A clinical decision aid to discern patients without and with midfacial and mandibular fractures that require treatment (the REDUCTION-II study): a prospective multicentre cohort study

Abstract

Purpose To assess the diagnostic accuracy of physical examination findings and to construct clinical decision aids to discern emergency department patients without and with midfacial and mandibular fractures that require treatment. Methods A prospective multicentre cohort study was conducted in four hospitals in the Netherlands. Consecutive maxillofacial trauma patients were included whereupon each patient underwent a standardized physical examination consisting of 15 and 14 findings for midfacial and mandibular trauma, respectively. The primary outcome was the decision whether to treat during the emergency department stay or within 24 h of admission. The diagnostic accuracy was calculated for the individual physical examination findings and ensuing clinical decision aids with the focus being on detecting midfacial and mandibular fractures that require active treatment. Results A total of 766 midfacial trauma patients were identified of whom 339 (44.3%) had midfacial fractures. Of those, 74 (21.8%) required active treatment. A total of 280 mandibular trauma patients were identified of whom 66 (23.6%) had mandibular fractures. Of those, 37 (56.0%) required active treatment. The decision aid for midfacial trauma consisting of facial depression, epistaxis, ocular movement limitation, palpable step-off, objective malocclusion and tooth mobility or avulsion had a sensitivity of 97.3 (90.7–99.3), a specificity of 38.6 (35.0–42.3), and a negative predictive value of 99.3 (97.3–99.8). The decision aid for mandibular trauma consisting of mouth opening limitation, jaw movement pain, objective malocclusion and tooth mobility or avulsion resulted in a sensitivity of 100.0 (90.6–100.0), a specificity of 39.1 (33.2–45.4), and a negative predictive value of 100.0 (96.1–100.0). Conclusion The clinical decision aids successfully identified midfacial and mandibular trauma patients requiring active fracture treatment and so may be useful in preventing unnecessary radiological procedures in the future. Trial Registration The study was registered at ClinicalTrials.gov with the identifier NCT03314480.

Diagnostic accuracy of the tongue blade test combined with clinical signs to detect maxillary and mandibular fractures in the emergency department

“…A recent study focused on how a combination of clinical findings can be used to predict maxillary and mandibular fractures. [9] However, the study of combining TBT with other clinical signs as a clinical decision tool is limited. A previous study concluded that negative TBT may be useful to rule out mandibular fracture, as the combined sensitivity was 95.4%, [6] but TBT should be used in adjunct with other clinical findings, as its sensitivity may be as low as 85.0%.…”

“…Malocclusion was defined as an objectively identified traumatic misalignment of the maxillary and mandibular dental arches. [9] Tenderness on palpation and swelling was defined as the presence of pain during palpation and swelling of the maxillary region (maxillary sinus, infraorbital rim, zygomaticomaxillary complex, Le Fort I, II, III complex and maxillary dentoalveolar complex) and mandibular region (symphyseal or parasymphyseal region, body, angle, ramus, coronoid process, condylar process and mandibular dentoalveolar complex). [9] For TBT, the patient was asked to bite on a tongue depressor until it was broken against twisting motion by an examiner, resulting in a negative test.…”

“…Maxillary fractures were defined as any fracture of the infra-orbital rim, maxillary sinus, zygomaticomaxillary complex, Le Fort I, II, III complex and maxillary dentoalveolar complex. [9] Mandibular fractures were defined as any fracture of the symphyseal or parasymphyseal area, body, angle, ramus, coronoid process, condylar process and mandibular dentoalveolar complex. [9] All radiological images were reviewed and reported by board-certified radiologists who were blinded in this study.…”

“…[9] Mandibular fractures were defined as any fracture of the symphyseal or parasymphyseal area, body, angle, ramus, coronoid process, condylar process and mandibular dentoalveolar complex. [9] All radiological images were reviewed and reported by board-certified radiologists who were blinded in this study. Patients who reported maxillary or mandibular fractures on facial X-ray or CT were referred to the oral and maxillofacial surgery (OMFS) team for further management.…”

Comparison outcome of open and close reduction treatments for parasymphysis mandibular fractures

“…1 The closed reduction procedure involves using intraoral elastic traction on the maxillary and mandibular teeth to gradually reposition them laterally. 16 Tooth occlusion can be achieved by IMF and elastic traction. The treatment plan also includes general health care measures, such as administering antibiotics and analgesics, roborantia, nutritious food, maintaining oral hygiene, and providing physiotherapy.…”