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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 4  |  Page : 1186-1192

Patterns of facial trauma in menoufia university hospital


Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission12-Nov-2016
Date of Acceptance20-Feb-2017
Date of Web Publication04-Apr-2018

Correspondence Address:
Soha H Abd El Magid Abd El Khalek
Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_620_16

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  Abstract 


Objective
The aim of this study was to analyze patterns of face injuries, the relationship between face trauma cases and instruments used, type of injuries, and outcome at Menoufia University Hospital.
Background
Among the innumerous injuries seen at trauma centers, facial trauma is one of the most prevalent, as the face is the most exposed and least protected part of the body.
Patients and methods
The present study was conducted on patients presenting with facial trauma to Menoufia University Hospital from the period between 1 January 2014 and 31 December 2014, regarding demographic data, types, instruments used, causes, and radiological pattern. Retrospective data were collected from files (January 2014–June 2014), and the prospective study was carried out between July 2014 and December 2014. All cases were included in the study after obtaining valid written consent for examination and photography.
Results
The total number of patients with facial injuries during the study period was 1038 patients. The most common age group among injured cases was 30– less than 50 years; 61.1% of facial injuries were due to assault, followed by 35.3% accidental injuries. The clinical outcome revealed that 68% of injured cases improved, whereas 17.5% of cases suffered from complications [e.g., scar (7.9%), facial deformity (7.7%), and infection (1.9%)]. 6.2% of the injured cases suffered from impaired function, and 4.4% of cases suffered from loss of function, whereas 3.9% of injured cases died.
Conclusion and recommendation
Pan facial traumas led to complications, loss of function, and had a high mortality rate. Strict legislation against violence and stricter implementation of traffic rules must be followed.

Keywords: assault, face trauma, maxillofacial trauma


How to cite this article:
Girgis NF, Zanaty AW, El Agmy SS, Abd El Magid Abd El Khalek SH. Patterns of facial trauma in menoufia university hospital. Menoufia Med J 2017;30:1186-92

How to cite this URL:
Girgis NF, Zanaty AW, El Agmy SS, Abd El Magid Abd El Khalek SH. Patterns of facial trauma in menoufia university hospital. Menoufia Med J [serial online] 2017 [cited 2020 Feb 17];30:1186-92. Available from: http://www.mmj.eg.net/text.asp?2017/30/4/1186/229234




  Introduction Top


Facial injuries are a common cause for presentation to the Emergency Department across all ages. Although there is a combination of major and minor injuries, the significant ones require complex reconstructive surgery and rehabilitation. Even minor facial injuries that cause scarring can be costly and have a personal impact on the injured person[1]. There are a number of possible causes for facial trauma, such as motor vehicle accidents, explosions, accidental falls, sports injuries, interpersonal violence, natural disasters, and work-related injuries[2]. During the last decade, interpersonal violence as the main cause of facial trauma has been increasing in countries such as the USA, Israel, Finland, and New Zealand, whereas studies from Africa and Asia and some European countries have shown that traffic accidents are the main cause[3]. In Egypt, sex distribution regarding facial injuries showed that males were at a higher risk than females with a ratio of 5.5: 1[4]. Disruption of soft tissues of the face can be disfiguring and may significantly damage underlying anatomical structures[5]. Recent advances in the science of reconstructive surgery and in the management of trauma patients have significantly improved the morbidity and mortality of patients with traumatic facial injuries[1].


  Patients and Methods Top


The present study was conducted on 1038 facial trauma patients who presented to Menoufia University Hospital from January 2014 to December 2014.

A valid, informed consent was obtained from each patient for examination and photography. A primary medicolegal report was filled for every case. A clinical sheet including complete patient data was designed for traumatized patients who arrived at the hospital. The study was approved by the Ethical Committee, Faculty of Medicine, Menoufia University.

Demographic and clinical data were collected from medical records (for a retrospective from January 2014 to June 2014) and from patients (for a prospective from July 2014 to December 2014). Subsequently, thorough assessment of the general condition of patients and local examination of face injuries were performed for all cases. Routine radiological screening and laboratory investigations were carried out if needed. Special investigations were carried out according to site of injury as follows: ocular ultrasound, computed tomography (CT) scan (orbital, nasal, and facial), plain radiography, and audiometry.

Outcome and complications at the time of discharge from hospital were assessed.

Statistical analysis

Data were collected, tabulated, statistically analyzed using a personal computer with Statistical Package of Social Science (version 20; IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp, USA) and the following statistics were applied.

Descriptive statistics

Qualitative data are presented as numbers and percentages.

Analytical statistics

The used tests of significance included the following:

The χ2-test was used to study the association between qualitative variables.

P values less than 0.05 were considered statistically significant, P values less than 0.001 were considered highly significant, and were considered nonsignificant at more than 0.05.


  Results Top


The total number of patients who had facial injuries during the study period was 1038. The most common age group among injured cases was 30– less than 50 (33.9%) years, and the least common age group involved was more than 50 (7.9%) years. 67.1% of injured persons were males with a male-to-female ratio of 2.04: 1. The majority of injured cases were from rural areas (60.7%). It was found that drivers accounted for 25.2% of cases. The majority of injuries (68.6%) were caused by blunt instruments, and 7.7% of injuries were caused by sharp instruments. Sharp and blunt instruments together caused 11.2% of injuries, 1.9% of injuries were due to firearms and 8.2% by heat, and 0.2% of cases had electrical injury. Both wet and chemical burns comprised 1.1% [Table 1].
Table 1: Sociodemographic characteristics of the studied cases and causative instruments (N=1038)

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In total, 61.1% of face injuries were due to assault, followed by accidents (35.3%), whereas self-inflicted injuries contributed to 3.7% [Figure 1].
Figure 1: Circumstance distribution among the studied groups.

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The relationship between circumstances of injury and age was statistically highly significant, with a P value less than 0.001. In the age group less than 7 years, 59.7% were accidental injuries and 40.3% were due to assault. In the age group 30– less than 50 years, injuries due to assault were 72.7 and 27.3% were accidental. The relationship was statistically highly significant where χ2 = 40.9 and the P value was less than 0.001 [Table 2].
Table 2: Relationship between circumstances of injury and age of the studied cases and causative instruments (N=1038)

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The relationship between circumstances of injury and causative instrument was statistically highly significant. 71.1% of injuries caused by blunt instrument were due to assault, 25.5% were accidental, and 3.4% were self-inflicted injuries. However, accidental injuries caused by combined sharp and blunt instruments were 62.1% and the rest (37.9%) were due to assault. Regarding physical injuries, more than 80% of them (81.1%) were accidental and 10.9% were due to assault. The majority of injuries caused by firearms (90.0%) were due to assault and 10.0% were accidental [Table 2].

The relationship between circumstances of injury and site of injures was statistically significant, with a P value less than 0.001. Concerning isolated eye injuries, 83.3% of cases were accidental, whereas 16.7% of cases were due to assault. Isolated nasal, ear, maxillofacial, and mandibular traumas were mainly due to assault followed by accidents [Table 3].
Table 3: Relationship between circumstances of injury and its site in the face among the studied groups (N=1038)

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The relationship between mixed forehead injuries and circumstances of injuries was highly significant, with χ2 = 34.3 and a P value less than 0.001. Among mixed forehead injuries with nasal and oral trauma, 65.6% were accidental and 32.0% were due to assault. Pan facial trauma was more prevalent – 96.8% in accidental injuries – and the relationship between injury and circumstances was highly significant, with χ2 = 84.7 and P value less than 0.001 [Table 3].

Regarding outcome, 68% of injured cases improved and 17.6% suffered from complications [e.g., scar (7.9%), facial deformity (7.7%), and infections (1.9%)]. 6.2% of injured cases suffered from impaired organ function and 4.4% of cases suffered from loss of function; 3.9% of injured cases died because of severe bleeding causing airway obstruction or because of inhalational injuries in case of burns as well as a high prevalence of associated head injuries [Figure 2].
Figure 2: Percentage distribution of the studied cases regarding outcome.

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The relationship between isolated eye injuries and outcome was statistically highly significant (P< 0.001), as 77.8% of cases developed permanent loss of vision and 16.6% of cases developed impaired vision. In addition, the relationship was significant in isolated nasal and ear trauma, with a P value less than 0.05 (81.8% of nasal trauma cases improved and 11.8% developed complications). 88.2% of ear trauma cases improved, 8.8% developed complications, and 3.0% had loss of function. The relationship between maxillofacial trauma and outcome was statistically highly significant, with a P value less than 0.001. 90.8% of isolated maxillofacial trauma cases improved and 7.9% developed complications. However, 61.5% of mixed maxillofacial and eye trauma cases developed complications and 4.6% developed loss of function. Regarding mixed forehead with nasal and oral injuries, 89.3% of cases improved and 6.5% developed complications. The relationship was statistically highly significant (P< 0.001). However, in mixed forehead with ocular and nasal trauma, 54.5% of cases developed complications, and 27.3% of cases died. The relationship was statistically highly significant with a P value less than 0.001. Pan facial trauma had a high mortality rate, as 74.4% of cases died and 20.9% developed complications. The relationship was statistically highly significant with a P value less than 0.001 [Table 4].
Table 4: Relation between outcome of injury and its site among studied cases

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The relationship between outcome and type of external soft tissue injuries among the studied cases was highly significant with a P value less than 0.001. Most of facial trauma cases with abrasions, contusions, both (abrasions and contusions), contused wounds, and cut wounds improved. Regarding firearm injuries, 60% of injured cases suffered from loss of function, 5% died, 15% improved, and 10% developed either complications or impaired function. Among physical injury cases, 47.3% developed complications, 27.3% died, 20% improved, and 5.4% suffered from impaired function [Table 5] and [Figure 3],[Figure 4],[Figure 5].
Table 5: Relationship between outcome and type of external injury among the studied cases (N=1038)

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Figure 3: A 30-year-old male after an alleged motorcycle accident with a contused wound in the right upper eye lid about 1.5 cm in length, abraded contusion on the left cheek about 4 × 5 cm, and a lacerated wound at the left side of the forehead about 4 cm in length (arrows).

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Figure 4: A 30-year-old male with history of violence showing (a) ecchymosis in the left upper eye lid about 3 × 4 cm and multiple semicircular contused wounds with loss of substance, with diameter of each about 3–6 mm at the left upper eye lid, right cheek, and ear (firearm injury) (arrows). (b) Computed tomography orbit shows hyperdense metallic rounded foreign body (shot) at the apex of the orbit (arrow).

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Figure 5: Motorcycle accident. (a) Facial asymmetry. (b) Subconjunctival hemorrhage, lower eye lid contusion. (c) Maxillofacial computed tomography is showing a fractured right maxilla.

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  Discussion Top


Injuries are one of the leading causes of the global burden of disease[6]. The position and anatomy of the face make it particularly vulnerable to trauma[1]. The commonest age groups among the injured cases were 30– less than 50 and 18– less than 30 years. This could be explained by the fact that this is the age of adolescence and adulthood where individuals start a more independent life, thus exposing themselves to all sorts of violence.

Concerning sex, 67.1% of cases were males with a male-to-female ratio of 2.04: 1. Khatri et al.[7] reported a male-to-female ratio of 4: 1; this is because males are more frequently engaged in stronger physical activities.

It was found that drivers accounted for 25.2% of cases, which is in agreement with the study of Samieirad et al.[8]. Disregard for safety while driving increases physical traumas. The study revealed that assault was the main cause for face injuries. This coincides with the results of Arslan et al.[9] and Wahid et al.[10] where interpersonal violence was the most prevalent cause of facial trauma, about 90.7%. 68.6% of face injuries were caused by blunt instruments, which is in agreement with Oneida et al.[11]. Moreover, Alves et al.[12] reported that 94.74% of individuals with facial trauma at the emergency room of the Santo Antonio Hospital had blunt injuries, 8.2% of facial injuries were caused by heat, and 1.1% due to scalding. This coincides with the study by Motamedi et al.[13] who showed that flame and scalding accidents were commonly responsible for facial burns.

The study showed that accidents occurred significantly in the age group less than 7 years. It was noticed that children are not well supervised by their family. This is in agreement with Collao-González et al.[14], who reported that the main causes for facial trauma in preschool children were falls and domestic accidents, associated with factors such as less motor development and child behavior.

The assault occurred significantly high in all other age groups which may explain with ease of acquiring weapons and increasingly aggressive behavior in society, similar results showed in the study of Khatri et al.[7] study in Delhi.

Regarding causative instruments and circumstances of injuries in the study, there was a high prevalence of injuries caused by blunt or sharp instruments (71.1 and 67.5%, respectively), followed by accidental injuries, and then self-inflicted injuries. Using blunt instruments in interpersonal violence outnumbered sharp instruments as the latter are prohibited by law, and hence are not frequently carried.

Facial injuries caused by both blunt and sharp instruments usually involved motor vehicle or motorcycle accidents, falls, and work-related accidents. This coincides with the study by Brasileiro and Passeri[15].

The majority of firearm injuries were due to assault. As penetrating trauma to the face may carry significant morbidity and mortality, the face is a major target in homicidal cases. The same result was observed by Haider et al.[16] who studied that the face is the most frequent area exposed to firearm injury.

The study revealed that accidentally isolated eye injuries were more frequent than assault ones. This is in agreement with Li et al.[17] who reported that accidental workplace injuries (36%) ranked first, followed by falls (32%), and assault (13%).

Assault was the most common cause of isolated nasal trauma in the study as the nose is an easy target in personal violence; this coincides with the study by Dawood[18] and Çil and Kahraman[19], who reported that the most common reason for nose injury was violence (60%). In addition, more than eighty percent of ear injuries were due to assault, which is in agreement with Chukuezi and Nwosu[20], who reported that assault was the commonest etiology for ear trauma (65.85%).

86.8% of isolated maxillofacial trauma was due to assault. This is in agreement with the study by Eggensperger et al.[21], who reported that the most common cause for isolated maxillofacial trauma (92.2%) was fights and facial blows. However, the main cause for mixed maxillofacial with nasal trauma was accidents, which coincides with Lone et al.[22], who observed that high incidence of nasal and zygomatic complex is obviously related to accidental injuries, explained by the prominent position of these anatomical structures within the facial skeleton. Moreover, in agreement with Lee et al.[23], mid-facial injuries were more frequently seen in motor vehicle accidents.

The main etiology for mandibular trauma in the present study was related to assault, which is in agreement with Olate et al.[24] and Lee et al.[23] who showed that mandibular fractures were more prevalent in interpersonal violence.

In the present study, all isolated forehead injuries were accidental. This is in agreement with Sahlin et al.[25] who reported that frontal contusions were the most frequent accidental facial injuries and road traffic crashes. In addition, mixed forehead injuries including the nose and mouth or eye and ear injuries were accidental. This result coincides with the study by Bajwa et al.[26]. In addition, Collao-González et al.[14] reported that the most common cause of injury in children in the T-shaped zone formed by the forehead, nose, and lips was accidental falling.

The results show that 77.8% of cases with ocular trauma developed permanent loss of vision, and 16.6% of cases developed impaired vision. This coincides with the study by Li et al.[17] where about 50% of ocular eye injuries had sustained profound visual loss. In addition, Pollard et al.[27] reported that ocular trauma is the leading cause of visual loss.

Only 7.9% of isolated maxillofacial trauma cases developed complications such as infection of wounds, malocclusion of fracture maxilla, or facial asymmetry; this was because of early medical evaluation, available radiological investigation, and treatment giving a promising outcome, and is in agreement with the study by Brasileiro and Passeri[15] who stated that overall maxillofacial fracture complications were found in only 7.4% of patients and the most common was infections. However, complications increased in mixed injury cases –61.5% of maxillofacial with eye trauma cases developed complications, and 4.6% of cases had loss of vision due to optic nerve affection – in agreement with Andrews et al.[28] and Sahlin et al.[25].

In mixed forehead with ocular and ear trauma, 54.5% of cases developed complications such as mastitis, otitis media, temporal bone fracture, and otorrhea, 27.3% of cases died as it was mainly associated with cranial injury leading to death, and 18.2% of cases developed permanent disabilities such as hearing loss. In agreement with Gilyoma and Chalya[29], pan facial trauma had a high mortality rate; 74.4% of cases died. This was mainly due to severe bleeding, causing airway obstruction, or due to inhalational injuries in case of burns with a need for ventilation and also a high prevalence of associated head injuries.

In the studied cases with abrasions, contusions, abraded-contusions, contused wounds, and cut wounds, there was a high rate of improvement due to early and appropriate management of external lesions by the effort and care of plastic surgeons with knowledge of the nature of facial injuries and alteration of the facial profile and soft-tissue landmarks.

The high morbidity and mortality associated with firearm injuries were due to the associated intracranial component of injury explained in a study by Offiah and Hall[30].


  Conclusion and Recommendations Top


Facial injury is fairly common in assault-related events affecting especially men in adulthood who are more prone to become involved in outdoor activities and aggression. Accurate policies of facial trauma prevention must be established, with protocol for management of these injuries as early and proper diagnosis of facial injuries is mandatory to minimize soft tissue complications and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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