Trends in Management and Cost Burden of Facial Fractures: A 14-Year Analysis.

OBJECTIVE: To discuss patient demographics and management and better understand the economic impact associated with the treatment of facial fractures at a major metropolitan level 1 trauma center. STUDY DESIGN: Retrospective chart review. METHODS: We identified 5088 facial fractures in 2479 patients who presented from 2008 to 2022. Patient demographics, mechanism of injury, associated injuries, treatment information, and hospital charges were collected and analyzed to determine factors associated with surgical management and increased cost burden. RESULTS: Our 14-year experience identified 1628 males and 851 females with a mean age of 45.7 years. Orbital fractures were most common (41.2%), followed by maxilla fractures (20.8%). The most common mechanism was fall (43.0%). Surgical management was recommended for 41% of patients. The odds of surgical management was significantly lower in female patients, patients age 65 and older, and patients who presented after the onset of the COVID-19 pandemic. The odds of surgical management was significantly higher for patients who had a mandible fracture or greater than 1 fracture. The average cost of management was highest for naso-orbito-ethmoidal fractures ($37,997.74 ± 52,850.88), followed by LeFort and frontal fractures ($29.814.41 ± 42,155.73 and $27,613.44 ± 39.178.53, respectively). The highest contributor to the total average cost of management was intensive care unit-related costs for every fracture type, except for mandible fractures for which the highest contributor was operating room (OR)-related costs. CONCLUSIONS: This study represents one of the largest comprehensive databases of facial fractures and one of the first to provide a descriptive cost analysis of facial trauma management. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3120-3126, 2024.

Epidemiology of Nasal Bone Fractures.

Importance: Although nasal bones are the most common type of facial fracture given their natural projection and vulnerability to trauma, there is a paucity of data on its trends. Objective: To report on the trends and costs associated with open and closed nasal bone fractures across the United States. Methods: A retrospective analysis from 2006 to 2014 was conducted of the Nationwide Emergency Department Sample by using the International Classification of Disease, Ninth Revision codes for closed and open nasal bone fractures (802.0 and 802.1) presenting to emergency departments (ED). Trend analysis of total number and rate of visits, discharges, admissions, and associated costs were conducted. Results: Data from 1,253,399.741 records were collected. The total number of ED visits decreased by 2.05% for both open and closed nasal fractures from 2006 to 2014 whereas their associated costs increased (p < 0.001 and p < 0.05 for closed and open nasal fractures). Notably, open fractures were consistently costlier whereas closed fractures had a greater percent-increase in costs (76.65%). Conclusions and Relevance: This study identified a significant rise in nasal fracture costs, which can be reduced via use of cheaper diagnostic modalities and cost-effective endoscopic procedures.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

National Trends in Pediatric Facial Fractures: The Impact of Health Care Policy.

BACKGROUND: Traumatic injuries are significant sources of morbidity and mortality in the pediatric population. Using a national database, this study aims to characterize pediatric facial fracture management and the effect of health care policy changes on populations receiving treatment. METHODS: A retrospective cohort study was performed using Healthcare Cost and Utilization Project Kids' Inpatient Database databases from 2000 to 2016. Pediatric patients admitted with a facial fracture diagnosis were included. Clinical outcomes include mortality, reduction of fracture during hospital stay, and open fracture reduction. The impact of the Affordable Care Act on patient demographics and management was assessed. RESULTS: Between 2000 and 2016, 82,414 patients were managed for facial fractures, 8.3 percent of whom were managed after implementation of the Affordable Care Act (n = 6841). Mean age was 15.2 years, and the male-to-female ratio was 2.9:1. Significant racial disparities were identified before the Affordable Care Act: African American and Native American patients had decreased odds of having facial fracture reduction during the initial hospital stay (OR, 0.84 and 0.86, respectively), and identifying as either Hispanic or Native American was associated with higher odds of mortality (OR, 1.4 or 2.4, respectively). Race was not contributory to patient mortality after the Affordable Care Act. Before Affordable Care Act implementation, patients receiving care with no charge (including charity care/charity research) had lower odds of having an open reduction or any reduction; insurance status was not contributory to management after the Affordable Care Act. CONCLUSION: Although the Affordable Care Act may have increased access to care for certain populations, race- and sex-associated differences in mortality rate and fracture management should be further investigated to ensure a national standard of equitable patient care.

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015.

OBJECTIVE: Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes. METHODS: The authors queried the MarketScan database (2007-2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs. RESULTS: The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non-CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6-13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2-44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7-5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5-4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001). CONCLUSIONS: The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

The Characteristics and Cost of Le Fort Fractures: A Review of 519 Cases From a Nationwide Sample.

PURPOSE: The aims were to report the characteristics of Le Fort fractures and to quantify the associated hospital costs. MATERIALS AND METHODS: From October 2015 to December 2016, the National Inpatient Sample was searched for patients admitted with a primary diagnosis of a Le Fort fracture. Predictor variables were drawn from demographic, admission, and injury characteristics. The outcome variable was hospital cost. Summary statistics were calculated and compared among Le Fort patterns. Univariate comparisons and multivariate regression analyses were conducted to determine predictors associated with cost. RESULTS: A total of 519 patients were identified in this cohort. Associated injuries included skull fractures (28%), intracranial hemorrhage (13%), cervical spine injury (9.8%), and concussion (9.1%). Seventy-three percent of patients received open reduction and internal fixation (ORIF) for their facial fractures during their admission, 13% received a tracheostomy, and 10% were mechanically ventilated for at least 1 day. The ventilation (P < .01) and tracheostomy (P < .01) rates increased with Le Fort complexity, as did length of stay (LOS; P < .01), costs (P < .01), and charges (P < .01). The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS. CONCLUSIONS: The prevalence of head injuries and the need for respiratory support substantially increased with Le Fort complexity. Hospital costs were not markedly influenced by the diagnosis and management of associated injuries. Instead, costs were predominantly driven by fracture complexity and the need for necessary procedures, such as ORIF, tracheostomy, and mechanical ventilation.

Epidemiology of facial fractures among older adults: A retrospective analysis of a nationwide emergency department database.

BACKGROUND/AIMS: The prevalence of facial fractures among older adults has increased in recent years, and nationwide studies about the epidemiological profile and outcomes of hospital-based ED visits for facial fractures among older adults are scarce. The aim of this study was to provide USA-wide data of hospital-based Emergency Department (ED) visits for facial fractures among older adults, and to investigate the outcomes associated with these visits. MATERIAL AND METHODS: The Nationwide Emergency Department Sample (NEDS) for the years 2008-2014 was used for the present study. All ED visits with a diagnosis of facial fractures in any of the diagnoses fields and only patients aged 65 years and above were included. RESULTS: A total of 540 748 ED visits matched the criteria (62.7% were females). Public insurance-Medicare-(85.2%) was the most common payer. The three most frequent facial fractures included fractures of the nasal bones (61.3%), fractures of "other" facial bones (16.7%), and fractures of the orbital floor (15.0%). Falls were the most common causes of facial fractures (81.8%). Following ED visits, 64.1% were treated and released, and 30.6% were admitted into the hospital. The mean ED charge per visit was US$5507. Total ED charges across the entire United States was US$2 518 289 555. CONCLUSIONS: Among older adults, nasal bone fractures are the most common type of facial fracture. Facial fractures are mainly caused by falls. There was no significant trend in mortality rates over the study period, and there was a significant financial burden associated with the facial fracture-related ED visits.

Management of Pediatric Isolated Skull Fractures: A Decision Tree and Cost Analysis on Emergency Department Disposition Strategies.

OBJECTIVE: Pediatric isolated skull fractures (ISFs) are common injuries that represent challenging disposition decisions for clinicians. The purpose of this study is to use a decision analysis to compare the clinical and cost-effectiveness of 3 emergency department (ED)-based disposition scenarios for a pediatric patient presenting with ISF. METHODS: We conducted a cost-effectiveness analysis comparing ED disposition scenarios that included current practice, increased at-home surveillance, and observation unit utilization. Current rates of admission, deterioration after initial diagnosis, and ED return after discharge, as well as cost of observation-only status, were obtained through literature review. Cost calculations using Healthcare Cost and Utilization Project data included total ED cost, admission without complication, and admission with deterioration. RESULTS: In current practice, 76% of subjects with ISF are admitted and 2.5% of those develop persistent or new symptoms. No patient diagnosed with ISF required neurosurgical intervention. Of those discharged home from the ED, 2.8% return with a new concern with 7.4% having new findings on imaging leading to admission. Total cost per 100 patients by current practice was US $583,587. Increasing at-home surveillance by 20% resulted in a total cost saving of US $113,176 per 100 patients while increasing returns to the ED from less than 1% to 1.1%. Admitting at the current rate to an observation unit resulted in a US $205,395 cost saving per 100 patients. CONCLUSIONS: Decreased inpatient utilization through home surveillance or observation unit use reduced cost associated with pediatric ISF management without increasing clinical risk owing to the low probability of clinical deterioration after initial diagnosis.

Facial Fractures in Patients With Firearm Injuries: Profile and Outcomes.

PURPOSE: Firearm injuries (FAIs) are a major public health issue in the United States. The objective of this study was to examine characteristics and outcomes of patients presenting to emergency departments (EDs) with facial fractures attributed to FAIs. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for the years 2008 to 2013 was used. All patients who visited EDs with FAIs and facial fractures were selected. The study focused on the following variables: 1) demographic characteristics, 2) types of facial fractures, 3) disposition status after ED visit or subsequent hospitalization, 4) charges (ED and hospitalization), and 5) patient outcomes. The inclusion criteria were a visit to a hospital-based ED with facial fractures and an external cause of FAI. Descriptive statistics were used to summarize findings. Multivariate logistic regression analysis was used to examine the simultaneous effects of patient-related factors on ED death. RESULTS: During the study period, a total of 15,469 patients (mean age, 34 years) visited hospital-based EDs with facial fractures attributed to FAIs. Most were uninsured male patients. The most common etiology of FAIs was assault. The most common facial fractures were open mandibular fractures and open maxillary and/or malar bone fractures. Approximately 27% of patients had a concomitant intracranial injury. After the ED visit, 74% were admitted. The mean ED charge per patient was $6,403, and the total ED charge across the United States was $76.48 million. The mean hospitalization charge per patient was $167,203. The total hospitalization charge across the United States was $1.9 billion. Patients with intracranial injuries (odds ratio [OR], 21.21; 95% confidence interval [CI], 7.16 to 62.85; P < .01), uninsured patients (OR, 4.24; 95% CI, 1.44 to 12.51; P < .01), and patients residing in areas with high household incomes (OR, 5.60; 95% CI, 2.51 to 12.46; P < .01) were high-risk groups for ED death. CONCLUSIONS: FAIs require substantial resources for stabilization and treatment by EDs. This study highlights the burden and impact of facial fractures in patients with FAIs in the United States.

Transfer of children with isolated linear skull fractures: is it worth the cost?

OBJECTIVE Children with skull fractures are often transferred to hospitals with pediatric neurosurgical capabilities. Historical data suggest that a small percentage of patients with an isolated skull fracture will clinically decline. However, recent papers have suggested that the risk of decline in certain patients is low. There are few data regarding the financial costs associated with transporting patients at low risk for requiring specialty care. In this study, the clinical outcomes and financial costs of transferring of a population of children with isolated skull fractures to a Level 1 pediatric trauma center over a 9-year period were analyzed. METHODS A retrospective review of all children treated for head injury at Riley Hospital for Children (Indianapolis, Indiana) between 2005 and 2013 was performed. Patients with a skull fracture were identified based on ICD-9 codes. Patients with intracranial hematoma, brain parenchymal injury, or multisystem trauma were excluded. Children transferred to Riley Hospital from an outside facility were identified. The clinical and radiographic outcomes were recorded. A cost analysis was performed on patients who were transferred with an isolated, linear, nondisplaced skull fracture. RESULTS Between 2005 and 2013, a total of 619 pediatric patients with isolated skull fractures were transferred. Of these, 438 (70.8%) patients had a linear, nondisplaced skull fracture. Of these 438 patients, 399 (91.1%) were transferred by ambulance and 39 (8.9%) by helicopter. Based on the current ambulance and helicopter fees, a total of $1,834,727 (an average of $4188.90 per patient) was spent on transfer fees alone. No patient required neurosurgical intervention. All patients recovered with symptomatic treatment; no patient suffered late decline or epilepsy. CONCLUSIONS This study found that nearly $2 million was spent solely on transfer fees for 438 pediatric patients with isolated linear skull fractures over a 9-year period. All patients in this study had good clinical outcomes, and none required neurosurgical intervention. Based on these findings, the authors suggest that, in the absence of abuse, most children with isolated, linear, nondisplaced skull fractures do not require transfer to a Level 1 pediatric trauma center. The authors suggest ideas for further study to refine the protocols for determining which patients require transport.

Epidemiology and resource utilization in pediatric facial fractures.

BACKGROUND: Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures. METHODS: Using the 2000-2009 Kids' Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes. RESULTS: Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges. CONCLUSIONS: There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.

Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly.

BACKGROUND: Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly. METHODS: We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention. RESULTS: Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p<0.0001). CONCLUSION: Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.

Linear nondisplaced skull fractures in children: who should be observed or admitted?

OBJECT: In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed. METHODS: After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children's hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus. RESULTS: Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7-395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2-43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit. CONCLUSIONS: Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.

Emergency department visits with facial fractures among children and adolescents: an analysis of profile and predictors of causes of injuries.

PURPOSE: The objectives of this study were to provide nationally representative estimates of hospital-based emergency department (ED) visits for facial fractures in children and adolescents, examine the burden associated with such visits, identify common types of facial fracture, and examine the role of patient-related demographic factors on the causes of facial fractures. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for 2008 to 2010 was used. All ED visits with a diagnosis of facial fractures in those no older than 21 years were selected. Demographic characteristics, types of facial fracture, causes of injuries, and hospital charges were examined. RESULTS: During the study period, 336,124 ED visits were for facial fractures in those no older than 21 years. Late adolescents (18 to 21 yr old) and middle adolescents (15 to 17 yr old) comprised 45.6% and 26.6% of all ED visits, respectively. Male patients comprised 74.7% of ED visits. The most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults (P < .05). Female patients were more likely to have falls, motor vehicle traffic accidents, and transport accidents, whereas male patients were more likely to have firearm injuries, pedal cycle accidents, and assaults (P < .05). Those residing at low annual income household levels were at a high risk for having firearm injuries, motor vehicle traffic accidents, and transport accidents (P < .05). CONCLUSIONS: Late adolescents, middle adolescents, and male patients comprise a significant proportion of these ED visits. Age, gender, and household income levels are significantly associated with the causes of facial fracture injuries.

Isolated skull fractures: trends in management in US pediatric emergency departments.

STUDY OBJECTIVE: Previous studies have suggested that children with isolated skull fractures are at low risk of requiring neurosurgical intervention, suggesting that admission to the hospital may not be necessary in many instances. We seek to evaluate current practice for children presenting to the emergency department (ED) for isolated skull fractures in US children's hospitals. METHODS: We conducted a retrospective multicenter cross-sectional study of children younger 19 years with a diagnosis of isolated skull fracture who were evaluated in the ED from 2005 to 2011, using the Pediatric Health Information System database. The primary outcome measure was the rate of hospital admission. Secondary outcomes were any neurosurgical procedure during hospitalization, repeated neuroimaging, duration of hospitalization, and cost of care. RESULTS: We identified 3,915 patients with isolated skull fractures, of whom 60% were male patients; 78% were hospitalized. Of hospitalized children, 85% were discharged within 1 day and 95% were discharged within 2 days. During hospitalization, 47 patients received repeated computed tomography imaging and 1 child required a neurosurgical procedure. Hospital costs were more than triple for hospitalized patients compared with patients discharged from the ED ($2,064 versus $619). CONCLUSION: Most children treated in EDs of US children's hospitals with isolated skull fractures are hospitalized. The rate of neurosurgical intervention is very low. A better understanding of current practice is necessary to assess whether these admissions are warranted or not.

Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation.

PURPOSE: The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions. METHODS: A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base. RESULTS: A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were $291 vs $1447 for those admitted for observation (P < .001). CONCLUSION: Patients with a presenting GCS of 15 and an ISF can be safely discharged from the emergency department after a short period of observation if they are asymptomatic and have a reliable social environment. This could result in significant savings by eliminating inpatient costs.

Epidemiology of facial fracture injuries.

PURPOSE: Injuries resulting from accidents are a leading cause of mortality and morbidity. The objective of this study was to present epidemiologic estimates of hospital-based emergency department (ED) visits for facial fractures in the United States. MATERIALS AND METHODS: The Nationwide Emergency Department Sample for 2007 was used. All ED visits with facial fractures were selected. Demographic characteristics of these ED visits, causes of injuries, presence of concomitant injuries, and resource use in hospitals were examined. All estimates were projected to national levels and each ED visit was the unit of analysis. RESULTS: During 2007 in the United States, 407,167 ED visits concerned a facial fracture. Patients' average age for each ED visit was 37.9 years. Sixty-eight percent of all ED visits concerned male patients, and 85,759 ED visits resulted in further treatment in the same hospital. Three hundred fourteen patients died in EDs, and 2,717 died during hospitalization. Mean charge per each ED visit was $3,192. Total United States ED charges were close to $1 billion. Mean hospitalization charges (ED and inpatient charges) amounted to $62,414. Mean length of stay was 6.23 days, and total hospitalization time in the entire United States was 534,322 days. Frequently reported causes of injuries included assaults (37% of all ED visits), falls (24.6%), and motor vehicle accidents (12.1%). CONCLUSIONS: The management of maxillofacial fractures in EDs across the United States uses considerable resources. The public health impact of facial fractures is highlighted in the present study.

Internações hospitalares por fraturas do crânio e dos ossos da face no Nordeste brasileiro / Hospital admissions for fractures of the skull and bones of the face in Northeast Brazil

Introdução: O aumento dos acidentes e da violência no Brasil tem repercutido na organização do sistema de saúde, o qual, por sua responsabilidade na atenção ao trauma, vem tendo seus gastos elevados. Objetivo: Realizar levantamento epidemiológico das internações decorrentes das fraturas do crânio e dos ossos da face, avaliando os gastos do Sistema Único de Saúde com as internações na região Nordeste por um de período de dez anos. Métodos: Estudo de série temporal com dados do Sistema de Informações Hospitalares. Foram selecionadas as internações cujo diagnóstico fazia parte do capitulo XIX da Classificação Internacional das Doenças e a sua distribuição segundo: sexo, faixa etária, Unidade Federativa, valor médio, permanência média e ano de internação. Resultados: Foram encontrados 67.086 registros de internações por essas fraturas. A incidência média das fraturas de crânio e dos ossos faciais foi de 13,66 por 100.000 habitantes. A maioria das internações ocorreu no sexo masculino, em 82,5%, e nas faixas etárias de 20 a 29 anos de idade. As Unidades Federativas que apresentaram elevados coeficientes foram Rio Grande do Norte, Paraíba e Sergipe. No período foram gastos R$ 39.058.339,80 com internação e o valor médio por internação aumentou até 2003. Conclusões: As incidências de fraturas dos ossos do crânio e da face cresceram no período avaliado nos estados do Nordeste, sendo mais frequente no sexo masculino e nas faixas etárias de 20 a 29 anos. Consequentemente, os gastos públicos com internações por causa de fraturas dos ossos do crânio e da face cresceram no decorrer dos anos (AU)

Introduction: The increase of accidents and violence in Brazil has affected the organization of health systems, whose expenditures have been increasing due to their responsibility for attending to injuries. Aim: To perform an epidemiological survey of hospital admissions due to skull fractures and maxillofacial injuries, evaluating the expenses of the Single Health System with hospitalizations in northeast Brazil for 10 years. Methods: Temporal series study with data from the Hospital Information System. The cases selected were those diagnosed as part of the XIX Chapter of the International Classification of Diseases (ICD) and their distribution according to sex, age group, state, mean value, mean stay, and year of admission. Results: There were 67.086 records of admissions due to these fractures. The mean incidence of skull fractures and maxillofacial injuries was 13.66 per 100.000 people. Most of the admissions occurred among males (82.5%) in their twenties. The states with the highest indexes were Rio Grande do Norte, Paraíba, and Sergipe. In this period, R$ 39.058.339,80 were spent with hospitalizations, and the mean value per hospitalization increased until 2003. Conclusions: The incidence of skull fractures and maxillofacial injuries increased in the studied period in the northeast states, being more frequent among males in the 20-29 age group. Consequently, the public expenses with hospitalizations due to skull and maxillofacial injuries have increased over the years (AU)

Routine early CT-scan is cost saving after minor head injury.

Significant hospital resources are invested in early detection of intracranial complications after minor head injuries (MHI). This study focuses on economic aspects of MHI management. 88 MHI patients underwent routine early CT-scan and at least 24 h in-hospital observation. The cost of this management was calculated, and compared to estimated costs of three alternative management protocols. CT-scans demonstrated intracranial lesions in eight (9%) patients, but none required neurosurgical intervention. The expense of our management was Norwegian Kroner (NOK) 576,136. An alternative management protocol including routing early CT-scan and discharge of patients with normal CT-findings, Glasgow coma score > or = 14 and no neurological deficits, was found to be safe, and estimated to reduce costs with 43% to NOK 326,669. It is concluded that routine early CT-scan is the most reliable and cost saving management procedure after MHI.