Predicting orbital fractures in head injury: a preliminary study of clinical findings

Abstract

Purpose Patients presenting to emergency departments (EDs) following head injury often undergo computed tomography (CT) of the head to exclude traumatic brain injury. In many cases, this does not show the maxillofacial skeleton. A proportion of these patients also sustain facial fractures, and when fractures involve the orbits, CT imaging is useful in diagnosis and management; obtaining a second scan may cause delay, incur greater cost, and increase radiation dose. The aim of this preliminary study was to examine the value of signs and symptoms of orbital fractures in predicting a fracture on CT. Methods The clinical records of 47 patients who underwent CT of the face following facial trauma were retrospectively examined for the presence of signs and symptoms of orbital fractures. Sensitivity, specificity, negative predictive value (NPV) and positive predictive values (PPV) were then calculated for each sign and symptom for the presence of an orbital fracture on CT. We also described a clinical decision instrument and examined the predictive values of this. Results Change in the position of the globe, reduced visual acuity, subconjunctival haemorrhage and change in sensation in the maxillary division of the trigeminal nerve were the most specific signs and symptoms for orbital fracture. Our clinical decision instrument had 80.0% sensitivity, 75.0% specificity, 90.3% PPVand 56.3% NPV for predicting the presence of an orbital fracture on CT in this population. Conclusions Our results demonstrate that signs and symptoms of orbital fractures may be useful for predicting these injuries, and a decision instrument could be used in the ED to identify patients likely to benefit from extending the radiation field to include the orbits where CT of the head is already planned. This work is however exploratory; and further prospective validation is required before a robust instrument can be recommended for clinical use.

Diagnostic accuracy of physical examination findings for midfacial fractures: a systematic review and meta-analysis

“…The reported mean age was 37.1 years, and the reported median age ranged from 28 to 50. The study population included midfacial trauma patients (n = 1) [58], maxillofacial trauma patients (n = 4) [56,60,61,64], orbital trauma patients (n = 2) [57,62], head and orbital trauma patients (n = 3) [54,55,65], minor head injury patients with a black eye (n = 1) [59], and traumatic brain injury patients with facial trauma (n = 1) [63]. All the studies had used CT as a reference test and thus no studies were included where CBCT was used as a reference test.…”

“…All the studies had used CT as a reference test and thus no studies were included where CBCT was used as a reference test. Any midfacial fracture was used as an outcome by one study [58], whereas any midfacial or mandibular fracture was used as an outcome by seven studies [54, 56, 59-61, 63, 64], and orbital fracture was used as an outcome by four studies [55,57,62,65]. In one study, midfacial and mandibular fracture outcomes were stratified as frontal sinus, zygoma, orbital floor, naso-ethmoidal, nasal, maxilla, and mandibular fractures [61].…”

“…A total of 24 distinct physical examination findings were identified as being related to the visual appearance of the patient and reported 52 times in the included studies [54][55][56][57][58][60][61][62][63][64][65]. The outcomes of the findings were any midfacial or mandibular fracture (n = 40), any midfacial fracture (n = 2), any orbital fracture (n = 7), orbital floor fracture (n = 1), and zygoma fracture (n = 2).…”

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

“…Although various studies have focused on how physical examination findings can be used to predict midfacial and mandibular fractures [3][4][5][6][7][8][9][10][11][12][13] and to stratify patients at risk of fractures and subsequently requiring radiological imaging of the maxillofacial region, studies on identifying patients that require treatment are limited [10,11]. In today's emergency department landscape, the primary assessment of trauma patients is mostly performed by emergency physicians and specialized trauma surgeons and, if maxillofacial fractures are diagnosed, an oral and maxillofacial surgeon is consulted to assess the need for active treatment.…”

Avaliação das repercussões clínicas após alterações no volume orbitário pós trauma: uma revisão sistematizada

“…Nesse sentido, as avaliações oftalmológicas (por meio de exames fundoscópicos e exames perioculares), juntamente com os métodos de diagnóstico por imagem, apresentam significância expressiva nas interpretações de tais repercussões clínicas, uma vez que é eficaz na avaliação das respostas do globo ocular e de suas estruturas, quando realizadas por profissionais especializados (Allison, Kearns & Banks, 2019;Kovar, et al, 2018).…”