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
Abstract
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
INTRODUCTION
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.
MATERIAL AND METHOD
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.
RESULT
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
DISCUSSION
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.
CONCLUSION
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.
Reference
- Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR,
Shahinian HK. Craniofacial and skull base trauma. J Trauma
2003 May; 54(5): 1026-34.
- Bataineh AB. Etiology and incidence of maxillofacial fractures
in north of Jordan. Oral Surg Oral Med Oral Pathol Oral Rehabil
Radiol Endod. 1998; 86: 31-5.
- Ugboko VI, Odusanya SA, Fagade OO. Maxillofacial fractures
in Semi-urban Nigerian Teaching Hospital. A review of 442 cases.
Int J Oral Maxillofac Surg. 1998; 27: 286-9.
- Marker P, Nielsen A, Bastian HL. Fractures of the mandibular
condyle. Part 2: Results of treatment of 348 patients. Br J Oral
Maxillofac Surg. 2000; 38: 422-6.
- Moosa Zargar, Ali Khaji, Mojgan Karbakhsh, Mohammad
Reza Zarie. Epidemiology Study of Facial Injuries during 13
months of Trauma registry in Tehran. Indian Journal of Medical
Sciences. 2004 Mar; 58(3): 109-14.
- Marker P, Nielsen A, Bastian HL. Fractures of the mandibular
condyle. Part 1: Patterns of distribution of types and causes of
fractures in 348 patients. Br J Oral Maxillofac Surg. 2000; 38:
417-21.
- Ellis E, Moos KF, el-Attar. Ten years of mandibular fractures:
an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol.
1985; 59: 120-9
- Convengton DS, Wainwright DJ, Teichgraeber JF, Park DH.
Changing patterns in the epidemiology and treatment of zygoma
fractures 10 years review. J Trauma. 1994; 37: 213-8.
- Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective
analysis of 1502 patients with facial fractures. Int J Maxillofac
Surg. 2001 Aug; 30(4): 286-90.
- Afzeliud LE, Rosen C. Facial fractures: a review of 368 cases.
Int J Oral Surg. 1980; 9: 25-32.
- Haug RH, Prather J, Indresano AT. An Epidemiology survey
of facial fractures and concomitant injuries. J Oral Maxillofac
Surg. 1990; 48: 926-32.
- Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Craniomaxillofacial
trauma: a 10 year review of 9,543 cases with 21,067
injuries. J Craniomaxillofac Surg. 2003 Feb; 31(1): 51-61.
- Magennis P, Shepherd J, Hutchison I, Brown A. Trends of
facial injuries: increasing violence more than compensates for
decreasing road trauma. BMJ. 1998; 316: 325-6.
Dr. A.K.Agnihotri MD:
Assistant Professor, Department of Forensic Medicine,
Manipal College of Medical Sciences and Teaching
Hospital, Pokhara, Nepal
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
Abstract
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
INTRODUCTION
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.
MATERIAL AND METHOD
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.
RESULT
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 |
DISCUSSION
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.
CONCLUSION
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.
Reference
- Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma 2003 May; 54(5): 1026-34.
- Bataineh AB. Etiology and incidence of maxillofacial fractures in north of Jordan. Oral Surg Oral Med Oral Pathol Oral Rehabil Radiol Endod. 1998; 86: 31-5.
- Ugboko VI, Odusanya SA, Fagade OO. Maxillofacial fractures in Semi-urban Nigerian Teaching Hospital. A review of 442 cases. Int J Oral Maxillofac Surg. 1998; 27: 286-9.
- Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 2: Results of treatment of 348 patients. Br J Oral Maxillofac Surg. 2000; 38: 422-6.
- Moosa Zargar, Ali Khaji, Mojgan Karbakhsh, Mohammad Reza Zarie. Epidemiology Study of Facial Injuries during 13 months of Trauma registry in Tehran. Indian Journal of Medical Sciences. 2004 Mar; 58(3): 109-14.
- Marker P, Nielsen A, Bastian HL. Fractures of the mandibular condyle. Part 1: Patterns of distribution of types and causes of fractures in 348 patients. Br J Oral Maxillofac Surg. 2000; 38: 417-21.
- Ellis E, Moos KF, el-Attar. Ten years of mandibular fractures: an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol. 1985; 59: 120-9
- Convengton DS, Wainwright DJ, Teichgraeber JF, Park DH. Changing patterns in the epidemiology and treatment of zygoma fractures 10 years review. J Trauma. 1994; 37: 213-8.
- Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective analysis of 1502 patients with facial fractures. Int J Maxillofac Surg. 2001 Aug; 30(4): 286-90.
- Afzeliud LE, Rosen C. Facial fractures: a review of 368 cases. Int J Oral Surg. 1980; 9: 25-32.
- Haug RH, Prather J, Indresano AT. An Epidemiology survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg. 1990; 48: 926-32.
- Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Craniomaxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003 Feb; 31(1): 51-61.
- Magennis P, Shepherd J, Hutchison I, Brown A. Trends of facial injuries: increasing violence more than compensates for decreasing road trauma. BMJ. 1998; 316: 325-6.
Dr. A.K.Agnihotri MD:
Assistant Professor, Department of Forensic Medicine,
Manipal College of Medical Sciences and Teaching
Hospital, Pokhara, Nepal
