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Reprinted by permission of J Craniofac Surg. 2012; 23(5):1324-1328.

O RIGINAL A RTICLE

Incidence of Major and Minor Brain Injuries in Facial Fractures

Aaron L. Grant, MD,* Adrianna Ranger, MD, FRCSC, Þ G. Bryan Young, MD, FRCPC, þ and Arjang Yazdani, MD, FRCSC*

Conclusions: Facial fractures are often associated with brain in- jury. A high level of suspicion is warranted for minor traumatic brain injuries. Key Words: Traumatic brain injury, concussion, facial fracture, craniofacial, craniofacial surgery ( J Craniofac Surg 2012;23: 1324 Y 1328) P lastic surgeons are responsible for treating numerous facial fractures induced by blunt or penetrating trauma. The National Trauma Data Bank reports upward of 30,000 facial fractures per year in the United States and Puerto Rico. 1 Physicians responsible for diagnosing and treating patients with facial fractures should be aware of the incidence of associated injuries. The significant forces required to induce fractures of the facial skeleton may be trans- mitted through the head and the neck and can result in traumatic injury to the cervical spine, the spinal cord, and the brain. Unfor- tunately, there is a paucity of information on the incidence of minor brain injury in this patient population. A number of reviews have looked at brain injuries in patients with facial fractures, 1 Y 10 but these reviews fail to differentiate between major and minor brain injuries. Moreover, most studies were retrospective and based upon large trauma registries, which tend to preselect patients with mul- tiple trauma and capture only major brain injuries. The incidence of minor brain injury and concussion in this population has thus been unknown. There has been recent interest in sports-related concussions and their significant morbidity. Persistent headaches and decreased concentration, among other symptoms, can limit function and safe return to work or play. These patients may also be at risk for ‘‘second impact syndrome’’: life-threatening swelling of the brain that occurs when a second concussion occurs shortly after the first injury. 11,12 Our experience has shown that many patients with facial fractures complain of symptoms associated with minor brain injury and have gone unexamined. The primary objective of this study was to pro- spectively determine the incidence of major and minor brain injuries in 100 consecutive patients with facial fractures. Secondary objec- tives were to identify (1) when and where minor brain injuries are being diagnosed and (2) which types of injury place patients at greater risk. Ontario Health Sciences Research Ethics Board. All patients who presented with facial fractures to the Victoria Hospital site of the London Health Sciences Centre and who were referred to the prin- cipal investigator/craniofacial surgeon were included in the study. Victoria Hospital is a level I trauma center serving a catchment area of approximately 3 million. Data were collected for a 9-month period, from September 2010 to May 2011. Patients with facial fractures re- ferred to other surgeons at our institution were excluded. MATERIALS AND METHODS Approval was obtained from the University of Western

Background: Facial fractures can be associated with brain and cervical spine injuries because impact forces are transmitted through the head and neck. Although major brain injury is commonly rec- ognized in these patients, incidence of minor brain injury is not well- known, despite potential morbidity and mortality. Objectives: This prospective study aimed to determine the inci- dence of both major and minor brain injuries in 100 patients pre- senting to a craniofacial surgery service with facial fractures and to identify characteristics associated with brain injury. Methods: Data were collected for a 9-month period by a cranio- facial surgeon at a level I trauma center. A questionnaire and checklist were designed to capture information about major and minor brain injury in patients with facial fractures. Assessments were completed in the outpatient clinic, emergency department, hospital ward, or in- tensive care unit during the first patient encounters. Results: The average age of patients was 34 years; 79% were male. Time between injury and assessment ranged from less than a few hours to 4 months. Incidence of brain injury was 67% overall: 29% with major brain injury and 38% with minor injury. Major brain injury was commonly diagnosed early in the emergency department or intensive care unit. Conversely, minor brain injury tended to be diagnosed late in the clinic. Patient age, mechanism of injury, and type of facial fracture predicted brain injuries overall, but mechanism of injury was the sole predictor of minor brain injury.

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From the University of Western Ontario *Division of Plastic Surgery, † Department of Neurosurgery, and ‡ Department of Neurology, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada. Received April 5, 2012. Accepted for publication May 6, 2012. Address correspondence and reprint requests to Aaron L. Grant, MD, University of Western Ontario Division of Plastic Surgery, London Health Sciences Centre, Victoria Hospital, Room E2-214 800 Commissioners Rd East, London, Ontario, Canada N6A 4G5;

E-mail: aaron.grant@londonhospitals.ca The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31825e60ae

The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012

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