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Medico-Legal Update

Study of Craniofacial Trauma in a Tertiary Care Hospital, Western Nepal

Author(s): Agnihotri A.K. MD, Joshi H.S. MD, Tsmilshina N. MPH

Vol. 5, No. 1 (2005-01 - 2005-03)

Agnihotri A.K. MD1, Joshi H.S. MD2, Tsmilshina N. MPH3

1Assistant Professor, Department of Forensic Medicine, 2Lecturer, Department of Community Medicine 3Tutor, Department of Community Medicine Manipal College of Medical Sciences and Teaching Hospital, Pokhara, Nepal


The present study was conducted in Manipal College of Medical Sciences, Pokhara, Nepal to find out the trends of craniofacial trauma. Out of 434 medico-legal cases, 170(39%) cases were brought to the emergency department with craniofacial injuries in the year 2003. The commonest age-group was 16-30 years. Males were sustained craniofacial injuries about 4 times more than females. The commonest cause was road traffic accident including 70% of the total cases. Soft tissue injury was the most common type of craniofacial trauma. Educating people to obey traffic rules, use of helmets by motorcyclists and separation of pedestrians from motor vehicles could reduce the number of craniofacial trauma cases.

Key words: Craniofacial injury, Traffic accident, Trauma, Prevention


Physical trauma is the leading cause of diseases and death all over world. Frequently, craniofacial injuries are life threatening injuries and require multidisciplinary team approach. Physician must evaluate the injuries carefully, triage properly and maintain high index of suspicion to improve survival and enhance functional recovery.1 Most of the craniofacial injuries are caused by blunt force but sharp weapons may also produce these injuries. Sometimes, the skull and/or its contents only become severely injured without evidence of external injuries. Our study aimed to evaluate pattern of craniofacial injuries in trauma patients brought to the hospital for treatment with the objective of giving preventive measures.


During a period of 12 months (Jan to Dec2003), 170 patients were brought to emergency department of Manipal Teaching Hospital, who sustained a total of 262 craniofacial injuries. Data were taken from the Accident Register for age and sex distribution, cause of injury and pattern of injuries. Statistical analyses were performed using the X2 method and a p<0.05 was accepted as being statistical significant.


Demographic profile: Craniofacial injuries contributed for 39% (170/434) of all medico-legal cases attending the emergency department of the hospital during our study period of one year 2003. The mean age was 28.64 15.92 (SD) with a range from 2 to 83 years. Males outnumbered females in all age group with male to female ratio of 4.2:1 (Table 1). The most common place of injury was on the street followed by home.

Table 1: Age and Sex Wise Distribution of Craniofacial Trauma Cases

Age Group Male Female Total
0-15 21 11 32
16-30 68 9 77
31-45 29 11 40
46-60 10 1 11
>60 9 1 10
Total 137 33 170

Cause of injury: The most common cause of craniofacial injuries was road traffic accident of 118 cases (69.4%) followed by acts of violence with 29 cases (17.1%) (Table 2). Pedestrians and motorcyclists formed the commonest form of road traffic accident.

Table 2: Distribution of Cases according to Cause of Injury

Cause Number Percentage
1. Road traffic accident 118 69.4
2. Acts of Violence 29 17.1
3. Fall from height 14 08.2
4. Animal attack 04 02.4
5. Miscellaneous 05 02.9
Total 170 100

Type of Injury: Out of 170 patients, 161 cases (95%) had external injuries. Among them, 22 cases were associated with facial bone fracture and 17 cases with cranial bone fractures (Table 3). Mandibular and nasal bone fractures were the most common type of bony injury. From our nine patients of no external injury, only 2 patients showed intracranial hematoma on CT examination.

Table 3: Distribution of Cases according to Type of Injury

Cause of Injury Type of Injury
  Soft Tissue Facial Bone Cranial Bone No Injury
Road traffic accident 110 15 14 8
Acts of Violence 29 5 1 0
Fall from height 13 1 2 1
Animal attack 4 1 0 0
Miscellaneous 5 0 0 0
Total 161 22 17 9


Craniofacial injuries are complex injuries and should not be overlooked. Sometimes, unnoticed craniofacial injuries along with fractures, cerebrospinal fluid fistulae and cranial nerve injuries can lead to blindness, diplopia, deafness, facial paralysis or meningitis.1

Craniofacial injury was found to be very common at all ages but in our study, most vulnerable age-group was 16 to 30 years that are consistent with previous studies.2-5 Previous studies5-7 showed overall ratios of male to female ranged from 3:1 to 5.4:1, similar ratio i.e. 4.2:1 has also been observed here. Road traffic accident was the main cause of craniofacial injuries. This finding is consistent with studies archived by Moosa Z el al5, Convington DS el al8, Iida S el al9 and Afzeliud LE10 but differs from the trend observed by Haug RH et al11, Gassner R et al12 and Magennis P et al13. Pedestrians and motorcyclists comprised the greatest proportion of our cases. Soft tissue injury was the most common type of craniofacial trauma followed by facial and cranial bone fractures.

The incidence of craniofacial trauma can be greatly reduced by educating people to obey traffic rules, improvement in interior home design, education in alcohol abuse and strict legislation against violence by prohibiting easy assess of dangerous weapons. Physical separation of pedestrian from vehicles by educating them to use zebra crossing and follow pedestrian crossing signs, and improvement in automotive safety devices and compliance by motor vehicle occupants such as utilization of “fullface helmets” by bicyclists/motorcyclists could be helpful in reducing craniofacial injuries due to road traffic accidents.


The study reviewed the pattern of craniofacial injuries in trauma patients. Majority of the patients were found in second and third decade of life. Males outnumbered females. Traffic accident was the main cause for the majority of our patients. Overall, the vast majority of injuries were simple in nature i.e. soft tissue injuries. Use of helmets by motorcyclists and separation of pedestrians from motor vehicles could reduce the number of craniofacial trauma cases due to road traffic accidents. For implementation of effective prevention programs for reduction of craniofacial trauma cases due to assault and fall from height, a detailed study seems to be necessary for the causes and pattern of injuries from these events.


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Dr. A.K.Agnihotri MD:
Assistant Professor, Department of Forensic Medicine,
Manipal College of Medical Sciences and Teaching Hospital, Pokhara, Nepal

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