|Year : 2015 | Volume
| Issue : 1 | Page : 1-5
Management of maxillofacial and orthopedic injuries: Is there a need for maxillofacial units in orthopedic hospitals?
OD Osunde1, AA Efunkoya2, KU Omeje2, IO Amole2
1 Department of Dental Surgery, Faculty of Medicine and Dentistry, University of Calabar and University of Calabar Teaching Hospital, Calabar; Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||19-Nov-2015|
Dr. O D Osunde
Department of Dental Surgery, Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar
Source of Support: None, Conflict of Interest: None
Background: The study compared the pattern of consultation and the treatment outcome of maxillofacial patients referred by different orthopedic units.
Materials and Methods: All consecutive major trauma patients referred from two orthopedic units to the maxillofacial unit of our institution, over a 4-year period, was retrospectively analyzed. Patients' demographics, time, and types of injury, the time interval between injury and maxillofacial consultation, time of treatment, and anesthesia requirement were obtained.
Results: Of the 156 referred cases, there were 138 (88.5%) males and 18 (11.5%) females with a male: female ratio of 7.7:1. Their ages ranged from 12 to 66 years, mean 34.5 (9.89) years. Road traffic accident (n = 145; 92.9%) was the most common etiology. Mandibular (n = 87; 55.8%) and zygomatic (n = 30; 19.2%) fractures were the most predominant maxillofacial injuries. For the orthopedic injuries, lower limb fracture were the commonest (60.9%). Majority (n = 66; 91.7%) of patients co-managed with the Aminu Kano Teaching Hospital Team were seen within 24 h compared to a period of 4 days to over 1-week for patients referred from National Orthopedic Hospital (NOH). The mean period required to treat maxillofacial patients referred from NOH was significantly longer than for intra-hospital consultation (P < 0.001).
Conclusion: Establishment of maxillofacial units in trauma and orthopedic hospitals will improve the overall management of the multiple trauma patients that may occasionally present with concomitant maxillofacial injuries.
Keywords: Concomitant, management, maxillofacial, and orthopedic, injuries
|How to cite this article:|
Osunde O D, Efunkoya A A, Omeje K U, Amole I O. Management of maxillofacial and orthopedic injuries: Is there a need for maxillofacial units in orthopedic hospitals?. Afr J Trauma 2015;4:1-5
|How to cite this URL:|
Osunde O D, Efunkoya A A, Omeje K U, Amole I O. Management of maxillofacial and orthopedic injuries: Is there a need for maxillofacial units in orthopedic hospitals?. Afr J Trauma [serial online] 2015 [cited 2020 Nov 26];4:1-5. Available from: https://www.afrjtrauma.com/text.asp?2015/4/1/1/169814
| Introduction|| |
Major trauma resulting in coexisting maxillofacial and orthopedic injuries are well documented in the literature.,, The mechanism of such high impact trauma is the result of high-velocity injury which are known to occur with road traffic accidents (RTAs) and gunshot wounds. Studies from Nigeria shows a high prevalence of orthopedic injuries occurring concomitantly with maxillofacial fractures,, In a recent study of mandibular fractures, from Kano, Northwestern Nigeria about 21.2% and 48.7% of concomitant injuries involved fractures of the lower and upper limb respectively. In a separate study, from the same center, Osunde et al. similarly observed that the concomitant orthopedic injuries were represented by 35.7% for the upper limb and 32.1% for the lower limb among children who sustained maxillofacial trauma. This corroborate studies from other parts of Nigeria including those from other regions of the world.,,
Orthopedic units were established primarily to cater for maimed war victims and offer services in orthopedic surgery/trauma, plastics and burns, and orthotics (a unit that fabricates missing limb parts). Maxillofacial surgery was part of the services orthopedic units were designed to provide from inception. In Nigeria, there are three orthopedic hospitals located in Kano, Lagos, and Enugu representing the old Northern, Western, and Eastern regions respectively. Kano is a large commercial city housing both the National Orthopedic Hospital (NOH) and the Aminu Kano Teaching Hospital (AKTH), and the two institutions are situated in different local government areas within the metropolis. Whereas the orthopedic hospital has been in existence since 1959, the AKTH which was established in 1994 commenced active maxillofacial services in 2000 and it serves as a major referral center for maxillofacial patients across several states in Northwestern Nigeria.
The present study was aimed at determining the pattern of consultations and comparing the treatment outcome of maxillofacial trauma patients with concomitant orthopedic injuries managed by either intra- or inter-hospital consultations from/to AKTH. To the authors' knowledge, such data on inter-hospital transfer of multiple injured orthopedic patients, from a major trauma unit or hospital to a maxillofacial unit appears to have not been evaluated in Nigeria, as revealed by a literature search.
| Materials and Methods|| |
A retrospective analysis of all consecutive multiple trauma cases with concomitant maxillofacial injuries presenting either the orthopedic hospital or at the orthopedic and trauma unit of our institution prior to referral to the Oral and Maxillofacial Surgery Department of the AKTH from January 2008 to December 2011 was undertaken. Information on patients' demographics, time of injury, time of presentation at the orthopedic hospital and time of referral by the orthopedic team were collated. Data also collated included time of presentation at the maxillofacial unit, the interval between injury and presentation, admission requirement, secondary treatment received, time of treatment and type of anesthesia administered. Patients with a concomitant neurological injury that resulted in a delay in treatment of orthopedic and maxillofacial injuries were excluded from the study. The pretreatment complications arising from a delay in referral to the maxillofacial unit were noted.
The collected data were analyzed using the Statistical Package for Social Sciences (SPSS version 13, Illinois, Chicago, USA). The analysis included frequencies and percentages for qualitative variables and means, and standard deviation (SD) for quantitative variables. Comparative statistics was done using Pearson's Chi-square, Fisher's exact, and student's t-tests as appropriate. A P < 0.05 was considered statistically significant.
| Results|| |
Over the 4-year period of study, 298 maxillofacial trauma patients were seen and managed in the Oral and Maxillofacial Surgery Department of AKTH. Of these, 142 (47.7%) were isolated maxillofacial injuries without any associated orthopedic injury presenting either at the accident and emergency or at the maxillofacial clinic of our institution. The remaining 156 (52.3%) cases were either referred by the orthopedic and trauma unit of our institution (n = 72; 46.2%) or referred from the NOH Dala (n = 84; 53.8%).
Of the 156 concomitant maxillofacial-orthopedic injured patients; 138 (88.5%) were males and 18 (11.5%) were females, giving a male: female ratio of 7.7:1. The ages of the patients ranged from 12 to 66 years, with a mean of 34.5 years (SD = 9.89). The gender distribution of the different age categories is shown in [Table 1]. The most predominant age group was the 21–30 years (n = 64; 41%), followed by the 31–40 years age bracket (n = 48; 30.8%), and the 41–50 years age group (n = 25; 16%). Majority of the patients were the victims of RTA, accounting for 145 (92.9%) cases. Other etiologic factors were gunshot (n = 5; 3.2%), assault (n = 4; 2.6%), and falls (n = 2; 1.3%).
The distribution of the observed concomitant maxillofacial-orthopedic injuries between the two referring orthopedic teams is shown in [Table 2]. Fractures of the mandible were the most predominant maxillofacial fractures (n = 87; 55.8%) followed by zygomatic fracture (n = 30; 19.2%). The number of patients with maxillofacial fractures which presented first at the NOH on account of concomitant orthopedic injuries were similar in number and features as those referred by the AKTH orthopedic team (P = 0.401) [Table 2]. For the orthopedic injuries, lower limb fracture were the commonest accounting for 60.9% of the cases, and this was distantly followed by upper limb fracture (n = 33; 21.2%) [Table 2].
|Table 2: Distribution of concomitant maxillofacial-orthopedic injuries among patients managed by the two orthopedic teams|
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Analysis of the time interval between the initial orthopedic assessment and first maxillofacial consultation showed that 66 (91.7%) of patients referred by the AKTH orthopedic team were seen within 24 h compared to a period of 4 days to over 1-week, for patients referred from NOH, and this time difference was significant (P < 0.001) [Table 3]. Overall, the time interval between injury and maxillofacial treatment ranged from 5 days to 28 days, with a mean of 15.1 days (SD = 6.44). There was a significant difference between the mean periods required to treat maxillofacial patients referred from NOH compared with those managed with the AKTH orthopedic team, 19.8 days versus 9.6 days respectively (P < 0.001).
|Table 3: Time interval between initial orthopedic assessment and maxillofacial consultation for patients referred by the two orthopedic teams|
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A survey of preoperative complications among the two sets of patients showed that 15 (17.9%) of the maxillofacial patients referred from NOH presented with complications ranging from mal-union (n = 7; 4.5%), healed poorly repaired facial laceration (n = 2; 1.3%), restricted mouth opening (pseudo temporomandibular joint ankylosis) arising from untreated zygomatic complex fracture (n = 4; 2.6%) and infections (n = 2;1.3%). None of these complications was observed among the maxillofacial patients referred from the AKTH orthopedic team. A total of 144 (NOH = 81; AKTH = 63) of the cases were treated by open reduction, fixation, and immobilization under general anesthesia (GA). The remaining 12 cases were treated by closed reduction under local anesthesia (LA); 9 of whom were referred by the AKTH Orthopedic team and the remaining 3 from NOH. This distribution was significant (P = 0.037). Two of the cases with pseudo temporomandibular joint ankylosis required tracheostomy because of difficult intubation, to enhance the administration of GA agents.
| Discussion|| |
For the effective and timely management of the multiply injured patient, globally, most health institutions have constituted a trauma team, the composition of which varies from one center to the other and from country to country. Although, the oral and maxillofacial surgeon has continued to play a vital role in the management of the multiply the injured patient, most trauma institutions, especially the orthopedic hospitals in Nigeria, exclude, albeit erroneously, the services of this specialist as a member of staff of these institutions. In the present study, the pattern of consultation and the treatment outcome of maxillofacial patients referred from two orthopedic team located in different institutions were compared to determine if patients with concomitant orthopedic and maxillofacial injuries have better treatment outcome in a hospital with both specialists.
The age and gender distribution of participants in the present study are in agreement with the results of previous studies that found the third decade and male predominance in the epidemiology of maxillofacial injuries.,,, RTA was observed to be the main mechanism of injury in our environment which supports the earlier report on the etiology of maxillofacial trauma.,, This study has shown that over half (52.3%) of the maxillofacial trauma cases seen within the study period first presented to the orthopedic surgeons, because of a concomitant orthopedic injury. This is expected as orthopedic surgeons, as the traditional team leader in a most accident, and emergency/trauma units are usually on the ground to do an initial evaluation of accident victims that present at the emergency units. The results of the present study corroborate the reported high prevalence of injuries to other skeletal structures occurring concomitantly with maxillofacial trauma.,,
Injuries of the oral and maxillofacial region requires immediate intervention, and when not instituted in the stipulated time, may lead to complications, wound infections, or disability. An analysis of the result of the study showed that it will take about twice as much time to treat a maxillofacial trauma patient referred from NOH than if the same patient was co-managed with the AKTH orthopedic team. Although traditionally, management of maxillofacial injuries are often delayed, in emergency medicine, to allow for management of a more severe and life – threatening concomitant injury, prolonged delays may be deleterious. Currently, there is a move toward the early and total repair of facial injuries, enhancing the functional and esthetic outcomes of the traumatized region., Although the severity of the injuries were not evaluated and standardized in both sets of patients, different types of preoperative complications ranging from mal-union, infections, to limited mouth opening were observed in the NOH patients. These complications probably developed owing to a delay in referral for specialized maxillofacial services, since similar complications were not observed in the co-managed AKTH patients.
This has obvious implications for the management of such patients. A mal-united fracture will require a re-fracture under GA, and preferably an open reduction and fixation because of instability that may be associated with such cases. This was reflected in the treatment modality and the choice of anesthesia in the two groups of patients. More of the AKTH cases were managed under LA (n = 9) compared to the NOH cases (n = 3) because they were devoid of complications arising from a delay in surgical intervention. In contrast, significantly more of the NOH patients required GA for treatment, with the attendant morbidity associated with the use of GA. The tracheostomy performed on two of the patients referred from NOH on account of malunited zygomatic complex fracture may have been avoided if the patients were seen shortly after the injury. A simple reduction of the fractured zygoma under LA via percutaneous approach would have sufficed.
The other advantage of having the orthopedic and maxillofacial surgeons rendering services in the same institution includes the possibility of joint management in certain multiple trauma patients. This will avoid the dangers and extra cost implication of repeated GA. In addition, the cost implications in terms of financial expenses, logistics of inter-hospital transfer of an orthopedic patient whose limbs have probably been fixated and immobilized is enormous when compared with the management of patients with same clinical features but referred within the same health institution. Inter-hospital transfer of an orthopedic patient whose skeletal fractures has been treated often requires the services of a nurse to accompany the patient, ambulance vehicle, and a driver. This may lead to additional costs for such patients compared to intra-hospital referred patients. Furthermore, the accompanying nurse would have been better utilized to attend to more profitable nursing care services within the institution if both services were available in the same hospital. In addition, there may be a need for re-admission for the inter-hospital referred patients at the recipient hospital for maxillofacial treatment. In this study, 81 (96.4%) out of the 84 cases referred from NOH required a fresh admission at AKTH to facilitate the administration of GA. In contrast, the patients referred by the AKTH orthopedic unit simply maintained their initial admission under orthopedic surgery and were free from the discomfort of moving from one hospital to another. Occasionally, the management of patients may require joint surgeries by both surgical specialties, and thus avoiding repeated surgery and multiple anesthesias. Prompt management of maxillofacial trauma alongside other associated injuries ensures the best functional and esthetic results.,
Apart from the elective management of the maxillofacial trauma, some multiple trauma patients may present with major hemorrhage and airway problem arising from maxillofacial injuries., Such an instance may necessitate emergency reduction and fixation of the fractured segment under LA in order to control the bleeding. Occasionally, the displaced mid-facial fractures may result in airway obstruction caused by the downward and backward displacement of the fractured segment of the middle third of the facial skeleton, as may occur in certain types of Le Fort II or III fractures. A simple maneuver by manually pulling the displaced segment upward and outward, to reduce the fracture, would restore the airway as well as reduce any associated bleeding. This can be better carried out by maxillofacial surgeons since they are more conversant with the anatomic structures of the craniomaxillofacial region.
The goals of treatment of maxillofacial trauma patients are restoration of the assumed premorbid occlusion, aesthetics, and function. One limitation of the study design was that records were retrieved only from the maxillofacial unit of AKTH after the patients were referred from the orthopedic unit/hospitals. This leads to an inability to compare the final outcome of both patients categories based on the outlined criteria above, owing to the retrospective nature of the study. Nevertheless, when looked at from the background of the preoperative complications, time between injury and treatment, anesthesia requirements, need for other secondary procedures as well as overall treatment cost, management of patients with both maxillofacial and orthopedic injuries in the same hospital setting may be a better option.
In a country like ours where resources may be limited and establishment of fully operational maxillofacial units in all the orthopedic hospitals may not be possible, the relevant authorities could set up mini maxillofacial units where feasible to address the maxillofacial trauma cases at these centers. Mini-maxillofacial units would consist of essential personnel and equipment required. These units would work in tandem with other existing surgical units, thereby reducing the costs of setting up a full maxillofacial unit. An ideal distribution of such units would be all orthopedic hospitals in Nigeria and selected General Hospitals and Medical Health Centers with a view to achieve an even distribution across the country. Alternatively, the establishment of trauma centers in some major cities of the country, as currently obtained in some Western nations, would enhance holistic management of the polytrauma patients. Where the distance between the orthopedic hospital and the tertiary maxillofacial unit is not so great, or if located in the same locality, both institutions could collaborate such that the polytrauma patients who are in need of maxillofacial services, could have the treatment carried out either simultaneously or at separate sessions at the orthopedic hospitals. This would go a long way in solving the problems of the inter-hospital movement of the polytrauma patient, need for re-admissions, as well as the overall cost of treatment.
| Conclusion|| |
This audit has shown the complementary role played by maxillofacial surgeons in the multidisciplinary management of the multiply injured patients presenting with co-existing orthopedic and maxillofacial injuries. Establishment of maxillofacial units in trauma and orthopedic hospitals will improve the overall management of the multiple trauma patients that may occasionally present with concomitant maxillofacial injuries. In this part of the globe where health care financing is still borne by the patient, having maxillofacial and orthopedic services within the same institution will result in less overall treatment cost for the multiple injured patient that may occasionally need the services of both specialties.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]