Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction.

BACKGROUND: Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure. METHODS: A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap. RESULTS: A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation). CONCLUSIONS: Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

Determinants of distal radius fracture management in polytrauma patients.

BACKGROUND: Over 640,000 distal radius fractures occur annually in the United States. No studies have been performed looking specifically at polytrauma patients who sustain distal radius fractures. We sought to determine variables affecting management of distal radius fractures in polytrauma patients. METHODS: An IRB-approved review of trauma patients from 2008-2011 was performed. Records for patients with distal radius fractures were examined, assessing age, gender, Glascow Coma Score, Injury Severity Score, mechanism, type, and characteristics of injury, as well as operative repair. A logistic regression was performed using SPSS 15.0. RESULTS: The database identified 12,054 patients, 434 sustaining a distal radius fracture. No statistically significant difference in operative repair based on mechanism of injury (p = 0.465) was identified. A total of 285 patients (65.7 %) underwent surgery for distal radius fractures. In univariate analysis, younger age was the only statistically significant demographic predictor of surgical intervention (p = 0.003). In both univariate analysis and logistic regression, open, intra-articular, displaced, and comminuted fractures, as well as those with concomitant ulna fractures were statistically significantly associated with operative repair. Fracture displacement was the most likely variable to be associated with surgical intervention (OR = 12.761, 95 % CI[7.219, 22.556]) (p < 0.001). CONCLUSIONS: In polytrauma patients, surgery for distal radius fractures is associated with younger age, open, intra-articular, displaced, and comminuted fractures, as well as concomitant ulna fractures. Displaced fractures were almost 13 times more likely to undergo surgical intervention than non-displaced fractures. Gender and mechanism of injury are not predictive of surgical intervention.

Delayed diagnosis of hand injuries in polytrauma patients.

Trauma patients are at high risk for delayed diagnosis of injuries, including those to the hand, with reports in the literature as high as 50%. As a result, patients may have prolonged disability and longer hospital stays with associated increased costs. Our objective was to elucidate risk factors for the delayed diagnosis of hand injuries. A review was performed from 2000 through 2009, assessing for age, sex, blood alcohol level, Glasgow Coma Score (GCS), Injury Severity Score (ISS), mechanism, injury type, length of stay, and timing of hand injury diagnosis. In this study, 36,568 patients were identified; 738 meeting criteria; 21.7% of patients had delayed diagnoses with 91.3% of patients diagnosed by the day after admission. Delayed diagnoses were more than 2 times higher for severely injured patients. Patients with delayed diagnoses had a lower GCS and a higher ISS and length of hospitalization. With a decreased GCS and elevated ISS, patients are at risk for delayed diagnoses of hand injuries. A focused tertiary survey is mandatory, particularly in patients with an altered mental status or with multiple injuries.

Reduction mammaplasty trends: a quality and fiscal analysis update.

BACKGROUND: Reduction mammaplasty remains one of the most common procedures performed by plastic surgeons today. The national health care quality and fiscal environments continue to evolve, with increasing emphasis on outpatient procedures and reduced lengths of stay (LOS). This study was designed to analyze the trends in reduction mammaplasty at our institution during the last 10 years with particular attention to LOS, complication rate, and readmission. We also evaluated the institutional fiscal implications with regard to reimbursement in the changing health care environment. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective chart review. An analysis of all reduction mammaplasties during the last 10 years was undertaken. Admission status [same day surgery (SDS), outpatient ambulatory, observation, and inpatient], LOS, mortality, morbidity, and readmissions were documented. A financial analysis was also performed comparing trends in hospital revenue and operating income. Revenue was defined as the amount that the hospital received from all sources, whereas operating income was the revenue reduced by all costs incurred to provide services. RESULTS: In this population, 1779 patients were identified (SDS, 499; outpatient ambulatory or observational, 694; and inpatient, 586). Twenty patients were readmitted within 30 days. The all-cause 30-day readmission rate was 11.24 per 1000 patients. The disease-specific readmission rate was 5.06 per 1000 patients (n=9). Only 1 patient with disease-specific complication requiring readmission had been classified as SDS. No cases of nipple compromise were identified in our study. Revenue per case was highly variable throughout the study period. In general, operating income has decreased during the last decade, despite a small increase for those patients who were truly inpatient. CONCLUSIONS: Reduction mammaplasty is a common procedure that is safe when performed on an outpatient basis. Institutional operating income, except in the case of inpatients, continues to decrease and could pose a challenge in the future should present trends continue.