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Plastic, Hand & Faciomaxillary Surgery Unit, The Alfred Hospital, Melbourne, VIC, Australia
Victorian Adult Burns Service and School of Public Health and Preventive Medicine, Monash
University, The Alfred Hospital, Melbourne, VIC, Australia
c
Translational Public Health Unit, Stroke and Ageing Research Centre, Southern Clinical School,
Monash University, Melbourne, VIC, Australia
b
KEYWORDS
Maxillofacial
fractures;
Epidemiology;
Management;
Complications;
Risk factors;
Australia
Summary Background and aim: Trauma is a leading cause of morbidity and mortality, with a
considerable proportion of trauma patients sustaining concomitant maxillofacial (MF) injuries.
The purpose of this study was to review and analyse the epidemiology, management and complications of patients with MF fractures managed by the Faciomaxillary Surgery Unit at the
Alfred Trauma Hospital in Melbourne.
The secondary objective of the study was to determine the risk factors for developing postoperative complications.
Methods: A retrospective records review was performed for 980 patients who were treated for
MF fracture(s) from January 2009 to December 2011. Descriptive statistics were used and independent demographic and injury-related factors assessed for association with outcome using
multivariate logistic regression.
Results: A total of 1949 MF fractures from 980 patients were treated over the study period.
Males (n Z 785, 80.10%) and patients aged 15e24 years (n Z 541, 55.20%) were the most
frequently affected (mean age (standard deviation, SD) 27.69 (19.22)). The most common aetiology was assault (n Z 293, 29.90%). The majority presented with fractures of the orbit
(n Z 359, 36.33%). In total, 803 fractures from 500 patients were treated operatively. Mandibular fractures were most commonly treated surgically (79.82%). Postoperative complications
occurred in 69 of 500 patients treated surgically (13.8%), most commonly due to infected
metalware (n Z 16, 3.20%). Multiple fractures were associated with a higher probability of
* Corresponding author. Faciomaxillary Surgery Unit, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia. Tel.: 61
03 9076 3626; fax: 61 03 9347 8799.
E-mail address: D.Morgan@alfred.org.au (D.J. Morgan).
1748-6815/$ - see front matter 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.10.022
184
Methods
A retrospective review of prospectively collected data was
conducted for 980 patients with MF fractures managed by
the Faciomaxillary Surgery Unit at the Alfred Hospital
(Melbourne, VIC, Australia) from January 2009 to December
2011. Patients with MF fractures were identified using the
units audit database (created in January 2009, Figure 1)
and were confirmed with hospital records. Those patients
with isolated dentoalveolar trauma were excluded, as they
were treated by dentists.
Demographic variables extracted from the medical records included age, gender and injury variables (Table 1).
Motor vehicle accidents (MVAs) included motorbike injuries,
and sporting injuries included cycling. The group classified
as other included events such as explosions, home or work
accidents and medical complications or conditions. For the
regression analyses, pedestrians were included in the group
other due to small subgroup numbers. The frequency and
pattern of facial fractures, their management and associated postoperative complications were also recorded. The
psychological complications of MF trauma were not studied
(e.g., posttraumatic stress disorder).
Anatomically, MF fractures were subdivided by bony
regions as shown in Table 2. All the paired bones (zygoma,
orbit, nasoorbitoethmoid (NOE) complex, hemimaxilla,
hemimandible and condyle) were considered to be single
unilateral units. Fractures of the zygoma, orbit, NOE complex and maxilla were not mutually exclusive. With regard
to the mandible, intracapsular fractures were defined as
Results
A total of 980 patients sustained 1949 MF fractures over the
3-year study period (n Z 197, 414 and 369, respectively).
Demographics of MF fractures
Males were affected more than females with a ratio of
approximately 4:1 (n Z 785, 80.10% vs. n Z 195, 19.90%)
and the mean (standard deviation, SD) age was 27.69
(19.22) (range 18e99). In both genders, the 15e24-yearold age group had the highest frequency of MF fractures
(n Z 541, 55.20%). There was a progressive decline in
the frequency of MF fractures with increasing age
(Figure 2).
Mechanism of injury
Data variables in reference to mechanism of injury are
summarised in Table 1. Assault was the most common
mechanism of injury (n Z 293, 29.90%), followed by MVA
(n Z 234, 23.88%). In the 15e44-year-old age group, the
most common mechanism of injury was assault followed by
MVA. However, in the 45e84-year-old age group, the most
common cause was falls followed by MVA (Figure 2). Assault
was the most frequent cause in males (n Z 267, 34.01%)
and falls was the most common in females (n Z 77,
39.49%). A history of preceding alcohol use was present in
142 patients (14.49%), of whom 70 were assault cases.
After other injures, patients who suffered sporting injuries most commonly sustained an isolated fracture
(n Z 91, 60.26%) and they were most likely to undergo
185
Figure 1
Management
Approximately half of the patients (n Z 500, 51.02%), with
a total of 803 fractures, were treated surgically. As many as
387 patients (39.49%) underwent an ORIF.
When analysing per bony injury, mandibular fractures had
the greatest proportion that were treated surgically (178 out
of 223 fractures, 79.82%) (Table 2). The majority of extracapsular condylar fractures underwent an intervention (22 and
16 out of a total of 62 extracapsular condylar fractures underwent an ORIF and placement of arch bars, respectively),
whilst most intracapsular condylar fractures were managed
conservatively (three and nine out of a total of 37 fractures
underwent an ORIF and placement of arch bars, respectively).
Most orbital wall fractures were managed conservatively
(294 of 403 fractures, 72.95%) and approximately half of
the maxillary fractures underwent an ORIF (208 fractures,
50.36%).
Complications
A total of 71 postoperative complications occurred in 69 out of
500 patients treated operatively (13.80%). The most common
complication was infected metalware (n Z 16 out of 500 patients, 3.20%), followed by malocclusion (n Z 14, 2.80%),
malunion (n Z 8, 1.60%), plate exposure (n Z 8, 1.60%),
palpable plate (n Z 7, 1.40%), wound infection (n Z 5, 1.00%),
abnormal facial contour requiring recontouring (n Z 4, 0.08%)
and nonunion (n Z 1, 0.02%). Enophthalmos occurred in eight
186
Table 1
MVA
Fall
Pedestrian
Other
Total
17
7
3
3
5
5
0
0
21
14
10
6
1
1
0
0
541
146
104
81
43
44
23
1
Age
15e24
200 (68.26)
151 (64.53)
25e34
49 (16.72)
29 (12.39)
35e44
29 (9.90)
25 (10.68)
45e54
12 (4.10)
15 (6.41)
55e64
2 (0.68)
8 (3.42)
65e74
0 (0.00)
4 (1.71)
75e84
0 (0.00)
2 (0.85)
85
1 (0.34)
0 (0.00)
Gender
Male
267 (91.13)
187 (79.91)
Female
26 (8.87)
47 (20.09)
ETOH
Yes
70 (23.89)
21 (8.97)
No
223 (76.11)
213 (91.03)
Isolated fracture
Yes
160 (54.61)
92 (39.32)
No
132 (45.05)
142 (60.68)
Surgery
Yes
170 (58.02)
131 (55.98)
No
123 (41.98)
103 (44.02)
ORIFa
Yes
121 (41.30)
118 (50.43)
No
172 (58.70)
116 (49.57)
Number of fractures per patient
1
160 (54.61)
92 (39.32)
2
79 (26.96)
67 (28.63)
3
35 (11.95)
30 (12.82)
4
19 (6.48)
45 (19.23)
Total
293 (29.90)
234 (23.88)
a
56
20
16
36
26
34
21
0
(26.79)
(12.39)
(7.66)
(17.22)
(12.44)
(16.27)
(10.05)
(0.00)
96
27
18
9
1
0
0
0
(63.58)
(17.88)
(11.92)
(5.96)
(0.66)
(0.00)
(0.00)
(0.00)
(42.50)
(17.50)
(7.50)
(7.50)
(12.50)
(12.50)
(0.00)
(0.00)
(39.62)
(26.42)
(18.87)
(11.32)
(1.89)
(1.89)
(0.00)
(0.00)
(55.20)
(14.90)
(10.31)
(8.30)
(4.39)
(4.49)
(2.35)
(0.10)
132 (63.16)
77 (36.84)
130 (86.09)
21 (13.91)
27 (67.50)
13 (32.50)
42 (79.25)
11 (20.75)
785 (80.10)
195 (19.90)
41 (19.62)
168 (80.38)
7 (4.64)
144 (95.36)
3 (7.50)
37 (92.50)
0 (0.00)
57 (100.00)
142 (14.49)
838 (85.51)
113 (54.07)
96 (45.93)
91 (60.26)
60 (39.74)
19 (47.50)
21 (52.50)
34 (64.15)
19 (35.85)
509 (51.94)
471 (48.06)
68 (32.54)
141 (67.46)
90 (59.60)
61 (40.40)
13 (32.50)
27 (67.50)
28 (52.83)
25 (47.17)
500 (51.02)
480 (48.98)
47 (22.49)
162 (77.51)
61 (40.40)
90 (59.60)
13 (32.50)
27 (67.50)
27 (50.94)
26 (49.06)
387 (39.49)
593 (60.51)
19
11
4
6
40
34
7
5
7
53
509
239
116
116
980
113
42
33
21
209
(54.07)
(20.10)
(15.79)
(10.05)
(21.33)
91
33
9
18
151
(60.26)
(21.85)
(5.96)
(11.92)
(15.41)
(47.50)
(27.50)
(10.00)
(15.00)
(4.08)
(64.15)
(13.21)
(9.43)
(13.21)
(5.41)
(51.94)
(24.39)
(11.84)
(11.84)
(100.00)
187
N (%)
40
15
2
1
11
5
8
2
84
(47.62)
(17.86)
(2.38)
(1.19)
(13.10)
(5.95)
(9.52)
(2.38)
(100.00)
39
2
33
3
2
79
(49.37)
(2.53)
(41.77)
(3.80)
(2.53)
(100.00)
294
48
21
12
28
403
(72.95)
(11.91)
(5.21)
(2.98)
(6.95)
(100.00)
205
205
1
2
413
(49.64)
(49.64)
(0.24)
(0.48)
(100.00)
139
54
135
14
342
(40.64)
(15.79)
(39.47)
(4.09)
(100.00)
156
122
3
25
306
(50.98)
(39.87)
(0.98)
(8.17)
(100.00)
8
16
2
19
48
51
46
17
16
223
(3.59)
(7.17)
(0.90)
(8.52)
(21.52)
(22.87)
(20.63)
(7.62)
(7.17)
(100.00)
25 (25.25)
3 (3.03)
9 (9.09)
Table 2 (continued )
Fracture
N (%)
Cons Mx e extracapsular
ORIF e extracapsular
Arch bars e extracapsular
Total
Total
24
22
16
99
1949
(24.24)
(22.22)
(16.16)
(100.00)
(100.00)
Discussion
To the best of our knowledge, this is one of only a few
studies investigating the risk factors for requiring surgical
intervention and developing postoperative complications in
a large cohort of patients with MF fractures.
The results of this study support previously published
data, that young males in the 20s are the most commonly
affected patient group.2,9,10 The majority of the patients
sustained a fracture in the region of the orbit, consistent
with an earlier study illustrating that patients with severe
trauma (Injury Severity Score >12) were more likely to have
an orbital floor fracture.11 However, when analysing fractures individually, the most common site was the maxilla,
consistent with earlier local3 and international studies.5,12
The maxilla occupies a relatively larger exposed area in
the facial skeleton and it is most commonly injured bilaterally in high-velocity, blunt traumas. Other reported
common MF fracture sites include the zygoma,12 nasal
bones9,13 and the mandible.9,10,14
MVAs, assaults and falls are the leading causes of MF
fractures worldwide, with their relative frequencies
differing both within and between countries, depending
upon the regions socioeconomic, cultural and environmental factors.6,8,10,13e15 Assault was the most common
aetiological factor in this series (29.90%), in concordance
with numerous international and local studies.9,13,16,17
Interestingly, in 2006 a previous Melbourne study demonstrated MVA to be the most common cause (69%) of MF
188
Figure 3
Table 3
Variable
Surgery yes/no
Odds ratio
(95%CI)
p-value
ORIFb yes/noa
Odds ratio
(95%CI)
p-value
Complications
yes/noa Odds
ratio (95%CI)
p-value
<0.001
0.75
0.30
0.37
0.06
0.24
0.58
0.006
0.15
0.015
0.48
0.018
Sex
Alcohol
Injury
Mechanism
Fracture
number
a
b
c
Male (ref)
Female
No (ref)
Yes
Assault (ref)
Fall
MVAc
Sport
Other
One (ref)
Two
Three
Four plus
0.49
0.80
1.13
0.66
(0.32,
(0.55,
(0.74,
(0.40,
0.75)
1.16)
1.72)
1.09)
0.92
2.09
0.75
3.08
(0.44,
(1.05,
(0.40,
(1.08,
1.95)
4.15)
1.40)
8.81)
<0.001
1.55 (1.12, 2.14)
2.64 (1.70, 4.10)
5.56 (3.89, 9.13)
0.76
1.48
2.31
3.71
(0.28,
(0.72,
(1.06,
(1.45,
2.04)
3.05)
5.02)
9.52)
<0.001
6.92 (3.69, 13.00)
4.36 (2.13, 8.96)
23.34 (6.98, 78.06)
<0.001
2.47 (1.22, 5.02)
2.59 (1.12, 6.02)
8.03 (3.95, 16.30)
Conclusion
Males, aged 15e24 years, were the most commonly
affected and assault was the most common aetiology of MF
fractures. The majority of patients sustained orbital fractures and approximately half sustained a fracture to more
than one bony region. Per bony injury, mandibular fractures had the highest percentage treated surgically. Highenergy mechanisms of injury were associated with an
increased risk of sustaining multiple fractures and developing postoperative complications. The data presented
189
11.
Conflict of interest
12.
None.
13.
Funding
None.
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