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Lin JAJ, Li PH, Liao CH, Hsieh CH, Kuo YC, Hsu TA, Chu YY, Fu CY. Evaluation of Concomitant Facial Fracture in Traumatic Brain Injury Patients-Simplification and External Validation of a Prediction Model. Ann Plast Surg 2024; 92:S27-S32. [PMID: 38285992 DOI: 10.1097/sap.0000000000003774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Patients with traumatic brain injuries (TBIs) often experience concurrent facial bone fractures. In 2021, a prediction model with 10 variables was published and precisely predicted concomitant facial fractures in TBI patients. Herein, external validation and simplification of this model was performed. METHODS Traumatic brain injury patients treated at a major referral trauma center were retrospectively reviewed for 1 year. The original prediction model (published in 2021), which was developed from a rural level II trauma center, was applied for external validation. A new and simplified model from our level I trauma center was developed and backwardly validated by rural level II trauma center data. RESULTS In total, 313 TBI patients were enrolled; 101 (32.3%) had concomitant facial fractures. When the previous prediction model was applied to the validation cohort, it achieved acceptable discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.713 and good precision, with a Brier score of 0.083. A new and simplified model with 6 variables (age, tooth rupture, epistaxis, facial lesion, eye injury, and intracranial hemorrhage) was created with excellent discrimination (AUC = 0.836) and good precision (Brier score of 0.055). The backward validation of this new model also showed excellent discrimination in the cohort used to develop the original model (AUC = 0.875). CONCLUSION The original model provides an acceptable and reproducible prediction of concomitant facial fractures among TBI patients. A simplified model with fewer variables and the same accuracy could be applied in the emergency department and at higher- and lower-level trauma centers.
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Affiliation(s)
| | - Pei-Hua Li
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Ying Chu
- From the Department of Plastic and Reconstructive Surgery
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Gala Z, Bai D, Halsey J, Ayyala H, Riddle K, Hohenleitner J, Hoppe I, Lee E, Granick M. Head Computed Tomography Versus Maxillofacial Computed Tomography: An Evaluation of the Efficacy of Facial Imaging in the Detection of Facial Fractures. EPLASTY 2022; 22:e22. [PMID: 35903430 PMCID: PMC9280063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND In an initial trauma evaluation, computed tomography of the head (CTH) is performed to assess for life-threatening intracranial injury. Given the high incidence of concomitant facial injuries, many facial fractures are diagnosed incidentally during this evaluation. Although maxillofacial CT (CTMF) is widely accepted as the most sensitive method for evaluating facial fractures, it is often excluded from the initial survey. Failure to obtain dedicated imaging can lead to increased costs related to a missed or delayed facial fracture diagnosis. Our study investigates the location and type of missed facial fractures on CTH by reviewing imaging data from patients who presented at a level 1 trauma center and underwent both CTH and CTMF. METHODS A retrospective review of all facial fractures diagnosed at a single institution from 2002 through 2016 was conducted. Inclusion criteria included adults aged 18 years or older who received CTH and then subsequent CTMF. Patients who had either CTH or CTMF only or combined CTH/CTMF were excluded. The facial fractures were further subdivided by location. RESULTS There were 501 patients with 1743 total facial fractures. CTH successfully identified 788 (45.21%) fractures, versus 1743 (100%) for CTMF. The most common fractures, in both cohorts, were nasal bone (15.7%) and orbital floor (12.8%) fractures. Using CTMF to identify missed fractures on CTH, significant differences were noted in the following locations: anterior table frontal sinus, medial/lateral pterygoid, maxillary sinus, lateral orbital wall, zygomatic arch, palate, and all types of mandible fractures excluding the mandibular condyle. CONCLUSIONS CTH for initial trauma evaluation often misses facial fractures. CTH alone was only sufficient in detecting posterior frontal sinus, orbital (excluding lateral wall), and mandibular condyle fractures. In patients with suspected facial injury, dedicated imaging should be performed to detect the location and extent of injury because CTH inadequately identifies most facial fractures.
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Affiliation(s)
| | - Di Bai
- Rutgers New Jersey Medical School, Newark, NJ
| | | | | | | | | | - Ian Hoppe
- University of Mississippi Medical Center, Jackson, MS
| | - Edward Lee
- Rutgers New Jersey Medical School, Newark, NJ
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Rozema R, Moumni ME, de Vries GT, Spijkervet FKL, Verbeek R, Kleinbergen JYJ, Bens BWJ, Doff MHJ, van Minnen B. A clinical decision aid for patients with suspected midfacial and mandibular fractures (the REDUCTION-I study): a prospective multicentre cohort study. Eur J Trauma Emerg Surg 2022; 48:4243-4254. [PMID: 35430710 PMCID: PMC9532332 DOI: 10.1007/s00068-022-01968-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 03/26/2022] [Indexed: 12/26/2022]
Abstract
Purpose To assess physical examination findings related to maxillofacial trauma to identify patients at risk of midfacial and mandibular fractures and then to construct a clinical decision aid to rule out the presence of midfacial and mandibular fractures in emergency department patients. Methods We performed a prospective multicentre cohort study in four hospitals in the Netherlands, including consecutive patients with maxillofacial trauma. Each patient received a standardized physical examination consisting of 15 and 14 findings for midfacial and mandibular traumas, respectively. Consequently, clinical decision aids were constructed with the focus being on ruling out the presence of midfacial and mandibular fractures, and diagnostic accuracy was calculated. Results A total of 993 consecutive patients were identified of whom 766 and 280 patients were suspected of midfacial and mandibular fractures, respectively. Midfacial fractures were diagnosed in 339 patients (44.3%), whereas mandibular fractures were observed in 66 patients (23.6%). The decision aid for midfacial trauma consisting of peri-orbital hematoma, epistaxis, ocular movement limitation, infra-orbital nerve paresthesia, palpable step-off and tooth mobility or avulsion, produced a sensitivity of 89.7 (86.0–92.5), a specificity of 42.6 (38.0–47.4), and a negative predictive value of 83.9% (78.4–88.2). The decision aid for mandibular trauma consisting of the angular compression test, axial chin pressure test, objective malocclusion, tooth mobility or avulsion and the tongue blade bite test resulted in a sensitivity of 98.5 (91.9–99.7), a specificity of 34.6 (28.5–41.2), and a negative predictive value of 98.7% (92.8–99.8). Conclusion The constructed clinical decision aids for maxillofacial trauma may aid in stratifying patients suspected for midfacial and mandibular fractures to reduce unnecessary diagnostic imaging. Clinical Trial Registration The study was registered at ClinicalTrials.gov with the identifier NCT03314480. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01968-1.
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Affiliation(s)
- Romke Rozema
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Mostafa El Moumni
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gysbert T de Vries
- Department of Emergency Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Frederik K L Spijkervet
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - René Verbeek
- Department of Emergency Medicine, Nij Smellinghe Hospital, Drachten, The Netherlands
| | | | - Bas W J Bens
- Department of Emergency Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michiel H J Doff
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Oral and Maxillofacial Surgery, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - Baucke van Minnen
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Rozema R, Doff MHJ, Delli K, Spijkervet FKL, van Minnen B. Diagnostic accuracy of physical examination findings for midfacial fractures: a systematic review and meta-analysis. Clin Oral Investig 2022; 26:3405-3427. [PMID: 35298710 PMCID: PMC8979892 DOI: 10.1007/s00784-022-04423-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/19/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis to assess the diagnostic accuracy of physical examination findings and related clinical decision aids for midfacial fractures in comparison to computed tomography and cone beam computed tomography. MATERIAL AND METHODS A systematic review was performed by searching the MEDLINE, Cochrane, EMBASE, and CINAHL databases. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled sensitivity, specificity, and diagnostic odds ratios with the corresponding 95% confidence intervals were calculated for each physical examination finding and reported clinical decision aids. RESULTS After screening 2367 records, 12 studies were included. High risk of patient selection bias was detected in three studies (25%). Additionally, high concerns regarding applicability were found for the patient selection in five studies (41.7%), and for the reference standard in eleven studies (91.7%). Of the total 42 individual physical examination findings, only 31 were suitable for a meta-analysis. High specificity and low sensitivity were found for most findings. The pooled diagnostic odds ratio ranged from 1.07 to 11.38. Clinical decision aids were reported by 8 studies, but none were constructed specifically for midfacial fractures. CONCLUSION Based on the current available evidence, the absence of physical examination findings can successfully identify patients who do not have a midfacial fracture, but the presence of individual findings does not necessarily mean that the patient has a midfacial fracture. Although various clinical decision aids were presented, none focused on exclusively midfacial fractures. CLINICAL RELEVANCE The diagnostic accuracy of physical examination findings can be used to diagnose a midfacial fracture so as to reduce unnecessary imaging, health care costs, and exposure to ionizing radiation.
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Affiliation(s)
- Romke Rozema
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Michiel H J Doff
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Oral and Maxillofacial Surgery, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - Konstantina Delli
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Frederik K L Spijkervet
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Baucke van Minnen
- Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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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. Eur J Trauma Emerg Surg 2022; 48:2547-2558. [PMID: 35211773 PMCID: PMC9360136 DOI: 10.1007/s00068-022-01892-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
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. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01892-4.
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Agrawal A, Savardekar A, Singh M, Pal R, Shukla DP, Rubiano A, Sinha VD, Menon GR, Galwankar S, Moscote-Salazar LR, Bhandarkar P, Munivenkatappa A, Meena U, Chakrabarty A. Orbital and Visual Apparatus Injuries in Patients with Head Injuries. Neurol India 2021; 69:1078-1079. [PMID: 34507456 DOI: 10.4103/0028-3886.325309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
| | - Amey Savardekar
- Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Mitasha Singh
- Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, NCR, India
| | - Ranabir Pal
- Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, NCR, India
| | - Dhaval P Shukla
- Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
| | - Andreas Rubiano
- Consultant Neurosurgeon, El Bosque University, RED LATINO. Latin American Trauma and Intensive Neuro-Care Organization, Bogota, Colombia
| | - Virendra D Sinha
- Department of Neurosurgery, S.M.S. Medical College, Jaipur, Rajasthan, India
| | - Geetha R Menon
- Scientist- D, National Institute of Medical Statistics, Indian Council of Medical Research, (Department of Health Research), Ansari Nagar, Rajasthan, India
| | - Sagar Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville Florida, US
| | - Luis R Moscote-Salazar
- RED LATINO- Latin American Trauma and Intensive Neuro-Care Organization, Bogota, Colombia
| | - Prashant Bhandarkar
- Department of Statistics, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Ashok Munivenkatappa
- Scientist C, VRDL Project, National Institute of Epidemiology (ICMR), Chennai, Tamil Nadu, India
| | - Ugan Meena
- Department of Neurosurgery, S.M.S. Medical College, Jaipur, Rajasthan, India
| | - Amit Chakrabarty
- Department of Neurosurgery, CK Birla Hospitals - RBH, Jaipur, Rajasthan, India
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Schneider M, Besmens IS, Luo Y, Giovanoli P, Lindenblatt N. Surgical management of isolated orbital floor and zygomaticomaxillary complex fractures with focus on surgical approaches and complications. J Plast Surg Hand Surg 2020; 54:200-206. [PMID: 32493085 DOI: 10.1080/2000656x.2020.1746664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Zygomaticomaxillary complex (ZMC) and orbital blow out fractures are commonly encountered midfacial fractures that may result in aesthetic and functional impairment. This retrospective study reports on the surgical treatment and associated postoperative complications in our patient collective. We evaluated 100 patients who underwent open reduction and internal fixation of midfacial fractures between 2010 and 2015. Preoperative clinical features, surgical technique and postoperative complications were analyzed. Surgery was performed with a mean latency of 7 days after trauma. We used titanium mesh and polydioxanone sheets to reconstruct the orbital floor. Most ZMC fractures were stabilized with two point fixation with titanium plates. Preoperative symptoms were present in 70 patients (70%). Infraorbital hypesthesia occurred in 49 patients, diplopia in 41 patients and ocular motility impairment in 24 patients. Postoperative symptoms persisted during a mean follow-up time of 4.5 months in 47 patients (47%) showing infraorbital hypesthesia in 24%, diplopia in 17%, ectropion in 7% and ocular motility impairment in 4%. Complications requiring revision were retrobulbar hematoma 3% (n = 3), ectropion 3% (n = 3), diplopia 1% (n = 1), exophthalmos 1% (n = 1), implant dislocation 1% (n = 1), implant discomfort 2% (n = 2), persisting fracture dislocation 1% (n = 1). All patients recovered without significant impairment. Surgery is required in the majority of the patients with midfacial fractures. Among others ectropion is challenging due to its aesthetic and functional impact on patients. To prevent ectropion, additional canthopexy or the transconjunctival surgical approach are reasonable options in selected cases. Level of Evidence: Level V, descriptive study. AbbreviationsCTcomputed tomographyOForbital floorPDSpolydioxanoneORIFopen reduction and internal fixationZMCzygomaticomaxillary complex.
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Affiliation(s)
- Martina Schneider
- Division of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Inga S Besmens
- Division of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Yeda Luo
- Division of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Division of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Division of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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