Trends in facial injury: increasing violence more than compensates for decreasing road trauma

British Medical Journal, Jan 31, 1998 by Patrick Magennis, Jonathan Shepherd, Iain Hutchison, Andrew Brown

Next week 200 of Britain's oral and maxillofacial surgeons will visit secondary schools to warn pupils about the risks of facial injury from drinking and fighting and, with the help of patients, to show them the consequences of such injuries. What are those risks, and how may they be prevented?

In few places is the effectiveness of legislation on seat belts and drinking and driving more obvious than in oral and maxillofacial trauma. From 1977 to 1987 the proportion of patients with maxillofacial fractures sustained in road accidents fell by 34%,[1] and rates of facial bone fracture sustained in road accidents fell from 6.2 to 4.1 per 100 000 population. Violent crime, however, more than compensated for this decrease, and, although the incidence of serious injury such as complex pan-facial fractures decreased, the overall incidence of facial injury rose from 20 to 24 per 100 000 population.[1] The proportion of injuries sustained in assaults increased from 40% in 1977 to 50% in 1987. Since then these trends have continued: the British Crime Survey has shown a 77% increase in violent crime of all types, while the rate of death and severe injury in road accidents has fallen by 38%.[2 3]

In one week last September the British Association of Oral and Maxillofacial Surgeons carried out a survey of facial soft tissue injuries and fractures in Britain. This first prospective national accident and emergency based survey identified 6114 patients with facial injuries from an estimated catchment population of 40 million.[4] From these data we estimate that about 500 000 people suffer facial injuries annually, 125 000 of them in assaults.

Many of these assaults affect teenagers and young adults and are associated with alcohol consumption by either the victim or the assailant (61% of cases in the survey). Among 15-25 year olds almost half the facial injuries were sustained in assaults, usually in bars or nearby streets, and 40% of these resulted in injury that necessitated specialist maxillofacial treatment.

About 30% of adults with a jaw fracture or a facial laceration more than 3 cm long develop post-traumatic stress disorder,[5] and this is reinforced by their facial scars, which serve as a constant reminder of the assault.[6] The psychological legacy of facial injury can persist long after the injury has occurred, and the low self esteem resulting from patients' perception of their deformity may limit their ability to achieve their full economic and emotional potential.[7] In young people this psychological burden places lifelong demands on them, their families, and the state.

The gloomy prospect for Britain of ever increasing numbers of alcohol related assaults may, however, not be inevitable. Other countries with similar alcohol consumption figures have not experienced such an epidemic of assaults in young people[8] Brief interventions to tackle alcohol misuse in the aftermath of injury are both effective and valued by patients. Furthermore, injury caused by drinking glasses could be reduced substantially by the universal use of toughened glasses in bars and clubs.[9]

Although the survey by the British Association of Oral and Maxillofacial Surgeons showed that four times more men than women sustained facial injuries in assaults, in the home the reverse was true. Nearly half of all facial injuries sustained in assaults on women occurred in the home, presumably by members of the immediate family, and almost half of these were associated with alcohol consumption by the victim or assailant.[4] This fits in with the result of a north London study which found that 2 in 3 men would use violence in "conflict" situations with their partners.[10]

Twenty per cent of schoolchildren identified in the survey were injured in assaults.[4] Although most schools have anti-bullying policies, the need for continued vigilance and re-evaluation of these policies is clear. Many of the injuries in children under 5 years occurred in falls at home, and although most were minor, maintenance of safety standards in homes remains important. In keeping with the national trends,[3] road traffic accidents accounted for only 5% of the facial injuries identified in the survey, affecting mainly 15-25 year olds. Importantly, 15% of road accident victims had consumed alcohol within four hours of their injury.[4]

Assault and alcohol consumption are therefore the two major factors responsible for serious facial injuries in young adults, although the effect of alcohol in increasing vulnerability to injury may be more important than its effect on aggression.[11] These injuries are preventable, though it is not dear how legislation could reduce assault rates. The most beneficial strategy may be to target 13-14 year olds and educate them about the dangers of excessive alcohol consumption and its association with assaults and road accidents. Which is why 200 oral and maxillofacial surgeons will be visiting schools next week carrying the message, "Save your face--drink sensibly."