CLINICAL STUDY
Examination of Life-Threatening Injuries in 431 Pediatric Facial Fractures at a Level 1 Trauma Center Ian C. Hoppe, MD, Anthony M. Kordahi, BA, Angie M. Paik, BA, Edward S. Lee, MD, and Mark S. Granick, MD Purpose: Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to examine a level 1 trauma center's experience with pediatric facial trauma resulting in fractures of the underlying skeleton with regards to epidemiology and concomitant injuries. Methods: A retrospective review of all facial fractures at a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patients aged 18 years or younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. A significance value of 5% was used. Results: During this period, there were 3147 facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review. The mean age of patients was 14.2 years with a male predominance (77.9%). The mechanism of injury was assault in 108 (37.9%), motor vehicle accident in 68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%), sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%). The mean Glasgow Coma Scale (GCS) on arrival to the emergency department was 13.7. The most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%). A skull fracture was present in 50 patients (17.5%). A long bone fracture was present in 36 patients (12.6%). A pelvic or thoracic fracture was present in 30 patients (10.5%). A cervical spine fracture was present in 10 patients (3.5%), and a lumbar spine fracture was present in 11 patients (3.9%). Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone From the Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ. Received February 17, 2014. Accepted for publication April 23, 2014. Address correspondence and reprint requests to Ian C. Hoppe, MD, Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers University, Ambulatory Care Center, Suite E1620, 140 Bergen St., Newark, NJ 07103; E-mail: [email protected]; [email protected] Presented at the 93rd Annual Meeting of the American Association of Plastic Surgery, April 5–8, Miami, FL. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001055
were significantly associated with intracranial hemorrhage (P < 0.05). Fractures of the zygoma and orbit were significantly associated with cervical spine injury (P < 0.05). The mean GCS for patients with and without intracranial hemorrhages was 11.0 and 14.6, respectively (P < 0.05). The mean GCS for patients with and without cervical spine fractures was 11.2 and 13.8, respectively (P < 0.05). Conclusions: Pediatric facial fractures in our center are often caused by interpersonal violence and are frequently accompanied by other more life-threatening injuries. The distribution of fractures parallels previous literature. Midface fractures and a depressed GCS showed a strong correlation with intracranial hemorrhage and cervical spine fracture. A misdiagnosed cervical spine injury or intracranial hemorrhage has disastrous consequences. On the basis of this study, it is the authors’ recommendation that any patient sustaining a midface fracture with an abnormal GCS be evaluated for the aforementioned diagnoses. Key Words: Adolescent, child, facial bones/injuries, infant, humans, multiple trauma/epidemiology/etiology/mortality, skull fractures/epidemiology/etiology/mortality, violence/statistics & numerical data (J Craniofac Surg 2014;25: 1825–1828)
P
ediatric facial fractures are a fairly uncommon injury, representing less than 15% of all facial fractures,1 and present a challenge in management. The goal of management in all pediatric patients presenting with facial fractures is anatomic reduction and healing without complication. Before treatment of the facial fracture, it is essential to identify concomitant injuries, such as intracranial injury and spine injury, that may pose a threat to life or quality of life if not identified and appropriately treated. A large retrospective study found that almost 65% of pediatric patients with a facial fracture exhibited associated injury.2 A recent study concluded that a concussion was documented in almost one third of all pediatric patients presenting with a facial fracture, with an increased risk if the skull, orbit, or maxilla were involved.3 A related study determined that more than half of all pediatric patients diagnosed with a facial fracture also presented with a serious associated trauma of a vital organ system.4 In a survey of the National Trauma Data Bank, it was found that pediatric patients with facial fractures exhibited a higher injury severity, longer length of hospital stay, longer time spent in an intensive care setting, increased number of days on a ventilator, and increased hospital charges compared with those without facial fractures.5 Other studies show varying degrees of concomitant injuries.6–14 It has been suggested that the presence of facial fractures actually represents a protective mechanism for the brain to reduce intracranial injury due to the force absorbing characteristics of the facial skeleton.15 A multicenter study examined this protective mechanism in injured bicyclists and discovered that facial fractures are actually associated with an increased risk for brain injury.16 The
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1825
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
TABLE 1. Distribution of Fractures Observed
Number of patients Mean age, y Number of fractures Mandible fractures Orbital fractures Zygoma fractures Nasal fractures Frontal bone/sinus fractures Palate fractures Le Fort variant fractures
Male
Female
Total
222 14.7 328 118 92 26 48 21 5 18
63 12.7 103 21 33 9 21 15 2 2
285 14.2 431 139 125 35 69 36 7 20
reason for this is likely related to the high-energy mechanism often associated with fracture of the facial skeleton. The objective of this study is to examine associations between modes of presentation, fracture patterns, and concomitant life-threatening injuries in all facial fractures diagnosed via a radiographic study at a level 1 trauma center during a predetermined period.
FIGURE 1. Concomitant injuries.
METHODS
length of hospital stay, and life-threatening injuries such as cervical spine injury and intracranial hemorrhage. A significance value of 5% was used.
After institutional review board approval, all facial fractures occurring at a level 1 trauma center (University Hospital, Newark, NJ) between January 2000 and December 2012 were collected based on International Classification of Disease, Revision 9, codes. These results were further refined to include only those patients in the pediatric population (age of 18 years or younger). Patient demographics were collected as well as mechanism of injury, Glasgow Coma Scale (GCS) on presentation, fracture locations, concomitant injuries, and fracture management strategies. Comparisons were made between type of fracture, mechanism of injury, GCS on presentation,
During this period, there were 3147 patients with facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review, with a total of 431 fractures. The mean age of patients was 14.2 years with a strong male predominance (78%). The mandible was the most common bone fractured followed by fractures of the orbit (Table 1). Figure 1
RESULTS
TABLE 2. Fracture Types and Concomitant Injuries Lumbar/ Cervical Spine No Cervical Odds Ratio Thoracic No Lumbar/Thoracic Fracture Spine Fracture (95% CI) Spine Fracture Spine Fracture Odds Ratio Mandible fracture Palatal fracture Zygoma fracture Orbital fracture Nasal fracture Frontal bone/sinus fracture Le Fort fracture
Mandible fracture Palatal fracture Zygoma fracture Orbital fracture Nasal fracture Frontal bone/sinus fracture Le Fort fracture
3 1 4 8 5 3
136 6 33 119 64 33
2 Skull Fracture 14 4 10 38 16 26 8
NS NS 4.9 (1.3–18.2)† 5.2 (1.1–25.1)† NS NS
3 2 2 8 6 3
18 NS 1 No Skull Odds Ratio Long Bone Fracture Fracture 125 0.33 (0.17–0.64)* 14 3 6.6 (1.4–30.2)* 4 27 NS 5 89 4.8 (2.4–9.4)* 19 53 NS 10 10 23.3 (10.1–53.9)* 5 12
3.4 (1.3–8.9)*
4
136 5 35 119 63 33
NS 11.9 (2.0–70.1)† NS NS 4.0 (1.2–13.6)† NS
ICH
No ICH
Odds Ratio
16 3 16 48 30 25
123 4 21 79 39 11
0.22 (0.12–0.41)* NS 2.7 (1.3–5.6) 3.8 (2.1–6.7)* 3.4 (1.9–6.1)* 10.3 (4.7–22.5)*
19 NS 8 12 NS No Long Bone Odds Ratio Abdominal/Pelvic/ No Abdominal/Pelvic/ Odds Ratio Fracture Thoracic Injury Thoracic Injury 125 NS 12 126 NS 3 10.3 (2.2–47.9)* 2 5 NS 32 NS 6 31 NS 108 NS 16 111 NS 59 NS 12 57 2.3 (1.0–5.1)† 31 NS 7 29 NS 16
NS
6
14
4.3 (1.5–12.2)*
*P < 0.01; †P < 0.05. CI, confidence interval; ICH, intracranial hemorrhage; NS, not significant.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
FIGURE 2. Concomitant injuries and type of fracture.
depicts the concomitant injuries observed in our series. The relationship between type of fracture and concomitant injuries is presented in Table 2 and Figure 2. Loss of consciousness with injury was significantly associated with thoracic/lumbar spine fracture, intracranial hemorrhage, skull fracture, long bone fracture, abdominal/pelvic/thoracic injury, and death. Those patients intubated in the emergency department were significantly more likely to have a cervical spine fracture, thoracic/lumbar spine fracture, intracranial hemorrhage, skull fracture, and abdominal/pelvic/thoracic injury. In addition, intubation in the emergency department was significantly associated with death. The mean GCS for patients sustaining a cervical spine fracture was 11.2, compared with 13.8 for those without a cervical spine fracture (P < 0.05, Fig. 3). The mean GCS for patients with an intracranial hemorrhage was 11.0, compared with 14.6 for those without an intracranial hemorrhage (P < 0.01, Fig. 4). The mean age of patients experiencing an intracranial hemorrhage was significantly lower than those without (12.8 versus 14.7 years old, P < 0.01). The total hospital length of stay was increased for patients experiencing an intracranial hemorrhage (11.2 versus 3.7 days, P < 0.01).
DISCUSSION Facial fractures in the pediatric population are associated with severe concomitant injuries. Similar to previous studies, there was a strong male preponderance,12,17–19 and the mandible was
FIGURE 4. Intracranial hemorrhage and GCS.
the most common bone fractured.17–19 Interestingly, in female patients in our series, the orbit was the most common bone fractured. The most common etiology of fractures in our series was interpersonal violence overall, interpersonal violence in men, and motor vehicle accident in women. The preponderance of interpersonal violence likely reflects the population treated at our institution, notably urban, often gang-affiliated males. One hundred twenty-seven patients (44.6%) had some form of concomitant multisystem injury. These injuries are likely a reflection of the degree of force required to fracture the facial skeleton. In our study, mandible fractures seem to portend a protective mechanism from several serious injuries: intracranial hemorrhages and skull fractures. Fracture of the mandible may represent a force absorbing mechanism, thus sparing the cranium and its contents from injury. Palatal fractures were associated with an increased rate of thoracolumbar spine fractures, skull fractures, and long bone fractures. Palatal fractures usually are due to a strong force, and the association of long bone fractures and thoracolumbar spine fractures likely reflects this. Fractures of the zygoma were associated with cervical spine injuries and intracranial hemorrhage. As the force is transmitted in a more cranial direction on the facial skeleton, the cervical spine and intracranial contents may be more likely to be traumatized. Orbital fractures were associated with cervical spine fractures, intracranial hemorrhage, and skull fractures. This is similar to the patterns seen with fractures of the zygoma in that there is likely more force transmitted to the cervical spine and intracranial contents. Nasal bone fractures were associated with thoracolumbar spine fractures, intracranial hemorrhage, and abdominal/pelvic injuries. The reason for these associations is unclear and may represent an anomaly due to the prominent position of the nose. Frontal bone/sinus fractures were associated with intracranial hemorrhage and skull fractures. Again, the tremendous force required to fracture the frontal bone places the intracranial contents at greater risk. Le Fort variant fractures were associated with skull fractures and abdominal/pelvic injuries. Cervical spine fractures and intracranial hemorrhages were associated with a lower GCS score. This is a logical association considering the severity of these injuries.
CONCLUSIONS FIGURE 3. Cervical spine fracture and GCS.
A large proportion of facial fractures in the pediatric population are associated with severe concomitant injuries. In general, as fractures move in a more cranial direction, there is an increased risk
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1827
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
for intracranial injuries and cervical spine fractures. A lower GCS on presentation portends a higher association with cervical spine injury and intracranial hemorrhage. The failure to identify these associated and serious injuries could have disastrous consequences, and every practitioner involved in treating facial fractures must be aware of this risk.
REFERENCES 1. Vyas RM, Dickinson BP, Wasson KL, et al. Pediatric facial fractures: current national incidence, distribution, and health care resource use. J Craniofac Surg 2008;19:339–349 2. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 2005;115:1500–1508 3. Afrooz PN, Grunwaldt LJ, Zanoun RR, et al. Pediatric facial fractures: occurrence of concussion and relation to fracture patterns. J Craniofac Surg 2012;23:1270–1273 4. Grunwaldt L, Smith DM, Zuckerbraun NS, et al. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg 2011;128:1263–1271 5. Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 2008;207:710–716 6. Gassner R, Tuli T, Hachl O, et al. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 2004;62:399–407 7. Thoren H, Schaller B, Suominen AL, et al. Occurrence and severity of concomitant injuries in other areas than the face in children with mandibular and midfacial fractures. J Oral Maxillofac Surg. 2012;70:92–96
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8. Thaller SR, Mabourakh S. Pediatric mandibular fractures. Ann Plast Surg 1991;26:511–513 9. Eggensperger Wymann NM, Holzle A, Zachariou Z, et al. Pediatric craniofacial trauma. J Oral Maxillofac Surg 2008;66:58–64 10. Grisoni ER, Pillai SB, Volsko TA, et al. Pediatric airbag injuries: the Ohio experience. J Pediatr Surg 2000;35:160–162 11. Holland AJ, Broome C, Steinberg A, et al. Facial fractures in children. Pediatr Emerg Care 2001;17:157–160 12. Kim SH, Lee SH, Cho PD. Analysis of 809 facial bone fractures in a pediatric and adolescent population. Arch Plast Surg 2012;39:606–611 13. MacIsaac ZM, Berhane H, Cray JJr, et al. Nonfatal sport-related craniofacial fractures: characteristics, mechanisms, and demographic data in the pediatric population. Plast Reconstr Surg 2013; 131:1339–1347 14. Mericli AF, DeCesare GE, Zuckerbraun NS, et al. Pediatric craniofacial fractures due to violence: comparing violent and nonviolent mechanisms of injury. J Craniofac Surg 2011;22:1342–1347 15. Lee KF, Wagner LK, Lee YE, et al. The impact-absorbing effects of facial fractures in closed-head injuries. An analysis of 210 patients. J Neurosurg 1987;66:542–547 16. Keenan HT, Brundage SI, Thompson DC, et al. Does the face protect the brain? A case–control study of traumatic brain injury and facial fractures. Arch Surg 1999;134:14–17 17. Munante-Cardenas JL, Olate S, Asprino L, et al. Pattern and treatment of facial trauma in pediatric and adolescent patients. J Craniofac Surg 2011;22:1251–1255 18. Singh G, Mohammad S, Pal US, et al. Pediatric facial injuries: it’s management. Natl J Maxillofac Surg 2011;2:156–162 19. Qing-Bin Z, Zhao-Qiang Z, Dan C, et al. Epidemiology of maxillofacial injury in children under 15 years of age in southern China. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:436–441
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Examination of Life-Threatening Injuries in 431 Pediatric Facial Fractures at a Level 1 Trauma Center Ian C. Hoppe, MD, Anthony M. Kordahi, BA, Angie M. Paik, BA, Edward S. Lee, MD, and Mark S. Granick, MD Purpose: Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to examine a level 1 trauma center's experience with pediatric facial trauma resulting in fractures of the underlying skeleton with regards to epidemiology and concomitant injuries. Methods: A retrospective review of all facial fractures at a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Patients aged 18 years or younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. A significance value of 5% was used. Results: During this period, there were 3147 facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review. The mean age of patients was 14.2 years with a male predominance (77.9%). The mechanism of injury was assault in 108 (37.9%), motor vehicle accident in 68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%), sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%). The mean Glasgow Coma Scale (GCS) on arrival to the emergency department was 13.7. The most common fractures were those of the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma (7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage was present in 70 patients (24.6%). A skull fracture was present in 50 patients (17.5%). A long bone fracture was present in 36 patients (12.6%). A pelvic or thoracic fracture was present in 30 patients (10.5%). A cervical spine fracture was present in 10 patients (3.5%), and a lumbar spine fracture was present in 11 patients (3.9%). Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone From the Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ. Received February 17, 2014. Accepted for publication April 23, 2014. Address correspondence and reprint requests to Ian C. Hoppe, MD, Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers University, Ambulatory Care Center, Suite E1620, 140 Bergen St., Newark, NJ 07103; E-mail: [email protected]; [email protected] Presented at the 93rd Annual Meeting of the American Association of Plastic Surgery, April 5–8, Miami, FL. The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001055
were significantly associated with intracranial hemorrhage (P < 0.05). Fractures of the zygoma and orbit were significantly associated with cervical spine injury (P < 0.05). The mean GCS for patients with and without intracranial hemorrhages was 11.0 and 14.6, respectively (P < 0.05). The mean GCS for patients with and without cervical spine fractures was 11.2 and 13.8, respectively (P < 0.05). Conclusions: Pediatric facial fractures in our center are often caused by interpersonal violence and are frequently accompanied by other more life-threatening injuries. The distribution of fractures parallels previous literature. Midface fractures and a depressed GCS showed a strong correlation with intracranial hemorrhage and cervical spine fracture. A misdiagnosed cervical spine injury or intracranial hemorrhage has disastrous consequences. On the basis of this study, it is the authors’ recommendation that any patient sustaining a midface fracture with an abnormal GCS be evaluated for the aforementioned diagnoses. Key Words: Adolescent, child, facial bones/injuries, infant, humans, multiple trauma/epidemiology/etiology/mortality, skull fractures/epidemiology/etiology/mortality, violence/statistics & numerical data (J Craniofac Surg 2014;25: 1825–1828)
P
ediatric facial fractures are a fairly uncommon injury, representing less than 15% of all facial fractures,1 and present a challenge in management. The goal of management in all pediatric patients presenting with facial fractures is anatomic reduction and healing without complication. Before treatment of the facial fracture, it is essential to identify concomitant injuries, such as intracranial injury and spine injury, that may pose a threat to life or quality of life if not identified and appropriately treated. A large retrospective study found that almost 65% of pediatric patients with a facial fracture exhibited associated injury.2 A recent study concluded that a concussion was documented in almost one third of all pediatric patients presenting with a facial fracture, with an increased risk if the skull, orbit, or maxilla were involved.3 A related study determined that more than half of all pediatric patients diagnosed with a facial fracture also presented with a serious associated trauma of a vital organ system.4 In a survey of the National Trauma Data Bank, it was found that pediatric patients with facial fractures exhibited a higher injury severity, longer length of hospital stay, longer time spent in an intensive care setting, increased number of days on a ventilator, and increased hospital charges compared with those without facial fractures.5 Other studies show varying degrees of concomitant injuries.6–14 It has been suggested that the presence of facial fractures actually represents a protective mechanism for the brain to reduce intracranial injury due to the force absorbing characteristics of the facial skeleton.15 A multicenter study examined this protective mechanism in injured bicyclists and discovered that facial fractures are actually associated with an increased risk for brain injury.16 The
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1825
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
TABLE 1. Distribution of Fractures Observed
Number of patients Mean age, y Number of fractures Mandible fractures Orbital fractures Zygoma fractures Nasal fractures Frontal bone/sinus fractures Palate fractures Le Fort variant fractures
Male
Female
Total
222 14.7 328 118 92 26 48 21 5 18
63 12.7 103 21 33 9 21 15 2 2
285 14.2 431 139 125 35 69 36 7 20
reason for this is likely related to the high-energy mechanism often associated with fracture of the facial skeleton. The objective of this study is to examine associations between modes of presentation, fracture patterns, and concomitant life-threatening injuries in all facial fractures diagnosed via a radiographic study at a level 1 trauma center during a predetermined period.
FIGURE 1. Concomitant injuries.
METHODS
length of hospital stay, and life-threatening injuries such as cervical spine injury and intracranial hemorrhage. A significance value of 5% was used.
After institutional review board approval, all facial fractures occurring at a level 1 trauma center (University Hospital, Newark, NJ) between January 2000 and December 2012 were collected based on International Classification of Disease, Revision 9, codes. These results were further refined to include only those patients in the pediatric population (age of 18 years or younger). Patient demographics were collected as well as mechanism of injury, Glasgow Coma Scale (GCS) on presentation, fracture locations, concomitant injuries, and fracture management strategies. Comparisons were made between type of fracture, mechanism of injury, GCS on presentation,
During this period, there were 3147 patients with facial fractures treated at our institution, 353 of which were pediatric patients. Upon further review, 68 patients were excluded because of insufficient data for analysis, leaving 285 patients for review, with a total of 431 fractures. The mean age of patients was 14.2 years with a strong male predominance (78%). The mandible was the most common bone fractured followed by fractures of the orbit (Table 1). Figure 1
RESULTS
TABLE 2. Fracture Types and Concomitant Injuries Lumbar/ Cervical Spine No Cervical Odds Ratio Thoracic No Lumbar/Thoracic Fracture Spine Fracture (95% CI) Spine Fracture Spine Fracture Odds Ratio Mandible fracture Palatal fracture Zygoma fracture Orbital fracture Nasal fracture Frontal bone/sinus fracture Le Fort fracture
Mandible fracture Palatal fracture Zygoma fracture Orbital fracture Nasal fracture Frontal bone/sinus fracture Le Fort fracture
3 1 4 8 5 3
136 6 33 119 64 33
2 Skull Fracture 14 4 10 38 16 26 8
NS NS 4.9 (1.3–18.2)† 5.2 (1.1–25.1)† NS NS
3 2 2 8 6 3
18 NS 1 No Skull Odds Ratio Long Bone Fracture Fracture 125 0.33 (0.17–0.64)* 14 3 6.6 (1.4–30.2)* 4 27 NS 5 89 4.8 (2.4–9.4)* 19 53 NS 10 10 23.3 (10.1–53.9)* 5 12
3.4 (1.3–8.9)*
4
136 5 35 119 63 33
NS 11.9 (2.0–70.1)† NS NS 4.0 (1.2–13.6)† NS
ICH
No ICH
Odds Ratio
16 3 16 48 30 25
123 4 21 79 39 11
0.22 (0.12–0.41)* NS 2.7 (1.3–5.6) 3.8 (2.1–6.7)* 3.4 (1.9–6.1)* 10.3 (4.7–22.5)*
19 NS 8 12 NS No Long Bone Odds Ratio Abdominal/Pelvic/ No Abdominal/Pelvic/ Odds Ratio Fracture Thoracic Injury Thoracic Injury 125 NS 12 126 NS 3 10.3 (2.2–47.9)* 2 5 NS 32 NS 6 31 NS 108 NS 16 111 NS 59 NS 12 57 2.3 (1.0–5.1)† 31 NS 7 29 NS 16
NS
6
14
4.3 (1.5–12.2)*
*P < 0.01; †P < 0.05. CI, confidence interval; ICH, intracranial hemorrhage; NS, not significant.
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
FIGURE 2. Concomitant injuries and type of fracture.
depicts the concomitant injuries observed in our series. The relationship between type of fracture and concomitant injuries is presented in Table 2 and Figure 2. Loss of consciousness with injury was significantly associated with thoracic/lumbar spine fracture, intracranial hemorrhage, skull fracture, long bone fracture, abdominal/pelvic/thoracic injury, and death. Those patients intubated in the emergency department were significantly more likely to have a cervical spine fracture, thoracic/lumbar spine fracture, intracranial hemorrhage, skull fracture, and abdominal/pelvic/thoracic injury. In addition, intubation in the emergency department was significantly associated with death. The mean GCS for patients sustaining a cervical spine fracture was 11.2, compared with 13.8 for those without a cervical spine fracture (P < 0.05, Fig. 3). The mean GCS for patients with an intracranial hemorrhage was 11.0, compared with 14.6 for those without an intracranial hemorrhage (P < 0.01, Fig. 4). The mean age of patients experiencing an intracranial hemorrhage was significantly lower than those without (12.8 versus 14.7 years old, P < 0.01). The total hospital length of stay was increased for patients experiencing an intracranial hemorrhage (11.2 versus 3.7 days, P < 0.01).
DISCUSSION Facial fractures in the pediatric population are associated with severe concomitant injuries. Similar to previous studies, there was a strong male preponderance,12,17–19 and the mandible was
FIGURE 4. Intracranial hemorrhage and GCS.
the most common bone fractured.17–19 Interestingly, in female patients in our series, the orbit was the most common bone fractured. The most common etiology of fractures in our series was interpersonal violence overall, interpersonal violence in men, and motor vehicle accident in women. The preponderance of interpersonal violence likely reflects the population treated at our institution, notably urban, often gang-affiliated males. One hundred twenty-seven patients (44.6%) had some form of concomitant multisystem injury. These injuries are likely a reflection of the degree of force required to fracture the facial skeleton. In our study, mandible fractures seem to portend a protective mechanism from several serious injuries: intracranial hemorrhages and skull fractures. Fracture of the mandible may represent a force absorbing mechanism, thus sparing the cranium and its contents from injury. Palatal fractures were associated with an increased rate of thoracolumbar spine fractures, skull fractures, and long bone fractures. Palatal fractures usually are due to a strong force, and the association of long bone fractures and thoracolumbar spine fractures likely reflects this. Fractures of the zygoma were associated with cervical spine injuries and intracranial hemorrhage. As the force is transmitted in a more cranial direction on the facial skeleton, the cervical spine and intracranial contents may be more likely to be traumatized. Orbital fractures were associated with cervical spine fractures, intracranial hemorrhage, and skull fractures. This is similar to the patterns seen with fractures of the zygoma in that there is likely more force transmitted to the cervical spine and intracranial contents. Nasal bone fractures were associated with thoracolumbar spine fractures, intracranial hemorrhage, and abdominal/pelvic injuries. The reason for these associations is unclear and may represent an anomaly due to the prominent position of the nose. Frontal bone/sinus fractures were associated with intracranial hemorrhage and skull fractures. Again, the tremendous force required to fracture the frontal bone places the intracranial contents at greater risk. Le Fort variant fractures were associated with skull fractures and abdominal/pelvic injuries. Cervical spine fractures and intracranial hemorrhages were associated with a lower GCS score. This is a logical association considering the severity of these injuries.
CONCLUSIONS FIGURE 3. Cervical spine fracture and GCS.
A large proportion of facial fractures in the pediatric population are associated with severe concomitant injuries. In general, as fractures move in a more cranial direction, there is an increased risk
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1827
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
for intracranial injuries and cervical spine fractures. A lower GCS on presentation portends a higher association with cervical spine injury and intracranial hemorrhage. The failure to identify these associated and serious injuries could have disastrous consequences, and every practitioner involved in treating facial fractures must be aware of this risk.
REFERENCES 1. Vyas RM, Dickinson BP, Wasson KL, et al. Pediatric facial fractures: current national incidence, distribution, and health care resource use. J Craniofac Surg 2008;19:339–349 2. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of 1251 maxillofacial fractures in children and adolescents. Plast Reconstr Surg 2005;115:1500–1508 3. Afrooz PN, Grunwaldt LJ, Zanoun RR, et al. Pediatric facial fractures: occurrence of concussion and relation to fracture patterns. J Craniofac Surg 2012;23:1270–1273 4. Grunwaldt L, Smith DM, Zuckerbraun NS, et al. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg 2011;128:1263–1271 5. Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg 2008;207:710–716 6. Gassner R, Tuli T, Hachl O, et al. Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 2004;62:399–407 7. Thoren H, Schaller B, Suominen AL, et al. Occurrence and severity of concomitant injuries in other areas than the face in children with mandibular and midfacial fractures. J Oral Maxillofac Surg. 2012;70:92–96
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
