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As many as 50–70% of people who survive traffic accidents have facial trauma. In most developed countries, violence from other people has replaced vehicle collisions as the main cause of maxillofacial trauma; however in many developing countries traffic accidents remain the major cause. Increased use of seat belts and airbags has been credited with a reduction in the incidence of maxillofacial trauma, but fractures of the mandible (the jawbone) are not decreased by these protective measures. The risk of maxillofacial trauma is decreased by a factor of two with use of motorcycle helmets. A decline in facial bone fractures due to vehicle accidents is thought to be due to seat belt and drunk driving laws, strictly enforced speed limits and use of airbags. In vehicle accidents, drivers and front seat passengers are at highest risk for facial trauma.
Facial fractures are distributed in a fairly normal curve by age, with a peak incidence occurring between ages 20 and 40, and children under 12 suffering only 5–10% of all facial fractures. Most facial trauma in children involves lacerations and soft tissue injuries. There are several reasons for the lower incidence of facial fractures in children: the face is smaller in relation to the rest of the head, children are less often in some situations associated with facial fractures such as occupational and motor vehicle hazards, there is a lower proportion of cortical bone to cancellous bone in children's faces, poorly developed sinuses make the bones stronger, and fat pads provide protection for the facial bones.
Head and brain injuries are commonly associated with facial trauma, particularly that of the upper face; brain injury occurs in 15–48% of people with maxillofacial trauma. Coexisting injuries can affect treatment of facial trauma; for example they may be emergent and need to be treated before facial injuries. People with trauma above the level of the collar bones are considered to be at high risk for cervical spine injuries (spinal injuries in the neck) and special precautions must be taken to avoid movement of the spine, which could worsen a spinal injury.
Mandible fracture causes vary by the time period and the region studied. In North America, blunt force trauma (a punch) is the leading cause of mandible fracture whereas in India, motor vehicle collisions are now a leading cause. On battle grounds, it is more likely to be high velocity injuries (bullets and shrapnel). Prior to the routine use of seat belts, airbags and modern safety measures, motor vehicle collisions were a leading cause of facial trauma. The relationship to blunt force trauma explains why 80% of all mandible fractures occur in males. Mandibular fracture is a rare complication of third molar removal, and may occur during the procedure or afterwards. With respect to trauma patients, roughly 10% have some sort of facial fracture, the majority of which come from motor vehicle collisions. When the person is unrestrained in a car, the risk of fracture rises 50% and when an unhelmeted motorcyclist the risk rises 4-fold.
The healing time for a routine mandible fractures is 4–6 weeks whether MMF or rigid internal fixation (RIF) is used. For comparable fractures, patients who received MMF will lose more weight and take longer to regain mouth opening, whereas, those who receive RIF have higher infection rates.
The most common long-term complications are loss of sensation in the mandibular nerve, malocclusion and loss of teeth in the line of fracture. The more complicated the fracture (infection, comminution, displacement) the higher the risk of fracture.
Condylar fractures have higher rates of malocclusion which in turn are dependent on the degree of displacement and/or dislocation. When the fracture is intracapsular there is a higher rate of late-term osteoarthritis and the potential for ankylosis although the later is a rare complication as long as mobilization is early. Pediatric condylar fractures have higher rates of ankylosis and the potential for growth disturbance.
Rarely, mandibular fracture can lead to Frey's syndrome.
Injury mechanisms such as falls, assaults, sports injuries, and vehicle crashes are common causes of facial trauma in children as well as adults. Blunt assaults, blows from fists or objects, are a common cause of facial injury. Facial trauma can also result from wartime injuries such as gunshots and blasts.
Animal attacks and work-related injuries such as industrial accidents are other causes. Vehicular trauma is one of the leading causes of facial injuries. Trauma commonly occurs when the face strikes a part of the vehicle's interior, such as the steering wheel. In addition, airbags can cause corneal abrasions and lacerations (cuts) to the face when they deploy.
Jaw dislocation is common for people who are in car, motorcycle or related accidents and also sports related activities. This injury does not pin point specific ages or genders because it could happen to anybody. People who dislocate their jaw do not usually seek emergency medical care. In most cases, jaw dislocations are acute and can be altered by minor manipulations. It was reported from one study that over a seven-year period at an emergency medical site, with 100,000 yearly visits, there were only 37 patients that were seen for a dislocated jaw.
A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an inanimate object as in a fall, or it may occur during transfer of a patient after an initial compound head injury.
Scapular fracture is present in about 1% of cases of blunt trauma and 3–5% of shoulder injuries. An estimated 0.4–1% of bone fractures are scapular fractures.
The injury is associated with other injuries 80–90% of the time. Scapular fracture is associated with pulmonary contusion more than 50% of the time. Thus when the scapula is fractured, other injuries such as abdominal and chest trauma are automatically suspected. People with scapular fractures often also have injuries of the ribs, lung, and shoulder. Pneumothorax (an accumulation of air in the space outside the lung), clavicle fractures, and injuries to the blood vessels are among the most commonly associated injuries. The forces involved in scapular fracture can also cause tracheobronchial rupture, a tear in the airways. Fractures that occur in the scapular body are the type most likely to be accompanied by other injuries; other bony and soft tissue injuries accompany these fractures 80–95% of the time. Associated injuries can be serious and potentially deadly, and usually it is the associated injuries, rather than the scapular fracture, that have the greatest effect on the outcome. Scapular fractures can also occur by themselves; when they do, the death rate (mortality) is not significantly increased.
The mean age of people affected is 35–45 years.
A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and the middle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.
Compound fractures may either be clean or contaminated. Intracranial air (pneumocephalus) may occur in compound skull fractures.
The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury.
Hyoid bones fractures represent 0.002% of all fractures; they are rare because the hyoid bone is well-protected by its location in the neck behind the mandible and in front of the cervical spine, as well as its mobility. 91.3% of hyoid bone fractures occur in men.
Condylar resorption is an idiopathic condition, though there are some theories relating to its possible cause. Because condylar resorption is more likely to be in young females, hormonal mediation may be involved. Strain on the temporomandibular joint from orthodontics or orthognathic surgery may be related to the condition. Reactive arthritis, rheumatoid arthritis, and psoriatic arthritis are other possible causes.
Neck trauma, commonly by strangulation, athletic activities, and car accidents, is the cause of a hyoid bone fracture. Other causes include violent vomiting, gunshot wounds, and hanging.
X-rays of the chest are taken in people with chest trauma and symptoms of sternal fractures, and these may be followed by CT scanning. Since X-rays taken from the front may miss the injury, they are taken from the side as well.
Management involves treating associated injuries; people with sternal fractures but no other injuries do not need to be hospitalized. However, because it is common for cardiac injuries to accompany sternal fracture, heart function is monitored with electrocardiogram. Fractures that are very painful or extremely out of place can be operated on to fix the bone fragments into place, but in most cases treatment consists mainly of reducing pain and limiting movement. The fracture may interfere with breathing, requiring tracheal intubation and mechanical ventilation.
Patients who have experienced a pathologic fracture will be investigated for the cause of the underlying disease, if it is unknown. Treatment of any underlying disease, such as chemotherapy if indicated for bone cancer, may help to improve the pain of a sternal fracture.
Because of the high frequency of associated injuries, clinicians are taught to suspect that a patient has multiple severe injuries if a sternal fracture is present. Sternal fracture is commonly associated with injuries to the heart and lungs; if a person is injured with enough force to fracture the sternum, injuries such as myocardial and pulmonary contusions are likely. Other associated injuries that may occur include damage to blood vessels in the chest, myocardial rupture, head and abdominal injuries, flail chest, and vertebral fracture. Sternal fractures may also accompany rib fractures and are high-energy enough injuries to cause bronchial tears (ruptures of the bronchioles). They may hinder breathing. Due to the associated injuries, the mortality rate for people with sternal fracture is high, at an estimated 25–45%. However, when sternal fractures occur in isolation, their outcome is very good.
There is controversy over the question of whether the presence of sternal fracture is an indication of cardiac injuries.
Most temporomandibular disorders (TMDs) are self-limiting and do not get worse. Simple treatment, involving self-care practices, rehabilitation aimed at eliminating muscle spasms, and restoring correct coordination, is all that is required. Nonsteroidal anti inflammatory analgesics (NSAIDs) should be used on a short-term, regular basis and not on an as needed basis. On the other hand, treatment of chronic TMD can be difficult and the condition is best managed by a team approach; the team consists of a primary care physician, a dentist, a physiotherapist, a psychologist, a pharmacologist, and in small number of cases, a surgeon. The different modalities include patient education and self-care practices, medication, physical therapy, splints, psychological counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, and arthrocentesis.
As with most dislocated joints, a dislocated jaw can usually be successfully positioned into its normal position by a trained medical professional. Attempts to readjust the jaw without the assistance of a medical professional could result in worsening of the injury. The health care provider may be able to set it back into the correct position by manipulating the area back into its proper position. Numbing medications such as general anesthetics, muscle relaxants, or in some cases sedation, may be needed to relax the strong jaw muscle. In more severe cases, surgery may be needed to reposition the jaw, particularly if repeated jaw dislocations have occurred.
Treatment involves pain medication and immobilization at first; later, physical therapy is used. Ice over the affected area may increase comfort. Movement exercises are begun within at least a week of the injury; with these, fractures with little or no displacement heal without problems. Over 90% of scapular fractures are not significantly displaced; therefore, most of these fractures are best managed without surgery. Fractures of the scapular body with displacement may heal with malunion, but even this may not interfere with movement of the affected shoulder. However, displaced fractures in the scapular processes or in the glenoid do interfere with movement in the affected shoulder if they are not realigned properly. Therefore, while most scapular fractures are managed without surgery, surgical reduction is required for fractures in the neck or glenoid; otherwise motion of the shoulder may be impaired.
Condylar resorption, also called idiopathic condylar resorption, ICR, and condylysis, is a temporomandibular joint disorder in which one or both of the mandibular condyles are broken down in a bone resorption process. This disorder is nine times more likely to be present in females than males, and is more common among teenagers.
In 2010 national statistics was done by Agency for Healthcare Research and Quality for posterior cruciate ligaments injuries. They found that 463 patients were discharge for having some type of PCL injury. The 18- to 44-year-old age group was found to have the highest injuries reported (figure 1). One reason why this age group consists of the majority of injuries to the PCL is because people are still very active in sports at this age. Men were also reported having more injuries to the PCL (figure 3).
Isolated and combined posterolateral knee injuries are difficult to accurately diagnose in patients presenting with acute knee injuries. The incidence of isolated posterolateral corner injuries has been reported to be between 13% and 28%. Most PLC injuries accompany an ACL or PCL tear, and can contribute to ACL or PCL reconstruction graft failure if not recognized and treated. A study by LaPrade "et al." in 2007 showed the incidence of posterolateral knee injuries in patients presenting with acute knee injuries and hemarthrosis (blood in the knee joint) was 9.1%.
Occlusal factors as an etiologic factor in TMD is a controversial topic. Abnormalities of occlusion (problems with the bite) are often blamed for TMD but there is no evidence that these factors are involved. Occlusal abnormalities are incredibly common, and most people with occlusal abnormalities do not have TMD. Although occlusal features may affect observed electrical activity in masticatory muscles, there are no statistically significant differences in the number of occlusal abnormalities in people with TMD and in people without TMD. There is also no evidence for a causal link between orthodontic treatment and TMD. The modern, mainstream view is that the vast majority of people with TMD, occlusal factors are not related. Theories of occlusal factors in TMD are largely of historical interest. A causal relationship between occlusal factors and TMD was championed by Ramfjord in the 1960s. A small minority of dentists continue to prescribe occlusal adjustments in the belief that this will prevent or treat TMD despite the existence of systematic reviews of the subject which state that there is no evidence for such practices, and the vast majority of opinion being that no irreversible treatment should be carried out in TMD (see Occlusal adjustment).
Trauma, both micro and macrotrauma, is sometimes identified as a possible cause of TMD; however, the evidence for this is not strong. Prolonged mouth opening (hyper-extension) is also suggested as a possible cause. It is thought that this leads to microtrauma and subsequent muscular hyperactivity. This may occur during dental treatment, with oral intubation whilst under a general anesthetic, during singing or wind instrument practice (really these can be thought of as parafunctional activities). Damage may be incurred during violent yawning, laughing, road traffic accidents, sports injuries, interpersonal violence, or during dental treatment, (such as tooth extraction).
It has been proposed that a link exists between whiplash injuries (sudden neck hyper-extension usually occurring in road traffic accidents), and the development of TMD. This has been termed "post-traumatic TMD", to separate it from "idiopathic TMD". Despite multiple studies having been performed over the years, the cumulative evidence has been described as conflicting, with moderate evidence that TMD can occasionally follow whiplash injury. The research that suggests a link appears to demonstrate a low to moderate incidence of TMD following whiplash injury, and that pTMD has a poorer response to treatment than TMD which has not developed in relation to trauma.
According to the posterior cruciate ligament injuries only account for 1.5 percent of all knee injuries (figure 2). If it is a single injury to the posterior cruciate ligament that requires surgery only accounted for 1.1 percent compared to all other cruciate surgeries but when there was multiple injuries to the knee the posterior cruciate ligament accounted for 1.2 percent of injuries.
In terms of overuse injuries a British study found that:
- 40 percent occurred in the fingers
- 16 percent in the shoulders
- 12 percent in the elbows
- 5 percent were the knees
- 5 percent back
- 4 percent wrists
One injury that tend to be very common among climbers is Carpal tunnel syndrome. It is found in about 25% of climbers.
Aetiology of CTS is multifactorial, the causative factors include:
- previous restorative procedures.
- occlusal factors
- developmental conditions/anatomical considerations.
- trauma
- others, e.g, aging dentition or presence of lingual tongue studs.
Most commonly involved teeth are mandibular molars followed by maxillary premolars, maxillary molars and maxillary premolars. in a recent audit, mandibular first molar thought to be most affected by CTS possibly due to the wedging effect of opposing pointy, protruding maxillary mesio-palatal cusp onto the mandibular molar central fissure.
604 injured rock climbers were prospectively evaluated from January 1998 to December 2001, due to the rapid growth of new complex finger trauma in the mid-1980s. Of the most frequent injuries, three out of four were related to the fingers: pulley injuries accounted for 20%, tendovaginitis for 7%, and joint capsular damage for 6.1%.
Future research into posterolateral injuries will focus on both the treatment and diagnosis of these types of injuries to improve PLC injury outcomes. Studies are needed to correlate injury patterns and mechanisms with clinical measures of knee instability and laxity.