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Multiple non-contiguous defects in an isolated orbital floor fracture: a case report
Abstracts / British Journal of Oral and Maxillofacial Surgery 53 (2015) e37–e110
A&E and analyse whether these were appropriate, necessary and justifiable. Methods: Patient administration system (PAS) facilitated data collection. This retrospective study included patients admitted under maxillofacial surgery through A&E from 01/06/2014 to 31/09/2014. Clinical Work Station revealed investigations which were performed. Individual test costs were obtained from the laboratory. Results: 191 patients (133 males & 58 females) with an age range of 16–87 years (mean = 36.62) were included. The most common reason for admission was a fractured mandible (33.5%) followed by a dental abscess (19.3%). £2121.96 was spent on blood investigations during this period (average of £11.11 per admission). Analysis revealed that the majority of blood investigations performed were unnecessary, when compared to current NICE guidance. This could represent savings of a few thousand pounds per year in this unit and specialty alone. Conclusions: Significant numbers of patients are receiving inappropriate and unnecessary blood investigations. This could be prevented through better communication with A&E (the majority of investigations were requested by them) and developing a protocol which would allow for streamlining on a national scale. http://dx.doi.org/10.1016/j.bjoms.2015.08.101 P 94 Panoramic radiographs for mandibular fractures – are we compliant with quality assurance? K. Howson ∗ , K. Rajaram, M. Maranzano, S. Clark Manchester Royal Infirmary, United Kingdom Panoramic radiography is the mainstay in evaluating mandibular fractures. It is not positioning errors. Repeating radiographs causes additional exposure thereby contradicting ALARA (as low as reasonably achievable) principle. Aim: To evaluate the incidence & causes of positioning errors and assess compliance with quality assurance with a view to reduce the occurrence of rejected radiographs. Materials and method: This retrospective study included panoramic radiographs used to diagnose mandibular fractures at Manchester Royal Infirmary from 1st April 2014 to 30th September 2014. Only surgically treated fractures were included. National Radiological Protection Board (NRPB) guidance notes 2001 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 were used as standards for quality assurance. Radiographs were assigned a quality assurance (QA) grade of 1 (excellent with no detected faults), 2 (some faults but diagnostic) or 3 (undiagnostic). Results: 123 radiographs were taken for 64 patients who underwent surgical treatment of a mandibular fracture. 5 were repeat exposures. 52% (n = 64) of radiographs had the condyles either partially or fully excluded. 83% (n = 102) had additional positioning errors. This affected the potential to
e71
diagnose either a condylar fracture or dislocation in 21.1% (n = 21) of cases. Quality Assurance (QA) grading revealed QA1 – 6.5% (n = 8), QA2 – 72.4% (n = 89) and QA3 – 21.1% (n = 26). Conclusion: Our results have been an eye-opener and suggest plenty of scope for improvement. Further discussion with radiologists to develop strategies to improve technique and enhance patient cooperation has been recommended. http://dx.doi.org/10.1016/j.bjoms.2015.08.102 P 95 Multiple non-contiguous defects in an isolated orbital floor fracture: a case report D. Johnston ∗ , M. Perry Royal Victoria Infirmary, Newcastle, United Kingdom Introduction: Current classifications of orbital floor fractures group cases according to the size of defect, number of walls involved and the presence/absence of soft tissue herniation. This case represents a deviation from the usual classification of isolated orbital floor fractures. A review of the literature using MEDLINE failed to identify any previous reports of non-contiguous multiple defects within a single orbital floor. Materials and methods: A 26-year-old male presented following an alleged assault complaining of pain on opening the eyelids. On clinical examination there was diplopia on upward gaze with a small degree of restricted elevation on looking up. Computed Tomography (CT) identified fractures of the left orbital floor with anterior and posterior defects noted, separated by a narrow bridge of intact bone. Results: The operative findings matched the radiological diagnosis of separate defects with a bridge of bone noted between the anterior and posterior defects. The orbital contents were herniated into the posterior (deeper) defect. These were reduced and a single pre-formed plate was laid over both defects. Conclusions and clinical relevance: This case reinforces the careful assessment of all CT views. The surgeon may have limited his dissection to expose the anterior defect only and not explore deeper to define the second (and clinically more important) defect. In this case diplopia was the indication for surgery and this could have remained if only the anterior defect had been defined. For complete diagnosis of all defects within the orbit, suspicion for multiple defects present should be considered. http://dx.doi.org/10.1016/j.bjoms.2015.08.103
A&E and analyse whether these were appropriate, necessary and justifiable. Methods: Patient administration system (PAS) facilitated data collection. This retrospective study included patients admitted under maxillofacial surgery through A&E from 01/06/2014 to 31/09/2014. Clinical Work Station revealed investigations which were performed. Individual test costs were obtained from the laboratory. Results: 191 patients (133 males & 58 females) with an age range of 16–87 years (mean = 36.62) were included. The most common reason for admission was a fractured mandible (33.5%) followed by a dental abscess (19.3%). £2121.96 was spent on blood investigations during this period (average of £11.11 per admission). Analysis revealed that the majority of blood investigations performed were unnecessary, when compared to current NICE guidance. This could represent savings of a few thousand pounds per year in this unit and specialty alone. Conclusions: Significant numbers of patients are receiving inappropriate and unnecessary blood investigations. This could be prevented through better communication with A&E (the majority of investigations were requested by them) and developing a protocol which would allow for streamlining on a national scale. http://dx.doi.org/10.1016/j.bjoms.2015.08.101 P 94 Panoramic radiographs for mandibular fractures – are we compliant with quality assurance? K. Howson ∗ , K. Rajaram, M. Maranzano, S. Clark Manchester Royal Infirmary, United Kingdom Panoramic radiography is the mainstay in evaluating mandibular fractures. It is not positioning errors. Repeating radiographs causes additional exposure thereby contradicting ALARA (as low as reasonably achievable) principle. Aim: To evaluate the incidence & causes of positioning errors and assess compliance with quality assurance with a view to reduce the occurrence of rejected radiographs. Materials and method: This retrospective study included panoramic radiographs used to diagnose mandibular fractures at Manchester Royal Infirmary from 1st April 2014 to 30th September 2014. Only surgically treated fractures were included. National Radiological Protection Board (NRPB) guidance notes 2001 and Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 were used as standards for quality assurance. Radiographs were assigned a quality assurance (QA) grade of 1 (excellent with no detected faults), 2 (some faults but diagnostic) or 3 (undiagnostic). Results: 123 radiographs were taken for 64 patients who underwent surgical treatment of a mandibular fracture. 5 were repeat exposures. 52% (n = 64) of radiographs had the condyles either partially or fully excluded. 83% (n = 102) had additional positioning errors. This affected the potential to
e71
diagnose either a condylar fracture or dislocation in 21.1% (n = 21) of cases. Quality Assurance (QA) grading revealed QA1 – 6.5% (n = 8), QA2 – 72.4% (n = 89) and QA3 – 21.1% (n = 26). Conclusion: Our results have been an eye-opener and suggest plenty of scope for improvement. Further discussion with radiologists to develop strategies to improve technique and enhance patient cooperation has been recommended. http://dx.doi.org/10.1016/j.bjoms.2015.08.102 P 95 Multiple non-contiguous defects in an isolated orbital floor fracture: a case report D. Johnston ∗ , M. Perry Royal Victoria Infirmary, Newcastle, United Kingdom Introduction: Current classifications of orbital floor fractures group cases according to the size of defect, number of walls involved and the presence/absence of soft tissue herniation. This case represents a deviation from the usual classification of isolated orbital floor fractures. A review of the literature using MEDLINE failed to identify any previous reports of non-contiguous multiple defects within a single orbital floor. Materials and methods: A 26-year-old male presented following an alleged assault complaining of pain on opening the eyelids. On clinical examination there was diplopia on upward gaze with a small degree of restricted elevation on looking up. Computed Tomography (CT) identified fractures of the left orbital floor with anterior and posterior defects noted, separated by a narrow bridge of intact bone. Results: The operative findings matched the radiological diagnosis of separate defects with a bridge of bone noted between the anterior and posterior defects. The orbital contents were herniated into the posterior (deeper) defect. These were reduced and a single pre-formed plate was laid over both defects. Conclusions and clinical relevance: This case reinforces the careful assessment of all CT views. The surgeon may have limited his dissection to expose the anterior defect only and not explore deeper to define the second (and clinically more important) defect. In this case diplopia was the indication for surgery and this could have remained if only the anterior defect had been defined. For complete diagnosis of all defects within the orbit, suspicion for multiple defects present should be considered. http://dx.doi.org/10.1016/j.bjoms.2015.08.103