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Facial Fractures of the Upper Craniofacial Skeleton Predict Mortality and Occult Intracranial Injury After Blunt Trauma: An Analysis

Bellamy, Justin L. BS*; Mundinger, Gerhard S. MD; Flores, José M. MPH*‡; Reddy, Sashank K. MD, PhD; Mithani, Suhail K. MD§; Rodriguez, Eduardo D. MD, DDS; Dorafshar, Amir H. MBChB, FAAP*†

doi: 10.1097/SCS.0b013e3182a30544
Original Articles

Purpose The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma.

Methods Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression.

Results Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P < 0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P < 0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face.

Conclusions The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

From the *Johns Hopkins School of Medicine; †Division of Plastic and Reconstructive Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine; and ‡Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; and §Division of Plastic and Reconstructive Surgery, Duke University, Durham, North Carolina.

Received April 11, 2013.

Accepted for publication June 30, 2013.

Address correspondence and reprint requests to Amir H. Dorafshar, MBChB, FAAP, Plastic, Reconstructive, and Maxillofacial Surgery, R. Adams Cowley Shock Trauma Center, Room P1G04K, 22 S Greene St, Baltimore, MD 21201; E-mail address:

This study has no sources of support and funding requiring acknowledgement.

Presented in part at the 57th Annual Meeting of the Plastic Surgery Research Council, June 15, 2012, Ann Arbor, Michigan.

The authors report no conflicts of interest.

© 2013 by Mutaz B. Habal, MD.