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depicts the concomitant injuries observed in our series. The relation-

ship between type of fracture and concomitant injuries is presented

in Table 2 and Figure 2.

Loss of consciousness with injury was significantly associ-

ated with thoracic/lumbar spine fracture, intracranial hemorrhage,

skull fracture, long bone fracture, abdominal/pelvic/thoracic injury,

and death. Those patients intubated in the emergency department

were significantly more likely to have a cervical spine fracture,

thoracic/lumbar spine fracture, intracranial hemorrhage, skull frac-

ture, and abdominal/pelvic/thoracic injury. In addition, intubation in

the emergency department was significantly associated with death.

The mean GCS for patients sustaining a cervical spine fracture was

11.2, compared with 13.8 for those without a cervical spine fracture

(

0.05, Fig. 3). The mean GCS for patients with an intracranial

hemorrhage was 11.0, compared with 14.6 for those without an intra-

cranial hemorrhage (

0.01, Fig. 4). The mean age of patients expe-

riencing an intracranial hemorrhage was significantly lower than those

without (12.8 versus 14.7 years old,

0.01). The total hospital

length of stay was increased for patients experiencing an intracranial

hemorrhage (11.2 versus 3.7 days,

0.01).

DISCUSSION

Facial fractures in the pediatric population are associated

with severe concomitant injuries. Similar to previous studies, there

was a strong male preponderance,

12,17

–

and the mandible was

the most common bone fractured.

–

Interestingly, in female

patients in our series, the orbit was the most common bone frac-

tured. The most common etiology of fractures in our series was in-

terpersonal violence overall, interpersonal violence in men, and

motor vehicle accident in women. The preponderance of interper-

sonal violence likely reflects the population treated at our institu-

tion, notably urban, often gang-affiliated males.

One hundred twenty-seven patients (44.6%) had some form

of concomitant multisystem injury. These injuries are likely a re-

flection of the degree of force required to fracture the facial skele-

ton. In our study, mandible fractures seem to portend a protective

mechanism from several serious injuries: intracranial hemorrhages

and skull fractures. Fracture of the mandible may represent a force

absorbing mechanism, thus sparing the cranium and its contents

from injury. Palatal fractures were associated with an increased rate

of thoracolumbar spine fractures, skull fractures, and long bone

fractures. Palatal fractures usually are due to a strong force, and

the association of long bone fractures and thoracolumbar spine

fractures likely reflects this. Fractures of the zygoma were associ-

ated with cervical spine injuries and intracranial hemorrhage. As

the force is transmitted in a more cranial direction on the facial skel-

eton, the cervical spine and intracranial contents may be more likely

to be traumatized. Orbital fractures were associated with cervical

spine fractures, intracranial hemorrhage, and skull fractures. This

is similar to the patterns seen with fractures of the zygoma in that

there is likely more force transmitted to the cervical spine and intracra-

nial contents. Nasal bone fractures were associated with thoracolumbar

spine fractures, intracranial hemorrhage, and abdominal/pelvic injuries.

The reason for these associations is unclear and may represent an anom-

aly due to the prominent position of the nose. Frontal bone/sinus fractures

were associated with intracranial hemorrhage and skull fractures. Again,

the tremendous force required to fracture the frontal bone places the intra-

cranial contents at greater risk. Le Fort variant fractures were associated

with skull fractures and abdominal/pelvic injuries.

Cervical spine fractures and intracranial hemorrhages were

associated with a lower GCS score. This is a logical association

considering the severity of these injuries.

CONCLUSIONS

A large proportion of facial fractures in the pediatric popula-

tion are associated with severe concomitant injuries. In general, as

fractures move in a more cranial direction, there is an increased risk

FIGURE 2.

Concomitant injuries and type of fracture.

FIGURE 3.

Cervical spine fracture and GCS.

FIGURE 4.

Intracranial hemorrhage and GCS.

The Journal of Craniofacial Surgery

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Volume 25, Number 5, September 2014