Epidemiologic Changes of Facial Bone Fracture before and after Coronavirus Disease 2019: A Level 1 Trauma Center in Korea

Abstract

Background The coronavirus disease 2019 (COVID-19) outbreak has had a major impact worldwide. Several countries have implemented restrictions on social interaction (“social distancing”). Several studies have reported that the epidemiology of trauma patients, such as those with facial bone fractures, has changed after COVID-19 pandemic. This study aimed to further explore these specific changes.

Methods This was a retrospective study of patients who presented to a single institution with facial bone fractures between January 1, 2016, and December 31, 2020. Baseline patient demographics, clinical information, type of fracture, etiology, and operative management were compared before and after COVID-19.

Results Of all cases, 3,409 occurred before COVID-19, and 602 occurred after COVID-19. Since the outbreak of COVID-19, the number of patients with facial fractures has not decreased significantly. A significant increase was noted in fractures that occurred outdoors (p < 0.001). However, a decrease was observed in operative management between the groups (p < 0.001). There was no significant difference in the proportion of assault, fall-down, industrial accident, or roll-down. In contrast, the proportion of traffic accidents and slip-down categories increased significantly (p < 0.05). Moreover, a significant decrease was found in the proportion of the sports category (p = 0.001)

Conclusions It was confirmed through this study that COVID-19 pandemic also affected epidemiology of facial fractures. Focusing on these changes, it is necessary to develop safety measures to reduce facial fractures.

Keywords

bone fracture - epidemiology - pandemic

Introduction

In March 2020, the World Health Organization officially declared the outbreak of coronavirus disease 2019 (COVID-19) as a pandemic.[1] As of November 2021, there have been more than 257.4 million cases of COVID-19 infection worldwide and 5.15 million deaths attributed to the virus.[2] In an effort to stop COVID-19 after obtaining “pandemic” classification in March 2020, countries around the world implemented “social distancing,” including home quarantine and curfews.[3] These public health measures reduced activity levels and exposure to sunlight, resulting in weakened bones and easier fractures.[4] Due to the direct influence of COVID-19, major changes in public behavior patterns have led to changes in regularly observed injury patterns (e.g., fear of going out and meeting people, change in shopping patterns).[5] [6] [7] [8] [9] Several trauma institutions have reported that the number of trauma patients, such as those with facial bone fractures, has decreased after COVID-19.[10] [11] Since COVID-19 pandemic, the cause of facial fractures has also changed. Although there are differences due to regional and cultural differences, etiology has also changed due to changes in falls, traffic accidents, and sports injuries.[12] [13] However, there have been few analyses on the trend or cause of this. This study aimed to confirm the epidemiological and etiological changes in facial bone fractures before and after the COVID-19 pandemic in patients who visited our hospital within the past 5 years.

Materials and Methods

This was a 5-year retrospective study of patients who presented to a single institution with facial bone fractures. Our hospital is a tertiary trauma center that covers a wide area in the eastern and central parts of Korea. All patients selected through medical record analysis had at least one radiologically proven fracture of a facial bone between January 1, 2016, and December 31, 2020. Approval for this study was granted by the Institutional Review Board of our hospital (details blinded for peer review). Written informed consent was obtained from all the study participants.

Baseline patient demographics, clinical information, type of fracture (nasal, maxillary, zygomaticomaxillary complex, orbital floor, other orbital, mandible, frontal sinus, LeFort, nasoorbitoethmoid, or panfacial), cause of injury, and operative management were recorded. Traffic accidents included injuries from cars, motorcycles, bicycles, and electric scooters. Slip-down included cases of being injured by falling or bumping after drinking. Based on the declaration date of the COVID-19 pandemic on March 11, 2020, the patient groups were divided into before and after groups and compared. Statistical comparisons before and after COVID-19 were performed by t-test and chi-squared test, Fisher's exact test, and Poisson regression analysis using R software version 4.0.4 (R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was set at p less than 0.05.

Results

The total number of patients who received treatment at our hospital for facial bone fractures between 2016 and 2020 was 4,011. [Table 1] shows the description of the cohort by mean age, sex, cognitive impairment, psychosis, cerebral infarction, site of injury, and operative management sustained per group. Of the cases, 3,409 were before COVID-19 and 602 were after COVID-19. There was a significant age difference between the groups; the patients in the before-COVID-19 group were younger than those in the after-COVID-19 group (43.4 ± 19.8 versus 48.6 ± 20.1, respectively) (p < 0.001). No statistical difference was noted between the two groups regarding gender or past history that could affect trauma. However, the proportion of patients with psychosis increased with a p-value of 0.05, and a significant increase was observed in fractures that occurred outdoors (p < 0.001). However, a decrease was found in operative management between the groups (p < 0.001, [Table 1]). When analyzing differential distribution of the prevalence of fracture cases based on Poisson regression, the number of patients before the COVID-19 outbreak was significantly high (coefficient: –0.858, 95% confidence interval [CI]: –1.179––0.537, p-value < 0.001), compared with those after the outbreak ([Fig. 1]). However, the fracture cases in January 2016 exhibited a remarkably high prevalent numbers compared with other times; therefore, we considered it as outlier. After removing the cases in January 2016, the number of fracture cases did not differ before and after the COVID-19 outbreak (coefficient: –0.334, –0.686–0.019, p-value: 0.063). In addition, no significant difference was noted between the two groups as regards the type of fracture, except for LeFort fractures (95% CI: 1.018–1.129, p-value = 0.002, [Table 2], [Supplemental Table S1], available in the online version). No statistical difference was observed in the proportions of assault, fall-down, industrial accident, or roll-down. In contrast, the proportion of traffic accidents increased significantly (95% CI: 1.000–1.058, p-value = 0.042) and slip-down categories also increased significantly (95% CI: 0.001–1.018, p-value = 0.001). However, the proportion of the sports category decreased significantly (95% CI: 0.898–0.961, p-value = 0.001, [Table 3], [Supplemental Table S1], available in the online version).

Table 1 General characteristics of the study population (n = 4,011)

Variables	Before COVID-19		After COVID-19		p-Value
	n	%	n	%
	3,409	85.0	602	15.0
Age (years), mean ± SD	43.4 ± 19.8		48.6 ± 20.1		<0.001a
Sex
Male	2,613	76.7	482	80.1	0.066
Female	796	23.3	120	19.9
Cognitive impairment
Yes	37	1.1	7	1.2	0.867
No	3,372	98.9	595	98.8
Psychosis
Yes	28	0.8	10	1.7	0.050
No	3,381	99.2	592	98.3
Cerebral infarction
Yes	19	0.6	5	0.8	0.423
No	3,390	99.4	597	99.2
Site
Outside	2,562	75.2	529	87.9	<0.001a
Indoor	847	24.8	73	12.1
Operation
Yes	1,520	44.6	210	34.9	<0.001a
No	1,889	55.4	392	65.1

Abbreviations: COVID-19, coronavirus disease 2019; SD, standard deviation.

t-test and chi-squared test were used. ^aSignificant at 95% confidence level.

Table 2 Facial bone fracture type (n = 4,011)

Variables	Before COVID-19		After COVID-19		p-Value
	n	%	n	%
	3,409	85	602	15
Nasal
Yes	1,487	43.6	240	39.9	0.087
No	1,922	56.4	362	60.1
Maxillary
Yes	56	1.6	12	2	0.539
No	3,353	98.4	590	98
ZMC
Yes	439	12.9	67	11.1	0.265
No	2,970	87.1	535	88.9
Orbital floor
Yes	301	8.8	53	8.8	0.984
No	3,108	91.2	549	91.2
Other orbital
Yes	490	14.4	100	16.6	0.153
No	2,919	85.6	502	83.4
Mandible
Yes	281	8.2	46	7.6	0.619
No	3,128	91.8	556	92.4
Frontal
Yes	27	0.8	7	1.2	0.36
No	3,382	99.2	595	98.8
LeFort
Yes	215	6.3	59	9.8	0.002[a]
No	3,194	93.7	543	90.2
NOE
Yes	4	0.1	2	0.3	0.224[b]
No	3,405	99.9	600	99.7
Panfacial
Yes	109	3.2	16	2.7	0.482
No	3,300	96.8	586	97.3

Abbreviations: COVID-19, coronavirus disease 2019; NOE, naso-orbito-ethmoidal; ZMC, zygomaticomaxillary.

^a Statistically significant p < 0.05.

^b Fisher's exact test.

Table 3 Cause of injury (n = 4,011)

Variables	Before COVID-19		After COVID-19		p-Value
	N	%	N	%
	3,409	85.0	602	15.0
Traffic accident
Yes	755	22.1	157	26.1	0.042a
No	2,654	77.9	445	73.9
Assault
Yes	612	18.0	91	15.1	0.106
No	2,797	82.0	511	84.9
Fall-down
Yes	304	8.9	54	9.0	>0.999
No	3,105	91.1	548	91.0
Industrial accident
Yes	167	4.9	20	3.3	0.114
No	3,242	95.1	582	96.7
Roll-down
Yes	126	3.7	18	3.0	0.463
No	3,283	96.3	584	97.0
Slip-down
Yes	933	27.4	207	34.4	0.001a
No	2,476	72.6	395	65.6
Sports
Yes	291	8.5	26	4.3	0.001a
No	3,118	91.5	576	95.7
Others
Yes	221	6.5	29	4.8	0.138
No	3,188	93.5	573	95.2

Abbreviation: COVID-19, coronavirus disease 2019.

Chi-square test was used. ^aStatistically significant p < 0.05.

Fig. 1 Number of facial bone fracture patients per month. COVID-19, coronavirus disease 2019.

Discussion

COVID-19 has resulted in widespread changes to a relatively sedentary lifestyle and decreased exposure to light (vitamin D deficiency). A consequence of stay-at-home policies is a negative change in bone health and environmental surroundings that has led to age-related changes in the number of traumatic bone fractures.[4]

Despite these changes after COVID-19 pandemic, the occurrence of facial fractures did not decrease. The reason for this is that most outdoor sports have decreased, but it can be thought of as an increase in new means of transportation (e.g., electric scooters) and an increase in alcohol consumption.[14] [15] [16] [17]

However, the average age of injuries has increased, which may have affected the decline in sports, where young people are mainly injured, and alcohol consumption is only available for adults, so this may have affected it. Furthermore, because of social distancing policies, the etiology of facial bone fractures has changed. Outdoor activities, such as vigorous exercise, decreased, and the occurrence of facial fractures subsequently decreased. However, there was an increase in fractures occurring outdoors rather than indoors due to a significant increase in slip-down injuries and traffic accidents. Slip-down injuries likely increased as a result of excessive alcohol consumption; hazardous alcohol use increased for those under lockdown compared with those not under restrictions.[14] [15]

A few possible reasons for the increase in facial bone injuries due to traffic accidents have been identified. The use of electric kickboards in Korea has increased rapidly in recent years, resulting in increased fractures.[16] [17] The greater use of kickboards was possibly due to a reluctance to use public transportation and a desire to avoid crowded spaces. For an accurate analysis, additional data should be recorded and reflected in future studies.

The reason for the decrease in surgical treatment is that hospitals are very crowded places, and people are reluctant to visit and even be admitted to hospitals because of the fear of COVID-19. In addition, before hospitalization for surgery, there were cases where COVID-19 was confirmed and the appropriate surgery period was missed due to isolation treatment.

Among the types of facial fractures, the only one that was statistically significant was the LeFort fracture, which may be caused by high-energy trauma (e.g., traffic accidents). However, in the similar case of panfacial fracture, no significant difference was noted; hence, it is believed that additional etiologic analysis is necessary.

This study had several limitations. First, it was conducted in a single institution; thus, representativeness may be low. Second, the study period did not include the full 1-year period after the COVID-19 pandemic declaration. In Korea, there are four distinct seasons, and there may be seasonal differences in the occurrence of facial bone fracture. Therefore, since the after-COVID-19 group does not reflect all seasons, the epidemiology of facial fractures may not account for changes depending on the season. Finally, the COVID-19 pandemic has become more severe over time. Social distancing policies have also become stricter, and further studies are needed to understand the effects of updated circumstances.

The COVID-19 pandemic has significantly changed the lifestyles of people around the world. For example, changes in alcohol consumption and means of transportation occurred as a result of the pandemic. This study confirmed that the epidemiology and etiology of facial fractures also changed. Because of these changes, it is necessary to prepare policies and safety measures to reduce facial fractures.

Conflict of Interest

None declared.

Authors' Contributions

J.K. conceptualized this study. J.H.K. contributed to data curation. J.H.K. did formal analysis. J.H.K. investigated the study. C.E.Y., S.W.K., and J.K. were involved in methodology. S.W.K., and C.E.Y. did the project administration. C.E.Y., S.W.K., and J.K. helped in providing resources. J.H.K. helped in providing software. C.E.Y., S.W.K., and J.K. supervised the study. S.W.K. and J.K. validated the study. J.H.K. contributed to visualization. J.H.K. wrote the original draft. J.K. reviewed and edited the manuscript. All the authors provided approval of final manuscript.

Ethical Approval

The study was approved by the Institutional Review Board of Wonju Severance Christian Hospital (IRB CR321049) and performed in accordance with the principles of the Declaration of Helsinki. The informed consent was waived because this study design is a retrospective chart review.

• References

• 1 World Health Organization (WHO). Director-General's opening remarks at the media briefing on COVID19 [Internet]. [Cited 2020 March 12]. Accessed October 8, 2022 at: https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march2020
• 2 World Health Organization (WHO). Coronavirus disease (COVID-19) pandemic [Internet]. [Cited 2021 Nov 23]. Accessed October 8, 2022 at: https://www.who.int
• 3 Sarac NJ, Sarac BA, Schoenbrunner AR. et al. A review of state guidelines for elective orthopaedic procedures During the COVID-19 outbreak. J Bone Joint Surg Am 2020; 102 (11) 942-945
• 4 Umeda-Raffa S, Pergolizzi Jr JV, Raffa RB. Bone fractures during the time of coronavirus. J Clin Pharm Ther 2021; 46 (02) 543-546
• 5 de Boutray M, Kün-Darbois JD, Sigaux N. et al. Impact of the COVID-19 lockdown on the epidemiology of maxillofacial trauma activity: a French multicentre comparative study. Int J Oral Maxillofac Implants 2021; 50 (06) 750-755
• 6 Lalloo R, Lucchesi LR, Bisignano C. et al. Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study. Inj Prev 2020; 26 (Suppl. 01) i27-i35
• 7 Salzano G, Dell'Aversana Orabona G, Audino G. et al. Have there been any changes in the epidemiology and etiology of maxillofacial trauma during the COVID-19 pandemic? An Italian multicenter study. J Craniofac Surg 2021; 32 (04) 1445-1447
• 8 Brooks SK, Webster RK, Smith LE. et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395 (10227): 912-920
• 9 Serafini G, Parmigiani B, Amerio A, Aguglia A, Sher L, Amore M. The psychological impact of COVID-19 on the mental health in the general population. QJM 2020; 113 (08) 531-537
• 10 Allevi F, Dionisio A, Baciliero U. et al. Impact of COVID-19 epidemic on maxillofacial surgery in Italy. Br J Oral Maxillofac Surg 2020; 58 (06) 692-697
• 11 Horan J, Duddy JC, Gilmartin B. et al. The impact of COVID-19 on trauma referrals to a National Neurosurgical Centre. Ir J Med Sci 2021; 190 (04) 1281-1293
• 12 Rozenfeld M, Peleg K, Givon A. et al. COVID-19 changed the injury patterns of hospitalized patients. Prehosp Disaster Med 2021; 36 (03) 251-259
• 13 Wang CJ, Hoffman GR, Walton GM. The implementation of COVID-19 social distancing measures changed the frequency and the characteristics of facial injury: the Newcastle (Australia) experience. Craniomaxillofac Trauma Reconstr 2021; 14 (02) 150-156
• 14 Killgore WDS, Cloonan SA, Taylor EC, Lucas DA, Dailey NS. Alcohol dependence during COVID-19 lockdowns. Psychiatry Res 2021; 296: 113676
• 15 Boschuetz N, Cheng S, Mei L, Loy VM. Changes in alcohol use patterns in the United States during COVID-19 pandemic. WMJ 2020; 119 (03) 171-176
• 16 Korea JoongAng Daily (Daily JA). Scooters crowd the streets of Seoul, causing backlash [Internet]. [Cited 2020 Sep 3]. Accessed October 8, 2022, at: https://koreajoongangdaily.joins.com/2020/09/03/business/industry/scooter-electric-scooter-electric-bike/20200903180000375.html
• 17 Kim M, Lee S, Ko DR, Kim DH, Huh JK, Kim JY. Craniofacial and dental injuries associated with stand-up electric scooters. Dent Traumatol 2021; 37 (02) 229-233

Publication History

Received: 31 March 2022

Accepted: 20 September 2022

Accepted Manuscript online:
25 September 2022

Article published online:
06 February 2023