M. C. Justin1, E. Kiwanuka3, M. A. Chaudhary1, E. J. Caterson1,2 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery, Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Plastic Surgery, Department Of Surgery, Harvard Medical School,Boston, MA, USA 3Brown University School Of Medicine,Division Of Plastic Surgery, Department Of Surgery,Providence, RI, USA
Introduction: The diagnosis of mild traumatic brain injury (mTBI) remains a diagnostic challenge that can lead to delay in diagnosis preventing early intervention. Force can be transmitted through the facial skeleton to the intracranial space leading to direct injury or coup/contrecoup insult. Facial fractures can serve as an objective surrogate marker of potential force transmission to the neural cavity. We hypothesize that, within the National Trauma Data Bank (NTDB), we can characterize the association of facial fractures and mTBI at all injury severity scores (ISS). A secondary hypothesis is that as injury moves up the craniofacial skeleton from the mandible there will be a stronger correlation of mTBI with facial fractures due to proximity to the cranial vault and required impulse to cause fractures of these bones.
Methods: Data from the NTDB (2007-2014) was used for this retrospective cross sectional study. Patients with mTBI and facial fractures were identified using the International Classification of Disease Ninth Revision (ICD9) codes. mTBI was identified with ICD9 codes utilizing the 2003 CDC definition for mTBI. Facial fractures were codified into nasal bone, mandible, malar and maxilla, orbital floor, and “other facial fractures.” Frontal bone fractures were not assessed for correlation as they are included with parietal and other skull vault fractures in ICD9 coding. Absence of diagnostic codes for other skull or facial fracture was then used to characterize individual types of facial fracture as the only type present. Further subdivision by ISS was performed.
Results: Of the 5,855,226 patients diagnosed with a traumatic injury, 19.2% were found to have a mTBI. The prevalence of mTBI in patients with isolated facial fractures ranged from 18.2% to 33.3%. The correlation strengthened going up the craniofacial skeleton with the lowest incidence within mandible fractures and highest within the other facial fracture category (table). At mild ISS, similar trends were demonstrated showing the lowest association of mTBI with mandible fractures and the highest incidence with isolated nasal bone fractures.
Conclusions: Isolated facial fractures have a high incidence of concurrent mTBI at all ISS levels. Without distracting from current trauma protocols and treatment of immediate life threatening injuries, clinicians can use this information in poly-trauma patients to alert to potential mTBI presence. Based on the level of the fracture going up the craniofacial skeleton one can also expect a higher likelihood of mTBI. Our data suggest that, within the context of trauma patients, facial fractures can serve as clinical markers for mTBI, raising both awareness and potential for early intervention.
