Missed injuries associated with maxillofacial trauma

ABSTRACT

Background:

Maxillofacial trauma in polytrauma settings is often associated with multiple injuries both trivial and life threatening, and their timely detection is the mainstay of definitive trauma management for preventing mortality and morbidity. Emergency management of all the patients reporting to our maxillofacial unit is either done by our center or they have been managed at the peripheral health care facility and relatively stable patient is referred to us. Anecdotally, we found inadequacies in transport methods, diagnosis, and detection of associated injuries in the patients referred to us from the peripheral health care facility. To substantiate our finding, this observational study has been planned.

Objective:

To identify, diagnose, and document missed injuries associated with the maxillofacial trauma.

Materials and Methods:

All the trauma patients referred to the maxillofacial unit directly from the peripheral health care facility during the period of October 2017 to March 2019 were included in this study.

Results:

We observed a total of 270 patients having both pure maxillofacial trauma and patients having documented other injuries associated with maxillofacial injuries. In our maxillofacial unit, functioning as a secondary screen, head to toe clinical examination was performed to document any previously missed out injuries. Missed injuries diagnosed by us included spinal injuries, temporal bone fractures, fractures of the styloid process, and even head injury.

Conclusion:

Frequent reassessment of trauma patients at all levels of trauma care and training health care personnel particularly those at peripheral health care facility and those involved in prehospital care are pivotal in managing the trauma patients in most efficient manner.

Sometime maxillofacial injuries are associated with other missed injuries, such as cervical spine injury, head injury, retro-bulbar hemorrhage, styloid process (SP) fracture, etc. These types of missed or overlooked injuries may worsen if they are not early identified and pre-hospital/intra-hospital care and attention is not provided.

These overlooked injuries and delayed diagnoses are very common problems in polytrauma patients. Frequently we notice several preventable post traumatic morbidities that were associated with previously overlooked injuries. Extensive literature search revealed that there is a dearth of literature in this area reporting these missed injuries, and this aspect has gone unnoticed by the trauma researchers. To fill this gap, we planned a study to detect, quantify, and analyze these missed injuries in patients particularly having maxillofacial trauma per se, reporting to our maxillofacial unit.

PURPOSE

• To identify and quantify missed injuries associated with maxillofacial trauma.

MATERIALS AND METHODS

A cross-sectional observational study has been planned. The study was approved by the Institutional Ethical Committee vide letter No. 111^th ECM IIA/P14 dated 16/11/2022.

All maxillofacial trauma patients reporting to our center were examined with an intention to detect some commonly overlooked injuries that can then be timely managed to minimize the morbidity associated with them. All such findings were recorded.

We also included those trauma patients who reported with morbidity associated with overlooked, missed, and maltreated maxillofacial injuries.

RESULTS

We observed 270 patients who reported at our trauma center maxillofacial unit from October 2017 to March 2019, most of them reported to us directly by peripheral health facilities bypassing the emergency department/casualty. The following observations were recorded from patient’s record and clinical examination by the attending surgeon Table 1.

Table 1.

Depicting number of patients reported to maxillofacial trauma unit with various missed injuries

Missed injuries	Number of Patients
Cervical spine injury	2
Clavicle fracture	2
Styloid process of temporal bone fracture	5
Head injury	1
Brachial plexus injury.	3

DISCUSSION

Cervical spine injury

Diagnosis of cervical spine injury may be missed, particularly when pain and symptoms from other parts of the body predominate. Many studies report wide difference in the incidence of cervical spine injury in maxillofacial trauma patients, ranging from 0% to 8%.[1]

Out of 270 cases, we found two cases of cervical spine fractures referred directly to our maxillofacial unit from the peripheral health care facility that were then referred to the Neurosurgery Department of our institute. As the advance trauma life support protocol says that presume a cervical spine injury in all patients with blunt polytrauma and particularly those with an altered level of consciousness and more so in supraclavicular injuries. These detected C spine injuries may have been missed out because of the absence of obvious features of C spine injury and lack of training of the health care personnel posted at peripheral health facility.

We observe many referred maxillofacial trauma patients having “No” cervical spine protection, and furthermore, these patients come on stretcher with flexion of the neck accentuated with a big pillow underneath their head. This malpractice can be reduced just by creating awareness among bystander population in general and at all levels of health care systems involved in patient transfer and transport in specific through short trainings, posters, banners, and other mass media communication, such as TV, social networking platforms, and internet-based communications. Significance of proper clinical and radiological evaluation of patients with facial fractures to recognize additional injuries even when pain and other symptoms from different body parts predominate cannot be underestimated.

A 5 days old polytrauma patient has been referred to our maxillofacial unit directly from a peripheral health care facility [Figure 1]. On examination, patient was found to be quadriplegic. Considering finding of quadriplegia, we expeditiously referred the patient for neurosurgery opinion, which turns out to be atalanto-axial subluxation. More than 3 mm distance between anterior arch of the atlas and dens on CT scan c-spine coupled with clinical examination findings of quadriplegia culminated to the diagnosis of this spinal instability. Patient was operated by neurosurgery team, and spinal fixation was done. We also fixed the mandibular para-symphyseal fracture using miniplates and screws in same polytrauma settings under general anesthesia. Patient recovered well. Had it not been referred to us, it would have been a life-threatening preposition or permanent disability and vegetative state. The only answer is training the peripheral health care personnel; although they could not be experts in diagnosing such injuries, still they can make a difference by just protecting spine by local measures such as manual inline spine stabilization and by putting cervical collars or rigid objects on the sides of neck area such as brick or sand bags during and before the transport of patient on stretcher to the definitive health care facility.

Figure 1.

Increased distance between anterior arch of the atlas and dens on CT scan c spine

Clavicle fracture

The clavicle fractures are normally reported as benign type of fractures, unless it is associated with brachial plexus injury. It is important for the patients to know about the status of their fracture because bracing affects the expected time of healing and reduces the time of returning to work.[2] The other common complication such as non-union may occur particularly if adequate initial immobilization has not been advised by the surgeons.[3] Many authors advise two views of radiograph to rule out the clavicle fractures, A-P view and cephalic view with 45° tilt, but in general practice, mostly a single view (A-P) is advised,[4] increasing the possibility of unnoticed clavicle fractures more so if the patient is a polytrauma patient with other grievous injuries. In our study, we observed two cases of clavicle fractures that were undiagnosed during initial examination.

Styloid fracture

Fracture of the SP of temporal bone may occur in association with other mandibular fractures particularly condylar fractures.[5] In busy emergency, sometime injury to the SP may be overlooked and that initial missed styloid injury may lead to various unnecessary treatments in future.[6]

In our study, we observed the patients presenting with symptoms related to mandible fractures, but intractable pain on turning the head and severe tenderness with the retromandibular region resulted in consideration of the SP fracture diagnosis. The diagnostic criteria described in existing literature for the SP fracture are symptoms of pain, tenderness of retromandibular region, combined with radiographic or computed tomography evidence of SP fracture, [Figure 2] and alleviation of symptoms after treatment.[6]

Figure 2.

CT face depicting fracture of the styloid process

The various treatment options available for fractured SP include conservative, medical, and surgical management. The initial treatment of SP fractures has usually been conservative, consisting of rest, liquid diet, muscle relaxants, nonsteroidal anti-inflammatory agents, analgesics, and the use of maxilla-mandibular fixation in conjunction with treatment of other facial fractures. However, when the patient’s symptoms do not resolve within a reasonable length of time, surgical removal of the distal portion of the fractured process is indicated for relief of pain.[7] Therefore, the initial diagnosis is important and it requires some attention by the surgeon to avoid any future complication.

Brachial plexus injury

The brachial plexus is derived from the spinal nerves of C-5, C-6, C-7, and T-l. The nerves emerge from the vertebrae and lie between the anterior and middle scalene muscles in the posterior triangle of the neck. The brachial plexus passes between the first rib and clavicle close to the head of the humerus and coracoid.

The injury may be because of trauma causing combination of stretching (traction) and compression of the plexus.

Sign and symptoms are described in existing literature, such as intense pain from neck down to arm and arm will feel like it is on fire or have pins and needles sensation and usually arm/hand may be weak and numb.

We observed three patients having undiagnosed brachial plexus injury. We observed all maxillofacial trauma patients with a special emphasis to the fractures at mandibular site to see any effect of trauma on brachial plexus.

Sometimes, this type of injury may occur by the movement of head during procedure on the operation theatre table, while we try to make surgical site more accessible by lateral rotation and extension/flexion of the head and neck and depressing the shoulder, resulting into injury of the plexus on the contralateral side because of stretching. Thus, documentation of these types of previously present injuries is very important to avoid any litigation that may arise at a later date for blame of negligence.

Head injury

According to Keenan et al.,[8] trauma patients with maxillofacial fractures have a higher risk of intracranial hemorrhage compared to patients without maxillofacial fractures. New Orleans Criteria[9] is a protocol to decide or consider diagnosis of head injury mandating CT investigation even if the GCS is 15. The protocol includes the following:

• Headache

• Vomiting

• Age more than or equal to 60 years

• Drug or alcohol intoxication

• Persistent anterograde amnesia

• Visible trauma above the clavicle

• Seizure

We observed a highly irritable and uncooperative case of maxillofacial trauma having history of road traffic accident because of “drunk and drive” that has been referred 72 h after the accident from a peripheral health care facility for the management of maxillofacial trauma. The patient was accompanying all the related investigations with clearance of possible head injury from the referring center along with the CT scan head that shows no obvious findings with respect to neurosurgical and head injury perspective. The irritability and uncooperative behavior were attributed to the alcohol withdrawal symptoms as patient is a known chronic alcoholic. Patient has been admitted to our wards for close monitoring. Three days post admission, bilateral ecchymosis appeared at the mastoid region that was not present initially on the day of admission. Considering this newly appeared sign as Battle’s Sign and its correlation with the irritability, we sought neurosurgical opinion, which suggested possibility of cranial base fracture and advised reinvestigation with CT scan head with finer sections as the initial one was at 3-mm interval. Additional medical management from neurological perspective has been instituted. As the patient’s condition was becoming better day by day and the attendants were reluctant for further investigations in spite of repeated counseling, the patient was discharged on request with findings of no neural deficit and usual precautions. Patient turned up for follow up after a week’s time with improvement of overall general condition. Although we did not arrive at a definitive diagnosis of cranial base fracture, still the possibility of its presence cannot be ruled out. Patient was lucky enough to sail through this tough time uneventfully, yet there may be instances where failure of prompt diagnosis could be disastrous.

CONCLUSION

Polytrauma management is a dynamic process that should include multiple revaluation from head to toe at different “points of care” (POC/ subsidiary specialty units), maxillofacial unit being one of them can act as a potential screening point. Examination should be done keeping in mind the lacunae in patient transfer and lack of training of peripheral healthcare provider. These POCs can diagnose any of these missed out injuries and save the patient from possible morbidity or mortality that may arise because of these injuries.

Additional takeaways are

1. Emphasis on mechanism of patient transfer to the definitive care by training and sensitizing the bystander and for that matter, training the masses by including roadside trauma management in school curriculum, such as manual inline spinal stabilization using roadside measures, positioning of the patient on the stretcher, etc., with airway and C-spine consideration dictated by airway breathing circulation protocol.

2. Documentation of such associated and missed out injuries are important for quality audits and to avert the litigation arising at a later date, with blame of negligence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.