Abstract
To know the clinical signs and radiological findings of different types of maxillofacial fractures following facial trauma in road traffic accidents. In this retrospective study, the medical records and computerized tomography scans of 100 patients who have sustained facial fractures in road traffic accident during 2021–2022 were reviewed at Raichur Institute of Medical Sciences, Raichur; for maxillofacial fractures. Data was tabulated and statistically analysed using SPSS software version 21. 100 patients who have sustained maxillofacial injuries in road traffic accident were included in the study. Male to female ratio was 8:1. Most common age group involved was 21–30 years. Maximum number of accidents occurred during night and 38% contributed to driving under the influence of alcohol. Clinical examination findings ranged from simple abrasion, swelling/odema/haematoma, contusion to lacerations and loss of tissue. Of 66 patients with Ear Nose Throat (ENT) bleed, 26 had ear bleed, 34 had nose bleed and 17 had oral cavity bleed. Maximum individuals in the study had orbital fractures (44%). 45% had associated head injury. 30 patients had associated injuries of upper limbs, 25 had lower limb injuries and 8% had blunt trauma. 47% patients required neurosurgical intervention, 44% ophthalmology, 39% faciomaxillary surgeon intervention. Maxillofacial injuries following road traffic accidents are more common as face is the most exposed part of the body. Managing patients with road traffic accidents requires multi disciplinary approach. Safety precautions while driving like use of driving accessories, following traffic rules plays major role. This study will help the policy makers to evolve a better trauma care program by focusing on the target groups and introducing cost effective preventive measures.
Keywords: Maxillofacial injuries, Road traffic accidents, Computerised tomography scan, Facial fractures
Introduction
Maxillofacial injuries resulting from Road Traffic Accidents (RTAs) are leading causes of hospital admissions in India, contributing to about 7.4–8.7% of emergency medical care. With the increase in use of vehicles, there is also increase in number of road traffic accidents. This can be attributed to rash driving by youngsters without using helmet/safety precautions or violating road traffic rules.
Being the most exposed part of the body, face is commonly prone to injuries [1]. Injuries include both soft tissue structures & fractures of bones of face. There can be simple abrasions, contusions, haematoma formation, cut lacerated wounds, loss of tissues, exposure of underlying bone/ cartilage, fractures of facial bones etc.
Mode of fall or direction of impact determines patterns of facial fractures [2]. Facial injuries following RTA’s are most of the time associated with other injuries of body like limbs, vertebrae, blunt trauma, head injury etc. [3]. The best modality of assessing these injuries would be Computerised Tomography scan of facial bones, with radiological evaluation of other involved parts. Because RTA patients have other associated injuries of other parts of body, multidisciplinary approach becomes essential for complete treatment. Hence this study is done to know the clinical features, different types of maxillofacial fractures following facial trauma in road traffic accidents and the need for multidisciplinary approach for the treatment of the patient.
Materials and Methods
Type of Study: Retrospective study.
Place of Study: Raichur Institute of Medical Sciences, Raichur.
Source of Data: Patient details from case sheets from Medical Records Department & Computerised Tomography scans from Radiology Department.
Duration of Study: 2021–2022.
Sample Size: 100.
Method of Data Collection
This retrospective study was conducted on 100 patients with maxillofacial trauma following road traffic accidents during 2021–2022 at Raichur Institute of Medical Sciences, Raichur. Data related to age, sex, area/address, type of motor vehicle (two wheeler, three wheeler, four wheeler etc.), time of accident (morning-5am to 12pm, afternoon-12pm to 4pm, evening-4pm to 8pm, night-8pm to 5am), patient was under the influence of alcohol/no, day of week (Monday to Sunday), clinical examination findings (abrasion, swelling, oedema, haematoma, contusions, cut lacerated wounds, loss of tissues, fracture of facial bones), computerized tomography scan findings (for fractures of facial bones, haematomas, subcutaneous emphysema, haemosinus etc.), associated injuries (injury to upper limbs, lower limbs, head injury, blunt traumas etc.), treatment underwent including the department involved in treatment (multidisciplinary approach) were collected from the case sheets available in medical records section and Computerised Tomography scans from radiology department, in our hospital. Collected data was tabulated, analysed using SPSS software version 21.
Inclusion Criteria
Patients of all ages, both sexes and who have suffered facial fractures due to road traffic accidents were included in the study.
Exclusion Criteria
Patients who have sustained facial fractures due to self fall, assault or facial injuries caused by other than road traffic accidents.
Statistical Analysis
Statistical Analysis was done using SPSS software version 21.
Ethical Approval
Ethical Approval was obtained from Institutional Ethical Committe, Raichur Institute of Medical Sciences, Raichur.
Results
The study included 100 patients aged between 12 and 68 years. Most of the individuals were males 89% & 11% were females. Maximum number of patients belonged to age group 21–30 yrs (37%), followed by 31–40 years (25%), 41–50 years (18%), 51–60 years (9%), 10–20 years (7%), 61–70 years (4%)[Figure 1].
Fig. 1.
Age distribution
Injuries sustained in accidents by two wheeler contributed to 87%, while it was 5% by four wheelers (car, lorry) & 8% others (auto etc.) (Fig. 2).
Fig. 2.
Type of vehicle
Of 100, 55% contributed for RTAs during night travel (travelling in dark) and 45% during day travel (travelling during sunlight). Majority had RTA during evening hours 4pm-8pm (30%) followed by night 8pm-5am (28%), morning 5am-12pm (24%) and noon 12pm-4pm (18%). (Figs. 3 and 4). Individuals travelling under the influence of alcohol contributed to 38% (Fig. 5).
Fig. 3.
Day/night
Fig. 4.
Time of fall
Fig. 5.
Under alcohol/drug influence/no
Number of RTAs varied during the week days, being more on Mondays 21% while on Tuesdays & Sundays it was 17% each (Fig. 6).
Fig. 6.
Day of week
Clinical examination findings ranged from simple abrasion, swelling/odema/haematoma, contusion to lacerations, loss of tissue and facial bone fractures (Picture 1). Severity of injuries sustained by drivers were more compared to passengers. Of 66 patients with ENT bleed, 26% had ear bleed, 34% had nose bleed and 17% had oral cavity (loose tooth or fall of tooth, laceration of lips or mucosal trauma) bleed (Fig. 7).
Picture 1.
Facial injuries sustained by patients in road traffic accident (From left to right-a, b, c, d, e, f, g, h, i) (a) abrasion & swelling over right side of cheek, contusion of right eye; (b) contusion of right eye, swelling of both cheeks, cut lacerated wound over left upper eyelid; (c) cut lacerated wound over left side of forehead, wound over right side of zygomatic area; (d) abrasions over right side of cheek, cut lacerated wound over nose with exposed nasal bones & cartilage, wound over left side of forehead, cut lacerated wound over left side of upper lip; (e) abrasions over upper half of face, cut lacerated wound over forehead, root of nose on either side, loss of tissue over forehead; (f) abrasion over right temporal region with avulsion of pinna; (g) abrasions over forehead, left zygomatic area, left side of cheek, nose with loss of left nasal alar tissue; (h) abrasion of skin over left posterior aspect of pinna with exposed pinna cartilage; (i) abrasion over nose with cut lacerated wound over nose extending to upper lip, cut lacerated wound of mucosal aspect of lower lip
Patients with clear watery nasal discharge (cerebrospinal fluid rhinorrhoea) contributed to 3% (Fig. 8).
Fig. 7.
ENT bleed
aximum individuals in the study had orbital fractures (44%) followed by maxillary sinus (38%), zygomatic arch (33%), temporal bone (32%), pterygoid plates (21%), maxilla (20%), nasal bones (20%), mandible (18%), sphenoid (18%), frontal (11%) and ethmoids (9%) in this order (Fig. 9) (Picture 2).
Fig. 8.
CSF rhinorrhoea
30% patients had associated upper limb injuries, 25% lower limb, 8% had blunt trauma (Fig. 10).
Fig. 9.
CT findings
Fig. 10.
Polytrauma
In 100 patients studied, 47% patients required neurosurgical intervention, 44% ophthalmologic, 39% faciomaxillary surgeon, 29% ENT, 19% Orthopedics, 14% Surgeon, 9% Medicine intervention and 6% patients were referred to higher hospital due to complications (Fig. 11).
Picture 2.
Computerised Tomography scan of patients with road traffic accident (From left to right-a, b, c, d, e, f, g, h, i) (a) 3D reconstructed CT scan showing fracture of left nasal bone, orbital plate of ethmoid bone & frontonasal process of maxilla; (b) CT scan showing fracture of right anterior wall of maxilla with haemosinus & subcutaneous emphysema of right cheek; (c) 3D reconstructed CT scan showing fracture of right zygomatic arch; (d) CT scan showing right temporal bone fracture; (e) 3D reconstructed CT scan showing fracture of maxilla with loss of teeth; (f) CT scan showing comminuted fracture of nasal bones; (g) CT scan showing fracture of mandible on right side; (h) 3D reconstructed CT scan showing fracture of anterior table of frontal sinus; (i) CT scan showing comminuted fracture of nasal bones, ethmoidal complex, nasal septum with orbital displacement with haematoma on left side of cheek
Fig. 11.
Intervening department
Discussion
Road traffic accidents are major cause of injury to maxillofacial area, in India. The combination of a large number of people using two wheelers, bad condition of roads, lack of street lights, bright head lights of opposing vehicles, poor visualization, driving under the influence of alcohol/drugs, non-favorable weather conditions, lack of safety precautions such as wearing helmets, seat belts and violation of safety rules add up to facial fractures in RTAs [3].
Public education in the form of educational campaigns aiming at strict enforcement & follow of traffic rules, avoiding driving under the influence of alcohol/drugs, educating about alternative transportation facilities, use of well maintained vehicles & avoid use of older vehicles, use of vehicles with seat belts etc. help prevent RTA’s.
There is also a role of policy makers in reducing RTA’s by issuing driving license strictly on the basis of proficiency, fixing minimum qualifications for drivers, carrying out regular medical health checkups for hearing & vision mainly, training on first aid, avoiding encroachment on footpath enabling smooth flow of traffic, avoiding random parking of vehicles on busy roads, educating on importance of golden hour by providing adequate treatment to accident victim, making provisions of ambulances & trained medical health personnels, first aid treatment on highways. Just establishing a fully equipped trauma care centres will not prevent RTA’s, but trauma centers may prevent mortality & reduce morbidity.
Maxillofacial fractures in our study was more commonly observed in males than in females (8:1). Similar results were found in a study by Agnihotri et al. [1], where male to female ratio was 6.3:1 and in study by Arslan et al. [4], it was 2.8:1. And also in study done by Abdullah WA et al. [10] out of 200 patients, 172 were males (86%) and 28 were females (14%). Increase in number of accidents in males could be due to more number of males travelling on vehicles than females.
Our study included patients in the age range of 12–68 years. Maximum number of patients belonged to age group 21–30 yrs (37%), followed by 31–40 years (25%), 41–50 years (18%), 51–60 years (9%), 10–20 years (7%), 61–70 years (4%) which was similar to other studies done by Alharbi et al. [2], Natu SS et al. [8] and Singh V et al. [9]. In a study by Menon et al. [3], maximum cases were in the age group of 16–30 years, followed by 31–45 group, 45–60 years, 0–15 years and > 60 years. This finding of increase in number of accidents in this age group can be attributed to more number of youngsters craze for use of vehicles without safety precautions & crossing road speed limits.
In our study, 87% individuals sustained injuries in RTA by two wheeler, 5% four wheeler (car, lorry) and 8% others (auto etc.). Other studies also have similar results like in a study by Rajay et al. [6], RTA by two wheelers contributed to 74.6% and those by non-two wheelers to 25.3% and also in a study by Agnihotri et al. [1] majority of the victims were two wheeler occupants (53.71%), followed by four-wheeler (21.14%). In a study done by Abdullah WA et al. [10] among males, motor vehicle accidents were the most frequent cause of injury (86.1%) in all age groups except those aged 0–9 years. Increased accidents with two wheelers can be attributed to ease of use & affordability for all the people.
In the study, 55% contributed for RTAs during night travel and 45% during day travel. Majority had RTA during evening hours (30%) followed by night (28%), morning (24%) and noon (18%). Increased number of accidents during night could be due to improper street lightings, glare of headlights of opposing vehicles & driving under the influence of alcohol.
In our study, number of RTAs varied during the week days, being more on Mondays (21%) followed by Tuesdays & Sundays (17%). In a study conducted by Rajay et al., majority of RTAs occurred on Mondays (17-17.9%) followed by Tuesday (14-14.7%), Wednesday (14-14.7%) during week days and 16.8% on Sundays [6]. In a study by Agnihotri et al., the rate of accident was higher during 1000–1400 h (23.14%) period and during weekends (38.0%)1. Increased RTA cases on Mondays can be because of weekend outings, late night parties & people travelling back to home or office on Sunday late nights & Monday morning respectively.
Clinical examination findings ranged from simple abrasion, swelling/odema/haematoma, contusion to lacerations and loss of tissue with facial bone fractures. Of 66 patients with ENT bleed, 26 had ear bleed, 34 had nose bleed and 17 had oral cavity (loose tooth or fall of tooth, laceration of lips or mucosal trauma) bleed.
Because this retrospective study does not include data on whether the injured patient was driver or passenger and what was the exact injury sustained by each of them, whether they were using driving accessories, authors cannot comment/conclude about safety accessories.
In our study, we found that 3 patients had watery nasal discharge and was suspected to have CSF rhinorrhoea. In a study by Jayaraju et al. out of 100 patients, four patients had post-traumatic cerebrospinal fluid (CSF) rhinorrhea [5].
Maximum individuals in our study had orbital fractures (44%) followed by maxillary sinus (38%), zygomatic arch (33%), temporal bone (32%), pterygoid plates (21%), maxilla (20%), nasal bones (20%), mandible (18%), sphenoid (18%), frontal (11%) and ethmoids (9%) in this order. 45% had associated head injury. 30 patients had associated injuries of upper limbs, 25 had lower limb injuries and had blunt trauma. In a study by Menon et al., among 348 patients, maximum incidence of fractures was in the mandible with 168 cases followed by 92 in zygomatic complex, combination of fractures in 53 cases, 13 LeFort I fractures, 9 frontal bone fractures, 3 fractures in other areas, 5 nasal fractures, and 5 LeFort II fractures [3]. In a study by Arslan et al., of 701 fractured bones in 422 patients the most frequent was maxillary bone 28.0% followed by nasal bone 25.3%, zygoma 20.2%, mandible 8.4%, frontal bone 8.1% and naso-ethmoido-orbital bone 3.1% [4]. In a study by Jayaraju et al. the commonest facial bone fractured was the maxilla (58%), followed by nasal bone [5].
In our study, 45% had associated head injury. In study by Alharbi et al., out of 166 cases, 9 cases (5.4%) had head injuries [2]. Similarly in a study done by Kim SH et al., associated injuries were seen in 21% of the children with facial fractures [7].
In our study, 47% patients required neurosurgery consultation, 44% required Ophthalmology consultation, 39% patients required maxillofacial surgeon intervention, 29% ENT, 19% Orthopedics, 14% surgeon, 9% Medicine and 6% patients were referred to higher hospital. In a study by Alharbi et al. majority of cases (83.1%) was treated by OMFS alone, other specialties such as neurosurgery, orthopedic, ophthalmology, general surgery, internal medicine, and dermatology were involved in the treatment of other injuries [2].
Conclusion
Road traffic accidents have become leading cause of hospital admissions in India. Increase in road traffic accidents is due to rash driving by youngsters without using safety driving accessories. Being the most exposed part, face is more commonly injured. Clinical examination findings ranged from simple abrasion, swelling/odema/haematoma, contusion to lacerations and loss of tissue. Majority of the patients in our study had orbital fractures (44%). Managing patients with road traffic accidents requires multi disciplinary approach. Precautions while driving like use of safety driving accessories, following traffic rules plays major role. This study will help policy makers evolve a better trauma care program by focusing on educating the target groups, introducing cost effective preventive measures like speed limits, use of safety driving accessories etc. & in establishment of fully equipped trauma care centres with specialist & supporting staff at each district level to provide good effective trauma care to the patients with multidisciplinary team involvement and without need for patient to go anywhere for further treatment. Just establishing a fully equipped trauma care centres will not prevent RTA’s, but trauma centers may prevent mortality & reduce morbidity.
Acknowledgements
None.
Abbreviations
- RTA
Road Traffic Accident
- CT scan
Computerised Tomography scan
- CLW
Cut Lacerated Wound
- ENT
Ear Nose Throat
- CSF
Cerebrospinal Fluid
Funding
None.
Declarations
Ethical approval
Obtained from Institutional Ethical Committee (IEC).
Competing Interests
None.
Financial support and sponsorship
None.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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