Patterns and Trends of Facial Fractures at a Tertiary Care Trauma Center in India—A 13 Years Retrospective Study

Abstract

Study Design: Retrospective study. Objective: The purpose of this study was to retrospectively analyze the prevalence, pattern, diagnosis, and treatment of the facial fractures falling under ambit of facial plastic surgery in a multi-specialty hospital at India from the year 2006–2019. Methods: This retrospective study analyzed 1508 patients, having orbital fractures (from 2006 to 2019) for demographic data, cause of trauma, type of fracture, and the treatment given. The data were compiled in excel and analyzed by using SPSS version 21.0. Results: Out of these 1508 patient (1127 (74.73%)–males and 381 (25.27%)–females), the etiology of injuries was Road traffic accident (RTA) (49.20%), assault (26.52%), and sports injuries (11.47%). The most common fracture pattern was Isolated Orbit and/or Orbital Floor fracture in 451 patients (32.08%), followed by Mid-facial fractures (21.93%). Also, 105 patients (6.96%) experienced ocular/retinal trauma along with other fractures. Conclusions: Orbit, peri-ocular, and mid-face trauma comprised a large position of this study. It requires a great deal of expertise to treat such complex trauma, which is not covered in one specialty alone. Hence, a holistic approach of craniofacial fracture management, rather than limiting these skills to water-tight craniofacial compartments becomes necessary. The study highlights the critical need of multidisciplinary approach for predictable and successful management of such complex cases.

Introduction

Trauma is the most common cause of death in the first 40 years of life [1]. As per the WHO statistics, approximately 1 million people die and 15–20 million individuals get injured annually due to Road traffic accidents (RTAs). Face being one of the most exposed parts of the human body, is commonly injured during RTA. It is also the least protected organ and the first point of contact in accidents and also the target for blows during assaults. All these reasons contribute to maxillofacial trauma being the most common traumatic injuries witnessed in urban trauma centers, either in isolated form or in association with other system injuries including a cranial, spinal, upper, and lower body [2,3,4].

The human face is a complex anatomical structure, with facial bones and components articulating and intertwining in a manner that the fracture of one bone can invariably disrupt the adjoining bones and other vital structures. Also, facial trauma can be life-threatening due to airway obstruction and associated damage to the brain leading to intra and extra-cranial hemorrhage [5].

The most common causes of facial fractures include road traffic accidents, assaults, fall from height, sports injuries, industrial or work-related injuries, and gunshot injuries to name a few [6,7,8].

Maxillofacial trauma can be challenging to clinicians and surgeons, as it includes a wide spectrum of multiplicities ranging from a simple dento-alveolar fracture to multiple fractures involving the entire facial skeleton compelling multidisciplinary treatment. These injuries not only cause physical trauma but can also result in functional, cosmetic, and psychological disabilities [9,10].

Among all the maxillofacial fractures, management of mid-facial fractures remains critical and delicate. Involvement of both the hard and soft tissues of the face often warrants immediate attention and early intervention to limit complications [11]. Long term functional complications might result in damage to the vital sensory structures responsible for vision, taste, olfaction, and hearing [10].

Within the mid-face fractures, the treatment of the orbital fractures is complex owing to the anatomy, and physiology of the ocular district [12,13]. Approximately 40% of craniofacial injuries accompany orbital wall fractures (OWF). Also, due to the extremely thin orbital floor, it is the most common orbital wall to get damaged. As per the literature, these fractures sum up to 84% of cases amongst the orbital fractures [14]. Orbital wall fractures commonly result in cosmetic as well as functional deformity. The cosmetic problem includes altered globe position resulting in hypoglobus (lower eye) or enophthalmos (sunken eye). The functional concerns involve entrapment of the extraocular muscles or adjacent tissues and limiting eye movement causing diplopia or double vision [10]. More than half of the patients with OWF present with other facial fractures and 30% of the patients have accompanied ocular injuries [15].

All these factors along with the fact that these fractures are difficult to evaluate owing to the anatomy of the defect area and the amount of soft tissue herniation, make the management of maxillofacial fractures challenging. These ailments often require a multidisciplinary outlook. However existing training programs are limited to specific areas but lack an integrated approach. Increased demand and a wide spectrum of injuries with overlapping anatomical borders involving the maxillofacial region in general and particularly the orbital region and the adjoining bones have led to the emergence of specialties like Oculo-Facial & Orbito-Facial plastics worldwide (ASOPRS) [16].

Advancement in technology has led to increased protective measures being implemented to prevent RTA. Also, trauma centers and transport facilities have helped in reducing the mortality rates associated with RTA, still, it is necessary to know and understand the pattern of injuries affecting the face [17]. The sequential and synchronized data about the demography, epidemiology, and etiology of maxillofacial injuries can assist health care providers to maintain detailed and regular data of facial trauma [4,15,16,17,18].

The purpose of this study was to retrospectively analyze the prevalence, pattern, diagnosis, and treatment of the facial fractures falling under the ambit of facial plastic surgery in a multi-specialty hospital in India from the year 2006–2019.

Material and Methods

Study Design

The medical records of the patients reported to The Esthetic Clinics between January 2006 and December 2019 (13 years) for maxillofacial injuries leading to hospitalization and surgical treatment were reviewed retrospectively. A total of 1508 records of the patients were found during the given period which was included for the screening. After the necessary clearance from The Institutional Ethical Committee, informed, written, and signed consents were taken from the patients regarding the use of identifiable photographs for study, research, and publication purpose. The records of the patients were thoroughly scrutinized for demographics (including patient’s age and gender), cause of trauma, type of maxillofacial fracture, and the treatment given. The data thus obtained, were statistically analyzed.

Inclusion & Exclusion Criteria

Records of the patients reported in the Department of Facial Plastic Surgery between January 2006 and December 2019 with isolated and/or complex maxillofacial fractures and operated by The Facial Plastic Surgery Department, and having a 2-year follow-up record was included. Records of the patients who primarily received treatment care at different institutions, had refused treatment, were referred to other hospitals, and the patients who were brought dead were excluded from the study. Patients with isolated dental or dental-alveolar fractures (with or without soft tissue lesions) were also excluded from the study.

Trauma Management

The initial management of facial trauma follows life support principles, as outlined by Early Management of Severe Trauma of the Royal College of Surgeons [18].

In the primary survey, life-threatening injuries were diagnosed and stabilized. The secondary survey was done for diagnoses of other injuries. Maxillofacial trauma not associated with airway obstruction or major bleeding was treated after the patient was stabilized, as part of the secondary survey.

Maxillofacial fractures were broadly distributed based on the etiology into Road traffic accidents (motorcycle, bicycle, heavy vehicle, and others), assaults, sports injuries, and others. All patients were assessed according to the Advanced Trauma Life Support guidelines and diagnosed utilizing a multi-slice computed tomography (CT) with 2 mm sections along with 3D reconstruction of the brain and face. CT examination was also extended to include neck, spine, chest, and abdomen. All patients recruited were classified based on the type of fracture pattern broadly into the following categories: complex facial fractures, upper facial fractures, mid-facial fractures, and lower facial fractures. Isolated Orbital wall or Orbital floor fracture and isolated mandibular fractures were considered separately.

Before intervention, neurological evaluation (to rule out head injury) was performed. An ophthalmic evaluation was done and recorded with all patients having signs and symptoms related to ophthalmic trauma including diplopia, ecchymosis, enophthalmos, and peri-orbital swelling.

The goals in the management of facial trauma include:

(1)

Restoring anatomy and eliminating deformity.

(2)

Restoring occlusion and masticatory abilities.

(3)

Restoring function includes nasal airflow and ocular function.

(4)

Minimizing morbidity.

(5)

Early return to function.

The surgical interventions included-closed reduction (with arch bars, eye loops, and inter-maxillary fixation) or open reduction and fixation of bone segments with wiring technique or internal rigid fixation with plates, mini plates, and screws and/or with autologous bone grafts if required.

Apart from these, procedures like craniotomy/cranioplasty, rhinoplasty, enucleation or evisceration, and retinal surgeries were carried out in concerned patients. Also, skin laser treatments were performed in patients as per the requirement.

Statistical analysis was done. Mean ± standard deviation (SD) and chi-square (χ2) test were used to analyze the data categorically. The level for statistical significance was set at P < .05 and a confidence interval of 95%. Statistical analysis was performed using SPSS version 21.

Results

During the period of 13 years of study, a total of 2854 patients were reported at the center for maxillofacial injuries, out of which 1508 (included in the study) patients had facial fractures. Patients’ demographics including age distribution as depicted in

Table 1. Distribution of patients about gender and growth stages at the time of trauma.

. Out of these 1508 patients, 1127 (74.73%) were males and 381 (25.27%) were females, with a mean age of (31.2 ± 1.9) and (28.2 ± 1.6), respectively (Figure 1). There was a significant positive association of age with the degree and nature of trauma as well.

Road traffic accidents were the most frequent etiological factor of maxillofacial fractures (49.20%) followed by assault (26.52%) and sports injuries (11.47%) as shown in

Table 2. Distribution of patients based on the etiology of Trauma (13-years data).

. Specific information concerning traffic accidents is shown in

Table 3. Distribution of patients based on the specific etiology about the cause of road traffic accidents.

which indicates motorcycle accidents (39.05%) to be the main cause of RTA, followed by a car accident, heavy vehicle accident, and bicycle accident in the decreasing order.

The most common fracture pattern (

Table 4. Percentage distribution of patients based on the facial fractures involved.

) noted was Isolated Orbit and/or Orbital Floor fracture in 451 patients (32.08%) followed by mid-facial fractures (21.93%), lower facial fractures (15.05%), isolated mandibular fracture 12.33%, complex facial fracture (8.04%), and upper facial fracture (6.57%).

It was noteworthy that 105 patients (6.96%) experienced ocular/retinal trauma apart from one or more fractures. It was interesting to note that out of 361 patients with mid-facial fractures and 121 complex facial fractures, 215 (59.55%) patients had associated orbital injuries. The associated soft tissue injuries are mentioned in

Table 5. Percentage distribution of patients based on the associated injuries.

.

Overall, 290 (19.23%) patients were treated by closed reduction including Inter-maxillary fixation. 833 patients (55.17%) patients were treated by Open Reduction and Internal fixation without using bone grafts, while 386 patients (25.59%) were treated by Open Reduction and Internal fixation using bone grafts. Apart from this, 115 patients (7.62%) required skin grafts. Craniotomy or Cranioplasty was done in 92 patients (6.10%). Rhinoplasty was required in 128 patients (1.48%). (

Table 6. Percentage distribution of patients based on the treatment done.

)

It was critical to note that 385 patients (25.53%) required orbital floor reconstruction. Enucleation or evisceration was performed in 15 patients (0.99%). (Figure 2A-C): 7 patients underwent enucleation/evisceration as a primary procedure, and in 8 patients it was done as a secondary procedure. A total of 63 patients (4.17%) underwent retinal surgeries. For cosmetic correction of soft tissue injuries, 567 patients (37.60%) underwent skin laser correction procedures 8–10 weeks postoperatively.

Discussion

A high incidence and prevalence of Head and Neck trauma in a pre-determined population makes it crucial to have a thorough understanding of the patterns of injuries affecting the face. This enables us to provide emergency care with sufficient and effective treatment. This epidemiological information can also contribute towards developing protocols and strategies related to trauma prevention programs and drives [19,20].

The purpose of this study was to retrospectively analyze the prevalence, pattern, diagnosis, and treatment given for facial injuries that were recorded at a tertiary trauma center over the period of 13 years (January 2006 to December 2019) to give the clinicians precious information about facial fractures under the ambit of facial plastic surgery.

In our study, it was noted that fractures were more common in young males and the peak incidence was noted in the second and third decades of life. This correlated with past studies from India as well as other parts of the world, suggesting that the third decade is perhaps the most active period of life in which people tend to remain outdoors in search of their livelihood and are thus more vulnerable to maxillofacial trauma [9,21,22].

This can also be attributed to the fact that they are majorly involved in outdoor activities and rash driving. The hypothesis is supported by several published studies [23,24,25].

Previous studies mentioned in the literature suggest RTA, alleged assault, and falls to be the most common cause of maxillofacial fractures. Approximately, 70% of maxillofacial fractures occurred in men [21,22,23,24,25]. In our study also, approximately 74.73% (3:1) trauma victims were males. Also, it was recorded that RTA was the most common cause of maxillofacial accidents (49.20%), followed by assaults (26.52%) and sports injuries (11.47%) in the decreasing order.

Literature suggests that this can be attributed to the fact that men are often the primary breadwinners of the family and tend to remain outdoors for a large period, thus making them susceptible to trauma in general and maxillofacial trauma in particular. Also, females drive less frequently and are therefore less likely to be involved in road traffic accidents. Also, they are less vulnerable to sport-related injuries and falls and violence related to alcohol consumption [25,26,27,28].

Past studies have recorded the body of the mandible as the most commonly involved site in Maxillofacial trauma [9,12]. However in recent times, this ratio has become smaller as fractures of the mid-face including orbit have significantly increased with the increased severity of road traffic accidents [5,29].

In our study also the most common fracture pattern noted was Isolated Orbit and/or Orbital Floor fracture and mid-facial fractures. This was followed by lower facial fractures, isolated mandibular fracture, complex facial fracture, and upper facial fracture.

In the past 15 years, maxillofacial trauma management protocol has been significantly influenced by innovations in technology and treatment protocols. The objectives such as early recovery, segment stability, restoring function, minimizing morbidity, and patients’ comfort have been considered paramount in the trauma management [20,30].

Since the adaptation of the principle of plating by Champy et al in 1978, surgeons are increasingly using rigid internal devices to treat many facial fractures owing to favorable results achieved. The appropriate use of plates, mini plates, and screws in such cases can be of great benefit as they can maintain the position of the reduced bone segments and do so without the need for inter-maxillary fixation [20,31,32,33,34,35].

In our study, statistics revealed that 290 (19.23%) patients, with stable fractures, were treated by closed reduction including inter-maxillary fixation. Patients with complex and multiple fractures (1219 patients) were treated by open reduction and internal fixation with or without using bone grafts. Apart from these 115 patients (7.62%) required skin grafts. Craniotomy or Cranioplasty was done in 92 patients (6.10%). Rhinoplasty was required in 128 patients (1.48%).

It is noteworthy that the functional consequence can result from trauma to the bones including orbit (eye, lacrimal apparatus, etc.). Also, disruption of the medial canthus or comminution of the frontal sinus and nasal skeleton can lead to esthetic concerns [20]. The most common fracture pattern noted was Isolated Orbit and/or Orbital Floor fracture in 451 patients (32.08%). The second most common type of fracture pattern included was mid-facial fractures (361 patients, 21.93%) As confirmed by the data of our present work a total of 385 patients (25.53%) required orbital floor reconstruction.

The management of mid-facial fractures hugely depends on the type of injury, surgeon’s experience, and available equipment. The orbital trauma, without any doubt, is the hardest to be treated for its location and related signs, and the prompt diagnosis and treatment of the same is the key to the success of the final treatment. Numerous papers in the past have highlighted the significance of early ophthalmological evaluation and CT-Scan imaging in cases of suspected orbital fractures. Timely intervention is recommended in patients with the evidence of entrapment, in the absence of entrapment, and also when immediate enophthalmos can be managed conservatively without surgery [20,34,35,36,37,38,39].

An ophthalmic evaluation was performed and recorded with all patients having signs and symptoms related to ophthalmic trauma including diplopia, ecchymosis, enophthalmos, and peri-orbital swelling. A close evaluation of orbit and orbital structure-related injury revealed that 105 patients (6.96%) experienced ocular/retinal trauma apart from one or more fractures. A total of 63 patients (4.17%) underwent retinal surgeries. Enucleation or evisceration was performed in 15 patients (0.99%).

Ocular trauma continues to account for a small proportion of all emergency admissions. Past studies suggest this ratio to be .3% in Scotland and about 0.25% in England. It was noted that the admission was done under the care of a consultant ophthalmologist leading to a steady decrease in the proportion of the cases over the decade. These admissions might be associated with poly-trauma of varying severity, requiring multi-professional (including ophthalmic) care for such patients. For example, about 6–7% of patients with major trauma also have an ocular injury. The need for the specialist should not be overlooked in any review or reconfiguration of emergency services to ensure that timely specialist care remains both accessible and available at all times [37,38,39].

As we know face is a cross-over zone and injury to one facial structure is often accompanied by damage to the adjoining area. The cosmetic defect as a result of trauma to the face is as significant as the physical and functional trauma. Also, facial trauma being an amalgamation of hard and soft tissue warrants an interdisciplinary approach including neuro-surgeon, oculoplastic surgeon, oral and maxillofacial surgeon, and plastic surgeon to optimize the outcome of a patient with facial trauma [16,40].

However, the clinical training of the oral and maxillofacial surgeon is broadly based on handling and managing hard tissue-related trauma to the face. Similarity Ear, Nose & Throat (ENT) and oculoplastic branches are more focused to manage hard and soft tissue trauma related to nose and orbital region, respectively. Also, the plastic surgery branch is more targeted towards soft tissue reconstruction of the damaged face [16,40].

Several changes in the training methods have been implemented over the years to ensure the maintenance of competencies. The scope and practice for Facial Plastic Surgery & Facial Cosmetic Surgery in the United States include craniomaxillofacial trauma reconstruction, microvascular reconstruction of the head and neck, correction of facial defects after skin cancer resection to name a few. Keeping in view, the same belief; The American Board of Facial Cosmetic Surgery was incorporated in 2015. They also showcase the growing spectra of Facial Plastic Surgery and Facial Cosmetic Surgery in Ophthalmology globally. Also, oculoplastics have progressed into Oculo-Facial & Orbito-Facial Specialties worldwide (ASOPRS) [16].

In our study, it was noted that orbit, eye, and peri-ocular trauma was large position of entire trauma. Hence specialists must be trained with the holistic approach of craniofacial fracture management rather than limiting these skills to water-tight craniofacial compartments because when there is a fracture, it does not limit itself to any anatomical landmarks. It has been unfortunately seen that training programs currently are training candidates to be good only in some aspects of facial trauma, depending on the main training and residency exposure of the fellowship preceptor—For instance, The OMFS surgeons are treating mandibular fractures well, while the oculoplastic surgeons seem to do better on the orbital fractures! Training programs owe it to patients globally, to train candidates holistically to manage hard and soft tissue trauma over the entire face effectively.

Conclusion

The limitation of the present study is its retrospective design. However, the large number of treated patients can give the clinicians, valuable information regarding the need for prompt diagnosis and early intervention. An understanding of the cause, severity, and temporal distribution of the facial trauma can facilitate clinical and research arrangements for implementing prevention protocols and better management of the received cases.

Last but not the least; it delineates the critical need for a multidisciplinary approach for predictable and successful management and the need to have fellowship training programs which holistically train candidates in all aspects of facial trauma.