Development of a financially viable model for the outpatient management of mandibular fractures in a Level 1 Major Trauma Centre

P21 / British Journal of Oral and Maxillofacial Surgery 52 (2014) e75–e127

The poster will identify which patients and which fracture patterns pose the greatest risk to post-operative haemorrhage. http://dx.doi.org/10.1016/j.bjoms.2014.07.246 P145 Clinical and post mortem analysis of combat neck injury used to validate a novel Coverage of Armour Tool John Breeze ∗ , Rob Fryer, Jonathan Hare, Nicholas Hunt, Russell Delaney Royal Centre for Defence Medicine Introduction: The Ministry of Defence requires an objective method of comparing between body armour designs for potential future conflicts post Afghanistan. The Coverage of Armour Tool (COAT) is a novel three dimensional model capable of comparing the coverage provided by body armour designs but limited information exists as to which anatomical structures require inclusion. Method: Hospital notes and post mortem records of all UK soldiers injured by an explosive fragment to the neck between 01 Jan 2006 and 31 December 2012 were analysed to determine which anatomical structures were responsible for death or functional disability at one year post injury. These structures were compared to those predicted by Abbreviated Injury Scores (AIS) and Functional Capacity Index (FCI) scores. Results: 13/81 survivors demonstrated complications at one year, most commonly upper limb weakness from brachial plexus injury or a weak voice from laryngeal trauma. 14/94 soldiers died from a neck wound alone, primarily from carotid artery damage, spinal cord transection and rupture of the larynx. Discussion: The use of AIS scores 5 + 6 in combination with FCI scores 1 + 2 was demonstrated to potentially reflect true morbidity and to a lesser degree mortality and we would recommend their use when choosing representative anatomical structures for the remaining body where the clinical data determined in this paper is not yet available. COAT should be developed to enable weapon and tissue specific information to be modelled such as the incorporation of a permanent wound tract. http://dx.doi.org/10.1016/j.bjoms.2014.07.247 P146 An audit on the use of ketamine sedation for the treatment of simple paediatric facial and intra-oral lacerations Faith Huiyan Chan ∗ , Sangeetha M. Thomas, Bernardo Costa, Mark J.A. Turner Peterborough City Hospital Introduction: Paediatric facial lacerations are common and children are not always able to tolerate local anesthesia

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alone. We compared the use of ketamine sedation and general anesthesia in treating paediatric facial and intra-oral lacerations by the Oral and Maxillofacial Surgery (OMFS) team at two Cambridgeshire hospitals. Methods: Retrospective data of paediatric facial and intraoral laceration patients who were seen by the OMFS team at the Emergency Department at both Cambridgeshire hospitals from 2012 to 2013 were collected. The number of patients who were treated with general anaesthetic and ketamine sedation was analysed. Results: 20% of procedures were carried out with ketamine sedation and 25% with general anaesthetic and the remaining with local anaesthetic. The use of ketamine was significantly higher in Peterborough City Hospital than in Addenbrooke’s Hospital, a trauma centre. Conclusions: Ketamine sedation has been a successful alternative to general anaesthesia in managing children with simple facial and intra-oral lacerations. Although general anaesthesia is often the preferred method, ketamine sedation may be more appropriate for suturing simple paediatric lacerations in children who cannot tolerate local anaesthesia alone. Ketamine sedation is a more cost-effective treatment, does not involve an inpatient stay, and is less likely to involve the delays in treatment that inpatient emergency operating often entails especially in busy units. However the administration of ketamine is dependent upon a suitably trained physician. The OMFS team should always consider ketamine sedation as an option in managing children with simple facial and intra-oral lacerations if local anaesthesia is deemed unsuitable. http://dx.doi.org/10.1016/j.bjoms.2014.07.248 P147 Development of a financially viable model for the outpatient management of mandibular fractures in a Level 1 Major Trauma Centre Jahrad Haq ∗ , S Chegini, K Fan, C Huppa, R Bentley King’s College Hospital, London Background: 200+ mandibular fractures are managed within this major trauma centre annually. A previous feasibility study has determined that outpatient management (DSU) of selected cases is clinically viable. If proven financially viable, there are potential cost, inpatient bed and CEPOD theatre-time savings to be made. Aim: To assess the economic feasibility of DSU management of mandibular fractures versus inpatient care. Methods: 75 non-continuous patients with mandibular fractures were included retrospectively. Cases were deemed suitable for DSU if they had a Mandible Injury Severity Score < 10, and were medically/socially appropriate for DSU. Comparative cost calculations were performed for inpatient and outpatient scenarios. These included:bed-day cost, theatre time, consumables and staffing.

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P21 / British Journal of Oral and Maxillofacial Surgery 52 (2014) e75–e127

Results: Overall average delay from admission to surgery was 0.9 days and inpatient length of stay (IPLOS) was 1.8 days. Of the seven patients assessed as suitable for DSU; mean delay to surgery was 1 day, and IPLOS 1.6 days. Cost comparison and financial savings: Inpatient and DSU theatre costs are comparable at £213.64 and £211.69 per 15mins respectively. Potential inpatient bed-day earnings are £1831. There is a premium ’intermediate OMFS procedure’ Healthcare Resource Group tariff of £102.80 as DSU over inpatient. Conclusion: A conservative 10% of mandibular fractures can be safely managed as outpatients. This should increase as the DSU service gains experience handling more complex fractures. A business case can be made to establish a rapidaccess link to existing DSU lists to release inpatient beds in a safe manner on the basis of increased income and decreased expenditure. http://dx.doi.org/10.1016/j.bjoms.2014.07.249 P148 Current trends in use of inter-maxillary fixation in the management of mandibular fractures: A national survey Rahul Jayaram ∗ , Beejal Patel, Helen Witherow, Andrew Stewart St Georges Hospital, London Introduction: Mandibular fracture management has evolved over the years and has undergone significant changes benefitting from improved internal fixation systems and techniques. The purpose of this study is to examine the current trends in use of inter-maxillary fixation in the management of isolated dentate mandibular fractures. Methods: A web based survey tool (www.surveymonkey. com ) was used set up, analyze the results and manage the survey. An initial pilot of the survey was trialed. This was then assessed and subsequently approved by the British Association of Oral and Maxillofacial Surgeons (BAOMS) education committee. Email surveys were sent out to all Fellows, Fellows in training and associate members of the association by the BAOMS office. Results: At the time of submission of the abstract there were 101 responses. 60% of the respondents being consultants and 35% registrars. The most common method for treating isolated dentate mandibular fracture was open reduction internal fixation with hand held occlusion. Adequacy of assistance and occlusion were the main reasons for using intraoperative IMF. IMF screws (44%) was the preferred method followed by custom-made arch bars (18%). Estimated application time for arch bars was 30-60 minutes by 53% and less than 30 mins by 45% of the respondents. 86% of respondents had experienced glove perforation or needle stick injuries while placing arch bars. 93% of the respondents stated their departments did not have a defined protocol for

the use of IMF. Full results shall be discussed at the time of presentation. http://dx.doi.org/10.1016/j.bjoms.2014.07.250 P149 The Management of First World War Jaw Injuries at the First Scottish General Hospital 1914 - 1918 Andrew Sadler ∗ , Rachel Bairsto Unit for the History of Dentistry, King’s College London Introduction: The First Scottish General Hospital, Aberdeen, was one of many hospitals created during WW1 for the treatment of injured soldiers. The ‘Jaw Injuries Unit’ was housed in the Aberdeen Girls’ High School where patients were managed by Dental Surgeon Captain James Crombie, a part time officer of the Territorial Force. Captain Crombie’s clinical records are held in the archive of the British Dental Association. Method: By examining Captain Crombie’s records, Xray images and photographs, the poster explores the pattern of injury, management and outcome of his 60 cases. Results: Of those injured by enemy action 45 had fractured mandibles (+/- maxilla), 2 maxilla alone, 5 had only soft tissue injury and there was 1 injury causing trismus. Noncombat injuries included 4 fractured mandibles. There was 1 case of osteomyelitis, 1 dental cyst and 1 of an abnormal jaw position. The mean time between injury to presentation was 36 days [range 4 - 485]. 18 mandibular fractures were fixed using Gunning’s splints, 8 with silver cap or other dental splints and 22 were managed with no fixation. 2 patients had late open reduction and fixation with Lane’s plates. Clinical cases will be presented and fixation techniques explained. Conclusion: The severity of the injuries with loss of bone, late presentation, poor dentitions and, most of all, chronic sepsis, meant that for most cases sub-optimal fracture reduction had to be accepted. Fixation and subsequent restoration of function with dental splints and prostheses meant that dental skills were more useful than surgical techniques. http://dx.doi.org/10.1016/j.bjoms.2014.07.251 P150 The Paediatric Orbital Fracture: 13-year experience at a major trauma unit Navin Vig ∗ , Sujata Kane, Indran Balasundaram, Simon Holmes, Chris Bridle Barts Health, London Paediatric orbital fractures are uncommon. The literature often describes the need for prompt treatment to avoid per-