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British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
Equine-associated maxillofacial injuries: retrospective 5-year analysis Shofiq Islam a,∗, Benjamin Gupta b, Christopher J. Taylor c, Jeffrey Chow b, Gary R. Hoffman d a
Department of Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK Department of Oral and Maxillofacial Surgery, The John Hunter Hospital, Newcastle, New South Wales, Australia c Wessex Deanery, Southern House, Ottobourne, Hampshire, UK d University of Newcastle, Consultant Maxillofacial surgeon, The John Hunter Hospital, Australia b
Accepted 23 September 2013 Available online 26 October 2013
Abstract We explored the relation between the causes of facial injuries in equestrians and the presence or absence of associated injuries. Over a 5-year period we retrospectively reviewed all patients who presented to the John Hunter Hospital, New South Wales, with facial injuries that had resulted from activity with horses. We analysed the rates of hard and soft tissue injuries, and of associated injuries by sex and mechanism. A total of 85 patients were included (50 female and 35 male) with an age range of 2–88 years. There was a significant difference in the rate of maxillofacial and associated injuries when groups were analysed for sex and mechanism of injury. Facial injuries caused by falling from a horse were more often associated with other injuries in men than in women (p < 0.05), and men were 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1 to 14) We also found significant differences in the rates of facial fracture. Women who had been kicked by a horse were more likely to sustain bony injuries than men (p < 0.05). Our data confirm the association between kicks and facial fracture, and this may provide an impetus for the development of appropriate protective equipment. Patients who sustain facial injuries when falling from a horse often present with associated injuries and this has practical implications for clinicians involved in their management. © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Equine; Trauma; Facial fracture; Horse related; Maxillofacial injury; Australia
Introduction The John Hunter Hospital is a tertiary referral trauma centre in the Hunter-New England region of New South Wales, Australia, with an urban and rural catchment area of roughly 130,000 km2 . It is the only level 1 trauma centre outside metropolitan Sydney, and serves a population of about 850,000. Horses are used recreationally and commercially in this region, and many of the injuries seen are caused by equestrian activities. These injuries can result in considerable morbidity, but rarely in death. Many papers have examined ∗
Corresponding author. Tel.: +44 0300 303 1573. E-mail address: [email protected] (S. Islam).
facial injuries caused by equestrian activity,1–4 but few focus on the incidence of such injuries and those associated with them. This has potential relevance for the composition of trauma teams in departments that treat patients injured in this way. We retrospectively explored patients’ characteristics and the type of maxillofacial injuries caused by horses in those who presented to the John Hunter Hospital. We considered the mechanism, the resulting facial injury, and the rate of associated injury. In particular, we evaluated the relation between the mechanism (falls from a horse compared with kicks) and the presence, or absence of other associated trauma. We also looked at the relation between the mechanism and the characteristics of the corresponding facial injury (hard
0266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.09.019
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
tissue compared with soft tissue), and considered potential differences in the rate of associated patterns of injury when stratified according to sex.
Method We retrospectively analysed trauma data over a 5-year period of patients who presented to the John Hunter Hospital with maxillofacial injuries caused by horses. Patients who matched our inclusion criteria were identified using the International Classification of Diseases 10 (ICD-10) clinical coding system. Data were retrieved from medical records and included patients’ characteristics, mechanism of injury, and injury pattern. From this dataset we explored 2 questions. The first concerned whether the mechanism of injury (fall or kick) was associated with other injuries, and the second asked whether the mechanism influenced the presenting injury pattern. The main predictor variable was mechanism of injury; the other was sex. The first outcome variable was the presence or absence of associated injuries (head, back, chest, or limb). The second was whether or not patients sustained bony or isolated soft tissue facial injuries. Those who had facial fractures with or without soft tissue injury were placed in the bony injury group. This study qualified for exemption according to the criteria of our local institutional review board. The data were analysed using SPSS version 10 for Windows (SPSS Inc, Chicago). Patients’ characteristics were assessed using frequency and descriptive statistics. The chi square test was used to analyse categorical variables. Probabilities of less than 0.05 were considered significant.
Results We identified 85 patients whose facial injuries resulted from activity with horses. There were 50 female and 35 male patients. The median age of male patients was 40 years and of female patients was 24 years. Of the study sample, 36 patients (42%) were female and under 30 years of age. Most of our patients (n = 53, 62%) were injured during recreational activities. Only 13% (n = 11) were injured when working, and in all these cases horses were being handled without the use of protective equipment. The remaining 25% were unknown. A total of 35 injuries resulted from kicks and 39 from falls; 11 were caused by trampling, dragging, biting, or head butting. Roughly one third of our group (34%, n = 29) sustained facial and associated injuries. The remaining 66% (n = 56) had isolated facial injuries. Associated injuries were seen in nearly half (46%, n = 18) of those who had fallen and in roughly a quarter (23%, n = 8) of those who had been kicked. Falls were associated with other injuries in 11 of the 17 men, and in 7 of the 22 women (Table 1).
125
Table 1 Mechanism of injury, sex, and associated injuries. Data are number. Men
Associated injuries No associated injuries
Women
Falls
Kicks
Other
Falls
Kicks
Other
11 6
2 10
3 3
7 15
6 17
0 5
There was a lack of documentation on the use of helmets on presentation to the emergency department. Only 29% (n = 25) of the records reviewed had clear documentation, and use of a helmet was recorded in only 20% (n = 17) of cases. There was a clear difference in the patterns of injury between men and women. Men had significantly more facial and associated injuries than women (11/17 in men compared with 7/22 in women, p = 0.04) when falls were compared, and were nearly 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1–14). There was no significant difference between the sexes with regard to maxillofacial and associated injuries in those who had been kicked. Based on mechanism, in men there was a marked difference between the incidence with which associated injuries occurred (11/17 for falls and 2/12 for kicks, p = 0.01). Men who had falls were 6 times more likely to have associated injuries then those who had been kicked (OR 6.5; 95% CI: 1.5–28; p < 0.05). In contrast, rates for maxillofacial and associated injuries in women were similar for falls (7/22) and kicks (6/23) (Table 1). The most common facial injuries in our group were isolated soft tissue injuries (n = 48; 56%). The remainder were hard tissue injuries (n = 37; 44%). Most commonly, facial fractures involved the midfacial structures (maxillary or orbitozygomatic complex fractures) (n = 36; 58%). Mandibular fractures accounted for a further 24% (n = 15) and others accounted for the remaining 18% (n = 11) (Table 2). There was a clear difference in injury pattern between men and women when mechanism was considered. Of those who had been kicked, 6/12 men and 19/23 women had hard tissue injuries (p = 0.04). In women, kicks were nearly 5 times more likely to cause bony injuries than in men (OR 4.7; 95% CI 1.1–23). Falls predominantly caused soft tissue damage and there was no significant difference between the sexes (Table 3). Table 2 Number of maxillofacial fractures caused by activity with horses. No. Mandibular Dental Maxillary Zygomatic Nasoethmoidal Nasal Orbital Frontal
15 6 2 9 2 9 14 5
126
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127 Table 4 Number of injuries associated with maxillofacial injuries.
Table 3 Hard and soft tissue injury by sex. Data are number. Men
Hard tissue Soft tissue
Women
No.
Falls
Kicks
Falls
Kicks
5 12
6 6
7 15
19 4
Head Neck and spine Upper limb Lower limb Chest or thorax Abdomen
8 4 9 5 5 4
Discussion Facial injuries caused by horses are not an uncommon presentation to trauma centres and constitute a small but important part of the trauma workload. They typically require operation.1,4 Our findings show that there was a significant difference in the rate of associated injuries between the sexes for falls. In men there were also differences between falls and kicks, and there was a predominance of associated injuries in the falls group (n = 18). Of the men who had fallen from a horse, only 4 were professional jockeys who would have had mandatory protective equipment; 7 had fallen during recreational activity, and the remainder were not recorded. Analysis of the female group did not show significant variance when stratified for the mechanism of related injury. Rates of associated injury were broadly similar for both sexes when kicks were considered separately. We are mindful that the differences highlighted between the sexes may be related to patterns of risk-taking behaviour, occupational handling, variations in riding activities, or a combination of these, but this conclusion could not be drawn from our data. Our results agree with those reported by other researchers. Norwood et al.5 explored whether mechanisms of injury from encounters with large animals could predict serious craniofacial injuries or injuries to the torso, or both. In their series, 79 injuries were associated with horses. Falls while riding were the most common causes, and the brain or craniofacial structures were most commonly injured. Interestingly, they found that injuries to the lower extremities were not strongly associated with multiple injuries to the body, but those to the upper extremities were closely associated with concomitant injuries to multiple body parts. In an analysis of all patients treated in American emergency departments between 2001 and 2003 for non-fatal injuries related to horses, Thomas et al.6 found that most were caused by falls, and the most common injuries were to the head or neck (23.2%), and the lower (22.2%) and upper extremities (21.5%). Our study has highlighted differences in the rates of hard and soft tissue injuries caused by kicks and falls. Those caused by falls were broadly equivalent in both sexes, but women had significantly more bony injuries when kicks were considered (p < 0.05). The incidence of bony injuries was considerably higher for kicks than for falls. Of those who presented with facial trauma after being kicked, 71% (25/35) had fractures, whereas only 31% (12/39) had fractures after a fall.
The findings of our study are consistent with previously published data. Ueeck et al.2 examined a case series of 62 patients treated for maxillofacial trauma related to activities with horses. In their study, young women constituted most of the injured group, and facial fracture was most often associated with being kicked by a horse; only 2 of 28 patients sustained a facial fracture following a fall. Antoun et al.4 analysed facial fractures in a group of 49 patients whose injuries were related to horses. They also found that the most common cause of facial fracture was a kick (69%). The use of helmets has been widely promoted to prevent craniofacial trauma, and the incidence of severe head injuries in those who wear helmets has been significantly reduced.5,7 Lim et al.8 studied the rate of patients injured during equestrian activities that presented to a Sydney teaching hospital, and showed an inverse relation between admissions and use of a helmet. All facial fractures in the series by Ueeck et al.2 occurred in patients who had not worn helmets. However, facial injuries, including blunt trauma to the face can still occur when helmets are worn because they typically do not protect against frontal impact to the face.3 We were unable to assess potential differences in the rate and pattern of facial injuries in riders who did or did not wear helmets because the documentation on their use was incomplete. Most fractures in our sample involved the mid-facial structures (n = 36; 58%). Mandibular fractures accounted for a further 24% (n = 15) of the total bony injuries. This finding is broadly in keeping with other published data. In their study of 45 patients with facial fractures caused by equestrian activities, Lee and Steenberg1 also noted that the midface was the most common site of injury. Antoun et al.4 reported that zygomatic complex fractures were the most common facial injury (63%), followed by mandibular fracture (34%). We think that our findings are relevant to clinicians involved in trauma care. A third of our patients had injuries elsewhere in the body (Table 4), and clinicians should be aware of this when assessing facial injuries in these patients. The management of trauma has evolved into a subspecialty and is typically delivered by a multidisciplinary team, often in a trauma centre. However, a considerable number of patients are seen in emergency departments in smaller district general hospitals. Our data highlight the importance of ensuring that
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
a comprehensive secondary survey is done when a patient presents with facial injuries caused by horses. Such injuries can be distracting and can divert attention from other serious problems. References 1. Lee KH, Steenberg LJ. Equine-related facial fractures. Int J Oral Maxillofac Surg 2008;37:999–1002. 2. Ueeck BA, Dierks EJ, Homer LD, et al. Patterns of maxillofacial injuries related to interaction with horses. J Oral Maxillofac Surg 2004;62:693–6. 3. Islam S, Walton GM, Dean F, et al. Multidisciplinary management of a complicated orbital injury inflicted by a horse. Ophthal Plast Reconstr Surg 2007;23:486–8.
127
4. Antoun JS, Steenberg LJ, Lee KH. Maxillofacial fractures sustained by unmounted equestrians. Br J Oral Maxillofac Surg 2011;49:213–6. 5. Norwood S, McAuley C, Vallina VL, et al. Mechanisms and patterns of injuries related to large animals. J Trauma 2000;48:740–4. 6. Thomas KE, Annest JL, Gilchrist J, et al. Non-fatal horse related injuries treated in emergency departments in the United States, 2001-2003. Br J Sports Med 2006;40:619–26. 7. Eckert V, Lockemann U, Püschel K, et al. Equestrian injuries caused by horse kicks: first results of a prospective multicenter study. Clin J Sport Med 2011;21:353–5. 8. Lim J, Puttaswamy V, Gizzi M, et al. Pattern of equestrian injuries presenting to a Sydney teaching hospital. ANZ J Surg 2003;73: 567–71.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
Equine-associated maxillofacial injuries: retrospective 5-year analysis Shofiq Islam a,∗, Benjamin Gupta b, Christopher J. Taylor c, Jeffrey Chow b, Gary R. Hoffman d a
Department of Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK Department of Oral and Maxillofacial Surgery, The John Hunter Hospital, Newcastle, New South Wales, Australia c Wessex Deanery, Southern House, Ottobourne, Hampshire, UK d University of Newcastle, Consultant Maxillofacial surgeon, The John Hunter Hospital, Australia b
Accepted 23 September 2013 Available online 26 October 2013
Abstract We explored the relation between the causes of facial injuries in equestrians and the presence or absence of associated injuries. Over a 5-year period we retrospectively reviewed all patients who presented to the John Hunter Hospital, New South Wales, with facial injuries that had resulted from activity with horses. We analysed the rates of hard and soft tissue injuries, and of associated injuries by sex and mechanism. A total of 85 patients were included (50 female and 35 male) with an age range of 2–88 years. There was a significant difference in the rate of maxillofacial and associated injuries when groups were analysed for sex and mechanism of injury. Facial injuries caused by falling from a horse were more often associated with other injuries in men than in women (p < 0.05), and men were 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1 to 14) We also found significant differences in the rates of facial fracture. Women who had been kicked by a horse were more likely to sustain bony injuries than men (p < 0.05). Our data confirm the association between kicks and facial fracture, and this may provide an impetus for the development of appropriate protective equipment. Patients who sustain facial injuries when falling from a horse often present with associated injuries and this has practical implications for clinicians involved in their management. © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Equine; Trauma; Facial fracture; Horse related; Maxillofacial injury; Australia
Introduction The John Hunter Hospital is a tertiary referral trauma centre in the Hunter-New England region of New South Wales, Australia, with an urban and rural catchment area of roughly 130,000 km2 . It is the only level 1 trauma centre outside metropolitan Sydney, and serves a population of about 850,000. Horses are used recreationally and commercially in this region, and many of the injuries seen are caused by equestrian activities. These injuries can result in considerable morbidity, but rarely in death. Many papers have examined ∗
Corresponding author. Tel.: +44 0300 303 1573. E-mail address: [email protected] (S. Islam).
facial injuries caused by equestrian activity,1–4 but few focus on the incidence of such injuries and those associated with them. This has potential relevance for the composition of trauma teams in departments that treat patients injured in this way. We retrospectively explored patients’ characteristics and the type of maxillofacial injuries caused by horses in those who presented to the John Hunter Hospital. We considered the mechanism, the resulting facial injury, and the rate of associated injury. In particular, we evaluated the relation between the mechanism (falls from a horse compared with kicks) and the presence, or absence of other associated trauma. We also looked at the relation between the mechanism and the characteristics of the corresponding facial injury (hard
0266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2013.09.019
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
tissue compared with soft tissue), and considered potential differences in the rate of associated patterns of injury when stratified according to sex.
Method We retrospectively analysed trauma data over a 5-year period of patients who presented to the John Hunter Hospital with maxillofacial injuries caused by horses. Patients who matched our inclusion criteria were identified using the International Classification of Diseases 10 (ICD-10) clinical coding system. Data were retrieved from medical records and included patients’ characteristics, mechanism of injury, and injury pattern. From this dataset we explored 2 questions. The first concerned whether the mechanism of injury (fall or kick) was associated with other injuries, and the second asked whether the mechanism influenced the presenting injury pattern. The main predictor variable was mechanism of injury; the other was sex. The first outcome variable was the presence or absence of associated injuries (head, back, chest, or limb). The second was whether or not patients sustained bony or isolated soft tissue facial injuries. Those who had facial fractures with or without soft tissue injury were placed in the bony injury group. This study qualified for exemption according to the criteria of our local institutional review board. The data were analysed using SPSS version 10 for Windows (SPSS Inc, Chicago). Patients’ characteristics were assessed using frequency and descriptive statistics. The chi square test was used to analyse categorical variables. Probabilities of less than 0.05 were considered significant.
Results We identified 85 patients whose facial injuries resulted from activity with horses. There were 50 female and 35 male patients. The median age of male patients was 40 years and of female patients was 24 years. Of the study sample, 36 patients (42%) were female and under 30 years of age. Most of our patients (n = 53, 62%) were injured during recreational activities. Only 13% (n = 11) were injured when working, and in all these cases horses were being handled without the use of protective equipment. The remaining 25% were unknown. A total of 35 injuries resulted from kicks and 39 from falls; 11 were caused by trampling, dragging, biting, or head butting. Roughly one third of our group (34%, n = 29) sustained facial and associated injuries. The remaining 66% (n = 56) had isolated facial injuries. Associated injuries were seen in nearly half (46%, n = 18) of those who had fallen and in roughly a quarter (23%, n = 8) of those who had been kicked. Falls were associated with other injuries in 11 of the 17 men, and in 7 of the 22 women (Table 1).
125
Table 1 Mechanism of injury, sex, and associated injuries. Data are number. Men
Associated injuries No associated injuries
Women
Falls
Kicks
Other
Falls
Kicks
Other
11 6
2 10
3 3
7 15
6 17
0 5
There was a lack of documentation on the use of helmets on presentation to the emergency department. Only 29% (n = 25) of the records reviewed had clear documentation, and use of a helmet was recorded in only 20% (n = 17) of cases. There was a clear difference in the patterns of injury between men and women. Men had significantly more facial and associated injuries than women (11/17 in men compared with 7/22 in women, p = 0.04) when falls were compared, and were nearly 4 times more likely to present with associated injuries than women (OR 3.9; 95% CI 1.1–14). There was no significant difference between the sexes with regard to maxillofacial and associated injuries in those who had been kicked. Based on mechanism, in men there was a marked difference between the incidence with which associated injuries occurred (11/17 for falls and 2/12 for kicks, p = 0.01). Men who had falls were 6 times more likely to have associated injuries then those who had been kicked (OR 6.5; 95% CI: 1.5–28; p < 0.05). In contrast, rates for maxillofacial and associated injuries in women were similar for falls (7/22) and kicks (6/23) (Table 1). The most common facial injuries in our group were isolated soft tissue injuries (n = 48; 56%). The remainder were hard tissue injuries (n = 37; 44%). Most commonly, facial fractures involved the midfacial structures (maxillary or orbitozygomatic complex fractures) (n = 36; 58%). Mandibular fractures accounted for a further 24% (n = 15) and others accounted for the remaining 18% (n = 11) (Table 2). There was a clear difference in injury pattern between men and women when mechanism was considered. Of those who had been kicked, 6/12 men and 19/23 women had hard tissue injuries (p = 0.04). In women, kicks were nearly 5 times more likely to cause bony injuries than in men (OR 4.7; 95% CI 1.1–23). Falls predominantly caused soft tissue damage and there was no significant difference between the sexes (Table 3). Table 2 Number of maxillofacial fractures caused by activity with horses. No. Mandibular Dental Maxillary Zygomatic Nasoethmoidal Nasal Orbital Frontal
15 6 2 9 2 9 14 5
126
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127 Table 4 Number of injuries associated with maxillofacial injuries.
Table 3 Hard and soft tissue injury by sex. Data are number. Men
Hard tissue Soft tissue
Women
No.
Falls
Kicks
Falls
Kicks
5 12
6 6
7 15
19 4
Head Neck and spine Upper limb Lower limb Chest or thorax Abdomen
8 4 9 5 5 4
Discussion Facial injuries caused by horses are not an uncommon presentation to trauma centres and constitute a small but important part of the trauma workload. They typically require operation.1,4 Our findings show that there was a significant difference in the rate of associated injuries between the sexes for falls. In men there were also differences between falls and kicks, and there was a predominance of associated injuries in the falls group (n = 18). Of the men who had fallen from a horse, only 4 were professional jockeys who would have had mandatory protective equipment; 7 had fallen during recreational activity, and the remainder were not recorded. Analysis of the female group did not show significant variance when stratified for the mechanism of related injury. Rates of associated injury were broadly similar for both sexes when kicks were considered separately. We are mindful that the differences highlighted between the sexes may be related to patterns of risk-taking behaviour, occupational handling, variations in riding activities, or a combination of these, but this conclusion could not be drawn from our data. Our results agree with those reported by other researchers. Norwood et al.5 explored whether mechanisms of injury from encounters with large animals could predict serious craniofacial injuries or injuries to the torso, or both. In their series, 79 injuries were associated with horses. Falls while riding were the most common causes, and the brain or craniofacial structures were most commonly injured. Interestingly, they found that injuries to the lower extremities were not strongly associated with multiple injuries to the body, but those to the upper extremities were closely associated with concomitant injuries to multiple body parts. In an analysis of all patients treated in American emergency departments between 2001 and 2003 for non-fatal injuries related to horses, Thomas et al.6 found that most were caused by falls, and the most common injuries were to the head or neck (23.2%), and the lower (22.2%) and upper extremities (21.5%). Our study has highlighted differences in the rates of hard and soft tissue injuries caused by kicks and falls. Those caused by falls were broadly equivalent in both sexes, but women had significantly more bony injuries when kicks were considered (p < 0.05). The incidence of bony injuries was considerably higher for kicks than for falls. Of those who presented with facial trauma after being kicked, 71% (25/35) had fractures, whereas only 31% (12/39) had fractures after a fall.
The findings of our study are consistent with previously published data. Ueeck et al.2 examined a case series of 62 patients treated for maxillofacial trauma related to activities with horses. In their study, young women constituted most of the injured group, and facial fracture was most often associated with being kicked by a horse; only 2 of 28 patients sustained a facial fracture following a fall. Antoun et al.4 analysed facial fractures in a group of 49 patients whose injuries were related to horses. They also found that the most common cause of facial fracture was a kick (69%). The use of helmets has been widely promoted to prevent craniofacial trauma, and the incidence of severe head injuries in those who wear helmets has been significantly reduced.5,7 Lim et al.8 studied the rate of patients injured during equestrian activities that presented to a Sydney teaching hospital, and showed an inverse relation between admissions and use of a helmet. All facial fractures in the series by Ueeck et al.2 occurred in patients who had not worn helmets. However, facial injuries, including blunt trauma to the face can still occur when helmets are worn because they typically do not protect against frontal impact to the face.3 We were unable to assess potential differences in the rate and pattern of facial injuries in riders who did or did not wear helmets because the documentation on their use was incomplete. Most fractures in our sample involved the mid-facial structures (n = 36; 58%). Mandibular fractures accounted for a further 24% (n = 15) of the total bony injuries. This finding is broadly in keeping with other published data. In their study of 45 patients with facial fractures caused by equestrian activities, Lee and Steenberg1 also noted that the midface was the most common site of injury. Antoun et al.4 reported that zygomatic complex fractures were the most common facial injury (63%), followed by mandibular fracture (34%). We think that our findings are relevant to clinicians involved in trauma care. A third of our patients had injuries elsewhere in the body (Table 4), and clinicians should be aware of this when assessing facial injuries in these patients. The management of trauma has evolved into a subspecialty and is typically delivered by a multidisciplinary team, often in a trauma centre. However, a considerable number of patients are seen in emergency departments in smaller district general hospitals. Our data highlight the importance of ensuring that
S. Islam et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 124–127
a comprehensive secondary survey is done when a patient presents with facial injuries caused by horses. Such injuries can be distracting and can divert attention from other serious problems. References 1. Lee KH, Steenberg LJ. Equine-related facial fractures. Int J Oral Maxillofac Surg 2008;37:999–1002. 2. Ueeck BA, Dierks EJ, Homer LD, et al. Patterns of maxillofacial injuries related to interaction with horses. J Oral Maxillofac Surg 2004;62:693–6. 3. Islam S, Walton GM, Dean F, et al. Multidisciplinary management of a complicated orbital injury inflicted by a horse. Ophthal Plast Reconstr Surg 2007;23:486–8.
127
4. Antoun JS, Steenberg LJ, Lee KH. Maxillofacial fractures sustained by unmounted equestrians. Br J Oral Maxillofac Surg 2011;49:213–6. 5. Norwood S, McAuley C, Vallina VL, et al. Mechanisms and patterns of injuries related to large animals. J Trauma 2000;48:740–4. 6. Thomas KE, Annest JL, Gilchrist J, et al. Non-fatal horse related injuries treated in emergency departments in the United States, 2001-2003. Br J Sports Med 2006;40:619–26. 7. Eckert V, Lockemann U, Püschel K, et al. Equestrian injuries caused by horse kicks: first results of a prospective multicenter study. Clin J Sport Med 2011;21:353–5. 8. Lim J, Puttaswamy V, Gizzi M, et al. Pattern of equestrian injuries presenting to a Sydney teaching hospital. ANZ J Surg 2003;73: 567–71.
