4%), orbital floor (15.7%), and other (16.1%) fractures. A total of 8528 fracture repairs were performed including nasal (17.1%), mandible (41.6%), malar (15.2%), maxillary (6.4%), and other (19.6%). Overall, from 1990 to 2011, fractures increased (Table 1, Fig. 1). There was a decrease in facial fractures from 1990 to 2000 but a large increase after 2000. Facial fracture repairs decreased from 1990 to 2011 (Table 2, Fig. 2). There were an estimated 2.23 million facial fractures from 1993 to 2010 for patients admitted to the hospital. These included nasal (24.0%), mandible (26.4%), malar/maxillary (20.1%), orbital floor (13.6%), and other (15.9%). Scaled and unscaled national data

FIGURE 2. DMC fracture repairs.

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TABLE 3. National Inpatient Fracture Trends Year

Nasal

Orbital Floor

1993–2010 β = 0.25 β = 0.17 P = 0.001 P < 0.001 1993–2000 β = −0.16 β = −0.09 P = 0.09 P = 0.10 2000–2010 β = 0.67 β = 0.39 P < 0.001 P < 0.001

TABLE 4. National Inpatient Facial Fracture Repair Trends

MalarMaxillary

Mandible

Other

Total

Year

β = 0.03 P = 0.57 β = 0.28 P = 0.01 β = 0.30 P = 0.003

β = −0.14 P = 0.01 β = −0.52 P < 0.001 β = 0.12 P = 0.13

β = 0.21 P < 0.001 β = −0.10 P = 0.26 β = 0.36 P < 0.001

β = 0.52 P = 0.03 β = −0.96 P = 0.02 β = 1.84 P < 0.001

β indicates the regression coefficient (slope) per population of 10,000.

Nasal

1993–2010 β = −0.06 P < 0.001 1993–2000 β = −0.14 P = 0.001 2000–2010 β = 0.01 P = 0.74

Malar

Maxillary Mandible

Other

Total

β = −0.08 β = −0.03 β = −0.18 β = −0.03 β = −0.38 P < 0.001 P < 0.001 P < 0.001 P = 0.07 P < 0.001 β = −0.20 β = −0.07 β = −0.43 β = −0.11 β = −0.95 P < 0.001 P = 0.01 P < 0.001 P = 0.01 P < 0.001 β = 0.01 β = 0.01 β = −0.01 β = 0.05 β = 0.06 P = 0.87 P = 0.34 P = 0.74 P = 0.10 P = 0.64

β indicates the regression coefficient (slope) per population of 10,000.

With the use of independent sources of data from the largest national inpatient database and, to our knowledge, the largest single-institution series of adult facial fractures, 2 consistent trends stand out. First, there was generally a decrease in fractures diagnosed in the 1990s and an increase in the 2000s. Second, there has been a decrease in fracture repairs in the 1990s, with no significant change since 2000. Intuitively, it would be expected that more fractures would correlate with more repairs. This suggests that higher numbers of nonoperative fractures are being identified. We theorize that these changes are due to more facial fractures being observed, a decreasing incidence of the primary causes of facial injuries (eg, MVCs, assaults, falls), and a decrease in injury severity. Yadav et al12 reported that, of the 4.1 million patients treated in the ER for eye and facial injuries in 2007, a total of 20% underwent computed tomographic (CT) scanning. They also noted that the rate of CT use in US ERs had quadrupled from 1996 to 2007. Other series have reported that approximately 95% of all facial fractures were diagnosed by CT from 2003 to 2005.13 This increasing use of CT likely has 2 main effects. First, less severe fractures may be diagnosed

compared with plain radiographs and clinical examination, which were standard in the past. Second, CT may decrease the need to explore or repair certain types of less severe fractures. Cadaveric and CT studies correlating orbital volume increases with enophthalmos for orbital fractures14,15 likely influenced patient selection for initial operative repair of midfacial fractures during this time. The effect of increased CT use on management of facial fractures is unclear but likely varies with fracture location. However, if the severity of facial fractures is decreasing, this would inherently lead to a more conservative approach. Future studies are needed to determine whether certain types of facial fractures are being treated more conservatively. The incidences of the major etiologies of facial fractures are changing. Morbidity and mortality related to MVCs are significantly decreasing. Seat belt use rates in facial fractures seem to being increasing as reported by several authors: 3% (1990–1995),4 8% (1996–2000),6 and 15% (2000–2004).5 There is a reduced risk for facial fractures with newer car models and the use of seat belts with and without frontal air bags. However, air bags alone do not seem to be protective.7 The incidence of aggravated assault nationally has been declining, although this has increased slightly in Detroit. It is unclear whether facial fractures due to other etiologies including unintentional falls are changing. The number of reported unintentional falls causing nonfatal injuries rose from 7.84 million in 2001 to 9.26 million in 2011.16 The significance of this is unclear because most falls do not result in facial fractures. Changes in less common causes of facial fractures including sports and recreational vehicle injuries are difficult to assess given their small number and significant variation depending on the institution. Roden et al17 recently reported their series of 1508 facial fractures from 2005 to 2010 and found that facial fractures from MVCs decreased from 40% to 27% whereas fallrelated fractures increased from 9% to 18%. Although they found that the overall number of fractures increased, the incidence of multisite facial fractures decreased from 25% to 10%. This decrease in multisite fractures may reflect a shift toward less severe facial injuries. Motor

FIGURE 3. National inpatient fractures.

FIGURE 4. National inpatient fracture repairs.

were very similar and showed no significant differences in trend. Similar to Detroit, fractures nationally increased from 1993 to 2010. However, fractures decreased during the 1990s and had a large increase since 2000 (Table 3, Fig. 3). National fracture repairs decreased from 1993 to 2010. There was a large decline in repairs during the 1990s, but numbers have been stable since 2000 (Table 4, Fig. 4). Since the early 1990s, the number of people injured in MVCs in Detroit precipitously declined, whereas the incidence of aggravated assault increased slightly (Table 5, Fig. 5). Nationally, motor vehicle–related fatalities have declined (Table 5, Fig. 6), and the assault rate has decreased by almost 40% (Table 5, Fig. 7).

DISCUSSION

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The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015

Adult Facial Trauma Epidemiology

TABLE 5. Assaults and MVCs Year 1993–2010 1993–2000 2000–2010

Detroit Assaults

Detroit MVC Injuries

National Assaults

National MVC Fatalities

β = 8.3 P = 0.01 β = 13.3 P = 0.03 β = 2.6 P = 0.81

β = −102.8 P < 0.001 β = −89.8 P = 0.01 β = −112.2 P < 0.001

β = −10.6 P < 0.001 β = −17.5 P < 0.001 β = −6.3 P < 0.001

β = −0.027 P < 0.001 β = −0.014 P < 0.001 β = −0.042 P < 0.001

β indicates the regression coefficient (slope) per population of 10,000.

vehicle collisions and gunshot wounds have been shown to be predictive of panfacial fractures, and assault has been shown to be predictive of isolated mandible fractures.13 There has been concern by some that procedural volume for facial trauma is decreasing, which would impact resident training. Although there seems to be a decline in fracture repairs around 2000, the mean number of annual inpatient fracture repairs in the United States was only 10% less during 2000 to 2010 than 1993 to 2000. This is consistent with findings from other authors who reported no statistically significant change in malar and mandible fracture repairs when comparing the years 1996 and 2006.3 However, the number of residents is increasing in specialties that treat most facial trauma. According to the Accreditation Council for Graduate Medical Education, from 2001 to 2012, the number of on-duty residents in otolaryngology and plastic surgery increased by 40% and 49%, respectively.18 Together, these trends imply that resident operative training volume is decreasing for facial trauma during this period. Shifts in coverage between surgical specialties at training hospitals may influence this perception as well.

FIGURE 5. City of Detroit.

FIGURE 7. National assaults.

There are important limitations to note in this study. Although all outpatient surgical centers affiliated with the DMC were included, some fractures were undoubtedly repaired at other outpatient surgical facilities. In addition, although there are 3 DMC adult hospitals including a level 1 trauma center located in the city of Detroit, there is 1 other level 1 trauma center in the city. Changes in population density within areas of the city during this time may have influenced the distribution of trauma, but we are not aware of any major changes during this time that would have a significant impact. The primary limitation of our national data is the use of an inpatient database. Allareddy et al1 used the Nationwide Emergency Department Sample to evaluate facial fractures for 2007. This is the best estimate of total facial fractures but has been available only since 2006. Notably, they found that 21% of patients with facial fractures were admitted, but there was no division by fracture type. The best fracture repair database is that used by Lee and Bhattacharyya,3 who compared both outpatient and inpatient fracture repairs using the National Hospital Discharge Survey (analogous to the NIS used in our study) and the National Survey of Ambulatory Surgery. Unfortunately, the National Survey of Ambulatory Surgery was started in 1996 but then stopped after that year and resumed again in 2006. Therefore, it is impossible to determine annual trends using these isolated years. Looking at nasal, zygomatic, and mandible fractures, they showed that the percentage of outpatient facial fracture repairs increased from 51% in 1996 to 61% in 2006, mostly because of more nasal fracture repairs in the ambulatory setting. Comparing 1996 with 2006, the percentage of facial fracture repairs performed during inpatient stays changed from 16% to 8.2% (nasal), 67% to 69% (zygomatic), and 90% to 85% (mandible). This suggests that inpatient data may be representative of nonnasal facial fracture repairs during this period. Future epidemiologic studies of facial trauma will likely rely on these comprehensive national data collection systems.

CONCLUSIONS Inpatient national data support a decrease in facial fractures and repairs during the 1990s. Since 2000, facial fracture diagnoses seem to have increased, but repairs are relatively stable. This is consistent with our large institutional series. Lack of available national ambulatory surgical data limits conclusive evidence of these trends. Factors such as CT use, assault rates, and vehicle safety regulations likely contribute to these changes. Increasing national data collection will allow improved analysis in the future.

FIGURE 6. National motor vehicle–related fatalities.

ACKNOWLEDGMENTS The authors thank Moneer Abdo for assistance with data collection; Jason Booza, PhD, and George Divine, PhD, for their epidemiologic contributions; and Joel Ager, PhD, for guidance with study design.

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10. Michigan Traffic Crash Facts [database online]. 1994–2009. Available at: http://www.michigantrafficcrashfacts.org. Accessed May 3, 2012 11. National Highway Traffic Safety Administration: Fatality Analysis Reporting System [NHTSA Web site]. Available at: http://www-fars. nhtsa.dot.gov/Main/index.aspx. Accessed May 3, 2012 12. Yadav K, Cowan E, Wall S, et al. Orbital fracture clinical decision rule development: burden of disease and use of a mandatory electronic survey instrument. Acad Emerg Med 2011;18:313–316 13. Erdmann D, Follmar KE, DeBruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2007;60:398–403 14. Parson GS, Mathog RH. Orbital wall and volume relationships. Arch Otolaryngol Head Neck Surg 1988;114:743–747 15. Whitehouse RW, Batterbury M, Jackson A, et al. Prediction of enophthalmos by computed tomography after ‘blow out’ orbital fracture. Br J Opthalmol 1994;78:618–620 16. National Center for Injury Prevention and Control: leading causes of non-fatal injury reports [CDC Web site]. Available at: http://www.cdc. gov/injury/wisqars/nonfatal.html. Accessed December 27, 2012 17. Roden KS, Tong W, Surrusco M, et al. Changing characteristics of facial fractures treated at a regional level 1 trauma center, from 2005 to 2010. Ann Plast Surg 2012;68:461–466 18. Graduate medical education data resource book [ACGME Web site]. 2001–2012. Available at: https://www.acgme.org/ads/public. Accessed May 5, 2013 19. Population estimates: historical data [US Census Bureau Web site]. Available at: http://www.census.gov/popest/data/historical/index.html. Accessed December 27, 2012

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Changing trends in adult facial trauma epidemiology.

The aim of this study was to determine whether the incidence of facial fractures has changed in the United States since 1990...
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