2017-18 HSC Section 3 Green Book

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

Grant et al

FIGURE 2. Degree of brain injury by patient age.

FIGURE 4. Brain injuries by facial fracture type.

Roughly half (51%) of the patients were first seen in the outpatient clinic, with the remainder divided between the inten- sive care unit, emergency department, and hospital ward (Table 1). Seventy-two percent were seen by the craniofacial surgery team within the first week of their injury V one third within 24 hours V but the delay between injury and the first assessment was as long as 4 months. The most common mechanism of injury was assault (33%), followed by falls (31%), and motor vehicle accidents (MVAs; 21%) (Table 2). Together, these 3 mechanisms accounted for 85% of the sample. The most common fracture pattern was nasal fracture, fol- lowed by mandibular fracture, but 11 different fracture types were identified, including multiple facial fractures. Two thirds of the patients had an associated major (29%) or minor (38%) brain injury, with 35% having documented findings on MRI, including intra- cranial hemorrhage and visible contusions. Twenty-two percent had major injuries besides facial fracture, most commonly extremity fractures. Skull fractures were diagnosed in 2 patients. Six patients, having among them combined, Le Fort III, and mandibular fractures, required some sort of neurosurgical intervention. All age groups (by decade) were more likely to experience a brain injury than not, but this was particularly marked among those younger than 10 years, those 30 to 49 years old, and especially those older than 70 years; all 6 patients older than 70 years had major brain injuries (Fig. 2). Teens and those in their twenties were relatively protected from brain injury. There was a statistically significant association between patient age and brain injury (Chi-squared test = 33.56, df = 14, P = 0.002).

Among the various mechanisms of injury, patients who had MVAwere most likely to have some sort of brain injury; all 21 were categorized as such, and most were major brain injuries (Fig. 3). Those injured in falls were the most likely group to sustain a minor brain injury. No patient who sustained a facial fracture by some mechanism other than MVA, fall, or assault, had major brain injury, but minor brain injuries were documented in more than 1 in 4 in this group, among which sports-related injuries were the most com- mon. There was a strong statistically significant association between the mechanism of injury and both the presence (Chi-squared test = 26.07, df = 5, P G 0.001) and degree (Chi-squared test = 33.14, df = 10, P G 0.001) of brain injury. There was also a strong association between the type of fa- cial fracture sustained and the risk of brain injury (Chi-squared test = 39.80, df = 20, P = 0.005), with all 6 patients with Le Fort fracture, and 7 (77%) of 11 patients with combined fractures, presenting with major brain injuries, versus only 1 of 19 with a nasal fracture, and zero of 5 with fractures of either the maxillary sinus or the zygo- matic arch having major brain injuries (Fig. 4). The presence of some other nonfacial injury (eg, extremity fracture) approached but did not achieve statistical significance for an association with degree of brain injury (Chi-squared test = 3.99, df = 1, P = 0.052). Time from injury to the first clinical encounter was shortest for those diagnosed with a major brain injury (69% assessed within 72 h), whereas 60% of patients with a minor brain injury were assessed beyond 3 days (Chi-squared test = 11.83, df = 4, P = 0.018). There was also a statistically significant association between where the craniofacial assessment took place and the degree of brain injury

FIGURE 3. Minor and major brain injuries by nature of injury.

FIGURE 5. Brain injuries presenting over time after facial fractures.

* 2012 Mutaz B. Habal, MD

96