When is it a good time to manage facial fractures? A systematic review

This summary is based on the article published in the International Journal of Oral and Maxillofacial Surgery: The effect of treatment timing on the management of facial fractures: a systematic review (August 2014)

M. J. L. Hurrell, M. D. Batstone

Context

Facial fractures are a common presentation to hospitals worldwide. Their treatment has evolved dramatically in recent decades, particularly since the introduction of open reduction and internal fixation.

However, many uncertainties remain. The relevance of delay from injury to treatment is commonly disputed amongst surgeons and in the literature. Intuitively, delaying the treatment of facial fractures could increase the risk of infection, the likelihood of technical difficulties, and the discomfort experienced by patients.

However, there are many reasons why delay beyond 72 h may be practical or unavoidable. Due to the multifactorial nature of the management process, outcomes may be affected by a multitude of factors.

Purpose of the Review

To examine broadly the effects of treatment delay on outcomes in the management of facial fractures, by identifying studies of any type that have examined the effects of timing of treatment on outcomes of any type, in the treatment of fractures of the human facial skeleton by widely accepted treatment methods.

Key Findings

An abundance of information is available regarding the timing of treatment of facial fractures. However, to date, there is a great deal of conjecture and discrepancy regarding recommendations.

Delay between injury and treatment for facial fractures can be divided into the following groups: delay between injury and presentation to health care, delay between presentation to health care and diagnosis, and delay between diagnosis and treatment. Factors that influence each group may differ.

Factors contributing to treatment delays: drug and alcohol intoxication; presentation outside working hours; misdiagnosis; inter-hospital transfer from a peripheral hospital; imaging; prioritization of more threatening injuries; unstable neurological status or intracranial injury; unstable haemodynamics; concurrent systemic disease or unstable medical condition; soft tissue oedema; mucosal laceration; coordination of theatre time with other services.

A number of studies have highlighted associations between treatment delay and better outcomes:

• Early fracture fixation, presumably surgically, could result in greater fluid administration, which could exacerbate intracranial hypertension. (1, 2)
• Patients with multiple injuries requiring input from multiple surgical disciplines may benefit medically, and fiscally, by a delay in treatment. Delay would allow for coordination of surgical disciplines under the same anaesthetic. (1, 3)
• Another proposed benefit of delay is facilitation of more complex imaging. (1) Delaying fracture repair reportedly allows for a greater sensitivity in diagnosis of additional, initially unrecognized fractures. (1, 4)

References

1. Weider L, Hughes K, Ciarochi J, Dunn E. Early versus delayed repair of facial fractures in the multiply injured patient. Am Surg 1999; 65:790–3.
2. Jaicks RR, Cohn SM, Moller BA. Early fracture fixation may be deleterious after head injury. J Trauma 1997;42:1–5. Discussion 5–6.
3. Zachariades N, Papavasilliou D, Papademe-triou I, Koundouris I, Rapidis A. Neglected fractures of the facial bones. J Maxillofac Surg 1984; 12: 36–40.
4. Rehm CG, Ross SE. Diagnosis of unsuspected facial fractures on routine head computerized tomographic scans in the unconscious multiply injured patient. J Oral Maxillofac Surg 1995; 53: 522–4.

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