Abstract
The treatment of midfacial fractures depends on the dislocation of the fracture and patient-related limitations. Surgical treatment risks iatrogenic complications. In 740 patients with midfacial fractures, the age, sex, fracture type, concomitant injuries, cause of accident and the decision to use operative or non-surgical treatment were recorded. Follow-up was performed 6 and 12 months after the injury. In 41% the fractures were isolated; they were multiple in 59%. Initially, hypaesthesia of the infraorbital nerve was present in 10% of the single and 16% of the multiple fracture patients. Surgical treatment was performed in 57% of the single and in 75% of the multiple fracture patients. Women underwent surgical treatment considerably less frequently than men. After 6 and 12 months, significantly more complications were present in the surgically treated cohort. Nerve disturbances and ‘meteorosensitivity’ were most prominent. These results, together with previous findings, indicate that there is a need for prospective clinical investigations that fulfil the criteria of evidence-based medicine to generate guidelines for decision making in trauma surgery. In the meantime, the decision to use surgical treatment for midfacial fractures has to be made carefully.
Introduction
Patients with midfacial fractures often present to maxillofacial emergency departments following sport accidents, traffic accidents or violence. Owing to the heterogeneous presentation of midfacial injuries and the concomitant injuries, deciding on treatment may be difficult and possible complications and their relative risk play a crucial role in the decision. The decision making process is complicated by the frequent presence of multiple fractures and concomitant injuries, and iatrogenic complications.
The initial diagnostic management is well established and standardized . A precise clinical and radiological examination includes the orbit, eye ball and soft tissues, and neighbouring structures . Concomitant injuries are common and include haematomas, ocular injuries, and nerve disturbances. The incidence of infraorbital nerve (ION) paraesthesias is common . The underlying pathophysiology is heterogeneous; the nerve can be injured because it lies within the fracture or it can be affected by haemorrhage or oedema. The influence of surgical procedures on the nerve’s regenerative capacity is also controversial. Another complication of midfacial fractures is meteorosensitivity (pain or discomfort caused by certain weather conditions), which is often mentioned by patients as a reason for decreased quality of life after osteosynthetically treated midfacial fractures.
These complications can also be provoked iatrogenically or can be reduced by the choice of treatment. Although many studies have investigated the complications related to different surgical treatments or types of fractures, little attention has been paid to complications related to non-surgical treatment.
The aim of this study is to investigate and evaluate complications related to midfacial trauma and to the non-surgical or surgical treatment used to treat it.
Materials and methods
The authors carried out a retrospective review of the records 844 patients with midfacial injuries introduced to their department between January 2001 and December 2003. These patients were treated either non-surgically or surgically. Surgical treatment is defined as active closed or open reduction with osteosynthesis; non-surgical treatment includes any other treatment option. The criteria for surgical treatment were displacement and/or impairment of functionality.
Initially the following parameters were recorded: age, sex, number of fractures, concomitant injuries, the cause of the accident, and the decision to use operative or non-surgical treatment. Follow-up examinations were performed 6 and 12 months after the injury. Any adverse event or complication was documented.
As well as the descriptive statistics, the following parameters: treatment decision, neurosensory changes, meteorosensitivity, pain and disturbing scars, were used for inferential statistics. Crosstabs were used to display the number of cases in each category defined by two or more grouping variables. χ 2 measures were applied to test the hypothesis that the row and column variables in a crosstabs were independent. Fisher’s exact test was used if sample sizes were small. The relative risk and the associated 95% confidence interval were calculated as measure of association between the presence or absence of a factor and the occurrence of an event. All statistical analyses were performed with SPSS 16.0 (SPSS Inc., Chicago, IL, USA). Statistical graphs were drawn with Microsoft Excel.
Materials and methods
The authors carried out a retrospective review of the records 844 patients with midfacial injuries introduced to their department between January 2001 and December 2003. These patients were treated either non-surgically or surgically. Surgical treatment is defined as active closed or open reduction with osteosynthesis; non-surgical treatment includes any other treatment option. The criteria for surgical treatment were displacement and/or impairment of functionality.
Initially the following parameters were recorded: age, sex, number of fractures, concomitant injuries, the cause of the accident, and the decision to use operative or non-surgical treatment. Follow-up examinations were performed 6 and 12 months after the injury. Any adverse event or complication was documented.
As well as the descriptive statistics, the following parameters: treatment decision, neurosensory changes, meteorosensitivity, pain and disturbing scars, were used for inferential statistics. Crosstabs were used to display the number of cases in each category defined by two or more grouping variables. χ 2 measures were applied to test the hypothesis that the row and column variables in a crosstabs were independent. Fisher’s exact test was used if sample sizes were small. The relative risk and the associated 95% confidence interval were calculated as measure of association between the presence or absence of a factor and the occurrence of an event. All statistical analyses were performed with SPSS 16.0 (SPSS Inc., Chicago, IL, USA). Statistical graphs were drawn with Microsoft Excel.
Results
Between January 2001 and December 2003, the data from 844 patients with midfacial injuries were recorded in a database. 740 patients (88%) presented had fractures in the midface and were included in this investigation. The main causes of these fractures and the concomitant injuries were sports accidents (33%) followed by road accidents (15%), violence (10%) and accidents at work (8%) ( Table 1 ).
| Injury mechanism | Percentage (%) |
|---|---|
| Sports accident | 33.1 |
| Traffic accident | 14.6 |
| Violence | 10.0 |
| Accident at work | 7.8 |
| Accident at home | 7.5 |
| Accident at playground | 5.8 |
| Suicidal attempt | 0.7 |
| Miscellaneous | 5.0 |
| Unknown | 15.5 |
Initial clinical presentation
The patients were classified as having single fractures ( n = 305; 41%) or multiple fractures ( n = 435; 59%) ( Fig. 1 a) and showed a gender distribution of 205 (27%) female and 535 (73%) male patients ( Fig. 1 b) with a mean age of 40.9 years.
Additional soft tissue injuries were present in 92%. 30% showed two soft tissue lesions and 36% at least three soft tissue injuries, defined as periorbital haematoma ( n = 385; 52%), laceration ( n = 382; 52%), bruise ( n = 287; 39%), midfacial haematoma ( n = 152; 21%) or excoriations ( n = 149; 21%). Hypaesthesia of the second branch of the trigeminal nerve was diagnosed in 98 patients (13%); only 1 patient had anaesthesia ( Fig. 2 ). Dental injuries were found in 19% ( n = 141). The dominant lesion was an avulsion ( n = 84; 11%), followed by lateral luxations ( n = 71; 10%), dental fractures with non-exposed pulp ( n = 63; 9%) and exposed pulp ( n = 25; 3%).
