- Email: [email protected]
Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective 10-Year Multicenter Review
Accepted Manuscript Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review Robert Shumate, DMD, Jason Portnof, DMD, MD, FACS, Melissa Amundson, DDS, Eric Dierks, DMD, MD, FACS, FACD, Robert Batdorf, BS, Patrick Hardigan, PhD PII:
S0278-2391(17)31344-7
DOI:
10.1016/j.joms.2017.10.019
Reference:
YJOMS 58025
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 30 May 2017 Revised Date:
15 October 2017
Accepted Date: 15 October 2017
Please cite this article as: Shumate R, Portnof J, Amundson M, Dierks E, Batdorf R, Hardigan P, Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review, Journal of Oral and Maxillofacial Surgery (2017), doi: 10.1016/ j.joms.2017.10.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
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Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review
CORRESPONDING AUTHOR: Robert Shumate, DMD
Chief Resident. Department of Oral and Maxillofacial Surgery Nova Southeastern University. Fort Lauderdale, FL
SC
Correspondence Address: 4121 Gateway Blvd. Newburgh, IN 47630
Fax - 812-426-9984 E-Mail – [email protected]
ADDITIONAL AUTHORS
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Phone – 812-858-3100
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Jason Portnof, DMD, MD, FACS
Associate Clinical Professor. Department of Oral and Maxillofacial Surgery Nova Southeastern University. Fort Lauderdale, FL
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Melissa Amundson, DDS
Private Practice, Head and Neck Surgical Associates. Residency Site Director, Department of Oral and Maxillofacial Surgery, Legacy Emanuel Hospital, Portland, OR
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Eric Dierks, DMD, MD, FACS, FACD
Senior Consultant, Head and Neck Institute, and Affiliate Professor, Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, OR
Robert Batdorf, BS
Dental Student. Nova Southeastern University College of Dental Medicine. Fort Lauderdale, FL
Patrick Hardigan, PhD Professor. Nova Southeastern University College of Dental Medicine. Fort Lauderdale, FL
ACCEPTED MANUSCRIPT
Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review Purpose: The purpose of this study was to analyze maxillofacial trauma sustained by patients age 75
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years and older. With the injury patterns identified treatment recommendations for the contemporary oral and maxillofacial surgeon are made.
Patients and Methods: This study was a retrospective case series using data from two level I trauma
SC
centers. The variables of interest included age at traumatic event, gender, mechanism of trauma, concomitant injuries, radiographic studies performed, management of maxillofacial injuries, and
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disposition. Numerical analysis was completed with statistical software.
Results: One hundred and seventy-six patients age 75 years and older who sustained facial trauma were identified. Ground level falls cause the majority of maxillofacial trauma in the geriatric population. The median age at the time of trauma was 83 and 85 for men and women respectively. The most common
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injuries were midface fractures. Intracranial hemorrhage was the most common concomitant injury, and all but one patient underwent computed tomography (CT) of at least the head after their traumatic
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event. The majority of the maxillofacial injuries were treated without operative repair.
Conclusions: The information gained from this study suggests that oral and maxillofacial surgeons
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should counsel geriatric patients regarding risk of falls, as well as encourage prevention of potential hazards for falls in their homes.
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In the United States 6% of the population is over the age of 751. Current trends indicate that this percentage will increase significantly by the year 2050. Between 2000 and 2010 this segment of the population increased by approximately 2 million people1. As the geriatric population continues to grow,
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concerns with treatment of maxillofacial trauma in this population will also grow2.
Unintentional injuries are the eighth leading cause of death in the geriatric population3, with more than half of these deaths attributed to falls. With more people living to advanced ages, it can be expected
SC
that trauma patients within this population will also grow. Due to medical comorbidities this population requires more frequent admission, often at an increased level of care4. Additionally, the geriatric
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population is at a higher risk of death from injuries versus younger patients with similar injuries. The specific aim of this study was to evaluate the injury patterns in patients over age 75 paying particular attention to mechanism, injury patterns, hospitalization time. Finally, the overall goal of this
Patients and Methods STUDY DESIGN AND SAMPLE
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study was then to make recommendations on management of geriatric maxillofacial injuries.
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To address the research purpose, the investigators designed and implemented a retrospective case series. The study population was identified using emergency room and inpatient data at two level I
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trauma centers between 2005 and 2015: Legacy Emanuel Medical Center in Portland, Oregon and Memorial Regional Hospital in Hollywood, Florida. To be included in the study, patients had to sustain maxillofacial trauma and be age 75 or greater. Due to the retrospective nature of this study, it was granted written exemption by the institutional review boards at both Legacy Emanuel Medical Center and Memorial Regional Hospital. DATA COLLECTION METHODS
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Patients were identified utilizing age at time of injury and International Classification of Diseases coding (ICD-9 codes) codes to identify maxillofacial injuries. Thereafter, retrospective chart review was used to
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compile data of interest. VARIABLES OF INTEREST
A database of statistical information was then created to sort and analyze the compiled information.
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Variables of interest included patient age at time of injury, gender, mechanism of injury, maxillofacial injury categorization, associated injuries sustained, radiographic studies performed and findings of those
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studies, management of maxillofacial injuries, discharge from emergency room versus inpatient admission, level of care upon admission, and length of stay (LOS). DATA ANALYSIS
With a database of variables of interest created, statistical software was used for quantification of data
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and graphical representation of results. Results
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PATIENTS
One hundred and seventy six patients met inclusion criteria of the study. Patient age ranged from 76 to
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98 years old. The average age for all patients was 85.09 years with a median age of 85. The median age for men was 83 years and the median age for women was 85 years. A total of 176 patients were included in this study. Tables 1 and 2 summarize age and gender data. MECHANISM OF INJURY
Patients were divided into five categories based on mechanism of injury: Ground level fall, pedestrian versus vehicle, motor vehicle collision, blunt assault, and gunshot wound. Ground level falls accounted
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for 153 patients in the study, a vast majority, at 86.9% of all patients. Motor vehicle collisions was the next most frequent mechanism accounting for fourteen patients. There were six gunshot wounds which were all self-inflicted and all resulted in the death of the patient. Finally, one patient was hit by a person
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on a snow sled and two patients sustained blunt assault. See Table 3 for complete detail of mechanism of injury.
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MAXILLOFACIAL FRACTURE PATTERNS
Facial fractures were divided into three broad categories: midface, mandible, and frontal bone. These
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three broad categories were then subdivided into appropriate injuries within those categories. Patients were also divided into those with a single maxillofacial fracture, and those with multiple maxillofacial fractures.
Midface fractures accounted for the largest number of fractures with 88.34% of patients sustaining midfacial fractures. The most common fracture was an orbital floor fracture while nasal bone fractures
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were the second most common fracture. There were 250 midface fractures in the data set. Mandible fractures accounted for 7.42% of maxillofacial fractures in this study. The most common
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location was a condylar fracture with the second most common location consisting of mandibular body fractures. There were 21 mandibular fractures in the data set. Unfortunately, it was not possible to
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classify all mandibular fractures into dentate and edentulous fractures. Finally, frontal bone fractures accounted for the least number of fractures. Anterior table fractures of the frontal sinus, posterior table fractures of the frontal sinus, and non-frontal sinus related fractures accounted for only 4.24% of the fractures in the data set or twelve total fractures.
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Most patients (65.34%) sustained only one facial fracture. Gunshot wounds and motor vehicle collisions were the only mechanisms to result in panfacial fractures. The average number of facial fractures in the data set is 1.61 per patient. Table 4 identifies all facial fractures in the study.
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A Facial Injury Severity Score5 (FISS) was calculated for each patient in the study. The average FISS for all patients was 1.94 with a minimum of 1 and maximum score of 16. The standard deviation for all
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patients FISS was 2.15. ASSOCIATED INJURIES
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An Injury Severity Score6 (ISS) was created for all polytrauma patients in the study. An average ISS of 11.7 was calculated for all polytrauma patients in the study. For patients admitted to a critical care unit, 12.9 was the average ISS. An average ISS of 9.5 was calculated for patients admitted to general care floors and telemetry units.
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Nearly half (48%) of geriatric trauma patients presented with more than isolated maxillofacial trauma. Analysis of associated injuries was completed by dividing patients injuries into four broad categories with subdivision within categories. The four categories are intracranial injuries, spinal injuries, trunk
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injuries, and orthopedic injuries.
Most associated injuries in the data set were intracranial injuries (hemorrhage or contusion within the
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calvarium). Of the 130 associated injuries, there were 70 intracranial injuries accounting for 53.85% of all associated injuries. Of the intracranial injuries, the most common injury was subarachnoid hemorrhage which was twice as common as the next injury, subdural hemorrhage. Spinal injuries accounted for 9.23% of all associated injuries with the majority of spinal injuries being cervical spine injuries. Non-cervical spine injuries accounted for only 25% of spinal injuries.
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Trunk injuries accounted for 13.85% of the associated injuries seen. The most common trunk injury was thorax injury, specifically rib fracture.
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The second most common category of associated injury was extremity orthopedic injuries and 23.08% of associated injuries occurred within this category. Forearm and hand injuries constituted slightly more than 60% of these injuries with humerus and femur injuries making up the balance. Table 5 summarizes
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the concomitant injuries. RADIOGRAPHIC STUDIES
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Patients in this study underwent at least one radiographic study. The imaging modality of choice was CT of the head. In addition, CT scans of other areas, plain films, and ultrasound studies were also frequently obtained.
All but one patient of the 176 patients in the study underwent a CT scan of the head without
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intravenous contrast. A total of 391 radiological studies were performed with CT scans of the head accounting for 44.76% of all studies performed. Interestingly, CT head scans also were the primary modality of diagnosis for fractures in 95% of patients.
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A dedicated CT Face without IV contrast was only required to diagnose 4.6% of facial fractures in this study. There was a significant overlap of findings in patients who had a head CT and maxillofacial CT.
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The significance of this will be discussed later. Plain film radiologic studies accounted for 26.6% of all studies performed. The majority of plain film studies were extremity films and chest radiographs. Focused Assessment with Sonography in Trauma (FAST) exam was performed only four times comprising just 1.02% of exams performed. It had a finding of free air and fluid in one patient.
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Other ultrasound examinations accounted for 5.37% of radiologic exams performed. These studies were often a part of a syncope workup, however some exams were deep vein thrombosis (DVT)
details of all radiologic exams is detailed in Table 6. OPERATIVE INTERVENTION
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surveillance exams. Ultrasound was able to diagnose two instances of DVT in this patient set. Complete
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The patients in this study rarely underwent operative intervention. In all, sixteen patients underwent operative intervention. Most of these sixteen patients underwent open reduction and internal fixation
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(ORIF) of their facial fractures. Those that did not undergo ORIF required only closed reduction of the nasal bones.
Of the patients that underwent operative repair of their maxillofacial injuries, none required more than one surgery. One patient did suffer non-life threatening post-operative hemorrhage, and one patient did expire in hospice following surgery; however, their facial fractures were not the cause of death.
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Operative intervention was only undertaken in 10.8% of cases. LEVEL OF CARE AND HOSPITAL STAY
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Patients age 75 years and greater are often admitted for observation due only to their advanced age and comorbidities even in more benign traumas. Likely due to medical frailty, many doctors will err on
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the side of caution with admittance when making disposition decisions. This is reflected in our patient data set where only forty patients were discharged without at least overnight observation in the hospital. The discharge rate directly from the emergency department was only 22.7%. Once a decision on admittance has been made, the remaining question is the level of care that will be required. In this data set, 69 patients were admitted to general care floors or telemetry units, accounting for 39.2% of patients in the study.
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The remaining patients in the study, aside from one who expired in the ER, were admitted to critical care units. A total of 66 patients were admitted to critical care units or 37.5% of patients in the study.
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However, when looking only at patients who were admitted to the hospital, it became clear that almost half of patients with maxillofacial trauma over age 75 are admitted to a critical care unit. In this study, 48.8% of admitted patients were treated in critical care units.
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The disposition of patients also has a clear link to the total LOS in the hospital. Patients admitted to critical care units had a mean stay of 8.5 days in the hospital compared to 3.0 days for those patients
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admitted to general care floors or telemetry. DEATH
As mentioned previously, elderly patients are more likely to be medically frail compared to younger trauma patients. However, patient deaths were somewhat less common than initially expected.
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A total of 11 patients in the study expired in the hospital as a direct result of their trauma. One of these patients expired in the emergency department, the rest expired in the critical care department. This accounted for a death rate of 6.25%.
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It should be noted, however, that only five of the eleven patients that died sustained unintentional
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trauma. Six of the eleven patient deaths resulted from self-inflicted gunshot wounds. Therefore, a true rate of unintentional deaths from trauma would be 3.4%. The six patients who died from self-inflicted wounds comprised 2.8% of the sample. DISCUSSION
This study was completed to analyze maxillofacial trauma sustained by patients age 75 years and older. By identifying injury patterns in this patient population, recommendations for evaluation and treatment by oral and maxillofacial surgeons are made.
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Patients greater than 75 years of age are at risk of maxillofacial injury from ground level falls7. This is not surprising given that the elderly are already at increased risk of falls8. Patients older than 75 are most likely to sustain midfacial fractures, particularly orbital floor and wall fractures9,10. The fact that
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most injuries are to the midfacial skeleton is not unexpected due to the relative weakness of the bones of the midface compared to the mandible and the calvarium11. Particularly in the elderly there can be significant maxillary sinus pneumatization further weakening the midface if the patients have undergone
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extraction of maxillary teeth12. It is somewhat surprising that orbital floor and wall fractures make up the majority of fractures sustained, as globally nasal fractures are the most common facial fracture13.
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Patients older than 75 with maxillofacial fractures are at a high risk of intracranial injuries, particularly hemorrhage14. Further studies are needed to assess links between therapeutic anticoagulation in these patients and intracranial hemorrhage due to trauma. In addition to intracranial injuries long bone fractures, particularly of the forearm, are a common finding in this group14.
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CT scans are the modality of choice for imaging patients who have sustained trauma15. While the majority of maxillofacial fractures in this study were diagnosed by head CT, a dedicated maxillofacial CT should be recommended based on further clinical findings. Given the most common fractures are
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fractures of the midface which is often imaged only partially with a head CT, clinical signs of trauma should guide additional facial radiologic studies. A study by Holmgren et al.15 indicated that patients with
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oral and facial soft tissue injuries should undergo maxillofacial CT to evaluate for underlying bony injuries, and those severely injured patients that do not undergo maxillofacial CT are at risk of increased LOS as many of these patients will require subsequent scans that could have been completed upon initial presentation.
Geriatric patients with maxillofacial fractures are likely to be admitted to critical care units, which will likely be associated with an increased hospital LOS8.
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This study analyzes data from only two trauma centers, both of which are in the United States. More comprehensive studies utilizing more data from more diverse locations would be required to make broader recommendations for the geriatric population16,17. A further weakness of this study is the
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inability to differentiate between dentate and edentulous patients. Unfortunately, the records did not always state the status of the patient’s dentition, and therefore comments about the effects of dentition on these fractures cannot be made from this study.
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CONCLUSIONS
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Overall, patients over the age of 75 should be counseled regarding potential hazards in the home that could result in falls. The risk of maxillofacial injury in the geriatric population is real and given the frequency of associated comorbidities with these patients there is a real risk of mortality that should not
DISCLOSURES
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be ignored.
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Dr. Dierks is a paid consultant of the KLS Martin Group.
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U.S. Census Bureau: The Older Population: 2010. 2010 Census Briefs: 1, 2011.
2.
Cillo JE, Holmes TM: Interpersonal Violence Is Associated With Increased Severity of Geriatric Facial Trauma., 2016.
3.
Kramarow E, Chen L-H, Hedegaard H, Warner M: Deaths From Unintentional Injury Among Adults Aged 65 and Over: United States, 2000–2013. Natl Cent Heal Stat Data Br: 8, 2015.
4.
Min L, Burruss S, Morley E, Mody L, Hiatt JR, Cryer H, Ha J-K, Tillou A: A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients. J Trauma Acute Care Surg 74: 1125, 2013.
5.
Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE: Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64: 408, 2006.
6.
Baker, Susan P.Brian O’Neill. William Haddon . Willian B Long: The Injury Severity Score: A Method For Describing Patients with Multiple Injuries and Evaluating Emergency Care. J Trauma 14: 187, 1974.
7.
Zelken JA, Khalifian S, Mundinger GS, Ha JS, Manson PN, Rodriguez ED, Dorafshar AH: Defining Predictable Patterns of Craniomaxillofacial Injury in the Elderly: Analysis of 1,047 Patients. J Oral Maxillofac Surg 72: 352, 2014.
8.
Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A: Survey of trauma patients requiring maxillofacial intervention, ages 56 to 91 years, with length of stay analysis. J Oral Maxillofac Surg 60: 1114, 2002.
9.
Chew DJ, Edmondson HD: A study of maxillofacial injuries in the elderly resulting from falls. J Oral Rehabil 23: 505, 1996.
10.
Kloss FR, Tuli T, H??chl O, Laimer K, Jank S, Stempfl K, Rasse M, Gassner R: The impact of ageing on craniomaxillofacial trauma-a comparative investigation. Int J Oral Maxillofac Surg 36: 1158, 2007.
11.
Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H: Cranio-maxillofacial trauma: A 10 year review of 9543 cases with 21 067 injuries. J Cranio-Maxillofacial Surg 31: 51, 2003.
12.
Sharan A, Madjar D: Extractions : A Radiographic Study. Int J Oral Maxillofac Implants 23: 48, 2008.
13.
Hwang K, You S: Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 43: 42, 2010.
14.
Toivari M, Suominen AL, Lindqvist C, Thor En H: Among Patients With Facial Fractures, Geriatric Patients Have an Increased Risk for Associated Injuries., 2016.
15.
Holmgren EP, Dierks EJ, Homer LD, Potter BE: Facial computed tomography use in trauma patients who require a head computed tomogram. J Oral Maxillofac Surg 62: 913, 2004.
17.
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16.
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1.
Zargar M, Khaji A, Karbakhsh M, Zarei MR: Epidemiology study of facial injuries during a 13 month of trauma registry in Tehran. Indian J Med Sci 58: 109, 2004. Filho MAMC, Lima Saintrain MV De, Silveira Dos Anjos RE Da, Pinheiro SS, Carvalho Pádua Cardoso L De, Moizan JAH, Aguiar ASW De: Prevalence of oral and maxillofacial trauma in elders admitted to a reference hospital in Northeastern Brazil. PLoS One 10: 1, 2015.
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Table 1 Age at Incident
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98 76 85.09 5.21
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Maximum Minimum Mean Standard Deviation
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Table 2 Subject Gender
Percent 65.9% 34.1%
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Count 116 60
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Gender Female Male
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Table 3
Mechanism
Percent 86.9% 0.6% 8.0% 1.1% 3.4%
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Ground Level Fall Pedestrian Versus Vehicle Motor Vehicle Collision Blunt Assault Gunshot Wound
Count 153 1 14 2 6
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Mechanism of Injury
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Table 4
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Percent 40.3% 42.0% 22.7% 23.9% 1.7% 1.7% 3.4% 2.3% 2.3% 1.7% 0.6% 0.6% 0.6% 1.7% 0.6% 1.7% 1.7% 2.8% 2.3%
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Count 71 74 40 42 3 3 6 4 4 3 1 1 1 3 1 3 3 5 4
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Fractures Nasal Bone Orbit Floor Orbit Wall Zygomaticomaxillary Complex Zygomatic Arch Isolated Maxillary Sinus Wall Maxillary Alveolar LeFort I LeFort II LeFort III Subcondylar Ramus Angle Body Parasymphysis Symphysis Frontal Bone Anterior Wall of Frontal Sinus Posterior Wall of Frontal Sinus
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Fractures Sustained
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Table 5
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Percent 52.3% 19.3% 9.7% 2.3% 6.8% 4.5% 1.7% 5.7% 2.8% 2.3% 11.4% 4.5%
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Count 92 34 17 4 12 8 3 10 5 4 20 8
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Type None Subarachnoid Hemorrhage Subdural Hematoma Skull Fracture Cerebral Contusion Cervical Spine Injury Other Vertebral Injury Thorax Abdomen Pelvis Long Bone Other Extremity Injury
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Other Injuries Sustained
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Table 6 Radiologic Exams Performed
Percent 59.1% 99.4% 49.4% 2.3%
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Count 104 175 87 4
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Exam Plain Film CT Head CT Other FAST
S0278-2391(17)31344-7
DOI:
10.1016/j.joms.2017.10.019
Reference:
YJOMS 58025
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 30 May 2017 Revised Date:
15 October 2017
Accepted Date: 15 October 2017
Please cite this article as: Shumate R, Portnof J, Amundson M, Dierks E, Batdorf R, Hardigan P, Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review, Journal of Oral and Maxillofacial Surgery (2017), doi: 10.1016/ j.joms.2017.10.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE
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Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review
CORRESPONDING AUTHOR: Robert Shumate, DMD
Chief Resident. Department of Oral and Maxillofacial Surgery Nova Southeastern University. Fort Lauderdale, FL
SC
Correspondence Address: 4121 Gateway Blvd. Newburgh, IN 47630
Fax - 812-426-9984 E-Mail – [email protected]
ADDITIONAL AUTHORS
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Phone – 812-858-3100
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Jason Portnof, DMD, MD, FACS
Associate Clinical Professor. Department of Oral and Maxillofacial Surgery Nova Southeastern University. Fort Lauderdale, FL
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Melissa Amundson, DDS
Private Practice, Head and Neck Surgical Associates. Residency Site Director, Department of Oral and Maxillofacial Surgery, Legacy Emanuel Hospital, Portland, OR
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Eric Dierks, DMD, MD, FACS, FACD
Senior Consultant, Head and Neck Institute, and Affiliate Professor, Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, OR
Robert Batdorf, BS
Dental Student. Nova Southeastern University College of Dental Medicine. Fort Lauderdale, FL
Patrick Hardigan, PhD Professor. Nova Southeastern University College of Dental Medicine. Fort Lauderdale, FL
ACCEPTED MANUSCRIPT
Recommendations for Care of Geriatric Maxillofacial Trauma Patients Following a Retrospective Ten Year Multicenter Review Purpose: The purpose of this study was to analyze maxillofacial trauma sustained by patients age 75
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years and older. With the injury patterns identified treatment recommendations for the contemporary oral and maxillofacial surgeon are made.
Patients and Methods: This study was a retrospective case series using data from two level I trauma
SC
centers. The variables of interest included age at traumatic event, gender, mechanism of trauma, concomitant injuries, radiographic studies performed, management of maxillofacial injuries, and
M AN U
disposition. Numerical analysis was completed with statistical software.
Results: One hundred and seventy-six patients age 75 years and older who sustained facial trauma were identified. Ground level falls cause the majority of maxillofacial trauma in the geriatric population. The median age at the time of trauma was 83 and 85 for men and women respectively. The most common
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injuries were midface fractures. Intracranial hemorrhage was the most common concomitant injury, and all but one patient underwent computed tomography (CT) of at least the head after their traumatic
EP
event. The majority of the maxillofacial injuries were treated without operative repair.
Conclusions: The information gained from this study suggests that oral and maxillofacial surgeons
AC C
should counsel geriatric patients regarding risk of falls, as well as encourage prevention of potential hazards for falls in their homes.
ACCEPTED MANUSCRIPT
In the United States 6% of the population is over the age of 751. Current trends indicate that this percentage will increase significantly by the year 2050. Between 2000 and 2010 this segment of the population increased by approximately 2 million people1. As the geriatric population continues to grow,
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concerns with treatment of maxillofacial trauma in this population will also grow2.
Unintentional injuries are the eighth leading cause of death in the geriatric population3, with more than half of these deaths attributed to falls. With more people living to advanced ages, it can be expected
SC
that trauma patients within this population will also grow. Due to medical comorbidities this population requires more frequent admission, often at an increased level of care4. Additionally, the geriatric
M AN U
population is at a higher risk of death from injuries versus younger patients with similar injuries. The specific aim of this study was to evaluate the injury patterns in patients over age 75 paying particular attention to mechanism, injury patterns, hospitalization time. Finally, the overall goal of this
Patients and Methods STUDY DESIGN AND SAMPLE
TE D
study was then to make recommendations on management of geriatric maxillofacial injuries.
EP
To address the research purpose, the investigators designed and implemented a retrospective case series. The study population was identified using emergency room and inpatient data at two level I
AC C
trauma centers between 2005 and 2015: Legacy Emanuel Medical Center in Portland, Oregon and Memorial Regional Hospital in Hollywood, Florida. To be included in the study, patients had to sustain maxillofacial trauma and be age 75 or greater. Due to the retrospective nature of this study, it was granted written exemption by the institutional review boards at both Legacy Emanuel Medical Center and Memorial Regional Hospital. DATA COLLECTION METHODS
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Patients were identified utilizing age at time of injury and International Classification of Diseases coding (ICD-9 codes) codes to identify maxillofacial injuries. Thereafter, retrospective chart review was used to
RI PT
compile data of interest. VARIABLES OF INTEREST
A database of statistical information was then created to sort and analyze the compiled information.
SC
Variables of interest included patient age at time of injury, gender, mechanism of injury, maxillofacial injury categorization, associated injuries sustained, radiographic studies performed and findings of those
M AN U
studies, management of maxillofacial injuries, discharge from emergency room versus inpatient admission, level of care upon admission, and length of stay (LOS). DATA ANALYSIS
With a database of variables of interest created, statistical software was used for quantification of data
TE D
and graphical representation of results. Results
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PATIENTS
One hundred and seventy six patients met inclusion criteria of the study. Patient age ranged from 76 to
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98 years old. The average age for all patients was 85.09 years with a median age of 85. The median age for men was 83 years and the median age for women was 85 years. A total of 176 patients were included in this study. Tables 1 and 2 summarize age and gender data. MECHANISM OF INJURY
Patients were divided into five categories based on mechanism of injury: Ground level fall, pedestrian versus vehicle, motor vehicle collision, blunt assault, and gunshot wound. Ground level falls accounted
ACCEPTED MANUSCRIPT
for 153 patients in the study, a vast majority, at 86.9% of all patients. Motor vehicle collisions was the next most frequent mechanism accounting for fourteen patients. There were six gunshot wounds which were all self-inflicted and all resulted in the death of the patient. Finally, one patient was hit by a person
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on a snow sled and two patients sustained blunt assault. See Table 3 for complete detail of mechanism of injury.
SC
MAXILLOFACIAL FRACTURE PATTERNS
Facial fractures were divided into three broad categories: midface, mandible, and frontal bone. These
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three broad categories were then subdivided into appropriate injuries within those categories. Patients were also divided into those with a single maxillofacial fracture, and those with multiple maxillofacial fractures.
Midface fractures accounted for the largest number of fractures with 88.34% of patients sustaining midfacial fractures. The most common fracture was an orbital floor fracture while nasal bone fractures
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were the second most common fracture. There were 250 midface fractures in the data set. Mandible fractures accounted for 7.42% of maxillofacial fractures in this study. The most common
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location was a condylar fracture with the second most common location consisting of mandibular body fractures. There were 21 mandibular fractures in the data set. Unfortunately, it was not possible to
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classify all mandibular fractures into dentate and edentulous fractures. Finally, frontal bone fractures accounted for the least number of fractures. Anterior table fractures of the frontal sinus, posterior table fractures of the frontal sinus, and non-frontal sinus related fractures accounted for only 4.24% of the fractures in the data set or twelve total fractures.
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Most patients (65.34%) sustained only one facial fracture. Gunshot wounds and motor vehicle collisions were the only mechanisms to result in panfacial fractures. The average number of facial fractures in the data set is 1.61 per patient. Table 4 identifies all facial fractures in the study.
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A Facial Injury Severity Score5 (FISS) was calculated for each patient in the study. The average FISS for all patients was 1.94 with a minimum of 1 and maximum score of 16. The standard deviation for all
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patients FISS was 2.15. ASSOCIATED INJURIES
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An Injury Severity Score6 (ISS) was created for all polytrauma patients in the study. An average ISS of 11.7 was calculated for all polytrauma patients in the study. For patients admitted to a critical care unit, 12.9 was the average ISS. An average ISS of 9.5 was calculated for patients admitted to general care floors and telemetry units.
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Nearly half (48%) of geriatric trauma patients presented with more than isolated maxillofacial trauma. Analysis of associated injuries was completed by dividing patients injuries into four broad categories with subdivision within categories. The four categories are intracranial injuries, spinal injuries, trunk
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injuries, and orthopedic injuries.
Most associated injuries in the data set were intracranial injuries (hemorrhage or contusion within the
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calvarium). Of the 130 associated injuries, there were 70 intracranial injuries accounting for 53.85% of all associated injuries. Of the intracranial injuries, the most common injury was subarachnoid hemorrhage which was twice as common as the next injury, subdural hemorrhage. Spinal injuries accounted for 9.23% of all associated injuries with the majority of spinal injuries being cervical spine injuries. Non-cervical spine injuries accounted for only 25% of spinal injuries.
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Trunk injuries accounted for 13.85% of the associated injuries seen. The most common trunk injury was thorax injury, specifically rib fracture.
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The second most common category of associated injury was extremity orthopedic injuries and 23.08% of associated injuries occurred within this category. Forearm and hand injuries constituted slightly more than 60% of these injuries with humerus and femur injuries making up the balance. Table 5 summarizes
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the concomitant injuries. RADIOGRAPHIC STUDIES
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Patients in this study underwent at least one radiographic study. The imaging modality of choice was CT of the head. In addition, CT scans of other areas, plain films, and ultrasound studies were also frequently obtained.
All but one patient of the 176 patients in the study underwent a CT scan of the head without
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intravenous contrast. A total of 391 radiological studies were performed with CT scans of the head accounting for 44.76% of all studies performed. Interestingly, CT head scans also were the primary modality of diagnosis for fractures in 95% of patients.
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A dedicated CT Face without IV contrast was only required to diagnose 4.6% of facial fractures in this study. There was a significant overlap of findings in patients who had a head CT and maxillofacial CT.
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The significance of this will be discussed later. Plain film radiologic studies accounted for 26.6% of all studies performed. The majority of plain film studies were extremity films and chest radiographs. Focused Assessment with Sonography in Trauma (FAST) exam was performed only four times comprising just 1.02% of exams performed. It had a finding of free air and fluid in one patient.
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Other ultrasound examinations accounted for 5.37% of radiologic exams performed. These studies were often a part of a syncope workup, however some exams were deep vein thrombosis (DVT)
details of all radiologic exams is detailed in Table 6. OPERATIVE INTERVENTION
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surveillance exams. Ultrasound was able to diagnose two instances of DVT in this patient set. Complete
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The patients in this study rarely underwent operative intervention. In all, sixteen patients underwent operative intervention. Most of these sixteen patients underwent open reduction and internal fixation
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(ORIF) of their facial fractures. Those that did not undergo ORIF required only closed reduction of the nasal bones.
Of the patients that underwent operative repair of their maxillofacial injuries, none required more than one surgery. One patient did suffer non-life threatening post-operative hemorrhage, and one patient did expire in hospice following surgery; however, their facial fractures were not the cause of death.
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Operative intervention was only undertaken in 10.8% of cases. LEVEL OF CARE AND HOSPITAL STAY
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Patients age 75 years and greater are often admitted for observation due only to their advanced age and comorbidities even in more benign traumas. Likely due to medical frailty, many doctors will err on
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the side of caution with admittance when making disposition decisions. This is reflected in our patient data set where only forty patients were discharged without at least overnight observation in the hospital. The discharge rate directly from the emergency department was only 22.7%. Once a decision on admittance has been made, the remaining question is the level of care that will be required. In this data set, 69 patients were admitted to general care floors or telemetry units, accounting for 39.2% of patients in the study.
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The remaining patients in the study, aside from one who expired in the ER, were admitted to critical care units. A total of 66 patients were admitted to critical care units or 37.5% of patients in the study.
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However, when looking only at patients who were admitted to the hospital, it became clear that almost half of patients with maxillofacial trauma over age 75 are admitted to a critical care unit. In this study, 48.8% of admitted patients were treated in critical care units.
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The disposition of patients also has a clear link to the total LOS in the hospital. Patients admitted to critical care units had a mean stay of 8.5 days in the hospital compared to 3.0 days for those patients
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admitted to general care floors or telemetry. DEATH
As mentioned previously, elderly patients are more likely to be medically frail compared to younger trauma patients. However, patient deaths were somewhat less common than initially expected.
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A total of 11 patients in the study expired in the hospital as a direct result of their trauma. One of these patients expired in the emergency department, the rest expired in the critical care department. This accounted for a death rate of 6.25%.
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It should be noted, however, that only five of the eleven patients that died sustained unintentional
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trauma. Six of the eleven patient deaths resulted from self-inflicted gunshot wounds. Therefore, a true rate of unintentional deaths from trauma would be 3.4%. The six patients who died from self-inflicted wounds comprised 2.8% of the sample. DISCUSSION
This study was completed to analyze maxillofacial trauma sustained by patients age 75 years and older. By identifying injury patterns in this patient population, recommendations for evaluation and treatment by oral and maxillofacial surgeons are made.
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Patients greater than 75 years of age are at risk of maxillofacial injury from ground level falls7. This is not surprising given that the elderly are already at increased risk of falls8. Patients older than 75 are most likely to sustain midfacial fractures, particularly orbital floor and wall fractures9,10. The fact that
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most injuries are to the midfacial skeleton is not unexpected due to the relative weakness of the bones of the midface compared to the mandible and the calvarium11. Particularly in the elderly there can be significant maxillary sinus pneumatization further weakening the midface if the patients have undergone
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extraction of maxillary teeth12. It is somewhat surprising that orbital floor and wall fractures make up the majority of fractures sustained, as globally nasal fractures are the most common facial fracture13.
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Patients older than 75 with maxillofacial fractures are at a high risk of intracranial injuries, particularly hemorrhage14. Further studies are needed to assess links between therapeutic anticoagulation in these patients and intracranial hemorrhage due to trauma. In addition to intracranial injuries long bone fractures, particularly of the forearm, are a common finding in this group14.
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CT scans are the modality of choice for imaging patients who have sustained trauma15. While the majority of maxillofacial fractures in this study were diagnosed by head CT, a dedicated maxillofacial CT should be recommended based on further clinical findings. Given the most common fractures are
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fractures of the midface which is often imaged only partially with a head CT, clinical signs of trauma should guide additional facial radiologic studies. A study by Holmgren et al.15 indicated that patients with
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oral and facial soft tissue injuries should undergo maxillofacial CT to evaluate for underlying bony injuries, and those severely injured patients that do not undergo maxillofacial CT are at risk of increased LOS as many of these patients will require subsequent scans that could have been completed upon initial presentation.
Geriatric patients with maxillofacial fractures are likely to be admitted to critical care units, which will likely be associated with an increased hospital LOS8.
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This study analyzes data from only two trauma centers, both of which are in the United States. More comprehensive studies utilizing more data from more diverse locations would be required to make broader recommendations for the geriatric population16,17. A further weakness of this study is the
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inability to differentiate between dentate and edentulous patients. Unfortunately, the records did not always state the status of the patient’s dentition, and therefore comments about the effects of dentition on these fractures cannot be made from this study.
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CONCLUSIONS
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Overall, patients over the age of 75 should be counseled regarding potential hazards in the home that could result in falls. The risk of maxillofacial injury in the geriatric population is real and given the frequency of associated comorbidities with these patients there is a real risk of mortality that should not
DISCLOSURES
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be ignored.
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Dr. Dierks is a paid consultant of the KLS Martin Group.
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U.S. Census Bureau: The Older Population: 2010. 2010 Census Briefs: 1, 2011.
2.
Cillo JE, Holmes TM: Interpersonal Violence Is Associated With Increased Severity of Geriatric Facial Trauma., 2016.
3.
Kramarow E, Chen L-H, Hedegaard H, Warner M: Deaths From Unintentional Injury Among Adults Aged 65 and Over: United States, 2000–2013. Natl Cent Heal Stat Data Br: 8, 2015.
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Min L, Burruss S, Morley E, Mody L, Hiatt JR, Cryer H, Ha J-K, Tillou A: A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients. J Trauma Acute Care Surg 74: 1125, 2013.
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Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Hommer L, Potter BE: Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 64: 408, 2006.
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Baker, Susan P.Brian O’Neill. William Haddon . Willian B Long: The Injury Severity Score: A Method For Describing Patients with Multiple Injuries and Evaluating Emergency Care. J Trauma 14: 187, 1974.
7.
Zelken JA, Khalifian S, Mundinger GS, Ha JS, Manson PN, Rodriguez ED, Dorafshar AH: Defining Predictable Patterns of Craniomaxillofacial Injury in the Elderly: Analysis of 1,047 Patients. J Oral Maxillofac Surg 72: 352, 2014.
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Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A: Survey of trauma patients requiring maxillofacial intervention, ages 56 to 91 years, with length of stay analysis. J Oral Maxillofac Surg 60: 1114, 2002.
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Chew DJ, Edmondson HD: A study of maxillofacial injuries in the elderly resulting from falls. J Oral Rehabil 23: 505, 1996.
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Kloss FR, Tuli T, H??chl O, Laimer K, Jank S, Stempfl K, Rasse M, Gassner R: The impact of ageing on craniomaxillofacial trauma-a comparative investigation. Int J Oral Maxillofac Surg 36: 1158, 2007.
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Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H: Cranio-maxillofacial trauma: A 10 year review of 9543 cases with 21 067 injuries. J Cranio-Maxillofacial Surg 31: 51, 2003.
12.
Sharan A, Madjar D: Extractions : A Radiographic Study. Int J Oral Maxillofac Implants 23: 48, 2008.
13.
Hwang K, You S: Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 43: 42, 2010.
14.
Toivari M, Suominen AL, Lindqvist C, Thor En H: Among Patients With Facial Fractures, Geriatric Patients Have an Increased Risk for Associated Injuries., 2016.
15.
Holmgren EP, Dierks EJ, Homer LD, Potter BE: Facial computed tomography use in trauma patients who require a head computed tomogram. J Oral Maxillofac Surg 62: 913, 2004.
17.
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Zargar M, Khaji A, Karbakhsh M, Zarei MR: Epidemiology study of facial injuries during a 13 month of trauma registry in Tehran. Indian J Med Sci 58: 109, 2004. Filho MAMC, Lima Saintrain MV De, Silveira Dos Anjos RE Da, Pinheiro SS, Carvalho Pádua Cardoso L De, Moizan JAH, Aguiar ASW De: Prevalence of oral and maxillofacial trauma in elders admitted to a reference hospital in Northeastern Brazil. PLoS One 10: 1, 2015.
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Table 1 Age at Incident
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98 76 85.09 5.21
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Maximum Minimum Mean Standard Deviation
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Table 2 Subject Gender
Percent 65.9% 34.1%
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Count 116 60
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Gender Female Male
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Table 3
Mechanism
Percent 86.9% 0.6% 8.0% 1.1% 3.4%
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Ground Level Fall Pedestrian Versus Vehicle Motor Vehicle Collision Blunt Assault Gunshot Wound
Count 153 1 14 2 6
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Mechanism of Injury
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Table 4
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Percent 40.3% 42.0% 22.7% 23.9% 1.7% 1.7% 3.4% 2.3% 2.3% 1.7% 0.6% 0.6% 0.6% 1.7% 0.6% 1.7% 1.7% 2.8% 2.3%
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Count 71 74 40 42 3 3 6 4 4 3 1 1 1 3 1 3 3 5 4
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Fractures Nasal Bone Orbit Floor Orbit Wall Zygomaticomaxillary Complex Zygomatic Arch Isolated Maxillary Sinus Wall Maxillary Alveolar LeFort I LeFort II LeFort III Subcondylar Ramus Angle Body Parasymphysis Symphysis Frontal Bone Anterior Wall of Frontal Sinus Posterior Wall of Frontal Sinus
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Fractures Sustained
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Table 5
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Percent 52.3% 19.3% 9.7% 2.3% 6.8% 4.5% 1.7% 5.7% 2.8% 2.3% 11.4% 4.5%
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Count 92 34 17 4 12 8 3 10 5 4 20 8
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Type None Subarachnoid Hemorrhage Subdural Hematoma Skull Fracture Cerebral Contusion Cervical Spine Injury Other Vertebral Injury Thorax Abdomen Pelvis Long Bone Other Extremity Injury
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Other Injuries Sustained
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Table 6 Radiologic Exams Performed
Percent 59.1% 99.4% 49.4% 2.3%
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Count 104 175 87 4
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Exam Plain Film CT Head CT Other FAST