Maxillofacial and concomitant serious injuries: An eight-year single center experience.

PURPOSE: Maxillofacial injuries are frequently associated with multiple trauma and can determine functional and aesthetic bad outcomes. The severity of maxillofacial injuries may be considerable and can divert clinicians' attention from other concomitant injuries which is less evident but potentially life-threatening. The aim of this study was to find out the concomitant injuries in patients referred to the Emergency Department (ED) of the University Hospital of Messina (North-East Sicily, Italy) for maxillofacial traumas.
METHODS: We retrospectively evaluated data of 240,833 patients admitted at the ED of the University Hospital of Messina from January 2008 to December 2015 because of maxillofacial injuries leading to hospitalization and surgical treatment. Patients who primarily received treatment care at different institutions, pediatric trauma patients and adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were excluded. Finally we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma.
RESULTS: The most frequent cause of maxillofacial trauma was road accidents (319 patients, 71.4%), among which motorcycle ones were prevalent. The maxillofacial injured who presented major lesions were 98 patients and minor lesions occurred in 349 patients; 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries (χ2 = 557.2, p < 0.0001). Five concomitant neglected lesions were found to be associated with severe maxillofacial traumas (χ2 = 17.13, p < 0.0001 vs minor lesions). All of the neglected lesions occurred in paucisymptomatic patients who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms.
CONCLUSION: Among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. We recommend the routine use of whole body CT scan, when the maxillofacial injuries appear prevalent, mainly in patients affected by maxillofacial major lesions.

Introduction

In western countries, trauma is the first leading cause of death before the 4th decade of life, as well as the third major cause in patients over 40 years old, being preceded only by cardiovascular diseases and neoplasms.1, 2 Maxillofacial injuries are frequently associated with multiple trauma, and may cause functional and aesthetic bad outcomes, because of the frequency of permanent deficits and potentially disfiguring scars that can dramatically affect patient's quality of life. These traumas are often complicated by traumatic brain injuries and/or serious facial substance loss. Fractures involving the middle and upper third of the face are more frequent compared to mandibular ones. The former are classified according to Le Fort (in type I or horizontal maxillary fracture, type II or pyramidal fracture, and type III or craniofacial disjunction), whereas the latter can be isolated or associated with lesions of the inferior alveolar ridge.4, 5, 6

In the worldwide literature, epidemiological data vary mainly according to different geographical areas, e.g. hospitals located in mountain areas of Central-Northern Europe and India report a broader series of cases.7, 8, 9 Diagnostic accuracy together with type and timing of treatments significantly affect the clinical evolution of such traumas, allowing to improve functional results and limit cosmetic damages. Interestingly, the severity of maxillofacial injuries may be considerable, and can divert clinicians' attention from other concomitant injuries that are less evident but potentially life-threatening.10, 11, 12, 13 The aim of this study was to find out the concomitant injuries in patients admitted for maxillofacial traumas to the Emergency Department (ED) of the University Hospital Messina (North-East Sicily, Italy).

Materials and methods

From January 2008 to December 2015, the data of 240,833 patients admitted at our ED because of maxillofacial injuries leading to hospitalization and surgical treatment were retrospectively evaluated. In our University Hospital, all index admission records, investigations and follow-up records are traceable from a single unique identification number, greatly facilitating research activities on the database.

Patients who primarily received treatment care at different institutions were not included. Pediatric trauma patients were excluded. Moreover, adult patients who were transferred in accordance with pre-existing agreements in case of paucity of beds were not included in this study. Applying the above criteria, we included 447 (0.2%) patients over the 8 years. Data were evaluated with emphasis on epidemiology (age, gender, mechanism of trauma), primary survey and abnormalities and pattern of trauma. Each patient record was individually reviewed. Follow-up information of patients was as much retrieved as available in records. Patients lost to follow-up were not contacted by telephone/by post due to logistic reasons.

All patients recruited were classified distinguishing the maxillofacial injuries, isolated or multiple, in major (e.g.: Le Fort type I, II, III and mandibular fractures) or minor lesions (e.g. involving orbital floor, zygomatic, maxillary sinus and antral wall, nasal and alveolar ridge). Mandibular fractures were considered separately when involving the anterior (symphyseal and parasymphyseal), middle (body) and posterior (condylar process, head, angle and ramus) portion. When fractures were multiple, the most severe one was considered in order to categorize the patient.

All patients were assessed at the ED, according to the Advanced Trauma Life Support guidelines and diagnosed by means of a multislice computed tomography (CT) of brain and face. CT examination was extended to the spine, neck, chest and abdomen (CT was injected for the study of chest and abdomen) when multiple simultaneous injuries occurred and/or integrated with targeted X-ray of selected skeletal region, routine laboratory tests and ultrasound scan. Furthermore, American Society of Anaesthesiologists' (ASA) classification of Physical Health, a routinely used system to predict the perioperative morbidity and mortality, was assessed in all the surgical patients as grading system for preoperative health. The distribution of ASA score was ASA1 (n = 86), ASA2 (n = 255), ASA3 (n = 91), ASA4 (n = 11) and ASA5 (n = 4). For all the 447 patients, 328 (73.4%) were directly admitted to the Maxillofacial Surgery Unit and underwent bone synthesis by use of screws and plates and/or autologous bone grafts; while the remaining 119 patients, who underwent a delayed maxillofacial treatment for concomitant serious injuries, were hospitalized and previously managed (115/119, 96.6%) in other wards, e.g. 49 in neurosurgery (for severe brain and spine injuries), 31 in thoracic (for sever chest trauma with or without pneumothorax), 27 orthopedic (for complex fractures), 9 in general surgery (for hemoperitoneum, spleen and liver injuries), and 3 intensive care unit (for coma or severe respiratory distress), respectively.

Results were expressed as mean ± standard deviation (SD). The chi-square (χ2) test was used to analyze categorical data. The level for statistical significance was set at p < 0.05. Statistical analysis was performed using SPSS version 21.

Results

Among the 447 patients, 383 (85.7%) were males aged (34.6 ± 14.1) years, and 64 (14.3%) were females aged (47.4 ± 19.6) years (p < 0.001 vs male group). The most frequent cause of maxillofacial trauma was road accidents, and among these, motorcycle ones were prevalent. Other causes and general data of patients are shown in Table 1.

Table 1

General data of the 447 patients with maxillofacial injuries.

Characteristics	n (%)
Gender
Male	383 (85.7)
Female	64 (14.3)
Age: mean ± SD, range (years)
Male	34.6 ± 14.1, 16–78
Female	47.4 ± 19.6, 18–89
Injury mechanism
Road accidents	319 (71.4)
Accidental falls	87 (19.5)
Workplace injuries	23 (5.1)
Violencea	18 (4.0)
Injury type
Associated lesion	358 (80.1)
Isolated lesion	89 (19.9)
Major lesions	98 (21.9)
Le Fort type I	2 (0.4)
Mandibular fractures	96 (21.5)
Minor lesions	349 (78.1)
Nasal fractures	117 (26.2)
Orbital floor fractures	108 (24.2)
Maxillary fractures	57 (12.7)
Zygomatic fractures	54 (12.1)
Alveolar fractures	12 (2.7)
Facial crash	1 (0.2)
Maxillofacial surgery	443 (99.1)
Neglected concomitant lesions	5 (1.1)
Splenic fractures	3 (0.7)
Kidney injury	1 (0.2)
Pelvic fracture	1 (0.2)

Distribution of gender showed significant difference (p < 0.001). Differences between proportions of patients undergoing immediate or delayed maxillofacial surgery based on major or minor lesions reached statistical significance (χ2 = 557.2, p < 0.0001); moreover, proportions of concomitant lesions were significantly different between major and minor lesions groups (χ2 = 17.13, p < 0.0001).

One patient was the victim of a gunshot wound. Four patients died before maxillofacial surgical treatment.

Lesions were associated in 358 (80.1%) cases, more frequently with traumatic brain injury or polytrauma, or isolated in 89 (19.9%) cases. In this study, maxillofacial injured patients presented major lesions were 98 patients (Fig. 1A–E) and minor ones were 349 patients. In detail, the former group included 2 Le Fort type I and 96 mandibular fractures (45 involving the posterior segment, 32 the anterior, and 19 the middle, respectively), whereas the latter included 117 nasal, 108 orbital floor, 57 maxillary, 54 zygomatic (Fig. 2), and 12 alveolar fractures. In only one case a “facial crash” was observed; this condition is a well-known lesion characterized by the simultaneous involvement of almost all facial bones (Table 1). In 66 (14.8%) patients a cutaneous involvement (i.e. wounds, hematoma, lacerations and abrasion) occurred and a careful debridement was necessary; nevertheless, aesthetic results did not worsen. Twelve patients required an orotracheal intubation at ED for acute obstruction or damage of the upper airways. Overall, no early mortality (within 48 h) was observed; however, four patients (0.9%) died before maxillofacial surgical treatment.

Fig. 1

Complex and multiple mandibular fractures in a 33-year old Italian male, victim of a motorcycle accident. A and B: Bilateral avulsion of condylar processes, axial and coronal views; C, D and E: Displaced symphyseal fracture involving the alveolar ridge, 3D reconstruction, axial and sagittal views. F: The same patient had Grade IV laceration of the spleen (coronal view) requiring urgent splenectomy, which was neglected.

Fig. 2

Right zygomaticomaxillary complex fracture in a 39-year old Belarusian female, victim of domestic violence.

Overall, 443 (99.1%) patients underwent maxillofacial surgery, immediate or delayed depending on the severity of concomitant injuries: considering the proportion of patients classified in major and minor lesions, a significant statistical difference was found (χ2 = 557.2, p < 0.0001).

In detail, 5 concomitant lesions that associated to severe maxillofacial traumas were nearly neglected, including 3 splenic fractures (Fig. 1F), 1 kidney injury and 1 pelvic fracture with active bleeding (χ2 = 17.13, p < 0.0001 vs minor lesions); all cases occurred in paucisymptomatic patients, who showed painless abdomen, no hemodynamic instability, no signs of hematoma of anterior and posterior abdominal wall or other suspicious clinical signs and symptoms.

Discussion

Maxillofacial injuries may occur isolated or, more frequently, associated with simultaneous injuries elsewhere. The missed concomitant lesions are reported in the literature up to 22%.15, 16 When a maxillofacial trauma occurred in a multiple injured patient, obviously the facial and brain CT was extended to spine, neck, chest and abdomen, which allows a more precise diagnosis of potential life-threatening underestimated organ lesions.

In our experience, among the patients admitted firstly in other surgical wards different from the Maxillofacial Surgery Unit, diagnosis was more difficult, especially for blunt abdominal traumas, in which patients showed only vague and nonspecific symptoms concealing serious and life-threatening injuries. Furthermore, we observed a penetrating neck wound involving the contralateral orbital floor, favorably managed by a multidisciplinary approach.

In the present study, it was found that the incidence was significantly higher in males (86%) as compared to females (14%). This is coincidence with Sohns et al's study on 784 patients, which noticed that the incidence of facial fractures was 64% in males and 36% in females. It has been shown in previous studies that in developing countries, the most common mode of injury is road traffic accidents.19, 20 In developing nations, the bad maintenance of roads, poor driving skills, lack of enforcement of traffic rules and regulations such as the use of seat belts and helmets are probable reasons responsible for extensive maxillofacial fractures. In developed nations, assault is the most common cause. In more recent literature, the most frequently reported cause of maxillofacial trauma is road accident, concerning patients aged between 20 and 40 years, and males.22, 23, 24, 25, 26 Males present a greater risk of involvement due to the daily-life activities, e.g. driving car, heavy work conditions, sports with physical contact.27, 28, 29, 30 In particular, the leading cause of trauma in our series was represented by motorcycle accidents. Therefore, the reduction of such traumatic events can be obtained only by an insistent traffic education program and the routine use of craniofacial protection.31, 32 Moreover, in our opinion, the highest frequency of facial fractures in the 3rd–4th decades of life is related to the most intense phase of life.

The particularity of the maxillofacial trauma, which is often burdened by functional deficits and disabling aesthetic sequelae, leads to underline the need for a greater social commitment in order to achieve, in the next decades, a reduction of the incidence of this disease: a particularly complex and expensive disease for the National Health System. On the other hand, medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focusing their attention on reducing the incidence of these injuries. To avoid missed injuries, re-evaluating patients 24 h after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests is necessary.

Missed injuries can be minor, requiring only conservative treatment, or can be clinically significant, requiring a prompt recognition. Few studies have defined “clinically significant” post hoc, with most studies not providing any definition. Even if the incidence of clinically significant missed injuries is unknown, they are more likely to lead to prolonged morbidity or mortality. Although mortality as a result of missed injuries is rare, a prospective study indicated that approximately 1% of the cohort required a surgical intervention for injuries detected after the hospital discharge. Injuries are often neglected during the primary and secondary surveys in trauma patients; namely, studies have suggested that a formal tertiary survey protocol lowers the number of missed injuries. Current international guidelines consider tertiary surveys, but do not mandate or formalise their implementation.

In our study, 99% of patients needed maxillofacial surgery, immediate or delayed depending on serious concomitant injuries. This percentage is significant if compared with proportion of patients with major/minor lesions. Interestingly, the number of concomitant lesions associated to severe maxillofacial traumas that was nearly neglected was 5, reaching a significant difference with respect to minor lesions: all cases occurred in paucisymptomatic and unsuspected patients. Based on these findings, we recommend the routine use of whole body CT scan when the maxillofacial injury appear prevalent, mainly in patients affected by maxillofacial major lesions.