Do Radiologists and Surgeons Speak the Same Language? A Retrospective Review of Facial Trauma

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1 Neuroradiology/Head and Neck Imaging Original Research Ludi et al. Assessing Language in Radiology and Surgery Reports of Facial Trauma Neuroradiology/Head and Neck Imaging Original Research Erica Kristen Ludi 1 Saurabh Rohatgi 2 Matthew E. Zygmont 2 Faisal Khosa 3 Tarek N. Hanna 2 Ludi EK, Rohatgi S, Zygmont ME, Khosa F, Hanna TN Keywords: CT, emergency department, facial, fractures, trauma DOI: /AJR F. Khosa is a 2013 ARRS Scholar. Received November 19, 2015; accepted after revision May 3, Based on a presentation at the Radiological Society of North America 2015 annual meeting, Chicago, IL. F. Khosa is supported by grant 1R56HL from the National Institutes of Health. 1 Emory University School of Medicine, Atlanta, GA. 2 Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 550 Peachtree Rd, Atlanta, GA Address correspondence to S. Rohatgi (sarohatgi@emory.edu). 3 Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada. This article is available for credit. AJR 2016; 207: X/16/ American Roentgen Ray Society Do Radiologists and Surgeons Speak the Same Language? A Retrospective Review of Facial Trauma OBJECTIVE. The objective of the present study is to examine the concordance of facial fracture classifications in patients with trauma who underwent surgery and to assess the epidemiologic findings associated with facial trauma. MATERIALS AND METHODS. Patients with trauma who underwent facial CT examination and inpatient operative intervention during a 1-year period were retrospectively analyzed. Patient demographic characteristics, the mechanism of injury, the radiology report, the surgical diagnosis, and clinical indications were reviewed. s were documented according to bone type and were classified into the following subtypes: LeFort 1, LeFort 2, Le- Fort 3, naso-orbital-ethmoidal, zygomaticomaxillary complex (ZMC), orbital, and mandibular. Concordance between the radiology and surgery reports was assessed. RESULTS. A total of 115,000 visits to the emergency department resulted in 9000 trauma activations and 3326 facial CT examinations. One hundred fifty-six patients (4.7%) underwent facial surgical intervention, and 133 cases met criteria for inclusion in the study. The mean injury severity score was 10.2 (range, 1 75). The three most frequently noted injury mechanisms were as follows: assault (77 cases [57.9%]), a traffic accident (21 cases [15.8%]), and a fall (20 cases [15%]). The three most frequently noted facial bone fractures were as follows: mandible (100 cases [75.2%]), maxilla (53 cases [39.8%]), and orbit (53 cases [39.8%]). The five descriptors most frequently found in the radiology and surgery reports were the mandibular angle (25 cases), the orbital floor (25 cases), the mandibular parasymphysis (22 cases), the mandibular body (21 cases), and ZMC fractures (19 cases). A classification was not specified in 31 of the radiologic impressions (22.5%), with 28 of 31 radiologists expecting the surgeon to read the full report. The descriptors used in the radiology and surgery reports matched in 73 cases (54.9%) and differed in 51 cases (38.3%). No classifications were used by one or both specialties in nine cases (6.8%). CONCLUSION. For 38.3% of patients needing facial surgery, descriptors used in the radiologic and surgery reports differed. Speaking a common language can potentially improve communication between the radiology and surgery services and can help expedite management of cases requiring surgery. I n 2007, facial fractures accounted for 407,167 emergency department (ED) visits in the United States [1]. The most common fracture types were closed nasal, orbital, malar, maxillary, and mandible fractures [1]. The number of cases of facial trauma requiring hospitalization from 1990 to 2011 was 2.23 million, with the number increasing over the past decade [2]. However, the percentage of facial fractures that underwent inpatient operative repair decreased between 1996 and 2006, likely as a result of improved detection and accurate categorization of clinically insignificant fractures [3]. Physical examination is generally insufficient to accurately classify facial injuries resulting from superficial soft-tissue swelling and inaccessibility of the deep midface. Imaging is critical for the surgeon to understand all involved anatomic structures and to appropriately plan the surgical approach and intraoperative technique [4, 5]. CT is the reference standard for facial imaging, and it can accurately detect and characterize surgically important injuries [4]. In addition to various classifications for facial fractures and injury patterns, including the zygomaticomaxillary complex (ZMC), LeFort, and naso-orbital-ethmoidal (NOE) 1070 AJR:207, November 2016

2 Assessing Language in Radiology and Surgery Reports of Facial Trauma fracture classifications, localizing descriptors for mandibular and orbital fractures also exist (Fig. 1). A familiarity with anatomic descriptors and classification schemes is optimal for diagnosis and efficient communication. The radiologist s interpretation of the CT scan plays an important role in presurgical planning for patients with facial trauma. However, it can be difficult for the radiologist to know which fractures are the most critical for the surgeon, and a difference in terminology used between specialties has the potential to create communication gaps [4]. In the present study, we examine concordance between the radiology and surgery reports of patients with facial trauma who were undergoing operative repair and assess whether the radiology reports used a standardized classification system for facial trauma. A secondary aim of the present study is to analyze the epidemiologic characteristics of facial fracture at our institution. Materials and Methods The present study was approved by the institutional review board at Emory University and is HIPAA compliant. The study was conducted at an urban level I trauma center where approximately 110,000 ED visits occur annually, resulting in 9000 trauma activations. Consecutive trauma activations occurring over 1 year (January 2013 through December 2013) were eligible for inclusion in the present study if they involved facial fractures resulting from trauma and required operative repair of these facial fractures. The exclusion criterion was patient age younger than 16 years. Patients with facial fractures that did not undergo surgical repair were excluded from the study. Data were obtained from the trauma registry. Information on demographic and clinical characteristics was gathered from the registry and included patient age and sex, the mechanism of trauma, the injury severity score [6], the facial surgical procedure performed, and the date of discharge from the hospital. Facial examinations were performed in accordance with institutional protocol, with the use of either a 64-MDCT system (LightSpeed VCT, GE Healthcare) or a 16-MDCT system (Brilliance, Philips Healthcare). Imaging parameters for both systems included helical acquisition at a fixed tube current of 180 ma and a tube voltage of 120 kv. Unenhanced facial CT examinations were obtained caudal to cephalad with the use of the 64-MDCT system, in axial soft-tissue reconstruction at 2.5-mm thickness, with axial, sagittal, and coronal bone filter-reformatted images acquired at thicknesses of 0.625, 1.25, and 1.25 mm, respectively. Coronal soft-tissue reformatted images were also created at a slice thickness of 2.5 mm. Correlating series were performed using the 16-MDCT system at slice thicknesses of 0.6, 1.2, and 3 mm because of differences in detector configuration. Three-dimensional reformatting capability was available on a PACS workstation (isite, Intellispace PACS Enterprise , Philips Healthcare) on a per-patient basis via use of a thin client portal application (IntelliSpace PACS Enterprise with isyntax 4.4, Philips Healthcare). Three-dimensional postprocessing was not used routinely in the radiology workflow of the ED. Data collected from the surgical notes involved preoperative and postoperative diagnoses, clinical indications, and findings. A numeric coding system was used to categorize the fractures. A C D Fig year-old man with facial fracture caused by trauma. A, Three-dimensional CT image shows LeFort I floating palate fracture (green line), LeFort II pyramidal fracture (blue line), and LeFort III craniofacial disjunction fracture (red line) pattern. B, Three-dimensional CT image shows zygomaticomaxillary complex fracture pattern (lateral and inferior orbital rim, zygomatic arch, and maxillary sinus walls) (red lines). C, Three-dimensional CT image shows naso-orbital-ethmoidal fractures (red lines) involving frontal process of maxilla and medial orbital rim. D, Three-dimensional CT image shows the following mandibular and orbital fracture subtypes: symphyseal (red line), parasymphyseal (orange line), body (light yellow line), angle (dark green line), ramus (dark blue line), condylar or subcondylar (purple line), and coronoid process (black line) fractures. Also seen are orbital floor (light green line), medial wall (light blue line), roof (pink line), and lateral wall (dark yellow line) fractures. With the help of an associate investigator, two boardcertified fellowship-trained attending physicians reviewed all charts and made direct comparisons between the full radiology and surgery reports. s were identified from the radiology reports and were categorized as the following types: mandible, maxilla, nasal complex (including nasal bones, nasal process of maxilla, and nasal septum), orbital wall, zygoma (or zygomatic arch), pterygoid plates, ethmoid, sphenoid, frontal bone, or other facial fracture. types included isolated fractures and those that involved fractures of multiple bones in combination. Mandible fractures were further subclassified as symphyseal, parasymphyseal, body, ramus, angle, condylar or subcondylar, or coronoid process fractures. B AJR:207, November

3 Ludi et al. TABLE 1: Epidemiologic Characteristics Associated With d Bones, as Indicated in the Radiology Report Characteristic Mandible Maxilla Orbital wall fractures were classified as follows: orbital floor, medial wall, lateral wall, or orbital roof fractures. The fracture subtype classifications used were LeFort 1, LeFort 2, LeFort 3, NOE, and ZMC, in addition to the different subtypes of orbital and mandibular fractures. Continuous variables were summarized with the use of descriptive statistics, such as range, mean, and median values. Categoric variables were expressed as frequencies and percentages. Data were analyzed using spreadsheet software (Excel 2010, Microsoft) and statistical software (SPSS, version 22, SPSS-IBM). Results During the 1-year study, approximately 115,000 ED visits resulting in more than 9000 trauma activations occurred. A total of 3326 facial CT examinations were performed, and 156 patients (4.7%) underwent facial surgical intervention. Nineteen patients had examinations performed at an outside institution, but no internal interpretation of those examinations was available; three patients did not have mention of a surgery on file; and one patient did not have a final radiology report. Twenty-three cases were therefore excluded from the present study. A total of 133 cases met the study criteria (Fig. 2). Clinical Characteristics The mean age of the patients was 34.3 years (range, years). A total of 115 of the patients (86.5%) were male patients. The mean injury severity score for the cohort was 10.2 (range, 1 75). The mean length of hospital stay was 8.0 days (range, 1 77 days). The mechanisms of injury are presented in Figure 3. Nasal Complex Orbital Zygomatic Pterygoid Epidemiologic Findings According to the Full Radiology Report The most frequently fractured facial bone that required surgical intervention was the mandible (100/133 cases [75.2%]). The maxilla was fractured in 53 patients (39.8%). Orbital fractures also occurred with the same frequency (53/133 [39.8%]). Nasal complex fractures were seen in 48 patients (36.1%), followed by zygomatic (33 patients [24.8%]), pterygoid (27 patients [20.3%]), ethmoid (24 patients [18.0%]), sphenoid (13 patients [9.8%]), and frontal bone (11 patients [8.2%]) fractures (Table 1). Classification of s in Radiology and Surgery Reports When radiology and surgery reports were directly compared, the most frequently reported descriptors of fracture were mandibular angle (25/133 [18.8%]), orbital floor (25/133 [18.8%]), mandibular parasymphysis (22/133 [16.5%]), mandibular body (21/133 [15.8%]), and ZMC (19/133 [14.3%]) fractures (Table 2). Classification Concordance and Discordance For 38 reports (28.6%), the classification on the surgery report and the radiology report matched exactly. In 35 comparisons (26.3%), the same classifications were reported, with additional fractures identified and described on the radiology report. For example, in multiple cases, the radiologist and the surgeon both reported mandibular classifications, but the radiologist identified and classified orbital bone fractures. In two cases, no classification was specified in either report. Therefore, there were 73 patients (54.9%) for Ethmoid Sphenoid Frontal Bone Other Facial Bone Total no. (%) of fractures 100 (75.2) 53 (39.8) 48 (36.0) 53 (39.8) 33 (24.8) 27 (20.3) 24 (18) 13 (9.8) 11 (8.2) 14 (10.5) Patient sex Male Female Injury mechanism Assaulted or struck Traffic Fall Gunshot wound Pedestrian Note Except where otherwise indicated, data are number of fractures. whom classification schemes both were used and matched well between the radiology and surgery reports (Fig. 4). Classifications differed for 58 cases (43.6%). For seven cases, discordance occurred because classification was absent in the surgery report. Among the 51 reports that included classifications but differed, mandibular and orbital subtypes were discordant in 35 (26.3%). An example of discordance was 115,000 Emergency department visits 9000 Trauma activations 3326 Facial CT imaging 156 Patients with facial surgery during admission to the hospital 23 Patients excluded 133 Patients included for chart review Fig. 2 Flow diagram of selection of patients for inclusion in study AJR:207, November 2016

4 Assessing Language in Radiology and Surgery Reports of Facial Trauma TABLE 2: Patterns and Distribution for 133 Cases of Facial Caused by Trauma Classification No. (%) of s LeFort I 3 (2.3) LeFort II 5 (3.8) LeFort III 4 (3.0) Naso-orbital-ethmoidal 6 (4.5) Zygomaticomaxillary complex 19 (14.3) Orbital wall classifications Orbital floor 25 (18.8) Medial orbital wall 2 (1.5) Lateral orbital wall 1 (0.8) Orbital roof 1 (0.8) Mandibular classifications Symphysis 5 (3.8) Parasymphysis 22 (16.5) Mandibular body 21 (15.8) Mandibular ramus 5 (3.8) Mandibular angle 25 (18.8) Condylar or subcondylar 13 (9.8) Coronoid 1 (0.8) Note Data include classifications that could be reconstructed from the radiology report. Numbers will not add up to 100% as some cases involved more than one time of fracture. a case for which the radiologist reported fractures of the mandibular ramus, angle, and coronoid process but for which the surgeon reported operating on a mandibular condyle fracture. For 16 of the 51 reports, the surgeon specified a classification in the surgery report, but the radiologist failed to classify the fracture. In those cases, reconstruction of the report was possible on the basis of the impression section of nine reports, but review of the full radiology report was required in seven cases. In three reports, the radiologist described a LeFort fracture, but the surgeon reported a ZMC fracture. In one case, the surgeon classified the fracture (a ZMC fracture) without mentioning all of the corresponding fractures mentioned in the full radiology report (Table 3). A classification was not specified in the impression section of 31 radiology reports (23.3%). Among 28 of these 31 reports (i.e., 21.1% of all 133 cases), the radiologist expected the surgeon to read the full report. The language used in these impressions included the following phrases: fractures as described above, refer to report above, or other fractures as detailed above. Three of 31 impressions reported individual bone fractures that were not included in the classification system (Fig. 5). Discussion CT is currently the reference standard for characterizing surgical maxillofacial injuries [4]. During acute trauma assessment, the radiologist is usually the primary specialist interpreting these injuries. Accurate interpretation and, potentially just as important, clear communication of the findings facilitate appropriate care of these patients [7, 8]. Some practices are incorporating the use of new technology in radiology, such as advanced 3D image postprocessing with mirror modeling and virtual surgical repair [9]. The advocacy of a multidisciplinary effort lends support to the idea that clear communication in radiology reports adds value and clearly directs care. However, data showing improved outcomes with the implementation of standardized reporting are lacking [10]. Radiology has been advocating for the use of structured reporting for some time and lauds the value of such efforts for the improvement in quality and consistency of patient care [11]. The present study shows that the reporting of facial fractures at our institution can be quite heterogeneous. Implementation of standard nomenclature, especially one developed in concert with all stakeholders, could improve patient care. In our experience, radiologists expected the surgeon to read the full radiology report in 21.1% of cases (28/133), instead of including the fracture classifications in the impression section of the report. With time pressures and work constraints, the surgeon may view the impression section only in addition to reviewing the images themselves. In the future, reporting could be improved by including fracture classifications in the impression section. In addition, in 26.3% of cases (35/133), classification differed in the description of mandibular or orbital fractures. The present study found both true inconsistencies and variation in the subjective descriptors evaluated in our review. For example, the radiologist identified medial wall and roof fractures, but the surgeon described operating on an orbital floor fracture. Alternatively, the surgeon described operating on a parasymphyseal mandibular fracture, whereas a mandibular body fracture was described in the radiology report. Similarly, there were times that the radiologist identified a mandibular body fracture but the surgeon reported a mandibular angle fracture. Given the differing anatomic location of the fractures, the approach used by the surgeon (i.e., intraoral versus submental) could differ and may affect the need for multiple incisions [12]. Other discrepancies include the radiologist classifying a LeFort fracture but the surgeon reporting a ZMC fracture. Similarly, the radiologist may simply classify orbital floor, medial wall, and mandibular body fractures, but the surgeon may classify LeFort or NOE complex fractures. When one refers back to the radiology report, there is a need to view the whole report to rebuild the LeFort or NOE classification. classifications and more streamlined organization within the impression section of the radiology report could help make the communication between specialties more cohesive. Moreover, the number of terms that can be used to describe anatomic fracture locations can be confusing. Descriptors such as paramedian, parasymphysis, parasymphyseal, and right versus left of midline could all be used to describe the same mandibular fracture. Sometimes, a fracture was described in relation to a tooth number by one specialty, whereas the corresponding surgical or radiology report included a mandibular anatomic descriptor. For orbital fractures, the language TABLE 3: Discordance in Classification in 51 Reports of Facial Caused by Trauma Category of Discordance No. of Reports Mandible or orbital subclassification difference 35 Surgeon classification with need to view full report to reconstruct and classify radiologically 7 Surgeon classification with reconstruction possible from impression 9 LeFort and zygomaticomaxillary fracture classification difference 3 Surgeon classification without classifying fracture mentioned in radiologic report 1 Note Three patients had discordance noted in multiple categories. AJR:207, November

5 Ludi et al. 15% 16% 8% 4% 58% of orbital blowout fracture versus orbital floor could be confusing. For the sake of our study, these minor language discrepancies were counted as concordant; however, consistency in language may smooth the transfer of fracture information from radiologist to surgeon. We would like to highlight two instances of radiologic-surgical discordance. First, for one patient, the radiologist reported fractures of the mandibular ramus, angle, and coronoid process, but the surgeon reported operating on a mandibular condyle fracture. Second, for three cases, the radiologist described a LeFort fracture, but the surgeon reported a ZMC fracture. It is unclear to what extent variations in reporting have on the outcomes and efficiency of patient care. Complex midfacial fracture patterns do not always fit cleanly into one pattern of injury. It is possible to have a ZMC fracture and components of a LeFort II fracture and to describe the pattern as a complex LeFort III fracture. If the surgical reporting was correct, these discrepancies could have resulted in improper presurgical planning, suboptimal skin incision, and even longer surgical time because of unexpected intraoperative findings. If the radiology reporting was correct, these cases could have resulted in inadequate treatment and poor outcomes. Although the clinical effect of these discrepancies was outside the scope of this study, we believe that it would be a fruitful area for further research. Similarly, the quality of the interpretation of the radiology report can be improved. Strategies at the systems level include checklists for facial trauma and structured reports and consistency. Individual performance metrics can be applied, including peer review, standardized training with procedural competency courses, integrated surgical conferences for feedback, and judicial management of deficient performances [13]. Assault (n = 77) Traffic accident (n = 21) Fall (n = 20) Gunshot wound (n = 10) Pedestrian (n = 5) Fig. 3 Pie chart of mechanism of injury for 133 cases of facial fracture caused by trauma. Traffic accident category includes motor vehicle collisions and motorcycle, all-terrain vehicle, and bicycle accidents. Quality improvement efforts can serve to enhance the dialogue that takes place between the radiology service and the clinical service, because the surgical services often review imaging independently of the radiologist. classification is important for standardization and universality within and across specialties. These classifications reliably help clinicians in many fields communicate findings, compare results, make treatment decisions, and effectively plan surgical approaches [14 18]. They convey much information in a succinct, shorthand fashion, which can be a large asset in a busy highvolume trauma center [14, 19]. Specifically, with regard to classification of maxillofacial fractures, benefits include identification of midface and upper face fracture patterns that can be associated with mortality predictions and recognition of occult intracranial brain injury [20, 21]. Consistent and accurate use of classification systems could lead to earlier identification and better management of high-risk facial fracture patterns [20]. A greater effort should be made to develop consensus and use a universal language across specialties managing the same patients care. Most of the patients in the present study were male (86.5%), which is consistent with the well-known preponderance of male patients among those with trauma ( % of cases) [22 28]. The mean age of patients in our cohort was 34.3 years, which is similar to prior studies in which the mean age ranged from 24.6 to 51.0 years [24, 29 32]. In the present study, the most frequent injury types were those caused by assault (57.9%), a traffic accident (15.8%), or a fall (15%). Similarly, studies by Lee [33] and Bakardjiev and Pechalova [34] identified assault as the most common injury mechanism, occurring in 44% and 61% of the patients in their cohorts, respectively [33, 34]. Conversely, a study by Sohns et al. [30] from 2013 reported that the mechanism of injury category with the highest frequency was falls (46%), followed by traffic accidents (28%) and violence (15%). We theorize that our younger urban study population was potentially more prone to engaging in risk-taking behavior and violence, compared with the older population studied by Sohns et al., which had a mean age of 51 years. The fracture pattern is an important characteristic to consider in patients with trauma. In the present study, the most commonly fractured bone was the mandible (75.2%), followed by the maxilla and the orbit, which occurred with the same frequency (39.8%). Similar to our results, the results of a study by Lee [33] identified mandibular fractures as the most common fracture pattern, occurring at a rate of 45.5%. A study by Vande- Griend et al. [2] reported that the three most common facial fractures requiring surgical intervention were mandible (41.6%), malar bone (15.2%), and maxilla (6.4%) fractures. In contrast to our study, a study by Allareddy et al. [1] found that among all patients presenting to the ED, closed nasal bone fractures occurred most frequently (55.8%), followed by malar and maxillary closed fractures (13.4%). In their study, VandeGriend and colleagues reported that the most frequent fractures encountered overall, irrespective of their need for operative intervention, involved the nasal bone (30.1%), the mandible (22.7%), and the orbital floor (15.7%). Differences in reported fracture rates appear to be related to inclusion criteria, because the studies by both VandeGriend and colleagues and Allareddy and colleagues included all patients entering the ED, contrary to the present 2 Cases with no classification given in either report 38 Cases with an exact match between surgical and radiology report 75 Concordant cases 35 Cases with additional fractures noted on radiology report Fig. 4 Classification concordance in radiology and surgical reports AJR:207, November 2016

6 Assessing Language in Radiology and Surgery Reports of Facial Trauma 102 Cases with classification noted in the impression 133 Cases with full radiology reports reviewed 28 Cases with expectation for surgeon to read full report study, which included only patients requiring inpatient surgery. Limitations The present study is limited by the fact that the cases evaluated were from a single level I trauma center. To begin with, the high prevalence of assault and mandibular fractures is likely representative of our specific urban setting. In addition, the study is retrospective in nature and a small number of patients were included in the final dataset. The study population was limited to patients undergoing surgery after admission to the hospital for trauma. We did not include patients who were referred for delayed surgery (e.g., patients who went home but then returned to undergo outpatient surgery). The fractures and injury mechanisms identified may be more severe than those communicated in other studies that include patients treated and released or patients who undergo outpatient surgery. The present study also did not include patients with minor injuries who did not seek medical attention or, on the opposite extreme, patients who died before undergoing surgery. With regard to classification discrepancies, it is possible that the surgeon may have noted additional fractures during surgery but did not repair them and thus did not include them in their surgery report. This possibility was generally accounted for in the data analysis but may have affected the orbital and mandible classification discrepancies. 31 Cases with no classification noted in the impression 3 Cases with no classification, only individual bone fractures Fig. 5 Flow diagram of classifications used in radiology reports for 133 cases of facial fracture caused by trauma. Conclusion Facial trauma comprises a significant proportion of ED visits. Limited physical examination, patient cooperation, polytrauma, and significant swelling over the face can conceal major findings and can present a challenge to the trauma surgeon. Accurate interpretation and communication of the findings noted on the CT scan are imperative to successful patient care and treatment. Using a common language and standardizing the nomenclature would improve communication between radiology and surgical services to allow accurate diagnosis and might help to expedite the management of cases requiring surgery. References 1. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011; 69: VandeGriend ZP, Hashemi A, Shkoukani M. Changing trends in adult facial trauma epidemiology. J Craniofac Surg 2015; 26: Lee LN, Bhattacharyya N. 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Facial fractures of the upper craniofacial skeleton predict mortality and occult intracranial injury after blunt trauma: an analysis. J Craniofac Surg 2013; 24: Audigé L, Cornelius CP, DiIeva A, Prein J, Craniomaxillofacial Classification Group 6. The first AO Classification System for fractures of the craniomaxillofacial skeleton: rationale, methodological background, developmental process, and objectives. Craniomaxillofac Trauma Reconstr 2014; 7:S006 S Kraft A, Abermann E, Stigler R, et al. Craniomaxillofacial trauma: synopsis of 14,654 cases with 35,129 injuries in 15 years. Craniomaxillofac Trauma Reconstr 2012; 5: Mourouzis C, Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg 2005; 34: Kühne CA, Krueger C, Homann M, Mohr C, AJR:207, November

7 Ludi et al. Ruchholtz S. Epidemiology and management in emergency room patients with maxillofacial fractures [in German]. Mund Kiefer Gesichtschir 2007; 11: Erol B, Tanrikulu R, Görgün B. Maxillofacial fractures: analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 2004; 32: Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003; 61: Mackenzie EJ, Rivara FP, Jurkovich GJ, et al. The National Study on Costs and Outcomes of Trauma. J Trauma 2007; 63:S54 S Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: a review. Epilepsia 2003; 44: Ansari MH. Maxillofacial fractures in Hamedan province, Iran: a retrospective study ( ). J Craniomaxillofac Surg 2004; 32: Sohns JM, Staab W, Sohns C, et al. Current perspective of multidetector computed tomography (MDCT) in patients after midface and craniofacial trauma. Clin Imaging 2013; 37: Sethi RK, Kozin ED, Fagenholz PJ, Lee DJ, Shrime MG, Gray ST. Epidemiological survey of head and neck injuries and trauma in the United States. Otolaryngol Head Neck Surg 2014; 151: Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102: Lee KH. Interpersonal violence and facial fractures. J Oral Maxillofac Surg 2009; 67: Bakardjiev A, Pechalova P. Maxillofacial fractures in Southern Bulgaria: a retrospective study of 1706 cases. J Craniomaxillofac Surg 2007; 35: FOR YOUR INFORMATION This article is available for CME and Self-Assessment (SA-CME) credit that satisfies Part II requirements for maintenance of certification (MOC). To access the examination for this article, follow the prompts associated with the online version of the article AJR:207, November 2016

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