2017-18 HSC Section 3 Green Book

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

Facial Fractures and Minor Brain Injury

Major brain injury was defined as an initial GCS score of less than 12 or a documented intracranial injury on computed tomog- raphy or magnetic resonance imaging (MRI). Minor brain injury was defined as GCS score of 13 or 14, any documented loss of con- sciousness, or perievent amnesia. These definitions were selected based on a review of relevant literature. 15 Y 17 Time from the traumatic event to the first clinical encounter was classified as follows: less than 72 hours, 3 days to 3 weeks, or greater than 3 weeks. As well, patient location at the time of the initial encounter (clinic, emergency department, ward, or intensive care unit) was documented and analyzed. Data analysis was primarily descriptive but included com- parisons of means (eg, mean age in those without brain injury versus minor brain injury versus major brain injury) using analysis of variance with Tukey test post hoc and of percentages using Pearson Chi-squared analysis. To identify predictors of all brain injuries and minor brain injury, 2 separate regression models were constructed; the first including and the second excluding those with major brain injuries, entering as independent variables the patient age, sex, and variables identified as statistically associated with degree of brain injury on bivariate testing. Because the first model had 3 options for the dependent variable (no brain injury, minor brain injury, and major brain injury), ordinal rather than binary logistic regression was per- formed. All inferential analyses were 2-tailed, and P G 0.05 was set as the threshold for statistical significance. RESULTS Most patients (79%) were male (Table 1). Patient age ranged widely from 6 to 88 years old, peaking in the teens and twenties, and with 60% of the sample between the ages of 10 and 39 (Fig. 1). The average age was 34.1 years.

TABLE 1. Demographics of 100 Consecutive Patients With Facial Fractures

Factors

Age

Mean, y

34.1

Median, y Maximum Minimum

41

6

88

Sex, % Male

79 21

Female

Location of first assessment, % Surgery clinic

51 17 22 10

Emergency department

Intensive care unit

Hospital ward

Time to initial assessment, d Mean delay

10

Minimum delay Maximum delay

0

120

The questionnaire and clinical checklist were designed in conjunction with a senior neurologist at our facility. The purpose of the questionnaire was to standardize the patient assessment and to focus on specific issues related to major or minor brain injury. The mechanism of injury, presence of loss of consciousness or amnesia, and Glasgow Coma Scale (GCS) score were included in the ques- tionnaire, along with elements of the Standardized Assessment of Concussion. The Standardized Assessment of Concussion was designed to be a standardized means of documenting the presence and se- verity of neurocognitive impairment associated with brain injury and concussion. 13 It ‘‘utilizes the domains of function most sensitive to the effects of minor brain injury.’’ 13 This tool was not designed (or used) as a device for diagnosing mild brain injury, but it provides objective data on mental status abnormalities. 13,14 The questionnaire was completed, along with a standard clinical assessment related to the facial fracture, at the first clinical encounter by the attending craniofacial surgeon or a member of his medical team trained in the assessment; in either instance, all responses were reviewed by the attending surgeon. Patients were assessed in multiple locations, including the outpatient clinic, the emergency department, the hospital ward, and the intensive care unit. Data recorded included demographic information and the mechanism of injury, use of protective devices, GCS score, sub- stance use, loss of consciousness, perievent amnesia, seizures, need for intubation, preexisting mood disorder, symptoms of neurocogni- tive impairment, and any neurosurgical intervention. Facial fractures were classified according to fracture pattern.

TABLE 2. Mechanism of Injury, Facial Fracture Pattern, and Associated Injuries

No. Patients

Mechanism of injury Assault

33 31 21 10

Fall

MVA

Sports related Blunt trauma

4 1

Crush

Fracture pattern Nasal

19 17 13 13 11

Mandibular

Zygomaticomaxillary

Orbital floor

Combined

Nasoorbitalethmoid

8 8 4 3 3 1

Frontal sinus

Zygomatic arch

Le Fort II Le Fort III

Maxillary sinus

Associated injuries Extremity

11

Spine

4 3 2 2

Thoracic

Skull fracture

Multiple injuries

FIGURE 1. Ages of patients presenting with facial fractures, by decade.

* 2012 Mutaz B. Habal, MD

95