Maxillofacial fractures in a budding teaching hospital: a study of pattern of presentation and care

Introduction Previous reports indicated that there is geographic and sociodemographic variation in the epidemiology of maxillofacial fractures. Audit of maxillofacial injuries managed at any institution is therefore necessary to understand the trends and proffer strategies for prevention. We therefore embarked on this study to determine the pattern of maxillofacial fractures and concomitant injuries in our institution. Methods We carried out a retrospective review of information on demography, aetiology and type of maxillofacial fracture, patients' status, type of crash, level of consciousness and concomitant injuries. The data collected was analysed with SPSS Version 20. Results A total of 233 patients aged 2 to 66 years were reviewed. A higher male preponderance (M:F 3.4:1) was observed. Road traffic crashes (RTC) accounted for 78.5% of injuries. Motorcycle related crashes were responsible for 69.4% of RTC and 54.5% of all fractures. Fracture of the mandible (63.2% n=172) was the most predominant skeletal injury and the body (25% n=43) was the most common site of fracture while the zygoma (29%) was predominantly affected in the midface. Ninety three patients (40%) suffered loss of consciousness. The relationship between aetiology of injuries and consciousness level of the patients was statistically significant (p=0.001). Of the 43 patients who had concomitant injuries, craniocerebral affectation (60.5%) was the commonest. Conclusion RTC remains the major aetiology of maxillofacial fractures. The mandible was mostly affected and nearly half of the patients have associated loss of consciousness. There is need for continual advocacy and enforcement of laws on preventive measures among road users.


Introduction
Skeletal injuries of the face constitute a substantial proportion of trauma globally [1][2][3][4]. Oral and maxillofacial injuries can pose considerable long term functional, aesthetic and psychological complications [3,5]. Such injuries constitute huge economic burden due to treatment costs, disabilities and man hour loss occasioned by hospital stay [6][7][8]. The epidemiology of maxillofacial fractures in different populations varies in type, severity and aetiology depending on the socio economic risk factors and cultural differences [9][10][11][12]. Brown and Cowpe [13] listed the aetiologic factors as road traffic crashes (RTC), falls, sports, industrial accidents, gunshots and assault. Some authors have also reported cases of animal attacks [14,15]. Although some studies indicated that assault is the leading cause of maxillofacial injuries in United States of America and most European nations [16][17][18], however, RTC remain the major aetiology in most developing countries including Nigeria [6,[19][20][21]. The high prevalence of RTC in developing countries has been linked to heavy reliance on road as the major mode of transportation [22,23]. Furthermore a sizeable number of unemployed youths take up jobs such as hawking and commercial motorcycling which predisposes them to RTC [7]. In Periodic audit of facial injuries helps policy makers to develop new strategies for prevention and to assess the proficiency of existing laws on road safety regulations and social habit of different populations [6][7][8][9][10]. There is no previous published work on this subject from our institution which hitherto was a secondary health care facility prior to its upgrade to a tertiary centre in 2008. Thus, the present study was designed to analyse the pattern of maxillofacial fractures and associated concomitant injuries encountered in our institution for comparison with reports from other parts of the globe.

Results
A total of 233 patients with maxillofacial fracture were seen during the study period. Patients' demography revealed a male preponderance of 180 to 53 (M:F 3.4:1) while the mean age was 29.6±11.78 (age range: 2-66 years). There was a comparatively higher prevalence of patients between 20 and 30 years of age Figure 1. Analysis of the aetiology of injuries Table 1

Discussion
Trends and characteristics of maxillofacial injuries vary from one population to another depending on certain peculiarities such as socioeconomic, cultural and environmental factors [6,7]. The Ekiti State University Teaching Hospital is a referral centre for Ekiti and four neighbouring states, serving a combined population of about ten million people. In addition, the state provides a major link for road transport between the North-central and south-western parts of Nigeria. Thus, we provide trauma care for a sizeable number of injured commuters along this route. The observed incidence in age is similar to previous reports where majority of the patients were in the third decade of life [1,8]. The third decade marked the active phase whereby individuals are more likely to indulge in injury prone adventures such as dangerous driving, violence and use of automobile for commercial purposes. Also, the advent of the use of motorcycle for commercial purpose in most Nigerian cities has been linked to the rising spate of youth unemployment [7,25]. The male preponderance of more than twice the number of females is also in agreement with previous reports where majority of injured patients were male [1,[6][7][8][9] RTC was the commonest aetiology of fractures in this study with a frequency of 78.5%. This is higher than the value reported by Adebayo et al [1] (56%) and Cheema and Amin [5] (56%) but comparable to the study by Adekeye et al [21] (76%), Ugboko et al [9] (72%) and Fasola et al [11] (71%), However, Oginni et al [7] and Abiose et al [22] reported slightly higher prevalence of 81.6 and 81% respectively. The fact that motorcycle related fractures constitute majority of RTC corroborates findings from similar studies [7,19,26]. In agreement with earlier reports, other causes of maxillofacial fractures such as assault, falls and sports were low in prevalence in this study [1,9,11]. The advent of motorcycles for transportation has a significant contribution to RTC in Nigeria because most riders are uneducated youths who do not adhere to traffic rules on protection and road usage [6,7]. Rising youth unemployment and rural/ urban migration has further popularised the use of motorcycle for commercial purpose in Nigeria [7,19,26]. Furthermore, motorcycles can navigate narrow ways, bypass traffic jams and they often carry more than the In agreement with some studies, the mandible was the most frequently fractured bone of the face in our series with the body being the most commonly affected part of the bone [7,11,14,20]. However, Odusanya [27] in a previous study from Nigeria established that the condyle was the most commonly fractured part of the bone. Similarly, recent reports by Mesgarzadeh et al [14] in Iran and Al Ahmed et al [12] in UAE revealed higher prevalence of fracture of the condyle. Some researchers also corroborated higher frequency of condylar fractures in North America and Europe [17,18]. However, findings from this study supported the claim of other authors who reported that fracture of the body and symphysis of the mandible has been observed to be related more to motocycle crashes [7,19,26]. In the current study, zygomatic bone was the most commonly fractured in the midface as alluded to by other studies [9,11,22,28]. Midface fractures were reported to be less prevalent than mandibular fractures probably because of the mobility of the latter and its proneness to injury [2,6,7]. However, Page number not for citation purposes 4 Gassner et al [29,30]

Competing interests
The authors declare no competing interest.

Acknowledgments
The authors acknowledge the effort of the resident doctors and the medical staff at the emergency ward and maxillofacial surgery clinic for helping with the data collection. Table 1: Aetiology of oral and maxillofacial injuries by gender

Nasal fractures
Reduction with Walsham's forcep 3 No active treatment 2 Total number of fractures 272 Figure 1: Revealed that the peak age incidence for oral and maxillofacial injury in this study is 21-30 years closely followed by 31-40 years. The least affected age groups were those above 50 years