Facial Fractures: Independent Prediction of Neurosurgical Intervention

Facial Fractures: Independent Prediction of Neurosurgical Intervention | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Facial Fractures: Independent Prediction of Neurosurgical Intervention Brandon Lucke-Wold, Kevin Pierre, Sina Aghili-Mehrizi, Gregory Murad This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-356292/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jan, 2021 Read the published version in Asian Journal of Neurosurgery → Version 1 posted You are reading this latest preprint version Abstract Background: Over half of patients with facial fractures have associated traumatic brain injury. Based on previous force dynamic cadaveric studies, Lefort type 2 and 3 fractures are more associated with severe injury. Whether this correlates to neurosurgical intervention have not been well characterized. The purpose of this retrospective data analysis is to characterize fracture pattern types in patients requiring neurosurgical intervention and to see if this is different from those not requiring intervention. Methods: Retrospective data was collected from the trauma registry from 2010-2019. Inclusion criteria: adults over 18, confirmed facial fracture with available neuroimaging, reported traumatic brain injury, and admission to ICU or floor bed. Exclusion criteria: patients less than 18 years old, patients with no neuroimaging, and patients that were deceased prior to initiation of neurosurgical intervention. Data included: basic demographic data, presenting Glasgow Coma Scale (GCS) score, mechanism of injury, type of traumatic brain injury, neurosurgical intervention, and facial fracture type. Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-Square analysis for demographic and injury characteristic data. Results: 1172 patients met inclusion criteria. 1001 required no neurosurgical intervention and 171 required intervention. No significant difference was seen between the non-intervention group and intervention group in terms of demographic data or baseline injury characteristics except for presenting GCS. A significant difference was seen between groups for presenting Glasgow Coma Scale (c 2 =67.71, p<0.001). The intervention group had greater number of patients with GCS<8 compared to the non-intervention group. Fracture patterns were overall similar between the non-intervention group compared to intervention group (c 2 =4.518, p=0.92), however subset analysis did reveal a 2 fold increase in Lefort type 2 fractures and notable increase in Lefort type 3 and panfacial fractures in the intervention group. The intervention group was further divided into those requiring external ventricular drain or intracranial pressure monitor only vs. patients requiring craniectomy, craniotomy, or burr holes with or with external ventricular drain or intracranial pressure monitor. A significant difference was seen between groups (c 2 =20.02, p=0.03). The craniectomy, craniotomy, or burr hole group was much more likely to have Lefort type 2 or 3 fractures compared to the external ventricular drain or intracranial pressure monitor group only. Conclusions: Lefort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm in order to improve patient care for trauma patients with facial fracture and traumatic brain injury. Neurosurgery Traumatic Brain Injury Lefort type 2 and 3 fractures Neurosurgical Intervention Statements Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Trauma is one of the leading causes of disability globally and represents the leading cause of death in the first four decades of life. 1 Roughly one of seven trauma patients admitted to the emergency room had maxillofacial fractures. 2 , 3 These include nasal bone, mandible, orbital, alveolar ridge, zygomatic, teeth, panfacial, isolated maxillary, and Le Fort type I-III fractures. 4 – 6 While facial fractures are often associated with injuries to nearby vital structures such as the airway, vasculature, and nerves, approximately half of facial fracture victims also present with concomitant traumatic brain injury (TBI). 7 – 10 Depending on the severity, TBI may be difficult to detect using current technology, potentially delaying treatment and worsening prognosis for patients. 8 Previous studies have also suggested an association between maxillofacial fractures and TBI. 3,7,8,11−24 A recent study by McCarty et al. proposed that Le Fort type fractures may be associated with more severe TBI. 8 This is likely due to diffuse axonal injury and shearing forces contributing to epidural and subdural hemorrhages secondary to the high-velocity facial trauma required to produce these fractures. 6 , 8 In a study by Elbaih et al., mid-facial fractures were correlated with an increased likelihood of concurrent epidural hemorrhage, subdural hemorrhage, and pneumocephalus. 5 Despite these findings, little is known about how fracture types predict TBI severity and which patients eventually require neurosurgical intervention such as intracranial pressure (ICP) monitoring, external ventricular drain (EVD) placement, or craniotomy or craniectomy. Thus, the present study is designed to develop an improved algorithm for the management of TBI in the context of known facial fractures with a hypothesis that patients with mid-face fractures are at increased risk for severe TBI (GCS < 8) warranting more aggressive neurosurgical intervention. Methods The study was submitted for institutional board review at University of Florida and abided by the highest international ethical research standards. Retrospective analysis of patients from 2010–2019 obtained through our trauma registry. Inclusion criteria: adults over 18, confirmed facial fracture with available neuroimaging, reported traumatic brain injury, and admission to ICU or floor bed. Exclusion criteria: patients less than 18 years old, patients with no neuroimaging, and patients that were deceased prior to initiation of neurosurgical intervention. In addition to basic demographic data, data collected included presenting Glasgow Coma Scale (GCS) score, mechanism of injury, facial fracture type, traumatic brain injury type, and type of neurosurgical intervention. Age was grouped into 7 categories: 1 (18–24 years old), 2 (25–34 years old), 3 (35–44 years old), 4 (45–54 years old), 5 (55–64 years old), 6 (65–74 years old), 7 (> 75 years old). Race was grouped into 5 categories: 1 (Caucasian), 2 (Black), 3 (Asian), 4 (Hispanic), 5 (Other). Sex was classified as male or female. GCS score was arranged: mild (14–15), moderate (9–13), or severe (8 or less). Mechanism of Injury was grouped into 7 categories: 1 (Assault), 2 (All-terrain vehicle or dirtbike accident), 3 (Gunshot wound or knife injury), 4 (Bicycle or moped accident), 5 (Motorcycle collision or motor vehicle collision), 6 (Fall), 7 (Other). Type of traumatic brain injury: 1 (Contusion), 2 (Diffuse axonal injury), 3 (Epidural hematoma), 4 (Subdural hematoma), 5 (Traumatic subarachnoid hemorrhage), 6 (Intracranial hemorrhage or intraventricular hemorrhage), 7 (Penetrating injury). Additional radiographic findings: 1 (Edema), 2 (Herniation), 3 (Pneumocephalus), 4 (Cerebral/Cerebellar laceration). Patients were divided into those with facial fracture and traumatic brain injury without neurosurgical intervention and into those with facial fracture and traumatic brain injury with neurosurgical intervention. Graphpad Prism 8.0 Software was used for analysis. Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-Square analysis for demographic and injury characteristic data. P < 0.05 was considered statistically significant. Results Based on the above inclusion/exclusion criteria 1985 patients were pooled from the overall trauma registry. On further review, 316 were too young, 403 had no traumatic brain injury, and 94 had no facial fracture. 1172 therefore met criteria for inclusion into the study. 1001 had facial fracture and traumatic brain injury with no neurosurgical intervention, 171 had facial fracture and traumatic brain injury with neurosurgical intervention. Table 1 has baseline demographic data. No significant difference was seen between groups for age (χ 2 = 8.08, p = 0.23). No significant difference was seen between groups for race (χ 2 = 0.6, p = 0.96). No difference was seen between groups for gender (χ 2 = 1.33, p = 0.25). Injury characteristics were compared in Table 2 . A significant difference was seen between groups for presenting Glasgow Coma Scale (χ 2 = 67.71, p < 0.001). Of note, in the non-intervention group 64% had mild TBI (GCS score 14–15) compared to 10% of the intervention group. Conversely, 74% of the intervention group had severe GCS score (3–8) compared to 22% of the non-intervention group. No significant difference was seen between groups for mechanism of injury (χ 2 = 7.58, p = 0.27), type of TBI (χ 2 = 3.09, p = 0.8), or additional radiographic findings (χ 2 = 1.71, p = 0.63). Fracture type patterns were similar between the non-intervention and intervention group (χ 2 = 4.518, p = 0.92) as seen in Fig. 1 . Subset analysis did however reveal a twofold increase in Lefort type 2 and panfacial fractures in the intervention group compared to non-intervention group. In the intervention group, 136/171 required an ICP monitor or EVD only, 12/171 required a craniotomy, craniectomy, or burr holes only, 23/171 required a craniotomy, craniectomy, or burr holes with EVD or ICP monitor (Fig. 2 ). A significant difference was seen in type of intervention depending on presenting facial fracture pattern (χ 2 = 20.02, p = 0.03). Of note, 24% of the craniotomy, craniectomy, burr hole group had Lefort type 2 fracture compared to only 9% in the ICP monitor only group. 15% of the craniotomy, craniectomy, burr hole group had Lefort Type 3 fracture compared to only 7% in the ICP monitor only group. 29% of the craniotomy/burr hole group had panfacial fractures compared to 7% of the ICP monitor only group (Fig. 3 ). Discussion Traumatic injury is a leading cause of death and disability worldwide. 1 A significant number of trauma victims present with maxillofacial fractures, with roughly half of these patients presenting with TBI. 2 , 25 , 3 There is a growing body of literature suggesting that maxillofacial fractures serve as predictors for the presence and severity of TBI. 5 , 8 , 13 , 15 , 16 , 19 , 23 This study aimed to determine whether certain types of maxillofacial fractures can predict the need for neurosurgical interventions in an effort to produce an algorithm for the management of TBI patients presenting with known facial fractures. A retrospective analysis of patients admitted to the UF Health Shands Hospital between 2010 and 2019 with known facial fractures and concurrent TBI was performed. Most patients were victims of motor vehicle collisions, motorcycle accidents, and falls. Most suffered orbital, nasal, and maxillary fractures in a distribution similar to the study done by Menon et al. with patients sharing similar demographics. 4 Patients were not more likely to require intervention based on age, race, gender, mechanism of injury, or specific radiologic findings of edema, herniation, pneumocephalus, or laceration. As anticipated, those taken for intervention had lower GCS scores. Patients with Le Fort type II, type III, and panfacial fractures were more likely to undergo neurosurgical intervention. Further, those presenting with these severe fractures were more likely to receive higher levels of neurosurgical intervention involving craniotomies, craniectomy, and burr holes compared to only EVDs or ICP monitors. This is consistent with the initial hypothesis that the high-velocity impacts required to produce the more severe type II and III Le Fort type fractures 6 , 26 are also more likely to lead to more severe neurologic injury. These results also support previous investigations that showed associations between midface fractures and more severe TBI. 5 Improved algorithms to identify and triage patients with facial fractures that are more likely to require neurosurgical interventions are being designed in collaboration with the UF Health Shands trauma, plastic, and oral and maxillofacial surgeon colleagues. Figure 4 shows an improved decision tree algorithm for managing patients with severe TBI. This algorithm is influenced by this study’s findings and Czerwinski’s and colleagues’ proposition for mandatory early CT-head to rule out TBI in patients presenting with facial fractures. This argument was also supported by Shibuya and colleagues’ study which showed that 11% of patients who underwent facial fracture repair had worsened GCS score following intervention due to underlying TBI. 27 , 28 Early surgical interventions improve outcomes. 29 The hope is that through initiation of the improved algorithm early imaging can be obtained, improved interactions between specialties can enhance patient care, and providers can ultimately act more quickly to intervene when indicated. This study’s retrospective nature serves as a limitation. The study was also limited by the trauma registry. For example, it was not possible to separately consider the use of EVDs versus other intracranial pressure monitoring devices because providers sometimes did not use specific International Classification of Diseases (ICD) coding. ICD coding also sometimes did not specify fracture types, only indicating the presence of a facial fracture. These injuries were successfully categorized by chart review. However, it is possible that some facial fractures for patients within this group were not recorded. We hope that the data and results from this initial study will serve as a catalyst for prospective investigations. Subsequent studies will look at the prospective implementation of the algorithm for patients with facial fractures and TBI. This will allow direct evaluation of effectiveness. Future studies can also implement the finite element head models reviewed and developed by Tse et al. to further determine fracture patterns more likely to be associated with severe TBI. 30 , 31 Declarations Funding: None Conflicts of Interest: none Data Material: University of Florida Trauma Registry Code: None Ethics: Marked Exempt by University of Florida IRB Consent: Not applicable; retrospective deidentified data Publication: all authors have seen and agree with the contents of this work for publication Contributions: BL formulated the project, collected the data, wrote the manuscript. KP helped with data collection and manuscript preparation. SA helped with data collection and manuscript preparation. GM was the primary PI for the project and coordinated support through the registry. References Søreide K (2009) Epidemiology of major trauma. Br J Surg 96(7):697–698 Hwang K, You SH (2010) Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 43(1):42–48 Martin RC 2nd, Spain DA, Richardson JD (2002) Do facial fractures protect the brain or are they a marker for severe head injury? Am Surg 68(5):477–481 Menon S, Sham ME, Kumar V et al (2019) Maxillofacial Fracture Patterns in Road Traffic Accidents. Ann Maxillofac Surg 9(2):345–348 Elbaih AH, El-Sayed DA, Abou-Zeid AE, Elhadary GK (2018) Patterns of brain injuries associated with maxillofacial fractures and its fate in emergency Egyptian polytrauma patients. Chinese journal of traumatology = Zhonghua chuang shang za zhi 21(5):287–292 Roumeliotis G, Ahluwalia R, Jenkyn T, Yazdani A (2015) The Le Fort system revisited: Trauma velocity predicts the path of Le Fort I fractures through the lateral buttress. Plast Surg (Oakv) 23(1):40–42 Pham TT, Lester E, Grigorian A, Roditi RE, Nahmias JT (2019) National Analysis of Risk Factors for Nasal Fractures and Associated Injuries in Trauma. Craniomaxillofac Trauma Reconstr 12(3):221–227 McCarty JC, Kiwanuka E, Gadkaree S, Siu JM, Caterson EJ. Traumatic Brain Injury in Trauma Patients With Isolated Facial Fractures. Journal of Craniofacial Surgery. 2020;31(5) Suri YV, Qasba KK, Mahajan TR (1996) MILITANCY TRAUMA: MAXILLOFACIAL INJURY, ANAESTHESIA AND CRITICAL CARE. Med J Armed Forces India 52(1):23–26 Davidoff G, Jakubowski M, Thomas D, Alpert M (1988) The spectrum of closed-head injuries in facial trauma victims: incidence and impact. Ann Emerg Med 17(1):6–9 Keenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP (1999) Does the Face Protect the Brain?: A Case-Control Study of Traumatic Brain Injury and Facial Fractures. Archives of Surgery 134(1):14–17 Rajandram RK, Syed Omar SN, Rashdi MFN, Abdul Jabar MN (2014) Maxillofacial injuries and traumatic brain injury–a pilot study. Dent Traumatol 30(2):128–132 You N, Choi MS, Roh TH, Jeong D, Kim SH (2018) Severe Facial Fracture is Related to Severe Traumatic Brain Injury. World Neurosurg 111:e47–e52 Joshi UM, Ramdurg S, Saikar S, Patil S, Shah K (2018) Brain Injuries and Facial Fractures: A Prospective Study of Incidence of Head Injury Associated with Maxillofacial Trauma. J Maxillofac Oral Surg 17(4):531–537 Zandi M, Seyed Hoseini SR (2013) The relationship between head injury and facial trauma: a case-control study. Oral Maxillofac Surg 17(3):201–207 Kraus JF, Rice TM, Peek-Asa C, McArthur DL (2003) Facial trauma and the risk of intracranial injury in motorcycle riders. Ann Emerg Med 41(1):18–26 Carlin CB, Ruff G, Mansfeld CP, Clinton MS (1998) Facial fractures and related injuries: a ten-year retrospective analysis. J Craniomaxillofac Trauma 4(2):44–48; discussion 43 Salentijn EG, Peerdeman SM, Boffano P, van den Bergh B, Forouzanfar T (2014) A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 42(6):705–710 Luce EA, Tubb TD, Moore AM. Review of 1,000 Major Facial Fractures and Associated Injuries. Plastic and Reconstructive Surgery. 1979;63(1) Lee KF, Louis KW, Lee YE, Jung Ho S, Seung Ro L (1987) The impact-absorbing effects of facial fractures in closed-head injuries. Journal of neurosurgery 66(4):542–547 Lim LH, Lam LK, Moore MH, Trott JA, David DJ (1993) Associated injuries in facial fractures: review of 839 patients. British Journal of Plastic Surgery 46(8):635–638 Pappachan B, Alexander M (2006) Correlating Facial Fractures and Cranial Injuries. Journal of Oral Maxillofacial Surgery 64(7):1023–1029 Lee HJ, Kim YJ, Seo DW et al (2018) Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury. Injury 49(5):963–968 Alvi A, Doherty T, Lewen G (2003) Facial fractures and concomitant injuries in trauma patients. Laryngoscope 113(1):102–106 Scheyerer MJ, Döring R, Fuchs N et al (2015) Maxillofacial injuries in severely injured patients. J Trauma Manag Outcomes 9:4–4 Phillips BJ, Turco LM (2017) Le Fort Fractures: A Collective Review. Bull Emerg Trauma 5(4):221–230 Czerwinski M, Parker WL, Williams HB (2008) Algorithm for head computed tomography imaging in patients with mandible fractures. J Oral Maxillofac Surg 66(10):2093–2097 Shibuya TY, Karam AM, Doerr T et al (2007) Facial fracture repair in the traumatic brain injury patient. J Oral Maxillofac Surg 65(9):1693–1699 Giuliani G, Anile C, Massarelli M, Maira G (1997) Management of complex craniofacial traumas. Rev Stomatol Chir Maxillofac 98(Suppl 1):100–102 Tse KM, Lim S, Tan VBC, Lee H (2014) A Review of Head Injury and Finite Element Head Models. American Journal of Engineering Technology Society 1:28–52 Yang B, Tse K-M, Chen N et al (2014) Development of a finite element head model for the study of impact head injury. Biomed Res Int 2014:408278–408278 Tables Table 1: Demographics Age in Years 1. 18-24 2. 25-34 3. 35-44 4. 45-54 5. 55-64 6. 65-74 7. 75+ Non-Intervention (n=1001) (176) 17% (165) 17% (151) 15% (169) 17% (128) 13% (94) 9% (118) 12% Intervention (n=171) (36) 21% (39) 23% (21) 12% (33) 19% (28) 16% (10) 6% (4) 3% P>0.05 Race 1. Caucasian 2. Black 3. Asian 4. Hispanic 5. Other 826 (83%) 118 (11%) 5 (1%) 34 (3%) 18 (2%) 135 (79%) 24 (14%) 1 (1%) 7 (4%) 4 (2%) P>0.05 Gender Male Female 723 (72%) 278 (28%) 136 (79%) 35 (21%) P>0.05 Table 2: Injury Characteristics Glasgow Coma Scale Mild (14-15) Moderate (9-13) Severe (3-8) Non-Intervention (n=1001) (636) 64% (140) 14% (226) 22% Intervention (n=171) (17) 10% (27) 16% (127) 74% P<0.001 Mechanism of Injury 1. Assault 2. ATV/Dirtbike 3. GSW/Knife 4. Bicycle/Moped 5. MCC/MVC 6. Fall 7. Other 1. 160 (16%) 2. 44 (4%) 3. 46 (5%) 4. 74 (7%) 5. 381 (38%) 6. 212 (22%) 7. 84 (8%) 16 (9%) 11 (6%) 9 (5%) 18 (11%) 77 (45%) 19 (12%) 21 (12%) P>0.05 Types of TBI Contusion DAI EDH SDH tSAH ICH/IVH Penetrating injury 61 (6%) 31 (3%) 49 (5%) 201 (20%) 295 (29%) 66 (7%) 11 (1%) 21 (12%) 23 (13%) 22 (13%) 63 (37%) 79 (46%) 27 (16%) 1 (1%) P>0.05 Additional Radiographic Findings Edema Herniation Pneumocephalus Cerebral/Cerebellar Laceration 25 (2%) 32 (3%) 34 (3%) 5 (1%) 20 (12%) 25 (15%) 10 (6%) 4 (2%) P>0.05 Cite Share Download PDF Status: Published Journal Publication published 01 Jan, 2021 Read the published version in Asian Journal of Neurosurgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-356292","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":22473728,"identity":"f586b012-a929-48f4-b722-1cde43100d01","order_by":0,"name":"Brandon Lucke-Wold","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-6577-4080","institution":"University of Florida College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Brandon","middleName":"","lastName":"Lucke-Wold","suffix":""},{"id":22473729,"identity":"e8e10f58-665e-4eb1-8d35-4e00e921d715","order_by":1,"name":"Kevin Pierre","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Pierre","suffix":""},{"id":22473730,"identity":"f7c6ece7-f76f-4acf-8dc5-5295f71ddabe","order_by":2,"name":"Sina Aghili-Mehrizi","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sina","middleName":"","lastName":"Aghili-Mehrizi","suffix":""},{"id":22473731,"identity":"ab64c0bd-63b1-402b-bcb5-28eb54158285","order_by":3,"name":"Gregory Murad","email":"","orcid":"","institution":"University of Florida College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gregory","middleName":"","lastName":"Murad","suffix":""}],"badges":[],"createdAt":"2021-03-23 23:19:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-356292/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-356292/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.4103/ajns.AJNS_251_21","type":"published","date":"2021-01-01T09:22:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":8330453,"identity":"d45e9826-841c-408b-bc9b-cc098966d135","added_by":"auto","created_at":"2021-04-22 14:34:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22895,"visible":true,"origin":"","legend":"Percentages of overall patients for the intervention vs. non-intervention group for type of facial fracture. 1-Nasal, 2-Alveolar Ridge, 3-Zygomatic, 4-Maxillary not specified, 5-Lefort 1, 6-Lefort 2, 7-Lefort 3, 8-Orbital, 9-Panfacial, 10-Mandible, 11-Teeth. No overall significant difference in aggregate fracture pattern between groups. There was a 2-fold increase however in Lefort Type II fractures in the intervention group. Additionally, more Lefort type 3 and panfacial fractures were seen in the intervention group. ","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-356292/v1/01ca7bf65ca1215d4b1148dd.png"},{"id":8330631,"identity":"d05a2c33-c736-448f-a29c-9cacc0ed1e0c","added_by":"auto","created_at":"2021-04-22 14:37:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6033,"visible":true,"origin":"","legend":"Type of neurosurgical intervention for trauma patients with facial fractures. ICP-intracranial pressure, EVD-external ventricular drain, Crani-decompressive craniectomy, craniotomy, or burr holes","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-356292/v1/4ff735733e83362c9b3cbf9c.png"},{"id":8330951,"identity":"5712d954-27e9-4934-8ab4-7e3022465a0f","added_by":"auto","created_at":"2021-04-22 14:40:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":7794,"visible":true,"origin":"","legend":"A significant difference was seen in type of intervention depending on presenting facial fracture pattern. Lefort type 2 fractures were \u003e2 fold as common in the craniotomy, craniectomy, burr hole group compared to ICP monitor only group. Similarly, there was a 2-fold increase in the craniotomy, craniectomy, burr hole group for Lefort Type 3 fracture compared to the ICP monitor only group. 29% of the craniotomy, craniectomy, burr hole group had panfacial fractures compared to 7% of the ICP monitor only group. ","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-356292/v1/8796b831bf6081cfcd632a52.png"},{"id":8330632,"identity":"5b7aaad3-6da9-434d-9691-9dc73873626f","added_by":"auto","created_at":"2021-04-22 14:37:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":31965,"visible":true,"origin":"","legend":"Improved algorithm for managing patients with suspected TBI and facial fractures. Patients with Lefort type 2 or 3 fractures are at greater likelihood for requiring neurosurgical intervention and should be grouped accordingly. ","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-356292/v1/b679b981c2048d4757cddfeb.png"},{"id":16574211,"identity":"95207366-d48f-468b-86ef-e3d58500f51a","added_by":"auto","created_at":"2021-12-18 09:22:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":296317,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-356292/v1/f8215947-4180-445f-8b68-6d4817c4f05d.pdf"}],"financialInterests":"","formattedTitle":"Facial Fractures: Independent Prediction of Neurosurgical Intervention","fulltext":[{"header":"Introduction","content":" \u003cp\u003eTrauma is one of the leading causes of disability globally and represents the leading cause of death in the first four decades of life.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Roughly one of seven trauma patients admitted to the emergency room had maxillofacial fractures.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e These include nasal bone, mandible, orbital, alveolar ridge, zygomatic, teeth, panfacial, isolated maxillary, and Le Fort type I-III fractures.\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e While facial fractures are often associated with injuries to nearby vital structures such as the airway, vasculature, and nerves, approximately half of facial fracture victims also present with concomitant traumatic brain injury (TBI).\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Depending on the severity, TBI may be difficult to detect using current technology, potentially delaying treatment and worsening prognosis for patients.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Previous studies have also suggested an association between maxillofacial fractures and TBI.\u003csup\u003e3,7,8,11\u0026minus;24\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA recent study by McCarty et al. proposed that Le Fort type fractures may be associated with more severe TBI.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e This is likely due to diffuse axonal injury and shearing forces contributing to epidural and subdural hemorrhages secondary to the high-velocity facial trauma required to produce these fractures.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In a study by Elbaih et al., mid-facial fractures were correlated with an increased likelihood of concurrent epidural hemorrhage, subdural hemorrhage, and pneumocephalus.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Despite these findings, little is known about how fracture types predict TBI severity and which patients eventually require neurosurgical intervention such as intracranial pressure (ICP) monitoring, external ventricular drain (EVD) placement, or craniotomy or craniectomy. Thus, the present study is designed to develop an improved algorithm for the management of TBI in the context of known facial fractures with a hypothesis that patients with mid-face fractures are at increased risk for severe TBI (GCS\u0026thinsp;\u0026lt;\u0026thinsp;8) warranting more aggressive neurosurgical intervention.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003e The study was submitted for institutional board review at University of Florida and abided by the highest international ethical research standards. Retrospective analysis of patients from 2010\u0026ndash;2019 obtained through our trauma registry. Inclusion criteria: adults over 18, confirmed facial fracture with available neuroimaging, reported traumatic brain injury, and admission to ICU or floor bed. Exclusion criteria: patients less than 18 years old, patients with no neuroimaging, and patients that were deceased prior to initiation of neurosurgical intervention.\u003c/p\u003e \u003cp\u003eIn addition to basic demographic data, data collected included presenting Glasgow Coma Scale (GCS) score, mechanism of injury, facial fracture type, traumatic brain injury type, and type of neurosurgical intervention. Age was grouped into 7 categories: 1 (18\u0026ndash;24 years old), 2 (25\u0026ndash;34 years old), 3 (35\u0026ndash;44 years old), 4 (45\u0026ndash;54 years old), 5 (55\u0026ndash;64 years old), 6 (65\u0026ndash;74 years old), 7 (\u0026gt;\u0026thinsp;75 years old). Race was grouped into 5 categories: 1 (Caucasian), 2 (Black), 3 (Asian), 4 (Hispanic), 5 (Other). Sex was classified as male or female. GCS score was arranged: mild (14\u0026ndash;15), moderate (9\u0026ndash;13), or severe (8 or less). Mechanism of Injury was grouped into 7 categories: 1 (Assault), 2 (All-terrain vehicle or dirtbike accident), 3 (Gunshot wound or knife injury), 4 (Bicycle or moped accident), 5 (Motorcycle collision or motor vehicle collision), 6 (Fall), 7 (Other). Type of traumatic brain injury: 1 (Contusion), 2 (Diffuse axonal injury), 3 (Epidural hematoma), 4 (Subdural hematoma), 5 (Traumatic subarachnoid hemorrhage), 6 (Intracranial hemorrhage or intraventricular hemorrhage), 7 (Penetrating injury). Additional radiographic findings: 1 (Edema), 2 (Herniation), 3 (Pneumocephalus), 4 (Cerebral/Cerebellar laceration).\u003c/p\u003e \u003cp\u003ePatients were divided into those with facial fracture and traumatic brain injury without neurosurgical intervention and into those with facial fracture and traumatic brain injury with neurosurgical intervention. Graphpad Prism 8.0 Software was used for analysis. Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-Square analysis for demographic and injury characteristic data. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e "},{"header":"Results","content":"\u003cp\u003eBased on the above inclusion/exclusion criteria 1985 patients were pooled from the overall trauma registry. On further review, 316 were too young, 403 had no traumatic brain injury, and 94 had no facial fracture. 1172 therefore met criteria for inclusion into the study. 1001 had facial fracture and traumatic brain injury with no neurosurgical intervention, 171 had facial fracture and traumatic brain injury with neurosurgical intervention. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e has baseline demographic data. No significant difference was seen between groups for age (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.08, p\u0026thinsp;=\u0026thinsp;0.23). No significant difference was seen between groups for race (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.6, p\u0026thinsp;=\u0026thinsp;0.96). No difference was seen between groups for gender (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.33, p\u0026thinsp;=\u0026thinsp;0.25).\u003c/p\u003e\n\u003cp\u003eInjury characteristics were compared in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. A significant difference was seen between groups for presenting Glasgow Coma Scale (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;67.71, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Of note, in the non-intervention group 64% had mild TBI (GCS score 14\u0026ndash;15) compared to 10% of the intervention group. Conversely, 74% of the intervention group had severe GCS score (3\u0026ndash;8) compared to 22% of the non-intervention group. No significant difference was seen between groups for mechanism of injury (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7.58, p\u0026thinsp;=\u0026thinsp;0.27), type of TBI (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.09, p\u0026thinsp;=\u0026thinsp;0.8), or additional radiographic findings (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.71, p\u0026thinsp;=\u0026thinsp;0.63).\u003c/p\u003e\n\u003cp\u003eFracture type patterns were similar between the non-intervention and intervention group (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.518, p\u0026thinsp;=\u0026thinsp;0.92) as seen in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Subset analysis did however reveal a twofold increase in Lefort type 2 and panfacial fractures in the intervention group compared to non-intervention group. In the intervention group, 136/171 required an ICP monitor or EVD only, 12/171 required a craniotomy, craniectomy, or burr holes only, 23/171 required a craniotomy, craniectomy, or burr holes with EVD or ICP monitor (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). A significant difference was seen in type of intervention depending on presenting facial fracture pattern (\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;20.02, p\u0026thinsp;=\u0026thinsp;0.03). Of note, 24% of the craniotomy, craniectomy, burr hole group had Lefort type 2 fracture compared to only 9% in the ICP monitor only group. 15% of the craniotomy, craniectomy, burr hole group had Lefort Type 3 fracture compared to only 7% in the ICP monitor only group. 29% of the craniotomy/burr hole group had panfacial fractures compared to 7% of the ICP monitor only group (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTraumatic injury is a leading cause of death and disability worldwide.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e A significant number of trauma victims present with maxillofacial fractures, with roughly half of these patients presenting with TBI.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e There is a growing body of literature suggesting that maxillofacial fractures serve as predictors for the presence and severity of TBI.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e This study aimed to determine whether certain types of maxillofacial fractures can predict the need for neurosurgical interventions in an effort to produce an algorithm for the management of TBI patients presenting with known facial fractures.\u003c/p\u003e\n\u003cp\u003eA retrospective analysis of patients admitted to the UF Health Shands Hospital between 2010 and 2019 with known facial fractures and concurrent TBI was performed. Most patients were victims of motor vehicle collisions, motorcycle accidents, and falls. Most suffered orbital, nasal, and maxillary fractures in a distribution similar to the study done by Menon et al. with patients sharing similar demographics.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Patients were not more likely to require intervention based on age, race, gender, mechanism of injury, or specific radiologic findings of edema, herniation, pneumocephalus, or laceration. As anticipated, those taken for intervention had lower GCS scores.\u003c/p\u003e\n\u003cp\u003ePatients with Le Fort type II, type III, and panfacial fractures were more likely to undergo neurosurgical intervention. Further, those presenting with these severe fractures were more likely to receive higher levels of neurosurgical intervention involving craniotomies, craniectomy, and burr holes compared to only EVDs or ICP monitors. This is consistent with the initial hypothesis that the high-velocity impacts required to produce the more severe type II and III Le Fort type fractures \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e are also more likely to lead to more severe neurologic injury. These results also support previous investigations that showed associations between midface fractures and more severe TBI.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eImproved algorithms to identify and triage patients with facial fractures that are more likely to require neurosurgical interventions are being designed in collaboration with the UF Health Shands trauma, plastic, and oral and maxillofacial surgeon colleagues. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows an improved decision tree algorithm for managing patients with severe TBI. This algorithm is influenced by this study\u0026rsquo;s findings and Czerwinski\u0026rsquo;s and colleagues\u0026rsquo; proposition for mandatory early CT-head to rule out TBI in patients presenting with facial fractures. This argument was also supported by Shibuya and colleagues\u0026rsquo; study which showed that 11% of patients who underwent facial fracture repair had worsened GCS score following intervention due to underlying TBI.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Early surgical interventions improve outcomes.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e The hope is that through initiation of the improved algorithm early imaging can be obtained, improved interactions between specialties can enhance patient care, and providers can ultimately act more quickly to intervene when indicated.\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s retrospective nature serves as a limitation. The study was also limited by the trauma registry. For example, it was not possible to separately consider the use of EVDs versus other intracranial pressure monitoring devices because providers sometimes did not use specific International Classification of Diseases (ICD) coding. ICD coding also sometimes did not specify fracture types, only indicating the presence of a facial fracture. These injuries were successfully categorized by chart review. However, it is possible that some facial fractures for patients within this group were not recorded.\u003c/p\u003e\n\u003cp\u003eWe hope that the data and results from this initial study will serve as a catalyst for prospective investigations. Subsequent studies will look at the prospective implementation of the algorithm for patients with facial fractures and TBI. This will allow direct evaluation of effectiveness. Future studies can also implement the finite element head models reviewed and developed by Tse et al. to further determine fracture patterns more likely to be associated with severe TBI.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eConflicts of Interest: none\u003c/p\u003e\n\u003cp\u003eData Material: University of Florida Trauma Registry\u003c/p\u003e\n\u003cp\u003eCode: None\u003c/p\u003e\n\u003cp\u003eEthics: Marked Exempt by University of Florida IRB\u003c/p\u003e\n\u003cp\u003eConsent: Not applicable; retrospective deidentified data\u003c/p\u003e\n\u003cp\u003ePublication: all authors have seen and agree with the contents of this work for publication\u003c/p\u003e\n\u003cp\u003eContributions: BL formulated the project, collected the data, wrote the manuscript. KP helped with data collection and manuscript preparation. SA helped with data collection and manuscript preparation. GM was the primary PI for the project and coordinated support through the registry.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eS\u0026oslash;reide K (2009) Epidemiology of major trauma. Br J Surg 96(7):697\u0026ndash;698\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHwang K, You SH (2010) Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 43(1):42\u0026ndash;48\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin RC 2nd, Spain DA, Richardson JD (2002) Do facial fractures protect the brain or are they a marker for severe head injury? Am Surg 68(5):477\u0026ndash;481\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenon S, Sham ME, Kumar V et al (2019) Maxillofacial Fracture Patterns in Road Traffic Accidents. Ann Maxillofac Surg 9(2):345\u0026ndash;348\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElbaih AH, El-Sayed DA, Abou-Zeid AE, Elhadary GK (2018) Patterns of brain injuries associated with maxillofacial fractures and its fate in emergency Egyptian polytrauma patients. Chinese journal of traumatology = Zhonghua chuang shang za zhi 21(5):287\u0026ndash;292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoumeliotis G, Ahluwalia R, Jenkyn T, Yazdani A (2015) The Le Fort system revisited: Trauma velocity predicts the path of Le Fort I fractures through the lateral buttress. Plast Surg (Oakv) 23(1):40\u0026ndash;42\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePham TT, Lester E, Grigorian A, Roditi RE, Nahmias JT (2019) National Analysis of Risk Factors for Nasal Fractures and Associated Injuries in Trauma. Craniomaxillofac Trauma Reconstr 12(3):221\u0026ndash;227\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarty JC, Kiwanuka E, Gadkaree S, Siu JM, Caterson EJ. Traumatic Brain Injury in Trauma Patients With Isolated Facial Fractures. \u003cem\u003eJournal of Craniofacial Surgery.\u003c/em\u003e 2020;31(5)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuri YV, Qasba KK, Mahajan TR (1996) MILITANCY TRAUMA: MAXILLOFACIAL INJURY, ANAESTHESIA AND CRITICAL CARE. Med J Armed Forces India 52(1):23\u0026ndash;26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidoff G, Jakubowski M, Thomas D, Alpert M (1988) The spectrum of closed-head injuries in facial trauma victims: incidence and impact. Ann Emerg Med 17(1):6\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeenan HT, Brundage SI, Thompson DC, Maier RV, Rivara FP (1999) Does the Face Protect the Brain?: A Case-Control Study of Traumatic Brain Injury and Facial Fractures. Archives of Surgery 134(1):14\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajandram RK, Syed Omar SN, Rashdi MFN, Abdul Jabar MN (2014) Maxillofacial injuries and traumatic brain injury\u0026ndash;a pilot study. Dent Traumatol 30(2):128\u0026ndash;132\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYou N, Choi MS, Roh TH, Jeong D, Kim SH (2018) Severe Facial Fracture is Related to Severe Traumatic Brain Injury. World Neurosurg 111:e47\u0026ndash;e52\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshi UM, Ramdurg S, Saikar S, Patil S, Shah K (2018) Brain Injuries and Facial Fractures: A Prospective Study of Incidence of Head Injury Associated with Maxillofacial Trauma. J Maxillofac Oral Surg 17(4):531\u0026ndash;537\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZandi M, Seyed Hoseini SR (2013) The relationship between head injury and facial trauma: a case-control study. Oral Maxillofac Surg 17(3):201\u0026ndash;207\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKraus JF, Rice TM, Peek-Asa C, McArthur DL (2003) Facial trauma and the risk of intracranial injury in motorcycle riders. Ann Emerg Med 41(1):18\u0026ndash;26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlin CB, Ruff G, Mansfeld CP, Clinton MS (1998) Facial fractures and related injuries: a ten-year retrospective analysis. J Craniomaxillofac Trauma 4(2):44\u0026ndash;48; discussion 43\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalentijn EG, Peerdeman SM, Boffano P, van den Bergh B, Forouzanfar T (2014) A ten-year analysis of the traumatic maxillofacial and brain injury patient in Amsterdam: incidence and aetiology. J Craniomaxillofac Surg 42(6):705\u0026ndash;710\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuce EA, Tubb TD, Moore AM. Review of 1,000 Major Facial Fractures and Associated Injuries. \u003cem\u003ePlastic and Reconstructive Surgery.\u003c/em\u003e 1979;63(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KF, Louis KW, Lee YE, Jung Ho S, Seung Ro L (1987) The impact-absorbing effects of facial fractures in closed-head injuries. Journal of neurosurgery 66(4):542\u0026ndash;547\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim LH, Lam LK, Moore MH, Trott JA, David DJ (1993) Associated injuries in facial fractures: review of 839 patients. British Journal of Plastic Surgery 46(8):635\u0026ndash;638\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePappachan B, Alexander M (2006) Correlating Facial Fractures and Cranial Injuries. Journal of Oral Maxillofacial Surgery 64(7):1023\u0026ndash;1029\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HJ, Kim YJ, Seo DW et al (2018) Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury. Injury 49(5):963\u0026ndash;968\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvi A, Doherty T, Lewen G (2003) Facial fractures and concomitant injuries in trauma patients. Laryngoscope 113(1):102\u0026ndash;106\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheyerer MJ, D\u0026ouml;ring R, Fuchs N et al (2015) Maxillofacial injuries in severely injured patients. J Trauma Manag Outcomes 9:4\u0026ndash;4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips BJ, Turco LM (2017) Le Fort Fractures: A Collective Review. Bull Emerg Trauma 5(4):221\u0026ndash;230\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCzerwinski M, Parker WL, Williams HB (2008) Algorithm for head computed tomography imaging in patients with mandible fractures. J Oral Maxillofac Surg 66(10):2093\u0026ndash;2097\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShibuya TY, Karam AM, Doerr T et al (2007) Facial fracture repair in the traumatic brain injury patient. J Oral Maxillofac Surg 65(9):1693\u0026ndash;1699\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiuliani G, Anile C, Massarelli M, Maira G (1997) Management of complex craniofacial traumas. Rev Stomatol Chir Maxillofac 98(Suppl 1):100\u0026ndash;102\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTse KM, Lim S, Tan VBC, Lee H (2014) A Review of Head Injury and Finite Element Head Models. American Journal of Engineering Technology Society 1:28\u0026ndash;52\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang B, Tse K-M, Chen N et al (2014) Development of a finite element head model for the study of impact head injury. Biomed Res Int 2014:408278\u0026ndash;408278\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eTable 1: Demographics\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123.65pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eAge in Years\u003c/span\u003e\u003c/p\u003e\n \u003ctable style=\"border: none;width:47.0pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e1. 18-24\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e2. 25-34\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e3. 35-44\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e4. 45-54\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e5. 55-64\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e6. 65-74\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 47pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e7. 75+\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eNon-Intervention (n=1001)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(176) 17%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(165) 17%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(151) 15%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(169) 17%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(128) 13%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(94) 9%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(118) 12%\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eIntervention\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e(n=171)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(36) 21%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(39) 23%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(21) 12%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(33) 19%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(28) 16%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(10) 6%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(4) 3%\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98.75pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123.65pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eRace\u003c/span\u003e\u003c/p\u003e\n \u003ctable style=\"border: none;width:91.55pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e1. Caucasian\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e2. Black\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e3. Asian\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e4. Hispanic\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 91.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e5. Other\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e826 (83%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e118 (11%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e5 (1%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e34 (3%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e18 (2%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e135 (79%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e24 (14%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e1 (1%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e7 (4%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e4 (2%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123.65pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eGender\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eMale\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eFemale\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e723 (72%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e278 (28%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e136 (79%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e35 (21%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98.75pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eTable 2: Injury Characteristics\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130.6pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eGlasgow Coma Scale\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eMild (14-15)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eModerate (9-13)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eSevere (3-8)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130.6pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eNon-Intervention (n=1001)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(636) 64%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(140) 14%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(226) 22%\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.05pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eIntervention\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e(n=171)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(17) 10%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(27) 16%\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e(127) 74%\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91.25pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eMechanism of Injury\u003c/span\u003e\u003c/p\u003e\n \u003ctable style=\"border: none;width:114.1pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e1. Assault\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e2. ATV/Dirtbike\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e3. GSW/Knife\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e4. Bicycle/Moped\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e5. MCC/MVC\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e6. Fall\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 114.1pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e7. Other\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003ctable style=\"border: none;width:117.55pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e1. 160 (16%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e2. 44 (4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e3. 46 (5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e4. 74 (7%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e5. 381 (38%)\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e6. 212 (22%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;height: 15pt;vertical-align: bottom;\"\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003cp\u003e\u003cspan style=\"font-size:11.0pt;color:black;\"\u003e7. 84 (8%)\u003c/span\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;margin-left:0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e16 (9%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e11 (6%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e9 (5%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e18 (11%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e77 (45%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e19 (12%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e21 (12%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eTypes of TBI\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eContusion\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eDAI\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eEDH\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eSDH\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003etSAH\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eICH/IVH\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003ePenetrating injury\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e61 (6%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e31 (3%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e49 (5%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e201 (20%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e295 (29%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e66 (7%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e11 (1%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;margin-left:0.25in;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e21 (12%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e23 (13%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e22 (13%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e63 (37%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e79 (46%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e27 (16%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e1 (1%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130.6pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eAdditional Radiographic Findings\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eEdema\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eHerniation\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003ePneumocephalus\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003eCerebral/Cerebellar Laceration\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 130.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e25 (2%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e32 (3%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e34 (3%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e5 (1%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:.5in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:15px;font-family: \"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003col style=\"margin-bottom:0in;list-style-type: decimal;\"\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e20 (12%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e25 (15%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e10 (6%)\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style=\"font-size:11.0pt;;\"\u003e4 (2%)\u003c/span\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 91.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:15px;font-family:\"Arial\",sans-serif;'\u003eP\u0026gt;0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Traumatic Brain Injury, Lefort type 2 and 3 fractures, Neurosurgical Intervention Statements","lastPublishedDoi":"10.21203/rs.3.rs-356292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-356292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\u003cp\u003eOver half of patients with facial fractures have associated traumatic brain injury. Based on previous force dynamic cadaveric studies, Lefort type 2 and 3 fractures are more associated with severe injury. Whether this correlates to neurosurgical intervention have not been well characterized. The purpose of this retrospective data analysis is to characterize fracture pattern types in patients requiring neurosurgical intervention and to see if this is different from those not requiring intervention. \u003c/p\u003e\u003cp\u003eMethods:\u003c/p\u003e\u003cp\u003eRetrospective data was collected from the trauma registry from 2010-2019. Inclusion criteria: adults over 18, confirmed facial fracture with available neuroimaging, reported traumatic brain injury, and admission to ICU or floor bed. Exclusion criteria: patients less than 18 years old, patients with no neuroimaging, and patients that were deceased prior to initiation of neurosurgical intervention. Data included: basic demographic data, presenting Glasgow Coma Scale (GCS) score, mechanism of injury, type of traumatic brain injury, neurosurgical intervention, and facial fracture type. Retrospective Contingency Analysis with Fraction of Total Comparison was used with Chi-Square analysis for demographic and injury characteristic data.\u003c/p\u003e\u003cp\u003eResults:\u003c/p\u003e\u003cp\u003e1172 patients met inclusion criteria. 1001 required no neurosurgical intervention and 171 required intervention. No significant difference was seen between the non-intervention group and intervention group in terms of demographic data or baseline injury characteristics except for presenting GCS. A significant difference was seen between groups for presenting Glasgow Coma Scale (c\u003csup\u003e2\u003c/sup\u003e=67.71, p\u0026lt;0.001). The intervention group had greater number of patients with GCS\u0026lt;8 compared to the non-intervention group. Fracture patterns were overall similar between the non-intervention group compared to intervention group (c\u003csup\u003e2\u003c/sup\u003e=4.518, p=0.92), however subset analysis did reveal a 2 fold increase in Lefort type 2 fractures and notable increase in Lefort type 3 and panfacial fractures in the intervention group. The intervention group was further divided into those requiring external ventricular drain or intracranial pressure monitor only vs. patients requiring craniectomy, craniotomy, or burr holes with or with external ventricular drain or intracranial pressure monitor. A significant difference was seen between groups (c\u003csup\u003e2\u003c/sup\u003e=20.02, p=0.03). The craniectomy, craniotomy, or burr hole group was much more likely to have Lefort type 2 or 3 fractures compared to the external ventricular drain or intracranial pressure monitor group only. \u003c/p\u003e\u003cp\u003eConclusions:\u003c/p\u003e\u003cp\u003eLefort type 2 and type 3 fractures are significantly associated with requiring neurosurgical intervention. An improved algorithm for managing these patients has been proposed in the discussion. Ongoing work will focus on validating and refining the algorithm in order to improve patient care for trauma patients with facial fracture and traumatic brain injury.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Facial Fractures: Independent Prediction of Neurosurgical Intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-04-22 14:33:58","doi":"10.21203/rs.3.rs-356292/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"258f65e3-792d-47f1-8ee2-ba1f50de860b","owner":[],"postedDate":"April 22nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":3827280,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2021-12-18T09:22:02+00:00","versionOfRecord":{"articleIdentity":"rs-356292","link":"https://doi.org/10.4103/ajns.AJNS_251_21","journal":{"identity":"asian-journal-of-neurosurgery","isVorOnly":true,"title":"Asian Journal of Neurosurgery"},"publishedOn":"2021-01-01 09:22:02","publishedOnDateReadable":"January 1st, 2021"},"versionCreatedAt":"2021-04-22 14:33:58","video":"","vorDoi":"10.4103/ajns.AJNS_251_21","vorDoiUrl":"https://doi.org/10.4103/ajns.AJNS_251_21","workflowStages":[]},"version":"v1","identity":"rs-356292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-356292","identity":"rs-356292","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}