2017-18 HSC Section 3 Green Book

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

Facial Fractures and Minor Brain Injury

injury. This indicates that the diagnosis of minor brain injury is often being missed. Currently, there is much focus in the media and in sports on the importance of concussions and other minor head injuries. Often, athletes with such diagnoses are sidelined for weeks to months and observed very carefully until their symptoms have resolved and risks are lower. 17 The literature shows that the best management of minor brain injury is early recognition and prevention of additional injury. 19,20 Unfortunately, in our experience, patients with facial fractures not related to a sports injury are often overlooked, and their minor brain injury tends to be undertreated. Moreover, there appear to be limited resources and follow-up available for this population. Given the potential morbidity associated with minor brain injury, more research clearly is warranted in this area. Our study has limitations, foremost being the relatively small sample size that prohibited further subgroup analysis, such as an analysis to determine which nonfacial injuries might be predictive of brain injury. Moreover, on binary logistic regression to iden- tify predictors of minor brain injury, only mechanism of injury was predictive. A larger sample size, providing the optimum 20 to 25 subjects per independent variable instead of the 14 per variable (71 subjects/5 variables) to which we had access, might have identi- fied fracture type as a predictor as well because it was the last varia- ble excluded from the model ( P = 0.116). Another limitation relates to the generalizability of our results, given that all subjects were re- cruited from a single craniofacial surgery service. Clearly, replicating our results in other patient populations would be advantageous. A further limitation is that there is no widely accepted diag- nostic tool for identifying minor brain injury, and the definitions used in this study might be contested. We also had very incomplete data on such potential predictors as substance use and the use of protective devices such as seat belts and helmets. Substance use, in particular, might have affected neurocognitive assessments and been a confounder, especially in our analysis of age as a predictor of brain injury. This being said, most patients diagnosed with minor brain injury were assessed in clinic when not probably under the influence of any potentially intoxicating substance. Despite the limitations of our study, we feel confident saying that emergency physicians, trauma specialists, and craniofacial sur- geons and others involved in the care of patients with facial trauma should be aware not only of the high risk of cervical spine and major brain injury but also of the more insidious effects of minor brain in- jury, when assessing persons who have sustained a facial fracture. As is being increasingly recognized in high-contact professional sports such as boxing and hockey, failure to recognize such injuries can sometimes lead to catastrophic consequences such as sudden, unex- pected death in the young. 21 Y 24 Further research into the mechanism of force transduction, additional risk factors for minor brain injury, and long-term functional consequences clearly is needed. REFERENCES 1. Mulligan RP, Mahabir RC. The prevalence of cervical-spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg 2010;126:1647 Y 1651 2. Carlin CB, Ruff G, Mansfeld CP, et al. Facial fractures and related injuries: a ten-year retrospective analysis. J Craniomaxillofac Trauma 1998;4:44 Y 48 3. Conforti PJ, Haug RH, Likavec M. Management of closed head injury in the patient with maxillofacial trauma. J Oral Maxillofac Surg 1993;51:298 Y 303 4. Davidoff G, Jakubowski M, Thomas D, et al. The spectrum of closed-head injuries in facial trauma victims: incidence and impact. Ann Emerg Med 1988;17:6 Y 9 5. Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990;48:926 Y 932

(Chi-squared test = 50.17, df = 6, P G 0.001). For example, patients diagnosed with major brain injury were most often assessed in the intensive care unit, with the diagnosis of major brain injury virtually always having been made by another service before craniofacial consultation. Conversely, patients without major brain injury were most often seen in the craniofacial surgery clinic, and a significant number of these patients had evidence of undiagnosed minor brain injury. In fact, 8 of the 9 patients first assessed by the craniofacial team beyond 3 weeks had either a major (2/9) or minor (6/9) brain injury; 2 of these patients were diagnosed with a minor brain injury 4 months after craniofacial fracture (Fig. 5). By ordinal logistic regression, patient age group ( P = 0.016), mechanism of injury ( P = 0.002), and type of fracture ( P = 0.005) were found to be predictive of degree of brain injury, whereas patient sex ( P = 0.091) and other injuries ( P = 0.374) were excluded from the model. However, when major brain injuries were excluded in binary logistic regression assessing for predictors of minor brain injuries alone, only the mechanism of injury ( P = 0.028) remained. head and the neck during facial trauma is not well understood. However, there is good evidence to suggest that patients with facial fractures are at high risk for associated cervical spine injuries, with the incidence varying from 0% to 9.6%. 2 Y 9 The reported incidence of associated brain injury varies much more widely in the literature, from 5% to 89%. 1 Y 10 This may be because these studies are retro- spective in nature and fail to clearly define ‘‘brain injury’’ or dif- ferentiate between major and minor brain injuries. A recent 4-year retrospective review of the National Trauma Data Bank in the United States and Puerto Rico showed a prevalence of head injury that ranged from 29% to 80% in patients with isolated facial fractures, and from 66% to 89% in those with multiple fractures. 8 The concern with these studies is that large trauma registries tend to preselect for patients with multiple trauma and major brain injury. Unless spe- cific information was documented related to minor brain injury, the incidence may have been erroneously low. There are potential risks to the patient if the diagnosis of minor head injury is missed. Symptoms such as impaired memory and concentration and persistent headaches can often limit function and safe return to work. In addition, patients may be at risk for second impact syndrome. If the severity and consequences of concussion are not recognized, then patients may be given inadequate advice re- garding follow-up and return to sports, work, and other potentially dangerous or problematic activities. 11 It has been our experience that physicians currently maintain a high level of suspicion for cervical spine and major brain injuries in patients with facial trauma, and there is often a low threshold to use computed tomography or MRI to aid with diagnosis. Unfortu- nately, diagnostic imaging has not been useful in the diagnosis of minor traumatic brain injury, and there is no widely accepted diag- nostic tool available. 18 According to Bellner et al, 15 the most commonly used criteria for diagnosing minor brain injury are (1) loss of consciousness, (2) pretraumatic and posttraumatic amnesia, and (3) impaired level of consciousness, as defined by a GCS score of 13 or 14. 3 These key components may be overlooked by a physician who is focusing on facial or other major trauma. In the current prospective study, 67% of patients with facial fractures had some form of brain injury. Twenty-nine patients were diagnosed with major brain injury, often early in the course of their treatment, or even before craniofacial consultation. However, a further 38 patients had evidence of minor brain injury. Most of these presented to the outpatient clinic 3 days to 3 weeks postinjury, and most were not yet diagnosed with any brain DISCUSSION The mechanism of force transmission that occurs through the

* 2012 Mutaz B. Habal, MD

97