A prospective analysis of physical examination findings in the diagnosis of facial fractures: Determining predictive value

The Impact of Using Intraoperative Computed Tomography on the Number of Surgical Approaches Used for Zygomaticomaxillary Complex Repair

Background: Zygomaticomaxillary complex (ZMC) fractures are repaired using a variety of surgical approaches. Utilization of intraoperative computed tomography (CT) may reduce the number of surgical approaches. Study Objective: To compare the use of intraoperative CT for the operative repair of ZMC fractures, as measured by the number of surgical approaches. Method: A retrospective review was completed on patients who underwent surgical repair of ZMC fractures by facial plastic and reconstructive surgeons at a tertiary hospital. Results: Eighty-four patients underwent open ZMC repair between 2009 and 2022. Patients had a median age of 42 years (range: 19-93, interquartile range 29-59), were 76.2% Male (n = 64) and 78.6% (N = 66) White. There were 38 and 46 patients in the pre- and post-intraoperative CT cohorts, respectively. The most common incision utilized was a gingivobuccal incision (98.8%), followed by a transconjunctival approach (47.6%). Cases in which CT was utilized had a significantly reduced number of incisions (mean incisions: 2.45 pre vs. 1.67 post, p < 0.001), with large reductions in the rate of transconjunctival incisions (pre-intraoperative CT: 73.7%; post-intraoperative CT: 26.1%, p < 0.001) and lateral canthotomy incisions (23.7% vs. 4.3%, p < 0.001). Conclusion: Intraoperative CT reduces the number of surgical approaches in patients with ZMC trauma.

Application Value of the CT Scan 3D Reconstruction Technique in Maxillofacial Fracture Patients

Purpose The aim of the study was to explore the application value of computerized tomography (CT) scan 3D reconstruction technology in maxillofacial fracture patients. Methods A total of 80 maxillofacial fracture patients who underwent surgical treatment in Shijiazhuang People's Hospital from January 2019 to January 2020 were enrolled. All of them received 128-slice spiral CT  scans before surgery, and the images were subjected to multiplanar reconstruction (MRP) and volume reconstruction (VR). Results A total of 181 fractures were found in 80 patients with maxillofacial fractures. The detection rates of axial CT, MRP, and VR were 77.90% (141/181), 93.92% (170/181), and 97.79% (177/181), respectively. The detection rates of the four inspection methods were statistically different. Taking the findings of surgical anatomy as the gold standard, the sensitivity of MRP and VR for the diagnosis of maxillofacial fractures was 90.06% (163/170) and 95.56% (174/177), with no significant difference. Conclusion CT scan 3D reconstruction technology has a high application value in the clinical diagnosis and treatment of maxillofacial fracture patients.

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

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% PPV and 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.

Imaging in traumatic mandibular fractures

A fracture of the mandible is a common trauma presentation amongst young males and represents one of the most frequently encountered fractured bones within the viscerocranium. Historically, assault was the dominant contributing factor but now due to the increased number of vehicles used per capita, motor vehicle accidents are the primary cause. Mandibular fractures can be classified anatomically, by dentition, by muscle group and by severity. The fracture may also be closed, open, comminuted, displaced or pathological. It is important that the imaging modality used identifies the classification as this will decide definitive treatment. X-ray projections have typically been used to detect a mandibular fracture, but are limited to an anteroposterior (AP), lateral and oblique view in an unstable trauma patient. These views are inadequate to detail the level of fracture displacement and show poor detail of the condylar region. Computer tomography (CT) is the imaging modality of choice when assessing a traumatic mandibular injury and can demonstrate a 100% sensitivity in detecting a fracture. This is through use of a multidetector-row CT, which reduces motion blur and therefore produces accurate coronal and sagittal reconstructions. Furthermore, reconstructive three-dimensional CT images gained from planar views, allows a better understanding of the spatial relationship of the fracture with other anatomical landmarks. This ensures a better appreciation of the severity and classification of a mandibular fracture, which therefore influences operative planning. Ultrasound is another useful modality in detecting a mandibular fracture when the patient is too unstable to be transferred to a CT scanner. The sensitivity however is less in comparison to a CT series of images and provides limited detail on the fracture pattern. Magnetic resonance imaging demonstrates use in assessing soft tissue injury of the temporomandibular joint but this is unlikely to be of priority when initially assessing a trauma patient.