CRANIOMAXILLOFACIAL TRAUMA

Facial Fractures in Patients With

Firearm Injuries: Profile and Outcomes
Shelly Abramowicz, DMD, MPH,* Veerasathpurush Allareddy, BDS, PhD,y
Sankeerth Rampa, MBA, MPH,z Min Kyeong Lee, DMD, DMSc,x
Romesh P. Nalliah, BDS, MHCM,k and Veerajalandhar Allareddy, MD, MBA{
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 intra-
cranial 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), unin-
sured 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 high-
lights the burden and impact of facial fractures in patients with FAIs in the United States.
Ó 2017 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:2170-2176, 2017

Non-accidental trauma is a common cause of injury to Approximately 14% of FAIs associated with assaults
the maxillofacial skeleton.1-5 Specifically, firearm result in head and neck injuries.8 FAIs are one of the
injuries (FAIs) have been identified as a public health leading causes of death among persons aged 15 to
issue6 with ongoing plans for firearm law reform.7 34 years.9 Data regarding the impact of maxillofacial

*Assistant Professor, Division of Oral and Maxillofacial Surgery,
Department of Surgery, Emory University School of Medicine,
Atlanta, GA; and Associate Chief, Section of Dentistry/Oral and
Maxillofacial Surgery, Children’s Healthcare of Atlanta, Atlanta, GA.
yProfessor, Department of Orthodontics, College of Dentistry and
Dental Clinics, University of Iowa, Iowa City, IA.
zGraduate Student, Health Services Research & Administration
Department, College of Public Health, University of Nebraska
Medical Center, Omaha, NE.
xAssistant Professor, Department of Dentistry, Children’s Hospital
of Los Angeles, Los Angeles, CA.
kAssociate Professor, College of Dentistry, University of Michigan
at Ann Arbor, Ann Arbor, MI.
{Associate Professor, Division of Critical Care, Stead Family
Children’s Hospital, University of Iowa, Iowa City, IA.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Abramowicz:
Division of Oral and Maxillofacial Surgery, Department of Surgery,
Emory University, 1365 Clifton Rd NE, Bldg B, Ste 2300, Atlanta,
GA 30306; e-mail: sabram5@emory.edu
Received May 6 2017
Accepted May 30 2017
Ó 2017 American Association of Oral and Maxillofacial Surgeons
0278-2391/17/30612-2
http://dx.doi.org/10.1016/j.joms.2017.05.035

2170
ABRAMOWICZ ET AL
injuries resulting from FAIs are scarce. This creates a
challenge to determining appropriate resource
allocation for focused specialized care and preventive
programs.
The objective of this study was to examine charac-
teristics and outcomes of patients presenting to emer-
gency departments (EDs) with facial fractures
attributed to FAIs.
Materials and Methods
The Nationwide Emergency Department Sample
(NEDS) for the years 2008 to 2013 was used for this
study. The NEDS is the largest all-payer nationally
representative database of all hospital-based ED visits
in the United States.10 The NEDS datasets are part of
the family of databases and software tools developed
for the Healthcare Cost and Utilization Project
(HCUP). The NEDS datasets were developed through
a federal-state-industry partnership sponsored by the
Agency for Healthcare Research and Quality (AHRQ).
The Nationwide Inpatient Sample datasets are released
annually by HCUP-AHRQ. This study was deemed insti-
tutional review board exempt by the Office of Human
Subjects Protection of the University of Iowa (institu-
tional review board protocol No. 201607754) because
publicly available datasets were used. Before the data-
sets were obtained from HCUP-AHRQ, a data user
agreement was completed.
All patients who visited hospital-based EDs with
facial fractures and an external cause of injury attrib-
uted to firearms were selected for analysis. Interna-
tional Classification of Diseases, Ninth Revision,
Clinical Modification diagnosis codes were used to
identify this cohort of patients.9 The International
Classification of Diseases, Ninth Revision, Clinical
Modification codes used for facial fractures included
the following: 802.0 (fracture of nasal bones—closed),
802.1 (fracture of nasal bones—open), 802.2 (fracture
of mandible—closed), 802.3 (fracture of mandible—
open), 802.4 (fracture of malar and maxillary
bones—closed), 802.5 (fracture of malar and maxillary
bones—open), 802.6 (fracture of orbital floor—
closed), 802.7 (fracture of orbital floor—open),
802.8 (fracture of other facial bones—closed), and
802.9 (fracture of other facial bones—open). The
external cause–of–injury codes used for identifying
FAIs included E922 (accident caused by firearm and
air gun missile), E965 (assault by firearms and explo-
sives), E970 (injury due to legal intervention by fire-
arms), E985 (injury by firearms, air guns, and
explosives, undetermined whether accidentally or
purposely inflicted), E955 (suicide and self-inflicted
injury by firearms, air guns, and explosives), and
E928.7 (other environmental and accidental causes
by firearms).
2171
The demographic characteristics of the study cohort
were examined and summarized by descriptive statis-
tics. Hospital ED charges and hospitalization charges
(in patients who were admitted as inpatients after
the ED visit) were adjusted to year 2013 dollar value
by use of the Bureau of Labor Statistics inflation calcu-
lator for hospital expenditures.11 The comorbidity
burden severity in the study cohort was computed
by the Charlson comorbidity severity index.12 The
outcome variable (dependent variable) was death in
the ED. A multivariate logistic regression model was
used to examine the association between patient-
and hospital-related variables (age, gender, insurance
status, comorbidity severity index, annual household
income level based on ZIP code of residence, occur-
rence of concomitant intracranial injury, type of FAI,
hospital region, teaching status of hospital, and year
of ED visit). The Taylor linearization method was
used to compute the standard errors in the regression
model. For each level of independent variable, the
odds of death in the ED and associated 95% confidence
intervals (CIs) were computed. The effect of clus-
tering of outcomes within hospitals was adjusted in
the regression model. Statistical tests were 2 sided,
and P < .05 was deemed statistically significant. Statis-
tical analyses were conducted by use of SAS-Callable
SUDAAN software (version 11.0.1; Research Triangle
Institute, Research Triangle Park, NC).
Results
During the study period, a total of 15,469 patients
visited hospital-based EDs with facial fractures attrib-
uted to FAIs. The demographic characteristics of the
study cohort are presented in Table 1. The mean age
was 34 years. Persons aged 22 to 30 years comprised
30% of patients. Male patients comprised 87.4% of pa-
tients. Close to 36% of ED visits occurred during week-
ends. The vast majority of patients (88.3%) did not
have a comorbid condition. The primary payers
included Medicaid (24.4%) and private insurance plans
(21.5%). Of the patients, 34.1% were uninsured. As-
sault by firearms or explosives (56.1%) was the most
common cause of FAIs, followed by self-inflicted in-
juries (22.1%). The lowest household income quartile
accounted for 45.1% of all ED visits, whereas the high-
est income quartile accounted for only 9.6% of all
ED visits.
Types of facial fractures are summarized in Table 2.
Common facial fractures included open mandibular
fractures (33.4%), open maxillary and/or malar bone
fractures (21.4%), open fractures of other facial bones
(19.6%), closed fractures of other facial bones (13.8%),
closed nasal bone fractures (13.5%), and closed
mandibular fractures (11.6%). Concomitant bodily in-
juries are presented in Table 3. The most common
2172 FACIAL FRACTURES AND FIREARM INJURIES

Table 1. CHARACTERISTICS OF PATIENTS WITH FACIAL Table 1. Cont’d

FRACTURES AFTER FIREARM INJURIES
Characteristic Data (Total N = 15,469)
Characteristic Data (Total N = 15,469)
Quartile 3 17.1%
Age
Quartile 4 (highest) 9.6%
#9 yr 0.7%
10-12 yr 0.4% * Income level cutoffs vary by year. Overall, households in
13-15 yr 2.3% quartile 1 have median household income levels that are
16-17 yr 3.8% within the 0th to 25th percentile of the entire nation. House-
18-21 yr 17.3% holds in quartile 2 have median income levels that are within
22-30 yr 29.9% the 26th to 50th percentile. Households in quartile 3 have
median income levels that are within the 51st to 75th
31-40 yr 16.8%
percentile. Households in quartile 4 have median income
41-50 yr 13.1% levels that are within the 76th to 100th percentile.
51-60 yr 8.6%
>60 years 7.1% Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral
Maxillofac Surg 2017.
Gender
Male 87.4%
Female 12.6%
Day of admission
After the ED visit, 15.9% of patients were dis-
Weekday 63.9%
Weekend 36.1%
charged routinely and 7.4% were transferred to
Comorbidity burden (based on Charlson severity index) another short-term care hospital (Table 4). Of the pa-
0 88.3% tients, 197 (1.4%) died in the ED. A total of 11,437 pa-
1 8.2% tients (73.9%) were admitted as inpatients to the
2 2.4% same hospital. After hospitalization, 58.6% were dis-
$3 1.1% charged routinely, 16.3% were transferred to a long-
Insurance status term care facility, 5.8% were discharged to a home
Medicare 7.5% health care facility, and 5.6% were transferred to
Medicaid 24.4% another short-term care hospital (Table 5). There
Private 21.5% were 1,434 patients (12.6%) who died after inpatient
Uninsured 34.1%
admission. The mean ED charge was $6,403 (inter-
Other insurance 12.5%
Type of firearm injury
quartile range, $2,040 to $7,957), and the total ED
Accident caused by firearm 14.3% charge across the entire United States was $76.48
and air gun missile million (Table 6). Among patients who were admitted
Assault by firearms and 56.1% as inpatients, the mean hospitalization charge was
explosives $167,203 (interquartile range, $45,421 to $210,732)
Injury due to legal 2.3% and the total hospitalization charge across the entire
intervention United States was $1.9 billion. The mean length of
by firearms stay in the hospital was 10.7 days (interquartile range,
Injury by firearms, air guns, 4.7% 1.9 to 13.2 days), and the total number of hospitaliza-
and explosives, tion days across the entire United States was
undetermined whether
121,956 days.
accidentally or purposely
inflicted
A summary of estimates from the multivariate logis-
Suicide and self-inflicted 22.1% tic regression model examining the odds of death in
injury by firearms, air guns, the ED is presented in Table 7. Patients with intracra-
and explosives nial injuries were associated with higher odds of
Other environmental and 0.9% death in the ED (odds ratio [OR], 21.21; 95% CI,
accidental causes by 7.16 to 62.85; P < .01) when compared with those
firearms without any intracranial injuries. Uninsured patients
Annual household income quartile* were associated with higher odds of ED death (OR,
Quartile 1 (lowest) 45.1% 4.24; 95% CI, 1.44 to 12.51; P < .01) when compared
Quartile 2 28.2% with patients covered by private insurance plans. Pa-
tients residing in areas with high household incomes
concomitant bodily injury was an open wound of the were associated with higher odds of ED death (OR,
head, neck, and/or trunk, which occurred in 58.8% of 5.60; 95% CI, 2.51 to 12.46; P < .01) when compared
patients. Intracranial injuries occurred in 27.1% with those in the lower household income quar-
of patients. tile groups.
ABRAMOWICZ ET AL 2173

Table 2. TYPES OF FACIAL FRACTURES Table 3. CONCOMITANT BODILY INJURIES

Type of Facial Fracture Data (Total N = 15,469) Bodily Injury Data (Total N = 15,469)

Nasal bones Fracture of neck of femur 0.4%

Closed 13.5% Spinal cord injury 1.7%
Open 9.2% Fracture of upper limb 7.7%
Mandible, closed Fracture of lower limb 2.5%
Unspecified site 4.3% Sprain and strain 0.4%
Condylar process 0.8% Intracranial injury 27.1%
Subcondylar 0.4% Crushing injury or internal 16.1%
Coronoid process 0.3% injury
Ramus 1.5% Open wound of head, neck, 58.8%
Angle of jaw 1.6% and/or trunk
Symphysis of body 1.1% Open wound of extremities 12.6%
Alveolar border of body 0.5%
Body, other and unspecified 1.7% Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral
Maxillofac Surg 2017.
Multiple sites 0.7%
Mandible, open
Unspecified site 7.1%
There are rising rates of homicide and suicide and
Condylar process 1.8%
Subcondylar 1.2% declining rates of unintentional FAIs.15,16 The
Coronoid process 0.7% overall suicide rate in the United States has
Ramus 5.5% increased by more than 11% since the 1990s.17 This
Angle of jaw 5.8% is similar to our findings, in which assault with fire-
Symphysis of body 4.4% arms was the most common cause of injury, followed
Alveolar border of body 1.9% by self-inflicted injuries.
Body, other and unspecified 8.3% In all cases of FAI, patients require immediate
Multiple sites 4.8% medical attention.15 Once these patients’ condition
Malar and maxillary bones is stabilized, oral and maxillofacial surgeons are likely
Closed 11.1%
to be consulted regarding facial injuries.8 As a part of
Open 21.4%
the initial evaluation, oral and maxillofacial surgeons
Orbital floor (blowout)
Closed 7.5% should determine the etiology of the FAI—intentional
Open 9.7% or accidental—because this affects immediate and
Other facial bones future surgical interventions. Additional health care
Closed 13.8% providers may need to be involved. For example, if an
Open 19.6% FAI is a result of intentional self-harm, evaluation of psy-
Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral
chiatric status18 and support networks (family,
Maxillofac Surg 2017.

Table 4. DISPOSITION STATUS AFTER ED VISIT

Discussion
Data (Total
This study reviewed characteristics and outcomes of Disposition After ED Visit N = 15,469)
patients who visited hospital-based EDs with facial
fractures resulting from FAIs with the use of a Routine discharge 15.9%
nationally representative hospital-based ED database. Transferred to another short-term care 7.4%
The study focused on the following: 1) demographic hospital
characteristics, 2) types of facial fractures, 3) disposi- Transferred to other facilities, including 0.6%
tion status after ED visit or subsequent hospitalization, skilled nursing facility, intermediate
4) charges (ED and hospitalization), and 5) pa- care facility, or another type of facility
tient outcomes. Discharged against medical advice 0.2%
Admitted as inpatient to same hospital 73.9%
Our study showed that the most common patients
Died in ED 1.3%
are male patients with an average age of 34 years Destination unknown 0.6%
without any medical comorbidities in the lowest
household income quartile. Most patients were in ED, emergency department.
the lowest household income quartile. These find- Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral
ings are consistent with previous reports.13,14 Maxillofac Surg 2017.
2174
Table 5. DISPOSITION STATUS AFTER INPATIENT
ADMISSION TO SAME HOSPITAL
Total
Disposition After ED Visit N = 11,437
Routine discharge 58.6%
Transferred to another short-term care 5.6%
hospital
Transferred to other facilities, including 16.3%
skilled nursing facility, intermediate
care facility, or another type of facility
Home health care 5.8%
Discharged against medical advice 1%
Died in hospital after inpatient admission 12.6%
ED, emergency department.
Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral
Maxillofac Surg 2017.
neighborhood, and so on) is necessary.19 In our study,
the most common injuries were open mandibular frac-
tures and maxillary and/or malar bone fractures. This
is important to know because, in most cases, despite
aggressive initial resuscitation and treatment, patients
require extensive staged rehabilitation and reconstruc-
tion. These secondary operations can take years to
complete and present a considerable financial burden
to achieve a functional result.
In our study, most patients (73.9%) were admitted to
the hospital for approximately 10.7 days. About half
(64.4%) were discharged home after hospitalization,
although occasionally with home health care. There
was a significant number of patients who died in the
hospital. Previous studies have provided mixed re-
ports regarding hospitalization. One report found an
increase in the in-hospital mortality rate.20 In contrast,
another study reported that the adjusted average
in-hospital mortality rate for patients admitted to hos-
pitals after FAIs decreased by 40% over the past
decade.21 This may be the result of better trauma man-
agement, improvement in triage in EDs, and expe-
diting of the immediate surgical management
of patients.
The costs of initial hospitalization for FAIs averaged
approximately $730 million per year.13 In our study,
Table 6. HOSPITAL CHARGES AND LENGTH OF STAY
Outcome Mean SE 25th Percentile Median 75th Percentile Total Across Entire United States
Hospital ED charges, $ 6,403 481 2,040
Hospitalization charges, $ 167,203 7,994 45,421
Length of stay in hospital, days 10.7 0.4 1.9
ED, emergency department.
Abramowicz et al. Facial Fractures and Firearm Injuries. J Oral Maxillofac Surg 2017.
FACIAL FRACTURES AND FIREARM INJURIES
the mean hospitalization charge was $167,203 per pa-
tient per hospitalization. Most patients (34.1%) were
uninsured, and the most common payer was Medicaid
(24.4%). This finding is important to note because it
shows that the government was responsible for most
of the costs associated with FAIs. This is consistent
with previous reports showing that the government
was responsible for 41% of the total costs of initial hos-
pitalization for FAIs. The bulk of government costs was
from Medicaid, which accounted for one third of the
total financial burden. Medicaid patients also had the
highest per-incident costs.13 These results indicate
that FAIs place a burden on governmental payers and
uninsured patients. These costs are likely to be ab-
sorbed by hospitals that experience high volumes of
FAIs such as urban hospitals.13 This information is
important when evaluating resources and providing
recommendations for public policy.
Regarding patient outcomes, this study showed that
patients with intracranial injuries resulting from FAIs
were more likely to die in the ED compared with those
without any intracranial injuries. This finding is similar
to findings of previous reports.8,22 Uninsured patients
were associated with a higher likelihood of death in
the ED when compared with patients covered by
private insurance plans. Patients residing in areas
with high household incomes were associated with
higher odds of death in the ED when compared with
patients in the lower household income quartile
groups. This information is helpful to determine
allocation of financial resources and development of
prevention programs.
The major strength of our study stems from the
breadth and scope of the sample: The Nationwide
Inpatient Sample is the largest available all-payer na-
tionally representative ED discharge dataset in the
United States. The results of this study could be gener-
alizable and thus negate the effects of single-center ex-
periences to a large extent. Several epidemiologic risk
factors for FAIs are identified in this study, and these
may be amenable to modification by tailored preven-
tive programs. A comprehensive characterization of
different types of facial fractures associated with FAIs
was performed in this study. Understanding the scope
3,826 7,957 76,484,075
98,994 210,732 1,901,418,816
5.7 13.2 121,956
ABRAMOWICZ ET AL 2175

Table 7. PREDICTORS OF DEATH IN HOSPITAL ED

of facial injuries in this cohort may enable optimization
of care that is provided in the ED, as well as long-
Characteristic OR (95% CI) P Value term care.
There were limitations to this study. The retrospec-
Age tive nature of the study does not allow us to analyze
1-yr increase 1.01 (0.99-1.03) .32 cause and effect inferences. Furthermore, the lack of
Gender patient-level variables (physiological and biological)
Female 0.34 (0.09-1.23) .10 precludes us from performing a comprehensive risk
Male Reference adjustment for outcomes; to offset this limitation, we
Insurance status
assessed and adjusted for a variety of available concom-
Medicare 3.59 (0.69-18.61) .13
Medicaid 0.56 (0.10-3.26) .52
itant bodily injuries in our analysis. Although we as-
Uninsured 4.24 (1.44-12.51) .01 sessed the disposition status after an ED visit, as well
Other insurance 0.81 (0.19-3.43) .78 as the disposition status after an inpatient admission,
Private insurance Reference our data do not capture the outcomes of patients
Admission day who were discharged from the ED or from the hospi-
Weekend 1.10 (0.54-2.22) .79 tal. In this study, nearly 16% of patients were trans-
Weekday Reference ferred to long-term care facilities, which suggests
Charlson comorbidity severity index that their post-injury morbidity rate was high. This lim-
1 1.19 (0.35-4.05) .78 itation likely underestimates the true burden of FAI
2 0.48 (0.05-4.31) .51 and its associated injuries both in terms of morbidity
$3 — —
and mortality and in terms of resource utilization.
No comorbid Reference
conditions
Lack of patient identifiers in the dataset (to preserve
Household income quartile confidentiality) prevents us from assessing repeat
Quartile 4 5.60 (2.51-12.46) < .001 visits of patients.
Quartiles 1-3 Reference The results of this study highlight the burden and
Intracranial injury impact of facial fractures in patients with FAIs. FAIs
Yes 21.21 (7.16-62.85) < .001 continue to exert a considerable impact on morbidity,
No Reference mortality, and resource utilization in the United States.
Suicide and self-inflicted injury by firearms, air guns, and High-risk cohorts and significant injuries are identified.
explosives The findings from this study may benefit the multidis-
Yes 0.45 (0.17-1.16) .10 ciplinary collaborative teams that frequently care for
No Reference
these patients.
Assault by firearms and explosives
Yes 0.48 (0.18-1.25) .13
No Reference References
Hospital region
Northeast 2.33 (0.62-8.77) .21 1. Mericli AF, DeCesare GE, Zuckerbraun NS, et al: Pediatric cranio-
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