|Year : 2019 | Volume
| Issue : 2 | Page : 87-92
Clinicodemographic characteristics of maxillofacial fractures with concomitant injuries in a tertiary hospital in north-central Nigeria
Benjamin I Akhiwu1, Helen O Akhiwu2, Samuel Lassa3, Moses Chingle3, Simon Yiltok4
1 Department Dental and Maxillofacial Surgery, Jos University Teaching Hospital/University of Jos, Jos, Nigeria
2 Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
3 Community Medicine Department, Jos University Teaching Hospital/University of Jos, Jos, Nigeria
4 Division of Plastic and Reconstructive Surgery, Department of Surgery, Jos University Teaching Hospital/University of Jos, Jos, Nigeria
|Date of Submission||28-Jun-2019|
|Date of Decision||29-Jul-2019|
|Date of Acceptance||09-Sep-2019|
|Date of Web Publication||13-Dec-2019|
Dr. Benjamin I Akhiwu
Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, University of Jos/Jos University Teaching Hospital, Lamingo, Permanent site
Source of Support: None, Conflict of Interest: None
Background: Maxillofacial injuries are any physical trauma to the soft tissues, bony structures, and special regions of the face. They are significant because injuries to this region can result in serious damage to sight, smell, breathing, eating, and talking. This study aims to describe the clinicodemographic characteristics of maxillofacial fractures seen in a teaching hospital and the types of concomitant injuries in these patients. Materials and Methods: This is a cross-sectional study of patients with maxillofacial fractures seen in a tertiary center. The study population was made up of 123 patients seen between January 2015 and December 2017. The independent variables were the demographic and clinical variables as well as the pattern of maxillofacial facial fractures whereas the outcome variable was concomitant injuries and maxillofacial fractures. Results: A total of 123 patients with maxillofacial fractures were recruited of which 80 patients had associated concomitant injuries. The male-to-female ratio was 7.2:1 with a mean age of 33.7 ± 10.2 years. The age group 21 to 30 years was most commonly affected whereas the unemployed and students were more predisposed. The most common fracture type in maxillofacial fracture patients was the zygomatic complex fractures whereas the most common fracture type was a combined facial and mandibular fracture in patients with concomitant injury. Concomitant injuries occurred in up to 65% of patients with maxillofacial fractures. The most common site of concomitant injuries was the upper limbs followed by the lower limbs. Conclusion: Concomitant injuries are commonly found to accompany maxillofacial fractures, hence the need for the managing team to look out for them.
Keywords: Concomitant injuries, maxillofacial fractures, tertiary hospital
|How to cite this article:|
Akhiwu BI, Akhiwu HO, Lassa S, Chingle M, Yiltok S. Clinicodemographic characteristics of maxillofacial fractures with concomitant injuries in a tertiary hospital in north-central Nigeria. J Med Trop 2019;21:87-92
|How to cite this URL:|
Akhiwu BI, Akhiwu HO, Lassa S, Chingle M, Yiltok S. Clinicodemographic characteristics of maxillofacial fractures with concomitant injuries in a tertiary hospital in north-central Nigeria. J Med Trop [serial online] 2019 [cited 2020 Jan 25];21:87-92. Available from: http://www.jmedtropics.org/text.asp?2019/21/2/87/272914
| Introduction|| |
The facial skeleton is one of the most complex arrangements of bony structures in the body and consists of the mandible, maxilla, zygoma, bony walls of the nasal cavities, paranasal sinuses, and the orbit.,
Maxillofacial injuries are defined as any physical trauma to the facial soft tissues, bony structures, the special regions of the face (e.g., the eyes, salivary glands, and facial nerves) or the teeth and surrounding dental structures., Maxillofacial injuries are clinically significant because the anatomical peculiarities of the face enables it to provide protection to important vital organs such as the brain, eyes, digsetive and respiratory systems. Injuries to this region can result in serious damage to sight, smell, breathing, eating, and talking that has a negative impact on the victim’s quality of life.
Facial fractures often result in serious morbidity and are sometimes associated with fatal consequences. According to a study carried out in 2011, in the United States, facial fractures accounted for over 407,000 emergency room visits per year, representing nearly 1 billion dollars in hospital bills. In reports from Greece and Iran, the prevalence of maxillofacial fractures in trauma patients has been reported to range from 46.1% to 74.4%., In Nigeria, there is a general consensus that the rate of maxillofacial fractures in trauma patients are significant but very few authors have actually put a figure to this claim. It is important to note that facial fractures have become a public health issue in many parts of Nigeria and globally owing to the attendant mortality, morbidity, and huge socioeconomic consequences. This statement is further supported by the study carried out by Bun in 2012. The author studied road traffic accidents in Nigeria and reported that the overall road traffic injury rate in Nigeria was about 41 per 1000 population and mortality from road traffic injuries was about 1.6 per 1000 population.
In Ibadan, southwest Nigeria, the prevalence of maxillofacial fractures over two 4-year periods, 13 years apart, was studied and it was observed that there was a 42% raise in the prevalence of maxillofacial fractures in more recent times. These rising trends have been attributed to the following: changes in population patterns, increasing industrialization and urbanization, as well as the increased mobilization of youths in search of employment. Others include deteriorating infrastructure, driving under the influence of drugs and alcohol, noncompliance with the use of seat belt, and crash helmet legislation., Hence, maxillofacial trauma is becoming a burden and a leading medical problem in emergency rooms worldwide. Knowledge of injuries associated with maxillofacial fractures is vital for the early stabilization and establishment of treatment protocols for these patients in the emergency departments. There is a considerable variation in the rate of injuries concomitant with maxillofacial fractures ranging from 12% to 22.2% that goes to influence the prognosis in these patients.,,, The prognosis of the injured patient is dependent on both the initial emergency treatment and the eventual definitive treatment given to the victim. Both forms of treatment are dependent on availability of the necessary facilities and expertise in a given health facility that attends to the patient.
Hence, this study was carried out to determine the pattern of maxillofacial fractures with concomitant injuries. The resultant data would be essential for identifying patients who would need more intensive intervention in the emergency room and hence improve patient survival.
| Materials and methods|| |
The study was carried out at a tertiary health center that sees about 130 to 150 patients with maxillofacial injuries yearly. This study was a retrospective study of all patients presenting with maxillofacial fractures to the accident and emergency unit as well as the dental and maxillofacial clinics of the hospital over a 3-year period (January 2015 to December 2017). However, those with fractures of the mandible following third molar extraction as well as evidence of pathological fractures of the mandible from any cause, incomplete records and patients without radiographs were excluded from the study.
The sample size was determined using the following formula:
where n = minimum sample size, z = the standard normal deviate at 95% confidence interval (1.96), q = 1.0–p, p = the proportion of the target population estimated to have concomitant injuries (using 0.0916), and d = degree of accuracy desired (0.05).
For the purpose of this study, a systematic sampling method was used. All the case notes of patients with maxillofacial fractures seen at the accident and emergency as well as the maxillofacial surgery clinics seen during the study period were retrieved. These case notes were then ordered by date. The numbers 1 to 10 was written on pieces of papers and rolled up and a number was then randomly selected; this number was the first case note that was recruited for the study. For every case note selected, two were skipped. When the required details were found missing or patient did not meet the inclusion criteria, then that case note was dropped and the next case note was picked until the desired sample size was obtained. Eventually, 123 patients were recruited for the study.
Data collection technique
Information was obtained using a well-structured questionnaire. The information in the questionnaire included age, gender, occupation, education, location of patient in the vehicle, protective measures, and the mechanism of injury. All patients’ plain radiographs were reviewed to determine the type and site of maxillofacial fractures. All patients had computed tomography (CT) scan done as part of their standard of care. Concomitant injuries were documented as well as the other necessary radiologic investigations carried out, such as ultrasonography for concomitant abdominal or pelvis injuries, whereas those with suspected chest trauma had plain chest radiographs carried out (anteroposterior and lateral views). Relevant preexisting conditions, deficits at discharge, and patients’ outcome were also documented into the relevant areas of the questionnaire.
The independent (predictor) variables included the sociodemographic and clinical variables whereas the dependent (outcome) variables are the maxillofacial fractures and concomitant injuries. Frequencies and percentages were used to describe the pattern of maxillofacial fractures as well as the types of concomitant injuries and the pattern of maxillofacial fractures by age and gender in patients with concomitant injuries.
Ethical approval was obtained from the institutional review board of the teaching hospital.
| Results|| |
A total of 123 patients with maxillofacial fractures were recruited for this study of which 80 patients (65%) had associated concomitant injuries. The mean age of the study population was 33.7 ± 10.2 years. There were more males affected than females with a male-to-female ratio of 7.2:1. Most of the individuals affected were students and the unemployed as well as individuals with primary education. The most common concomitant injury was in the upper limb (41.3%) followed by the lower limb (31.3%) and, third, on the skin (15%). Other sociodemographic characteristics of the study population and other concomitant injuries and their frequency of occurrence are documented in [Table 1].
|Table 1: Sociodemographic characteristics, distribution, and site of concomitant injuries in the study population|
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[Figure 1] shows the pattern of maxillofacial fractures seen in the study population. Some patients had more than one fracture type. The zygomatic complex fracture was the most common fracture type seen (49; 39.8%) followed by fractures involving multiple facial bones (48, 39.0%). The least common facture type was the Le forte II fracture (1, 0.8%). Other types of fractures seen and their frequencies of occurrence are presented in [Figure 1].
[Figure 2] shows the pattern of maxillofacial fractures in the patients with concomitant injuries, where combined fractures of the mandible and the facial bones was the most common fracture type seen in these group of patients (55; 68.8%) and Le forte II fracture least common (1; 1.25%).
|Figure 2: Pattern of maxillofacial fractures in patients with concomitant injuries.|
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| Discussion|| |
The maxillofacial region occupies the most prominent position in the human body, rendering it vulnerable to injuries. Maxillofacial fractures vary from country to country and even within the same nation, as different regions suggest different personal behavior patterns. Hence, regional studies are important to be able to identify the peculiarities of each region.
At the end of this study, a total of 123 patients with maxillofacial fractures were recruited. They were made up of 87.8% males and 12.2% females giving a male-to-female ratio of 7.2:1 with the 21 to 30 years’ age group most commonly affected. Of all the patients recruited for the study, 65% of them had associated concomitant injuries.
This observed gender differences are similar to several past studies, and this has been attributed to the fact that men are more involved in outdoor activities hence are likely to be involved in road traffic accidents; they are also more frequently exposed to violent conduct, participate in sports, and other related activities.,
Meanwhile the highest incidence in the 21 to 30-year age group has been attributed to the fact that this age group is the active age group, they usually travel for their day-to-day activities, tend to drive motor vehicles carelessly, and are most likely to be involved in violence, dangerous exercises, and sports.,
The unemployed were the most commonly affected group of individuals; this could probably be attributed to the fact that the unemployed are always on the move in search of jobs and this puts them at risk of accidents and sustaining maxillofacial fractures. Students are the second group that commonly presented with maxillofacial fractures. This could also be attributed to the fact that these are university students who are in the active age group in addition to having them move from one campus to another for lectures. In a study carried out by Zhou et al., the incidence of maxillofacial fractures was highest among the unemployed. Montovani et al. in their study observed that there was a higher incidence of facial trauma in students and masons that is similar to the findings we have recorded. This study therefore brings to the fore that in this environment, males between the age of 21 and 30 who are students or unemployed are most at risk of maxillofacial fractures.
When the pattern of maxillofacial fractures were closely studied, among all the patients recruited for the study, the zygomatic complex fracture was the most common maxillofacial fracture observed followed by multiple facial bones fracture and, third, multiple mandibular fractures (39.8%, 39.0%, and 29.3%, respectively) whereas among patients with concomitant injuries, the pattern of maxillofacial fractures observed was combined mandibular and facial fractures (68.8%), followed by the zygomatic complex fractures (17.5%), and parasymphyseal fracture (7.5%).
A large number of studies, have demonstrated that fracture of the mandible is the most common type of maxillofacial fracture and this has been attributed to the mobility of this bone, its prominent position in relation to the facial skeleton, as well as its lack of protection. However, in our study, the zygomatic complex was the most common site of fracture observed (39.8%). In a similar retrospective review of 2680 cases of maxillofacial fractures carried out in Colombia, it was observed that zygomatic complex fractures were the third most common maxillofacial fracture accounting for 18% of cases. The most common was the fracture of the mandible and the maxilla.
The exact reason for these different patterns of fractures is not really known but it has been postulated that the pattern of maxillofacial fracture is most likely related to the mechanism of injury, magnitude, and direction of impact force as well as the site., It is worthy to note that a number of midface fractures are often missed because such cases are poorly demonstrated on plain radiograph, which is the most common imaging modality in most Nigerian health institutions. The CT scan that is the imaging of choice for maxillofacial fractures is restricted to use only in patients who can afford the high cost of such technique, hence the tendency to miss fractures of the zygomatic complex. This may also have contributed to the observed high prevalence of zygomatic complex fractures observed in this study because all the patients that were recruited for this study had a CT scan done as part of their standard of care. This study shows that when there is the presence of multiple facial and mandibular fractures, concomitant injuries must be actively looked out for. There is also the need for all centers that treat trauma to make CT scan part of their standard of care.
In this study, 65% of all the patients who sustained maxillofacial fractures had concomitant injuries of other sites of the body with the most common site of concomitant injuries being the upper limbs (41.3%) and then the lower limbs (31.3%) before skin lacerations (15.0%).
In the study by Ajike et al., carried out in Kaduna state, northern Nigeria, concomitant injuries were seen in 8.5% of cases of maxillofacial fractures. This finding is far less than the concomitant injury rate we recorded in our study; however, they also reported that majority of these cases were orthopedic injuries. On the other hand, Bello et al. carried out a study in Abuja, central Nigeria, where concomitant injuries were found in as high as 93.2% of patients with maxillofacial injuries. The most common concomitant injuries they recorded was lacerations to the soft tissue of the face and neurologic injury. Alvi et al. in their study found that cerebral and pulmonary injuries were the most common concomitant injuries in patients with maxillofacial fractures. With these differing reports from within the same country and between countries, the importance of local knowledge of these associated injuries cannot be overemphasized. This will help to provide useful strategies for patient care and prevention of further complications.
In conclusion, maxillofacial fracture tends to occur more in men than women with the unemployed at higher risk than other members of the population. It is important to note that concomitant injuries are commonly found to accompany maxillofacial fractures hence the need for the managing team to look out for them.
The research was supported by the Fogarty International Centre (FIC) of the National Institutes of Health and also the Office of the Director, National Institutes of Health (OD), National Institute of Nursing Research (NINR), and the National Institutes of Neurological Disorders and Stroke (NINDS) under award number D43TW010130. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990;48:926-32.
Sing G, Mohammad S, Pal US, Hariram MLR, Sing N. Pediatric facial injuries: it’s management. Natl J Maxillofac Surg 2011;2:156-62.
Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma patients. Laryngoscope 2003;113:102-6.
Taiwo AO, Soyele OO, Godwin NU, Ibikunle AA. Facial fracture management in northwest Nigeria. J Surg Tech Case Rep 2013;5;65-71.
Allareddy V, Allareddy ZV, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69:2613-8.
Zacharides N. Fractures of the facial skeleton. J Crani Max Face Surg 1990;18:151-3.
Latifi H. Prevalance of different kinds of maxillofacial fractures and their associated factors are surveyed in patients. Glob J Health Sci 2014;6:66-73.
Bun E. Road traffic accidents in Nigeria. A public health problem. Afrimedic J 2012;3:34-6.
Fasola AO, Nyako EA, Obiechina AE, Arotiba JT. Trends in the characteristics of maxillofacial fractures in Nigeria. J Oral Maxillofac Surg 2003;61:1140-3.
Kaul RP, Sagar S, Singhal M, Kumar A, Jaipuria J, Misra M. Burden of maxillofacial trauma at level 1 trauma center. Craniomaxillofac Trauma Reconstr 2014;7:126-30.
Udeabor S, Akinmoladun VI, Olusanya A, Obiechina A. Pattern of midface trauma with associated concomitant injuries in a Nigerian Referral Centre. Niger J Surg 2014;20:26-9.
] [Full text]
Adebayo ET, Ajike SO, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 2003; 41: 396–400.
Ugboko VI, Odusanya SA, Fagade OO. Maxillofacial fractures in a semi-urban Nigerian Teaching Hospital. A review of 442 cases. Int J Oral Maxillofac Surg 1998;27:286-9.
Norholt SE, Pedersen TK, Jensen J. Lefort I miniplate osteosyntesis: a randomized, prospective study comparing resorbable PLLA/PGA with titanium. Int J Oral Maxillofac Surg 2004;33:245-52.
Ajike SO, Adebayo ET, Amanyiewe EU, Ononiwu XX. An epidermiological review of maxillofacial fractures and concomitant injuries in Kaduna, Nigeria. Niger J Surg Res 2005;7:251-5.
Araoye MO. Research methodology with statistics for health and social sciences. In Sample Size Determination and Subject Selection. 1st edn. Ilorin, Nigeria: Nathadex publishers 2004. pp. 115-29.
Hashim H, Iqbal S. Motorcycle accident is the main cause of maxillofacial injuries in the Penang Mainland, Malaysia. Dent Traumatol 2011;27:19-22.
Elhammali N, Bremerich A, Rustemeyer J. Demographical and clinical aspects of sports-related maxillofacial and skull base fractures in hospitalized patients. Int J Oral Maxillofac Surg 2010;39:857-62.
Desai J, Lownie JF, Cleaton-Jones P. Prospective audit of mandibular fractures at the Charlotte Maxeke Johannesburg Academic Hospital. S Afr J Surg 2010;48:122-6.
Zhou HH, Liu Q, Yang RT, Li Z, Li ZB. Maxillofacial fractures in women and men: a 10-year retrospective study. J Oral Maxillofac Surg 2015;73:2181-8.
Montovani JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiology and incidence facial fractures in children and adults. Braz J Otorhinolaryngol 2006;72:235-41.
Taiwo AO, Soyele OO, Godwin NU, Ibikunle AA. Facial fracture management in Northwest Nigeria. J Surg Tech Case Rep 2013;5:65-71.
Akhiwu BI, Adebola RA, Ladeinde AL, Osunde OD, Lawal IU. Mandibular Fractures: demographic and clinical characteristics. Niger J Ortho Trau 2012;11:113-21.
Cavalcanti AL, Bezerra PK, Oliveira M, Granville-Gracia AF. Maxillofacial injuries and dental trauma in patients aged 19-80 years, Recife, Brazil. Rev Esp Cir Oral Maxilofac 2010;32:11-6.
Batista AM, Ferriera FO, Marques LS, Ramos-Jorge LS, Ferriara MC. Risk factor associated with facial fractures. Braz Oral Res 2012;6:119-25.
Obimakinde OS, Ogundipe KO, Rabiu TB, Okoje VN. Maxillofacial fractures in a budding teaching hospital: a study of pattern of presentation and care. Pan Afr Med J 2017;26:218.
Bello SA, Olaitan AA, Fasola AO, Olaomi OO, Adebayo ET, Olokun BA et al.
Concomitant injuries associated with maxillofacial fractures in Abuja, Nigeria. Nig Q J Hosp Med 2013;23:33-8.
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