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

James R Allison,Robert J Banks,Andrew Kearns

doi:10.1007/s10140-019-01720-0

James R Allison, Robert J Banks + Show 1 more

Open Access

https://doi.org/10.1007/s10140-019-01720-0

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Abstract

PurposePatients 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.MethodsThe 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.ResultsChange 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.ConclusionsOur 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.

Highlights

There were over 21 million attendances to emergency departments (EDs) in hospitals in England between April 2017 and March 2018, and in over 443,758 cases the first recorded diagnosis was “head injury” [1]
computed tomography (CT) is an indispensable modality for the diagnosis and management of facial trauma [9], and this is true of fractures of the orbit due to the complex local anatomy, which is not usually well demonstrated using plain film techniques [10]; CT is useful in identifying complications of orbital fractures such as entrapment of the extraocular muscles and orbital compartment syndrome
Forty-seven patients were included in the analysis, and of these 35 (74.5%) had a fracture involving any part of the bony orbit

Summary

Introduction

There were over 21 million attendances to emergency departments (EDs) in hospitals in England between April 2017 and March 2018, and in over 443,758 cases the first recorded diagnosis was “head injury” [1]. Many of these patients will have had fractures of the facial skeleton, as these injuries are seen in a significant proportion of patients who present with head injury [2]. Well-recognised guidance exists to identify patients who are likely to benefit from computed tomography (CT) imaging of the head and neck to exclude injury to the brain and cervical spine [6], this often does not include the facial skeleton [7] (Fig. 1). CT is an indispensable modality for the diagnosis and management of facial trauma [9], and this is true of fractures of the orbit due to the complex local anatomy, which is not usually well demonstrated using plain film techniques [10]; CT is useful in identifying complications of orbital fractures such as entrapment of the extraocular muscles and orbital compartment syndrome

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