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Fractures of the Mandibular Condylar Base Are Associated With Severe Blunt Internal Carotid Artery Injuries
Neil M. Vranis, BA1, Gerhard S. Mundinger, MD2, Justin L. Bellamy, BS3, Abhishake Banda, MD, DDS2, Robin Yang, MD, DDS2, Amir H. Dorafshar, MBChB2, Eduardo D. Rodriguez, MD, DDS2.
1University of Maryland School of Medicine, Baltimore, MD, USA, 2Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA, 3The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Purpose: Fractures of the mandibular condyle at the head, neck, and base are common following blunt facial trauma. Patients with these fractures have also been shown to be at increased risk for concomitant blunt carotid artery injuries (BCAI), though this relationship remains poorly understood. Further elucidation of the relationship between specific condylar fracture patterns and BCAI may improve vascular injury screening criteria and treatment for craniofacial trauma patients.
Methods: A retrospective cohort study was performed for all patients that presented to the R Adams Cowley Shock Trauma Center with mandibular condyle fractures from 2000 to 2012. In addition to demographic information, authors reviewed computed tomographic (CT) imaging to confirm and codify condylar fracture location, displacement, and comminution. Additional facial fractures were also systematically recorded. Condyle fractures were classified according to the Strasbourg Osteosynthesis Research Group (SORG) classification system as follows: fracture of the condylar head (SORG 1), fractures of the condylar neck (SORG 2), and fractures of the condylar base (SORG 3). Cerebrovascular injuries were confirmed by review of CT and magnetic resonance imaging (MRI) angiography, and were graded according to the Biffl scale from 1 (vessel with less than 25% intimal stenosis) to 5 (vessel transection). Severe BCAI was defined as a Biffl score greater than 1. Adjusted relative risk estimates were obtained using multivariable regression with STATA 12 software.
Results: We identified 527 consecutive patients with 657 condyle fractures. Of these fractures, 150 (22.8%) were SORG 1, 203 (30.9%) were SORG 2 and 304 (46.3%) were SORG 3. 32 (6.1%) patients sustained 44 BCAI’s, with 21 (4.0%) patients suffering a severe BCAI. Severe BCAI occurred in 2 (1.3%) of SORG 1, 2 (1.0%) of SORG 2 and 17 (5.6%) of SORG 3 fractures. After accounting for the effect of age, mechanism of injury, and concurrent LeFort I, II and III fractures, adjusted multivariable regression analysis found that SORG 3 fractures were independently associated with a 4.03 -fold increased risk of severe BCAI (p-value <0.01).
Conclusion: In blunt trauma patients with mandibular condyle fractures, there is an increased risk of severe BCAI with involvement of the condylar base compared to condylar head or neck. We hypothesize that base fractures constitute a relatively longer condylar moment arm that may displace and injure the internal carotid artery. Given the urgent nature of treating BCAI, the presence of a condylar base fracture should heighten suspicion for a severe internal carotid artery injury.
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