Trends in the aetiology of maxillofacial fractures in the United Kingdom (19774987) M. R. Telfer,
G. M. Jones, J. P. Shepherd
Departments of Oral and Maxillofacial Surgery, Bristol Royal tnfirmury, Frenchay and Southmead Hospituls, Bristol and University Department of Oral Medicine, Surgery and Puthology, Bristol Dentul School, Bristol -.
._
SUMMARY. A survey was undertaken to assess changes in the aetiology of maxillofacial fractures in the United Kingdom between 1977 and 1987, using data which had been collected in British departments of Oral and Maxillofacial Surgery. Data were available from units serving 17 million people and included details of patients from a broad spread of rural and urban areas. Analysis of data from the 27 maxillofacial units able to supply details from both 1977 and 1987 showed an overall increase of 20% in numbers of patients with maxillofacial fractures, though a trend towards fewer severe injuries was also a feature over the same period. Numbers of natients injured in road accidents had decreased by 34%, numbers of patients injured in assaults had increased by 47% whilst numbers of patients injured in all other ways had increased by 39%. _ __
INTRODUCTION
Huelke, 196i), but studies in the last dccadc have shown that assaults are now the commonest cause of maxillofacial fractures in many developed countries, though road accidents remain the most frequent cause of injury in many developing areas (Brown & Cowpe, 1985). Road traffic accidents remain an important cause of maxillofacial injuries in the United Kingdom, especially those of a more serious nature, but the incidence has been significantly affected by two legislative measures: the compulsory wearing of seat belts and drink-driving laws. Rutherford et al. (1985) assessed the medical effects of seat belt legislation and found a 15% decrease in hospital attendance and a 25% decrease in hospital admission of patients injured in road accidents over this period. The Department of Transport’s Casualty Report on road accidents for 1985 and 1988 showed a continued seat belt utilization of over 90% and estimated the decrease in death and injury due to this measure as 20-23% for car drivers and 2830% for front seat passengers. Two factors have been consistently implicated in the increase in facial bone fractures due to alleged assault: alcohol and unemployment. This is discussed later and comparisons made between trends in facial bone fractures and the incidence of all violent crime in England and Wales.
Continuing audit of the aetiology of maxillofacial trauma is important because this information reflects the effectiveness of preventive measures, such as the introduction of seat belt legislation, because it suggests new ways in which injuries could be prevented and because it is an important indicator of changing resource and training needs in oral and maxillofacial surgery. Demand for the treatment of facial fractures has increased since the end of the Second World Ward (Schuchart et al., 1966; Rowe & Williams, 1985). Brook and Wood (1983) showed a 270% increase in the number of patients with facial fractures seen in adults over a 15-year period (1965-1980) in the Grampian region of Scotland, in the context of an increase of only 7% in the relevant population. Adi et (11. (1990) compared the numbers of patients with mandibular fractures in the Dundcc area of Scotland in the period 1977-1985 with numbers reported in a study by Shuker (1972) carried out between 1961-1970 and found an increase of 115%. The aetiology of maxillofacial fractures has changed over the last three decades and continues to do so. The main causes in all countries are road accidents, assaults, falls and sport injuries. Adi et al. (1990) found that falls were the second most common cause of mandibular fractures, though it is recognised that many assaulted patients report that their injuries arc due to falls. Road accidents have. in the past, been the most frequent cause of facial fractures in many countries including Nigeria (Adekey, 1980), Libya (Khalil & Shalidi, 1981), Europe (Van Hoof et ul., 1977; Afzelius & Rosen, 1980) and the United States of America (Hagan &
METHOD
There have been several studies published in recent years which have analysed the aetiology and incidence of facial bone fractures on a district basis in Britain. but little information is available nationally, though many units have collected relevant informa250
Maxillol’acial
tion prospectively over many years. A survey was therefore undertaken to investigate the aetiology of facial bone fractures on a national basis over the 11-year period 1977-1987. A questionnaire was circulated to all consultant oral and maxillofacial surgeons in the United Kingdom requesting details of numbers of patients with facial bone fractures, both treated and untreated, seen by them in the individual years 1977 and 1987. Information relating to cause was requested in three categories: road accidents, assaults, and all other causes. Although data were available from hospitals serving a population representative of the UK as a whole, some centres were unable to provide all the necessary information. This may have been due to a number of factors. Firstly, many consultants were appointed to new posts between 1977 and 1987 and recording practices had been improved thereby. Secondly, the need for audit has been increasingly recognised during this period, not least to monitor training opportunities and the effects of seat belt legislation. Thirdly, the time necessary for audit has been formally included in weekly schedules only very recently. Table 1- Data availability
Year Both 1977 & 1987 alone
1987
and population
served. by year
Number of maxillofacial units
Population
27 42
10.6 million 17.3 million
xrvcd’
Table 2 - Numhcr of patients with maxillofacial injuries, by cause, 1987 Aetiology
No.
Road accident Assault Other
745 2156 1404
(17.3) (SO. I) (32.6)
Total
4305
(100)
Table 3 - Number cause
of patients
(%)
of patients with maxillofacial
fractures,
Road accidents Assault Other
606
(29)
2130
(100)
2551
(31) (40)
(17) (SO) (33) (100)
* Only includes units able to provide data for both 1977 and 1987.
in the aetiology of maxillofacial Number patients
due due due due
Kingdom
(lY77-1987)
251
RESULTS Fully completed questionnaires were received from 27 units, which currently serve a population of 10.6 million and data from 1987 only were received from a further 15 units which serve a population of 6.7 million (Table 1). In 1987, the total number of patients with facial bone fractures seen in these units was 4305 (mean number/unit: 103 patients), of which assault was the commonest cause, accounting for 50% of patients. Road traffic accidents were responsible for just 17%, whilst the balance, 33%, were due to other causes, particularly sports injuries, falls and industrial accidents (Table 2). In 1977, 661 patients, 31% of the total, suffered facial fractures in road accidents but this had fallen to 439, 17% of the total number, by 1987. Conversely, assaults in 1977 caused fractures in 863 (40%) of patients. By 1987, numbers of assault patients had risen to 1270, almost 50% of the total number. Patients with fractures due to ‘other causes’ also incrcascd in number; from 606 (29%) in 1977 to 842 (33%) in 1987 (Table 3). Statistical analysis was carried out using the chisquared test to establish the significance of trends in each of the three aetiological categories and also in relation to total numbers of patients over the 1l-year period. In the units able to supply details for both 1977 and 1987, total numbers of patients with facial bone fractures had risen from 2130 (mean number: 79/unit) in 1977 to 2551 in 1987 (mean number: 94/unit), an increase of 20%, which was highly statistically significant (Table 4). Road accidents caused fractures of the facial bones in 661 patients in 1977, but this had fallen to just 439 in 1987; a decrease of 34%. Assault, however, had become a much more frequent cause of injury over the decade, from 863 to 1270 patients, an increase of 47%. Other causes of maxillofacial fractures had also become more important. numbers of patients rising from 606 in 1977 to 842 in 1987; a 39% increase. All these changes were highly statistically significant (Table 4).
by
Number and (‘X)* of patients 19X7 439 1270 842
661 863
Total
Fractures Fractures Fractures Fractures
in the United
DISCUSSION Number and (%)* of patients 1977
TaMe 4 -Trends
fractures
to to to to
road accidents assaults other causes all causes
661 g63 606 2130
Hill et al. (1984), in a prospective 4-year study in Bradford, showed that most maxillofacial fractures (35% of patients) resulted from assaults and that ‘misadventure’ (falls and other mishaps) was the second most common cause, accounting for fractures in 27% of patients. In that study, road accidents were responsible for fractures in only 23% of
fractures of 1977
Numhcr patients 439 I270 x42 2551
of IYX7
Direction and magnitude of change
Significance (p value)
down 34% up 47% up 3’)‘:: up 20%”
p p p p
< < <
. F. (1961). An analysis of 319 case reports of mandibular fractures. Journal of Oral Surgery,
Anuethesia and Hospiral Dental Service, 19.93. Health Service Journal Map o/the Nalionul He&h Service ( 1989). The Health Service Journal. Hill, C. M., Crosher. R. F., Carroll, M. J. & Mason, D. A. (1984). Facial fractures-the results of a prospective four year study. Journul of Muxillo-Facial Surgery, 12,267. Home Office Criminal Statistics England and Wales (1087). Notifiable offcnces of violence against the person recorded by the police by offence. Hospital In Patient Enquiry (1977). Main tables, series MB4 No. IO, Department of tlealth and Social Services and Office of Population Censuses and Surveys. Hospital In Patient Enquiry (1985). Main tables, series MB4 NO. 27. Department of Health and Social Services and Office of Population Censuses and Surveys. Khalil, A. F. & Shaladi, 0. A. (1981). Fractures of the facial
Maxillofacial bones in the Eastern
region of Libya.
Bribsh Journal of Oral
Surgery, 19.300.
fractures
in the United
Kingdom
(1977-1987)
255
S. ‘I‘. (1972). The Maxillo,Jacial I;rrrclure.s in Eacfer Region M. Med. Sci. thesis. Dundee University. (Cited in Adi. M.. Ogden, G. R., Chisholm. D. M. An analysis of mandibular fractures in Dundee. Scotland. 1977 to 19X5 (1990). Brirish Journal of Oral and Maxillofuciul Surgery, 28,
Shukcr.
-Scotlund.
McDade. A. M., McNicol. R. D., Ward-Booth, P.. Chesworth, & Moos. K. F. (1982). The actiology of maxillofacial injuries. with special reference to the abuse of alcohol. In~ternationalJournal of Oral Surgery, I I, 152. Mwanki, I). 1~. & Guthua. S. W. (I(990). Occurrence and characteristics of mandibular.fracturcs in Nairobi, Kenya.
J.
British Journal of Oral and Maxillofucial Surgery. 28.200. Perkins, C. S. & Layton, S. A. (198X). The aetiology of maxillofacial injuries and the seat belt law. British Journalof
Oral and Maxillofacial Surgery, 26,353. Roberts, A. H. N.. Carroll, M. J. & Lamb, R. J. (1983). Windscreen injuries and scat belts. Lancer, 845.340. Rowe, N. L. &Williams. J. 1-I. (1985). MaxiNofuciulInjuries. p. 999. Edinburgh & London: Churchill Livingstone. Rutherford, H., Grcenfield. T., Ilayes, tI.‘R. M. & Nelson. J. K. (19X5). The medical cffccts of scat belt legislation in the United Kingdom. Research report 13. London: Her Majesty’s Stationery Office. Schuchart, K., Schwenzer, N., Rottke, B. 6t Lentrodt. J. (1966). Ursachcn Haufigkeit und lokalization der fraturen dcs Geischtsschadels. Fortschrirte kiefer und gesich/.schirugie. 11, I. Shcphcrd, J. P.. Shapland, N., Irish, M.. Scully. C., Lcslic. I. J. & Parsloe, P. (1986). Assault rates and unemployment.
Luncet, 854. 103X. Shepherd, J. P., Shapland, M., Scully, C. & Leslie, I. J. (198Xa). Alcohol intoxication and severity of injury in assault. Rrifish
Medical Journal. 2%. 1299.
194.) Smith, S. J. (1982).
Victimisation
of Criminology. 22. Smith, ‘I‘. (IIT)(
in the inner city. Bri/ish Journal
386.
Poverty and health in the 1990s. Briri.sh Medical
Journal, 301,349. R. (19X2). Uncmploymcnt and crime. Home Office Research Bulletin 14. London: I ler Majesty’s Stationery
Tarling,
Office. Van Hoof, R. F., Mcrkx, C. A. & Stekelcnhurg, E. C. (1977). The different patterns offractures of the facial skeleton in four European countries. International Journul of Oral
Surgery. 6.3. Voss, R. (1982). The aetiology of jaw fractures in Norwegian patients. Journalof Mu&o-FacialSurgery. 10, 146.W,ood. G. D. (1983). Facial fractures and scat belts. Brirish
Denral Journal, 154.353.
The Authors M. R. Teller FDSRCS, FRCS Registrar in Oral and Maxillofacial Surgery G. M. Jones FDSRCPS, FRCS Senior Registrar in Oral and Maxillofacial Surgery
J. P. Shepherd M.Sc, PhD, FDSRCS
Shepherd, J. P., Scully. C., Shapland, M., Irish, M. & Leslie. I. J. (19XXb). Assault: characteristics of victims attending an inner city hospital. Injury. 19, 185. Shepherd, J. P., Irish, M. & Scully, C. (1989). Alcohol consumption by victims of violence and hy comparable UK populations. British Journal Addiction, x4, 1045. Shepherd, J. P., Robinson, 1.. & Levers, B. G. II. (1990). The roots of urban violence. Injury. 21, 139.
Consultant/Reader
in Oral and Maxillofacial
Surgery
Correspondence and requests for offprints to M. R. ‘l‘clfcr. Department of Oral and Maxillofacial Surgery. Southmead Hospital, Westbury-on-Trym, Bristol
of
Paper received 9 October 1990 Accepted 28 February I991
G. M. Jones, J. P. Shepherd
Departments of Oral and Maxillofacial Surgery, Bristol Royal tnfirmury, Frenchay and Southmead Hospituls, Bristol and University Department of Oral Medicine, Surgery and Puthology, Bristol Dentul School, Bristol -.
._
SUMMARY. A survey was undertaken to assess changes in the aetiology of maxillofacial fractures in the United Kingdom between 1977 and 1987, using data which had been collected in British departments of Oral and Maxillofacial Surgery. Data were available from units serving 17 million people and included details of patients from a broad spread of rural and urban areas. Analysis of data from the 27 maxillofacial units able to supply details from both 1977 and 1987 showed an overall increase of 20% in numbers of patients with maxillofacial fractures, though a trend towards fewer severe injuries was also a feature over the same period. Numbers of natients injured in road accidents had decreased by 34%, numbers of patients injured in assaults had increased by 47% whilst numbers of patients injured in all other ways had increased by 39%. _ __
INTRODUCTION
Huelke, 196i), but studies in the last dccadc have shown that assaults are now the commonest cause of maxillofacial fractures in many developed countries, though road accidents remain the most frequent cause of injury in many developing areas (Brown & Cowpe, 1985). Road traffic accidents remain an important cause of maxillofacial injuries in the United Kingdom, especially those of a more serious nature, but the incidence has been significantly affected by two legislative measures: the compulsory wearing of seat belts and drink-driving laws. Rutherford et al. (1985) assessed the medical effects of seat belt legislation and found a 15% decrease in hospital attendance and a 25% decrease in hospital admission of patients injured in road accidents over this period. The Department of Transport’s Casualty Report on road accidents for 1985 and 1988 showed a continued seat belt utilization of over 90% and estimated the decrease in death and injury due to this measure as 20-23% for car drivers and 2830% for front seat passengers. Two factors have been consistently implicated in the increase in facial bone fractures due to alleged assault: alcohol and unemployment. This is discussed later and comparisons made between trends in facial bone fractures and the incidence of all violent crime in England and Wales.
Continuing audit of the aetiology of maxillofacial trauma is important because this information reflects the effectiveness of preventive measures, such as the introduction of seat belt legislation, because it suggests new ways in which injuries could be prevented and because it is an important indicator of changing resource and training needs in oral and maxillofacial surgery. Demand for the treatment of facial fractures has increased since the end of the Second World Ward (Schuchart et al., 1966; Rowe & Williams, 1985). Brook and Wood (1983) showed a 270% increase in the number of patients with facial fractures seen in adults over a 15-year period (1965-1980) in the Grampian region of Scotland, in the context of an increase of only 7% in the relevant population. Adi et (11. (1990) compared the numbers of patients with mandibular fractures in the Dundcc area of Scotland in the period 1977-1985 with numbers reported in a study by Shuker (1972) carried out between 1961-1970 and found an increase of 115%. The aetiology of maxillofacial fractures has changed over the last three decades and continues to do so. The main causes in all countries are road accidents, assaults, falls and sport injuries. Adi et al. (1990) found that falls were the second most common cause of mandibular fractures, though it is recognised that many assaulted patients report that their injuries arc due to falls. Road accidents have. in the past, been the most frequent cause of facial fractures in many countries including Nigeria (Adekey, 1980), Libya (Khalil & Shalidi, 1981), Europe (Van Hoof et ul., 1977; Afzelius & Rosen, 1980) and the United States of America (Hagan &
METHOD
There have been several studies published in recent years which have analysed the aetiology and incidence of facial bone fractures on a district basis in Britain. but little information is available nationally, though many units have collected relevant informa250
Maxillol’acial
tion prospectively over many years. A survey was therefore undertaken to investigate the aetiology of facial bone fractures on a national basis over the 11-year period 1977-1987. A questionnaire was circulated to all consultant oral and maxillofacial surgeons in the United Kingdom requesting details of numbers of patients with facial bone fractures, both treated and untreated, seen by them in the individual years 1977 and 1987. Information relating to cause was requested in three categories: road accidents, assaults, and all other causes. Although data were available from hospitals serving a population representative of the UK as a whole, some centres were unable to provide all the necessary information. This may have been due to a number of factors. Firstly, many consultants were appointed to new posts between 1977 and 1987 and recording practices had been improved thereby. Secondly, the need for audit has been increasingly recognised during this period, not least to monitor training opportunities and the effects of seat belt legislation. Thirdly, the time necessary for audit has been formally included in weekly schedules only very recently. Table 1- Data availability
Year Both 1977 & 1987 alone
1987
and population
served. by year
Number of maxillofacial units
Population
27 42
10.6 million 17.3 million
xrvcd’
Table 2 - Numhcr of patients with maxillofacial injuries, by cause, 1987 Aetiology
No.
Road accident Assault Other
745 2156 1404
(17.3) (SO. I) (32.6)
Total
4305
(100)
Table 3 - Number cause
of patients
(%)
of patients with maxillofacial
fractures,
Road accidents Assault Other
606
(29)
2130
(100)
2551
(31) (40)
(17) (SO) (33) (100)
* Only includes units able to provide data for both 1977 and 1987.
in the aetiology of maxillofacial Number patients
due due due due
Kingdom
(lY77-1987)
251
RESULTS Fully completed questionnaires were received from 27 units, which currently serve a population of 10.6 million and data from 1987 only were received from a further 15 units which serve a population of 6.7 million (Table 1). In 1987, the total number of patients with facial bone fractures seen in these units was 4305 (mean number/unit: 103 patients), of which assault was the commonest cause, accounting for 50% of patients. Road traffic accidents were responsible for just 17%, whilst the balance, 33%, were due to other causes, particularly sports injuries, falls and industrial accidents (Table 2). In 1977, 661 patients, 31% of the total, suffered facial fractures in road accidents but this had fallen to 439, 17% of the total number, by 1987. Conversely, assaults in 1977 caused fractures in 863 (40%) of patients. By 1987, numbers of assault patients had risen to 1270, almost 50% of the total number. Patients with fractures due to ‘other causes’ also incrcascd in number; from 606 (29%) in 1977 to 842 (33%) in 1987 (Table 3). Statistical analysis was carried out using the chisquared test to establish the significance of trends in each of the three aetiological categories and also in relation to total numbers of patients over the 1l-year period. In the units able to supply details for both 1977 and 1987, total numbers of patients with facial bone fractures had risen from 2130 (mean number: 79/unit) in 1977 to 2551 in 1987 (mean number: 94/unit), an increase of 20%, which was highly statistically significant (Table 4). Road accidents caused fractures of the facial bones in 661 patients in 1977, but this had fallen to just 439 in 1987; a decrease of 34%. Assault, however, had become a much more frequent cause of injury over the decade, from 863 to 1270 patients, an increase of 47%. Other causes of maxillofacial fractures had also become more important. numbers of patients rising from 606 in 1977 to 842 in 1987; a 39% increase. All these changes were highly statistically significant (Table 4).
by
Number and (‘X)* of patients 19X7 439 1270 842
661 863
Total
Fractures Fractures Fractures Fractures
in the United
DISCUSSION Number and (%)* of patients 1977
TaMe 4 -Trends
fractures
to to to to
road accidents assaults other causes all causes
661 g63 606 2130
Hill et al. (1984), in a prospective 4-year study in Bradford, showed that most maxillofacial fractures (35% of patients) resulted from assaults and that ‘misadventure’ (falls and other mishaps) was the second most common cause, accounting for fractures in 27% of patients. In that study, road accidents were responsible for fractures in only 23% of
fractures of 1977
Numhcr patients 439 I270 x42 2551
of IYX7
Direction and magnitude of change
Significance (p value)
down 34% up 47% up 3’)‘:: up 20%”
p p p p
< < <
. F. (1961). An analysis of 319 case reports of mandibular fractures. Journal of Oral Surgery,
Anuethesia and Hospiral Dental Service, 19.93. Health Service Journal Map o/the Nalionul He&h Service ( 1989). The Health Service Journal. Hill, C. M., Crosher. R. F., Carroll, M. J. & Mason, D. A. (1984). Facial fractures-the results of a prospective four year study. Journul of Muxillo-Facial Surgery, 12,267. Home Office Criminal Statistics England and Wales (1087). Notifiable offcnces of violence against the person recorded by the police by offence. Hospital In Patient Enquiry (1977). Main tables, series MB4 No. IO, Department of tlealth and Social Services and Office of Population Censuses and Surveys. Hospital In Patient Enquiry (1985). Main tables, series MB4 NO. 27. Department of Health and Social Services and Office of Population Censuses and Surveys. Khalil, A. F. & Shaladi, 0. A. (1981). Fractures of the facial
Maxillofacial bones in the Eastern
region of Libya.
Bribsh Journal of Oral
Surgery, 19.300.
fractures
in the United
Kingdom
(1977-1987)
255
S. ‘I‘. (1972). The Maxillo,Jacial I;rrrclure.s in Eacfer Region M. Med. Sci. thesis. Dundee University. (Cited in Adi. M.. Ogden, G. R., Chisholm. D. M. An analysis of mandibular fractures in Dundee. Scotland. 1977 to 19X5 (1990). Brirish Journal of Oral and Maxillofuciul Surgery, 28,
Shukcr.
-Scotlund.
McDade. A. M., McNicol. R. D., Ward-Booth, P.. Chesworth, & Moos. K. F. (1982). The actiology of maxillofacial injuries. with special reference to the abuse of alcohol. In~ternationalJournal of Oral Surgery, I I, 152. Mwanki, I). 1~. & Guthua. S. W. (I(990). Occurrence and characteristics of mandibular.fracturcs in Nairobi, Kenya.
J.
British Journal of Oral and Maxillofucial Surgery. 28.200. Perkins, C. S. & Layton, S. A. (198X). The aetiology of maxillofacial injuries and the seat belt law. British Journalof
Oral and Maxillofacial Surgery, 26,353. Roberts, A. H. N.. Carroll, M. J. & Lamb, R. J. (1983). Windscreen injuries and scat belts. Lancer, 845.340. Rowe, N. L. &Williams. J. 1-I. (1985). MaxiNofuciulInjuries. p. 999. Edinburgh & London: Churchill Livingstone. Rutherford, H., Grcenfield. T., Ilayes, tI.‘R. M. & Nelson. J. K. (19X5). The medical cffccts of scat belt legislation in the United Kingdom. Research report 13. London: Her Majesty’s Stationery Office. Schuchart, K., Schwenzer, N., Rottke, B. 6t Lentrodt. J. (1966). Ursachcn Haufigkeit und lokalization der fraturen dcs Geischtsschadels. Fortschrirte kiefer und gesich/.schirugie. 11, I. Shcphcrd, J. P.. Shapland, N., Irish, M.. Scully. C., Lcslic. I. J. & Parsloe, P. (1986). Assault rates and unemployment.
Luncet, 854. 103X. Shepherd, J. P., Shapland, M., Scully, C. & Leslie, I. J. (198Xa). Alcohol intoxication and severity of injury in assault. Rrifish
Medical Journal. 2%. 1299.
194.) Smith, S. J. (1982).
Victimisation
of Criminology. 22. Smith, ‘I‘. (IIT)(
in the inner city. Bri/ish Journal
386.
Poverty and health in the 1990s. Briri.sh Medical
Journal, 301,349. R. (19X2). Uncmploymcnt and crime. Home Office Research Bulletin 14. London: I ler Majesty’s Stationery
Tarling,
Office. Van Hoof, R. F., Mcrkx, C. A. & Stekelcnhurg, E. C. (1977). The different patterns offractures of the facial skeleton in four European countries. International Journul of Oral
Surgery. 6.3. Voss, R. (1982). The aetiology of jaw fractures in Norwegian patients. Journalof Mu&o-FacialSurgery. 10, 146.W,ood. G. D. (1983). Facial fractures and scat belts. Brirish
Denral Journal, 154.353.
The Authors M. R. Teller FDSRCS, FRCS Registrar in Oral and Maxillofacial Surgery G. M. Jones FDSRCPS, FRCS Senior Registrar in Oral and Maxillofacial Surgery
J. P. Shepherd M.Sc, PhD, FDSRCS
Shepherd, J. P., Scully. C., Shapland, M., Irish, M. & Leslie. I. J. (19XXb). Assault: characteristics of victims attending an inner city hospital. Injury. 19, 185. Shepherd, J. P., Irish, M. & Scully, C. (1989). Alcohol consumption by victims of violence and hy comparable UK populations. British Journal Addiction, x4, 1045. Shepherd, J. P., Robinson, 1.. & Levers, B. G. II. (1990). The roots of urban violence. Injury. 21, 139.
Consultant/Reader
in Oral and Maxillofacial
Surgery
Correspondence and requests for offprints to M. R. ‘l‘clfcr. Department of Oral and Maxillofacial Surgery. Southmead Hospital, Westbury-on-Trym, Bristol
of
Paper received 9 October 1990 Accepted 28 February I991
