lnt. J. Oral Maxillofac. Surg.

1995;24:409-412 Copyright 9 Munksgaard 1995

Printed in Denmark. All rights reserved
lnternaaonalJournalr
Oral&
MaxillofacialSurgery
ISSN 0901-5027

Trauma; oral surgery

Maxillofacial and associated K. E. Down, D.A. Boot, D. F. Gorman

Regional Centre for Maxillofacial Surgery,
Walton Hospital, Liverpool, UK

injuries in severely traumatized

patients: implications of a
regional survey
K. E. Down, D. A. Boot, D. F. Gorman." Maxillofacial and associated injuries in
severely traurnatized patients: implications o f a regional survey. Int. J. Oral Maxillo-
fac. Surg. 1995; 24: 409-412. 9 Munksgaard, 1995

Abstract. The aim of this paper was to study the incidence and causes of facial
injuries occurring in conjunction with major trauma, and to examine the role
of the maxillofacial surgeon in the management of severely injured patients. A
prospective study was undertaken of 1088 patients seen in 16 hospitals over a 1-
year period. A total of 161 (15%) patients sustained facial injuries. Of these, 33%
died at the scene of the incident and 21% died in hospital, There was poor
resuscitation in 32% of patients, and a total of 32 injuries were missed in 19
patients. The involvement of the maxillofacial surgeon in the management of
severely injured patients is examined. Our findings emphasize the need for early Key words: maxillofacial injuries; multiple
referral to the maxillofacial surgeon. It is concluded that maxiUofacial surgery trauma.
should be an on-site speciality, closely associated with the neurosurgical centre. Accepted for publication 14 'June 1995

There is increasing recognition that pa- of the maxillofacial surgeon in the man- 1) All survivors of trauma with an Injury Se-
tients who have sustained multiple agement of severely injured patients. verity Score (ISS) over 15 (see below)
trauma benefit from early multidisci- 2) All victims of trauma who died, except
plinary management within a special- elderly patients with isolated neck of fe-
Material and methods mur fractures, or minor pelvic fractures.
ized unit, or trauma centre 7. The advan-
Sixteen hospitals in the Mersey Region of
tages of a trauma team leader and All victims of severe trauma were included
England and North Wales participated in the
agreed treatment protocols, along with in a prospective, epidemiologic study, over a
survey. The total population served was 3.2
rapid on-site surgical subspeciality in- period of 1 year, from 1 May 1989 until 30
million in a confined region.
volvement, lead to a more ordered and April 1990. Criteria for patient inclusion
were as follows:
logical approach to the management of
major trauma 2~. Table 2. Maxillofacial bony injuries
Facial injuries occur in a significant Injury No. of patients
proportion of patients admitted with
multiple trauma. The importance of Mandibular 46
Table 1. Place of injury Zygoma 27
early involvement of the oral and max-
No. of Le Fort 27
illofacial surgeon in the assessment and Place of injury patients Percentage Nasoethmoidal 19
treatment of these patients has been Dentoalveolar 15
emphasized previously5. Road 112 70%
Supraorbital rim 4
Other public place 27 17%
The aim of this paper was to study Orbital floor 2
Home 13 8%
the incidence and cause of facial in- Orbit NFS 3
Work 9 5%
juries occurring in conjunction with Maxilla NFS 2
major trauma and to examine the role Total 161
NFS: Not further specified.
410 D o w n et al.

Vehicle driver

Rut sut ~ 10

Front smt passenger ~ s

Pe~dz~n 28

Motor c y ~ 22

Pillion passenger m 3
- ,. 9
Fall - he~ht 21

Fall - level l "

Cy~ 1 3
Assault ~ 6
Spo~ II1
Other 16
I
5 10 15 20 25 30 35 40 45
Nundx~ of la~tlents

Fig. 1. Mechanism of injury.

-Q

Information was documented prospect-
ively, by ambulance personnel, nurses, and
doctors, from the time of the emergency call
to discharge or death. Comprehensive forms
were used to record data. Data recorded in-
cluded personal details, accident scene, in-
jury mechanism, physiological variables, and
injury description and treatment. Cause of
death was determined by autopsy. Retrospec-
tive analysis of case notes was carried out
where possible.
Two internationally recognized parameters
were used tb record injury as follows.

A b b r e v i a t e d Injury'Scale ;
Table 3. Facial soft-tissue injuries Injuries were recorded using the Abbreviated
AIS score Injury No. Injury Scale (AIS) 1. Every injury is assigned
a six-digit code based on its anatomic site,
1 Superficial abrasions, contusions, and lacerations 38 nature, and severity. The sixth digit (the AIS
2 Abrasions, contusions, and avulsion injuries involving ,~<25 cm 2 skin; score) describes the severity of the injury,
lacerations into subcutaneous tissue t>5 cm 30 from 1 (minor) or 6 (fatal).
3 Avulsion injuries involving >25 cm 2 skin; Pharyngeal haematoma;
Complex penetrating injury to neck 3
Injury Severity S c o r e
AIS: Abbreviated Injury Scale.
The overall severity of multiple injuries has
been quantified using the ISS 4. The ISS is the
sum of the squares of the highest AIS score

=
in three of the six predetermined regions of
Spinal Injuries 20 the body. The maximum ISS is 75
(52+52+52). Severe trauma is defined by an
ISS over 158.
Abdominal Injuries 17
Results

A total o f 1088 victims o f severe t r a u m a

Chestl~uries were included in the study, o f w h o m 658

Table 4. MaxiHbfacial injury and ISS

Orthopaedic Injuries
AIS score of facial No. of Median
injuries ~' patients ISS
i 1 "Minor,' 8 23
Head Injuries 89 2 "Moderate" 35 31.5
I 3 "Serious" 57 29
r i
o lO 20 30 40 50 60 70 80 90 4 "Severe" 8 35
Number of patients Total 108
Fig. 3. Associated injuries. ISS: Injury Severity Score.
 M a x i l l o f a c i a l injury in severe t r a u m a 411
Multiple injuries were deemed to be
Cause of death at scene of incident the cause of death in 60%-of victims at
the scene of the incident. Head injuries
PENETRATING were the major cause of death in hospi-
INJURIES SPINAL tal (Fig. 2).
A total of 161 severely injured pa-
8gj~ERSIET
~//INJURIES2% tients sustained facial injuries, and 108
of them were admitted to hospital.
I These 108 patients are examined in
more detail.

HEADINJURIES~ i
9 Maxillofaclal injuries
MULTIPLE The maxillofacial bony injuries sus-
INJURIES tained are listed in Table 2. The soft-
60%
tissue facial injuries recorded are pre-
sented in Table 3. The majority of facial
RESPIRAT
f

soft-tissue injuries were "minor" (AIS

OBSTRUCTION 1) or "moderate" (AIS 2). three "ser-
2% ious" injuries (AIS 3) were documented:
an avulsion injury, a pharyngeal haema-
toma, and a complex penetrating injury
of the neck.
Table 4 shows that the severity of
Cause of hospital deaths maxillofacial injuries does not correlate
SPINAL with the overall severity of injuries sus-
INJURIES ABDOMINAL tained.
9%. INJURIES
PENETRATI
INJURIESNG
~ k\ // 3% /INJURIES
MULTIPLE
Maxillofacial management
. 15% Of the 108 patients admitted with facial
injuries, 66 (61%), were referred to max-
illofacial surgeons. Seventy-seven per
CHEST" ~ ~ ~ RESPIRATORY cent of referrals occurred within 24 h
INJ3U;IES ~ OBSTRU%CTION after admission. There was a delay in
the referral of six patients, resulting in
four of these patients having separate
general anaesthetics for maxillofacial
and orthopaedic procedures. Forty-two
patients received treatment by maxillo-
facial surgeons (Table 5).
HEADINJURIES
64%
Associated injuries
Head injuries were the most frequently
Fig. 2. Cause of death. associated injuries, occurring in 89 pa-
tients (82%) (Fig. 3).

were admitted to hospital. A total of
161 patients (15%) sustained facial in-
juries. The following data are con-
Table 5. Maxillofacial treatment
Procedure
Conservative treatment
Local anaesthetic procedure
General anaesthetic procedure
Maxillofacial surgeons only
Other specialities
Total
cerned with these t61 patients. Case-
note retrieval for this group was 82%.
The age range was from 1 to 92 years,
with the most frequent age for injury
being 17 years. The male to female ratio
was 3 : 1.
Road traffic accidents accounted for
No. of
patients 70% of severe trauma with facial in-
juries (Table 1). The mechanisms of in-
14 jury are presented in Fig. 1. Of the 161
7 Airway management
people injured, 53 (33%) died at the
25 scene of the incident or in transit to
20 hospital. A further 34 people (21%)
died in hospital. The overall survival
66
was 46%.
Missed injuries
There were 19 patients in whom injuries
were not diagnosed at initial presen-
tation, often resulting in a failure to
provide the requisite treatment. A total
of 32 injuries were missed, including
four maxillofacial injuries (Table 6).
Review of case notes shows that resusci-
tation was inadequate in 32% of pa-
tients. Particular omissions in airway
management are presented in Table 7.
412 Down et aL
Table 6. Missed injuries
Head and neck
Le Fort II
Mandibular body
Mandibular condyle
Tooth
Epidural haematoma
Subdural haematoma
Intracerebral haematoma
Skull
Spine
Complete thoracic cord syndrome
Complete cervical cord syndrome
Incomplete cervical cord syndrome
Abdomen
Spleen lacerations
Liver laceration
Discussion
This study evaluated the incidence of
facial trauma in severely injured pa-
tients. The areal~involved in the study
was extensive and can be considered as
representative of England and Wales.
A large proportion, 15%, of major
trauma victims sustained facial injuries.
Of the 658 seriously injured patients ad-
mitted, 108 0 6 % ) sustained facial in-
juries. Clearly, the maxillofacial sur-
geon is an essential component in plan-
ning for trauma care by virtue of the
large proportion of severely trauma-
tized patients sustaining facial injuries.
Early involvement of the maxillo-
facial surgeon in multiple trauma is es-
sential to diagnose accurately and treat
facial injuries. This would ensure access
to the "window of opportunity" in or-
der that facial injuries may be treated in
conjunction with orthopaedic and head
Table 7. Omissions in airway management
Chest No. of
1 Flail chest 2 Omission patients
1 Myocardial contusion 1 Delayed intubation 16
1 Pneumothorax l
Inadequate supplemental oxygen 9
1 Haemopnemothorax 1
No arterial blood gases 8
2 Lung contusion 1 Missed chest injuries 5
1 Sternum 3 Inadequate cervical spine
1 Rib 2 assessment 3
1 Inappropriate opiates given 2
Orthopaedic
No escort for transfer 2
Pelvic 2 Inadequate chest drain 2
1 Tibia 1 No chest x-ray 1
1 Metatarsal 1
1 Metacarpal 1
Finger 1
2
1 4. BAKERSP, O'NEILL B, HADDONW, LONG
WB. The Injury Severity Score: a method
for describing patients with multiple in-
juries and evaluating emergency care. J
injuries. It is desirable that maxillofacial Trauma 1974: 14: 187-96.
expertise be immediately available. 5. HAYTERJP, WARDAJ, SMITHEJ. Maxillo-
The high incidence of accompanying facial trauma in severely injured patients.
head injuries suggests that the maxillo- Br J Oral Maxillofac Surg 1991: 29: 370-
facial unit should be closely affiliated 3.
with the regional neurosurgical centre. 6. REDMONDAD, JOHNSTONES, MARYOSHJ,
We advocate that all staff involved in TEMPLETONJ. A trauma centre in the UK.
trauma management have knowledge Am R Coll Surg Engl 1993: 75:317 20.
7. ROYAL COLLEGEOF SURGEONSOF ENG-
and experience of a logical system of LAND. (1988). Report of the Working
trauma management, such as Advanced Party on the Management of Patients
Trauma Life Support 3, if deficiencies in with Major Injuries.
patient care are to be avoided. 8. SMITH E J, WARD A J, SMITH D. Trauma
scoring methods. Br J Hosp Med 1990:
44:114-8.
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