QS2: The Underreporting Of Traumatic Brain Injuries In Pediatric Craniomaxillofacial Trauma - A 20 Year Retrospective Cohort Study

PURPOSE: Despite clinical concerns associated with traumatic brain injuries (TBIs), they remain grossly underreported: 46% of TBIs in adult craniomaxillofacial (CMF) trauma patients remained unrecorded at discharge. This has not been studied in the pediatric CMF trauma population. Consequently, this is the first retrospective study to characterize concomitant pediatric TBI and CMF trauma patients, including incidence, presentation, documentation, and outcomes. The authors hypothesize that TBI in pediatric CMF trauma is associated with worse prognosis and remains under-recorded. METHODS: An IRB-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high volume, tertiary trauma center between January 1(st), 1990 to December 31(st), 2010. Patients were included if they were (1) age younger than 15 years and (2) confirmed presence of CMF injury by means of imaging, radiology report, and physical examination. Patient charts were reviewed for demographic information, dentition stage, CMF fracture patterns, mechanism of injury, presentation, need for operative management, length of stay, and mortality at 2 years. Charts were reviewed to identify concomitant TBIs, defined as intracranial injury, cerebral hemorrhage, brain concussion, epilepsy or seizures (post-traumatic), and traumatic brain injury (documented). Data was analyzed using two-tailed Student’s t-tests and chi square analysis. Point-biserial correlation coefficients were calculated between a continuous and dichotomous variable; Pearson correlation coefficients were calculated between continuous variables. A P value ≤ 0.05 was considered statistically significant. RESULTS: Of the 2966 pediatric CMF trauma patients identified and included for analysis (mean age of 7 +/- 4.7 years old, predominantly white, 59.8%, and male, 64.0%), 809 had concomitant TBI (frequency of 27.3%). Only 13 of the 809 TBI cases were documented in charts (1.6%). Concomitant TBI with CMF trauma patients were more likely to be male (69.1% vs 62%, P < 0.05), and be caused by blunt injury (98.9% vs. 95.5%, P < 0.05), compared to CMF trauma patients without TBI. TBI patients had a higher mortality rate at two years (8.0% vs 4.8%, P < 0.05). Mortality at two years, length of stay in hospital, and time to follow up significantly increased from mild to severe TBIs. Concomitant TBI and CMF trauma patients were also more likely to present with skull & upper third fractures than CMF trauma without TBI (81.8% vs 61.1%, P < 0.05). CONCLUSION: In this 20-year retrospective review, concomitant TBI injuries were present in a significant number of pediatric CMF trauma cases (27.3%) but was not documented for most cases. Given the importance of initial management and long-term care in TBI patients, it is critical for clinicians to remain vigilant for and manage TBIs in pediatric CMF trauma patients in collaboration with appropriate neurology and/or neurosurgery teams. Future prospective studies are necessary to better characterize TBI patient injury patterns and outcomes to generate practice guiding recommendations for this patient population.