The combined craniomaxillofacial fractures are those fractures of fronto maxillary and front nasal areas extending to the base of the skull  . Ironically, the face and head are prone to frequent injuries. Due to the close anatomic proximity of maxillofacial bone and cranium, usually the patients with maxillofacial fractures are at an increased risk of and suffer from traumatic head injury simultaneously which can lead to primary or secondary brain damage in case of a miss or late diagnosis in such cases   . This makes accurate diagnostic evaluation necessary, especially in cute stage to clarify emergent injuries; to preoperatively plan the reconstruction of functional areas; and to guide the physical, psychological, and social rehabilitation process  .
Epidemiological data associated with the craniomaxillofacial trauma depend on the demographic data from the population studied, which include the geographic region, socio-economic situation, and time factors which can influence the type and frequency of injuries in the population     . Several studies for determination of the prevalence and etiology of craniomaxillofacial traumas have been carried out worldwide with the aim of characterizing patterns, identifying new trends for occurrences of these injuries, planning and evaluating preventive measures and health policies, and developing priority goals for research in this area    , but the studies from Egypt are few  .
Craniomaxillofacial fractures result from blunt or penetrating injury. Blunt injuries are far more common, resulting from vehicular accidents altercations, sporting-related trauma, occupational injuries, and falls. Penetrating injuries mainly are the result of gunshot wounds, stabbings, and explosions  - 
It is important to understand that maxillofacial traumas represent one of the greatest challenges to public health services worldwide, because of their high incidence and significant financial cost involved in their management so the pattern and etiological factors of craniomaxillofacial fractures in Assiut need to be determined as such database is necessary for planning prevention strategies and managemensic medicine experts, but also for emerent. Also; we believe that the findings of this study will be helpful for not only forgency doctors and surgeons.
2. Patients & Methods
This retrospective hospital based, study was carried out on 1745 patients with craniomaxillofacial fractures admitted to Trauma unit, Assiut University Hospitals (Single Tertiary Hospital) between January 2010 and December 2017. Data of the admitted injury cases were obtained from the database office at the Trauma Unit of Assiut University Hospitals. The collected data includes basic demographic data of the cases regarding age, sex, residence, occupation, mechanisms of trauma, anatomical sites of fractures, types of management and outcome.
The data were obtained in Excel program. Coding of causes of injuries was carried out using the tenth revision of the international classification of diseases (ICD-10) codes (World health Organization 2010)  . Inclusion criteria: All patients who reported to the trauma unit, Assiut University Hospital with maxillofacial fractures (patients who were admitted as well as those who were treated as outpatients) were included in the study. Exclusion criteria consisted of patients who expired before examination, admitted with soft tissue injuries and readmitted with complications were excluded from the study.
According to GCS, patients classified into 3 grades: mild (GCS 13-15), moderate (GCS 9-12) and severe (GCS 3-8)  . Fractures of the facial skeleton were classified into mandibular fracture (Symphyseal & parasymphyseal, body, angle, ramus and condylar fracture), maxillary fractures, zygomatic fracture, frontal bone fractures, nasal bone, nasoethmoidal fractures and multiple site fractures.
CT scan, 3DCT scans are the current imaging standard for evaluating frontal bone fractures. In the multitraumatized patient, craniomaxillofacial and brain CT was often be part of an extensive CT examination including the cervical spine, trunk, and sometimes extremities. Other body segments were imaged as needed to exclude or detect other system injuries. Collaboration is usually arranged between the teamwork according the extent of craniomaxillofacial trauma and mainly depends on the Neurosurgeons, Maxillofacial surgeons. Pediatrician and Oph-thalmic surgeon may have a role.
In the present series, approaches to the craniomaxillofacial fractures were according to the guidelines described in the literature, including repositioning of the displaced fracture segments into anatomic position, with a focus on the lattice supports in relation to each other and to the cranial base. Open reduction and internal fixation with miniplates was done in the cases of displaced fractures. Undisplaced fractures were managed conservatively and provided acceptable functional and aesthetic results. Postoperative CT scans were obtained to assess bony reconstruction and follow-up intracranial injuries.
2.1. Statistical Analysis
Data was collected in Excel sheet (Microsoft office 2010), then were analyzed using SPSS version 22 (SPSS, Inc., Chicago, IL). The results were expressed as frequency and percent in qualitative data and mean ± SD for quantitative data. Chi-square test was used for comparison of qualitative data to express the prevalence of cranio maxillofacial fractures with sociodemographic data, causes, types and anatomical sites of the sustained injuries to the study population. P values less than 0.05 were considered statistically significant.
2.2. Ethical Consideration
The study was conducted after getting ethical clearance and the permission from Assiut University Teaching Hospital administration. Thorough explanation of the purpose of the study and how data will be treated with respect and confidentiality was provided to the participants. The study protocol was approved by the ethical committee, faculty of medicine, Assiut University, Egypt.
Retrospective hospital based study include 1745 patients with combined craniomaxillofacial fractures admitted to trauma unit, Assiut University Hospital between January 2010 to December 2017. A Overall prevalence of cranio maxillofacial injuries was 3% (total number of patients were 58166). The distribution of craniomaxillofacial by age among the study subjects revealed that the age group 18 - 40 years presented with (48.4%). There was an overwhelming male patient’s ranged preponderance in all age groups (87.5%). The overall male: female ratio was 7:1. The most frequently cause of cranio maxillofacial injuries was motor car and motorcycle accident with a proportion of (37.7%) and (30. %) respectively. Accidental fall accounted for the fractures in 15% mostly involving children who fell while playing, elderly people who fell down due to systemic illness, or men Assault and firearm had relatively the same proportional, 5.9% and 4.8% respectively. Table 1 shows that 53.2% of patients GCS were mild (12 - 15).
Road traffic accident was the most frequent etiology of the traumas found in the present study, predominating among the men―1071 cases. Motor car accidents were more frequent in men―575 cases (87.5%) compared to 82 women (12.5%). Accidents with motorcycles happened to 496 men (94.7%) and 28 women (5.3%) commonly in age group 18 - 40: 313 cases caused by motor car and 315 cases caused by motor cycle. 182 men and 87women fell. Fall from height in 140 men (67.3%) and 42 women (32.7%) respectively. Fall on the ground in 42 males (68.9%) and 19 women (32.1%). Fall was common in children (fall from height in 136 cases; 65.4% and fall on the ground in 39 cases 63.9%). Interpersonal violence was frequent etiology of the traumas found in the present study, predominating among the men―96 cases (94.1%) and 6 women (5.9%), commonly in age group 18 - 40 (59 cases). It is important to stress that this category, rarely occurred in children and elderly population of our sample (9 and 5 cases respectively). 79 men (91.9%) and 7 woman (8.1%) suffered injuries caused by fire arms. Majority in age group (18 - 40) 56 cases, rarely occurred in children and elderly population of our sample (9 and 5 cases respectively) as shown in Tables 2-4.
Glasgow coma scale in different forms of trauma is shown in Table 5.
Mandibular fracture has been showed to be the most affected hard tissue involved with injuries (47.7%), followed by the maxillary bone fracture (19.1%),
Table 1. Demographic data of hospitalized injured cases in the studied period (2010: 2017).
zygomatic fracture (17.2%), frontal bone fractures (8.8%). Other sites for hard tissue involvement were seen in small proportion such as nasal bone, nasoethmoidal fractures and multiple sites injuries 4.3%, 2.9% respectively (Table 6).
All aspects regarding trauma have a great importance in the world today, being among the main causes of morbidity and mortality and Egypt is not different in this aspect. Craniomaxillofacial trauma involves serious esthetic and functional problems that lead to various consequential complications. Epidemiological studies on facial trauma are diverse regarding inclusion criteria for patients and injuries considered, and their results also vary according to factors like geographic
Table 2. Mechanisms of trauma among hospitalized injured cases in the studied period (2010: 2017).
Table 3. Pattern of trauma in both male and female in the studied sample.
Chi square test was used. P-value < 0.0001.
Table 4. Pattern of trauma in different age groups in the studied sample.
Chi square test was used. P-value < 0.001.
Table 5. Glasgow coma scale in different forms of trauma in the studied sample.
Chi square test was used. P-value < 0.006.
Table 6. Frequency of injuries according to the anatomical sites.
location, socioeconomic status and cultural environment.
In this study, 58,166 patients attended Trauma unit, Assiut University Hospitals (Single Tertiary Hospital) between January 2010 to December 2017 and among them 3% (n = 1745) cases presented with cranio maxillofacial injuries. The association between traumatic head injury and maxillofacial fractures has not been firmly established in the literature. The differences and conflicts in studies regarding the association globally are very wide. The prevalence of traumatic head injury in a patient with maxillofacial ranges from 7.6% to 8.9% in some studies   while in other studies, this percentage can reach up to 86% in more serious maxillofacial  . The variations of the results can refer to the habitual, socioeconomic, cultural differences in the studied populations as well as the differences in the etiology and methodological criteria applied in various studies     .
Pediatric craniomaxillofacial injuries are less common in comparison with adults as regards, to the anatomical, social and environmental aspects  . The lower frequency of facial fractures in children than in adults is generally reported. This is due to the elasticity of bones in children and the presence of tooth buds. In terms of age groups, facial fractures occur most frequently in people of second and third decade which is in concurrence with the other studies    . In our series, highest number of men and women suffered trauma in this age group. The possible explanation for this as also reported in literature is that this age group is the most active age group that are involved in different activity such as travelling for day-to-day activities, take part in dangerous exercises and sports, driving motor vehicles carelessly, and are most likely to be involved in violence hence placing them at high risk of sustaining these injuries   . As a result of increasing active elderly population, more maxillofacial injuries occur in the population than ever before. The absolute increase in trauma victims in the elderly population relates to more active lifestyles, increased life expectancy and a general increase in the percentage of elderly persons in the population.
Predominance of men in such patient population is a relatively consistent finding in most of the studies. Male:female ratio of 7:1, as in our study, is comparable with all such studies in which it varies from 2:1 to 8:1    . This is attributed to the fact that men are involved in most of the outdoor activities and work in Egypt and most of the women especially in rural areas are confined to the house works.
Maxillofacial injuries are becoming very common in the urban as well as rural areas. In the developed nations, the major cause of the injuries is the interpersonal violence while in the developing nations it is mainly attributed to road traffic accident   . The underlying reasons for that high rate include absence or defects of road traffic regulations and its application, lack of legislation regarding compulsory seat belts and helmet, risky driving, bad road quality, less safety of the vehicles, and increased usage of motor vehicles and cycles. The most important factor is the forbidden of alcohol drinking in Islamic countries according to their religion which may effectively lead to lower rates of assault‑related maxillofacial fractures, thus making the proportional contribution of road traffic accident higher  .
Egypt is similar to the majority of African developing countries, with an increasing urban population, an insufficiency of public transport and a non-compliance with speed limits and seat belt laws. In this study, the most frequently cause of cranio maxillofacial injuries was motor car and motorcycle accident with a proportion of (37.7%) and (30%) respectively. Accidental fall accounted for the fractures in 15%. Assault and firearm had relatively the same proportional, 5.9% and 4.8% respectively. Strict road traffic laws and implementation of safety norms like mandatory seat belts, air bags, helmet wearing for motorized two-wheelers and speed limits have greatly reduced maxillofacial injuries due to RTA in the developed countries   .
Although fall was the third category in the order of frequency, it was the one which proved to be the most important trauma mechanism in age group. Aging is characterized by the gradual reduction in biological functions, with multiple sensory deficits, visual and auditory among them, changes in cognition and memory, and bone and muscle disorders increasing the risk of falls; while in children, a number of factors cause falls, since it is not only neurological centers which are involved, but also all those associated with balance and movement which are still being developed, and children do not know the difference between dangerous actions and the safe ones    . In the developing countries, interpersonal violence is the second leading cause of maxillofacial injuries   . But in our study the second most common reason for the injury was accidental falls (16.0%).
Mandible (47.7%) and maxilla (19%) fractures were the most prevalent injuries found in our study. Mandible fracture was the one which occurred more often in all trauma categories, except for non-lethal weapons and “others”. The results from the present study are in agreement with the literature    . Shankar et al.  in a retrospective analysis showed that the second most common type of fracture in maxillofacial region was maxillary fracture which is in agreement with our study. Minor differences in the frequency of fractures can be caused by variations in the etiology of fracture in various studied. The vulnerability of this bone can be explained by its anatomically prominent position in the facial skeleton.
In the present study, surgical treatment was required in 48% of the cases, when compared to the conservative one, and this data was statistically insignificant. The indications for surgery included simple or complex factures with skull involvement, associated injuries, bruises and sutures for scalp laceration. The surgical approach is in agreement with the present protocol from the department of Neurosurgery and maxillofacial surgery, following the world trend, including reduction, immobilization and fixation to the proper anatomical position of the fragments which shifted in relation to the other bones and the skull base. Non-shifted fractures are treated conservatively and the shifted ones are treated by open reduction and rigid internal fixation with miniplates    .
We faced some limitations in this study. Study subjects were ascertained along with many study variables using electronic medical records. These sources were not primarily designed for research purposes and could have had missing or incorrectly entered information. We did not have access to the records of patients who died at the scene, as no medical records were available for these cases. Also, the histories of accidents and other injuries were provided by victims, witnesses, or paramedic personnel at the scene which may be unreliable in some cases. Although we tried to elucidate the exact causes of the injuries and what had happened at the trauma scenes, it is likely that some patients or their accompanied persons were not able to remember the trauma details completely or accurately. Also it is a single Centre study it may be helpful to enroll more medical centers from major cities and smaller cities, as well as both rural and urban areas, for better understanding of the causes and extents of craniomaxillofacial injuries in Egypt.
Epidemiological characteristics of facial fractures in this study are similar to that generally reported in developing countries. Facial trauma happened most frequently to young adult men. Most of the injuries were due to RTA. The most common anatomical sites affected by primary fractures on the face were the mandible. This clinical and epidemiological bank of data could gave the ground for health care providers to precisely plan the management options and goals in this patients and establishment of preventional health programs to reduce the impact of these injuries in the community. We recommend improving public awareness by applying road traffic regulations, encouraging the rules for compulsory usage of seat belts and helmet, avoiding risky driving, and enhancing road quality.
We would like to thank Dr. Medhat Elaraby from the Community Medicine and Epidemiology Department, Faculty of Medicine, Assiut University for his kind assistance in providing statistical support during the analysis of the study data.
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