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Single view radiographic screening of midfacial trauma
J. OralMaxillofac. Surg. 1998;27:356-357 Printed in Denmark. All rights reserved
Copyright 9 Munksgaard 1998
lnL
ln~aadonalJoumalof
Oral& Ma ofaad Surgery I$$N 0901-5027
Single view radiographic screening of midfacialtrauma
A. J. Sidebottom 1, T. C. Lord 2 1Regional Maxillofacial Unit, Fazakedey Hospital, Liverpool; 2Maxillofaclal Unit, Countess of Chester Hospital, Chester, UK
A. s Sidebottom, T. C. Lord." Single view radiographic screening o f midfacial trauma. Int. J. Oral Maxillofac. Surg. 1998; 27: 356-357. 9 Munksgaard, 1998 Abstract. SIDEBOTTOMet al. 4 have previously shown that one occipitomental 15~ view (OM15) is sufficient for screening the majority of cases of midfacial injury. This audit study investigates the effect of introducing a one-view OM15 screening policy into the Accident & Emergency department (A&E) of a district general hospital. Six hundred and twenty-one patients had midfacial radiographic screening over a one-year period. Six hundred and one patients had all notes and radiographs'~vailable. Only eight required further views to confirm diagnosis. Thirty-eight fractures were diagnosed with two insignificant fractures of the antral wall missed. The cost saving was s for films alone. Eighty hours of radiographer time were additionally saved. There was no increase in referrals to the maxillofacial team. Single-view radiographic screening for midfacial injuries in A&E attenders is both safe and economical. Extrapolated to the U K population as a whole this would amount to a cost saving to the National Health Service of s 000.
Facial injuries account for about 2% of cases attending Accident and Emergency (A&E) departments. These injuries prove difficult for A&E officers to assess due to insufficient undergraduate training in maxiUofacial history-taking and examination techniques. Early soft tissue swelling additionally masks deformity. Facial view radiographs are frequently requested to exclude a fracture in midfacial injuries. These commouly comprise 2-4 views2. ROGERS et al.2 have shown on radiographic review alone that a single-view screening policy may be adequate for assessment of these injuries. SID~OTTOM et al. s subsequently compared a three-view with a single-view radiographic screening policy (using the OM15 ~ view) for midfacial injuries in a prospective clinical trial. The OM15 view was chosen as it does not superimpose the orbital floor on the petrous ridge. Single-view screening was found to be sufficient to exclude
a fracture in 83% of cases, with no fractures missed. The one other patient had further radiographs requested by the maxillofacial team (OM30 and lateral face, and subsequent CT scan) to confirm an orbital floor fracture. Eighty-six per cent of patients had a correct diagnosis from OM15 and clinical examination alone, the remaining 14% requiring OM30 and lateral face to confirm a diagnosis. The sensitivity was 87.5% which compared favourably with a three-view policy of OM15, OM30 and lateral face. The reduction in the number of exposures by 56% follows National Radiation Protection Board (NRPB) recommendations on dose limitation. To determine whether a single OM15 view is sufficient in the clinical setting, we introduced this screening policy for patients attending A&E at the Countess of Chester Hospital, who were referred for radiographic investigation following midfacial injury.
Key words: rnidfacial injuries; radiographic screening; trauma. Accepted for publication 16 May 1998
Materials and methods
Following interdepartmental approval, all patients with midfacial injuries requiring radiographic investigation attending the Countess of Chester Hospital A&E between 1 May 1996 and 30 April 1997 were submitted into the trial. The radiographer was asked to record all patients referred from A& E for "facial views". The patients were also recorded on the A&E computer. Patients with severe midfacial and craniofacial trauma were excluded from the study, since in such cases computerised tomography (CT) scans are the investigation of choice. The A&E doctor assessed the patient clinically and with the aid of the OM15. The treatment options were then: 1) no treatment; 2) refer for further views; or 3) refer for maxillofacial surgical opinion. Any patient where further views were requested or a maxillofacial opinion sought was noted and their further management and final diagnosis was recorded. All radiographs were reviewed by a senior radiologist within 48 hours (as was already standard protocol)
Screening o f midfacial trauma Table 1. Types of midfacial fracture encountered during screening
Type of fracture
Number of incidences
Zygomatic complex Zygomatic arch Nasal bones
30 3 1 (in addition to zygomatic complex) 2 1 2
Orbital floor Le Fort Antral wall
and any patient with an incorrect diagnosis was noted and sent for a further clinical evaluation within a few days of the injury. The referral rates were compared with the same period in 1995/96 when three-view screening was standard protocol (OMI5, OM30, lateral face).
Results
Six hundred and twenty-one patients were referred from A&E for "facial views" during the study period. Of these full data has been obtained on 601, and these comprise the group to be discussed. Six hundred and thirteen radiographs were taken of the latter group of patients; four patients required one further view and four required two further views. Compared with a three-view screening policy this amounts to a saving of 1190 films. One hundred and thirty patients were referred to the maxillofacial team for an opinion. Thirty-six of these had midfacial fractures (Table 1). During the previous 12-month period 591 patients had facial view radiographs of whom 131 were referred to the maxillofacial team. There was no increase in referrals following the introduction of this policy. Two patients had a fracture on radiological review which was not diagnosed by A&E. These patients were reviewed with their radiograph in the maxillofacial department and both had an antral wall fracture which was undisplaced and clinically insignificant. Discussion
Reducing radiographic exposure is part of good clinical practice. This is especially important around the eyes
where radiation exposure may be related to cataract formation and meets with NRPB recommendations on dose limitation. The reduction in patient exposure is 13.5 cGycm 2 of radiation per film for a single facial radiograph. The diagnostic yield of one fracture per 15.8 patients screened highlights the problem of over screening (6.8% fracture rate). One thousand, one hundred and ninety films have been saved, a 66% reduction compared with a three,view policy. The cost of a single facial radiograph is s and this policy has already saved the local Health Authority Trust s on films alone without jeopardising the patients. Additional cost savings include a reduction in radiographer time of approximately 4 minutes per film taken (80 hours in total). This benefit is further appreciated in the drunken or uncooperative patient, who should be asked to return later as these radiographs require patient co-operation to be satisfactory. The missed fractures were clinically insignificant and were diagnosed on routine review by a senior radiologist, which was already hospital policy. Previous reviews on radiographic screening in A&E found missed fracture rates of 0.6-7% s which compares favourably with this study (0.3%). No studies have specifically examined missed facial fractures in A&E. We would not recommend this policy for patients with multiple injuries and severe midfacial or craniofacial trauma. These patients often have cervical spine injuries I which may become unstable during positioning for OM views. CT scans also provide a better assessment of the extent of trauma to both the facial and intracranial structures for these complex injuries. Methods suggested for reducing radiographic exposure have been investigated. A simple poster with guidelines showing when to refer for facial radiographs 4 did not show a significant reduction in referral rates. Recommendations in an A&E manual 6 stating when to refer for facial radiographs has also not reduced referrals. The introduction of a single-view radiographic screening policy for midfacial injuries has proven
357
both a safe and economical method of managing ambulant patients attending A&E following midfacial trauma. This method reduces radiation exposure, saves departmental costs and saves the radiographer's time. In conclusion, single-view radiographic screening of midfacial injuries in A&E attenders maintains high diagnostic efficacy and reduces radiation exposure whilst achieving significant economic benefits. If extrapolated to the United Kingdom as a whole this would save the National Health Service in the region of s 000. Acknowledgments. We would like to thank
the radiology, A&E and maxillofacial departments at the Countess of Chester Hospital, Chester, UK, for their help and wholehearted support. References
1. BmRh'E JC, BUTLER PEM, BRADY FA. Cervical spine injuries in facial trauma. Int J Oral Maxillofac Surg 1995; 24: 26. 2. Ro6ERs SN, BRADLEYS, MICHAEL SP. The diagnostic yield of only one occipitomental radiograph in cases of suspected midfacial trauma - or is one enough? Br J Oral MaxiUofac Surg 1995: 33: 90-2. 3. SmEBOTTOMAJ, CORNELrOSP, ALLENPE, COBBY M, ROGERS SN. Routine posttraumatic radiographic screening of midfacial injuries; is one view sufficient? Injury 1996: 27: 311-3. 4. SIDEBOTTOMAJ, JONESDC, ALLEN PE, ROGERS SN. Reducing radiological exposure following midfacial injury. Br J Oral Maxillofac Surg 1996: 34:267 (abstract). 5. THOMAS HG, MASON AC, SMrrH RM, F~GUSON CM. Value of radiographic audit in an accident service department. Injury 1992: 23: 47-50. 6. WEnSTERK, MALnqSTJ. An audit of facial radiographs taken in an Accident and Emergency Department. Br J Oral Maxillofac Surg 1996: 34:257 (abstract),
Address: Mr A. J. Sidebottom 31, Ravenswood Road Redland Bristol BS6 6B W UK Tel." +44 (0)151 529 5280 (work) +44 (0)117 973 2076 (home) Fax: +44 (0)151 529 5288 (work)
Copyright 9 Munksgaard 1998
lnL
ln~aadonalJoumalof
Oral& Ma ofaad Surgery I$$N 0901-5027
Single view radiographic screening of midfacialtrauma
A. J. Sidebottom 1, T. C. Lord 2 1Regional Maxillofacial Unit, Fazakedey Hospital, Liverpool; 2Maxillofaclal Unit, Countess of Chester Hospital, Chester, UK
A. s Sidebottom, T. C. Lord." Single view radiographic screening o f midfacial trauma. Int. J. Oral Maxillofac. Surg. 1998; 27: 356-357. 9 Munksgaard, 1998 Abstract. SIDEBOTTOMet al. 4 have previously shown that one occipitomental 15~ view (OM15) is sufficient for screening the majority of cases of midfacial injury. This audit study investigates the effect of introducing a one-view OM15 screening policy into the Accident & Emergency department (A&E) of a district general hospital. Six hundred and twenty-one patients had midfacial radiographic screening over a one-year period. Six hundred and one patients had all notes and radiographs'~vailable. Only eight required further views to confirm diagnosis. Thirty-eight fractures were diagnosed with two insignificant fractures of the antral wall missed. The cost saving was s for films alone. Eighty hours of radiographer time were additionally saved. There was no increase in referrals to the maxillofacial team. Single-view radiographic screening for midfacial injuries in A&E attenders is both safe and economical. Extrapolated to the U K population as a whole this would amount to a cost saving to the National Health Service of s 000.
Facial injuries account for about 2% of cases attending Accident and Emergency (A&E) departments. These injuries prove difficult for A&E officers to assess due to insufficient undergraduate training in maxiUofacial history-taking and examination techniques. Early soft tissue swelling additionally masks deformity. Facial view radiographs are frequently requested to exclude a fracture in midfacial injuries. These commouly comprise 2-4 views2. ROGERS et al.2 have shown on radiographic review alone that a single-view screening policy may be adequate for assessment of these injuries. SID~OTTOM et al. s subsequently compared a three-view with a single-view radiographic screening policy (using the OM15 ~ view) for midfacial injuries in a prospective clinical trial. The OM15 view was chosen as it does not superimpose the orbital floor on the petrous ridge. Single-view screening was found to be sufficient to exclude
a fracture in 83% of cases, with no fractures missed. The one other patient had further radiographs requested by the maxillofacial team (OM30 and lateral face, and subsequent CT scan) to confirm an orbital floor fracture. Eighty-six per cent of patients had a correct diagnosis from OM15 and clinical examination alone, the remaining 14% requiring OM30 and lateral face to confirm a diagnosis. The sensitivity was 87.5% which compared favourably with a three-view policy of OM15, OM30 and lateral face. The reduction in the number of exposures by 56% follows National Radiation Protection Board (NRPB) recommendations on dose limitation. To determine whether a single OM15 view is sufficient in the clinical setting, we introduced this screening policy for patients attending A&E at the Countess of Chester Hospital, who were referred for radiographic investigation following midfacial injury.
Key words: rnidfacial injuries; radiographic screening; trauma. Accepted for publication 16 May 1998
Materials and methods
Following interdepartmental approval, all patients with midfacial injuries requiring radiographic investigation attending the Countess of Chester Hospital A&E between 1 May 1996 and 30 April 1997 were submitted into the trial. The radiographer was asked to record all patients referred from A& E for "facial views". The patients were also recorded on the A&E computer. Patients with severe midfacial and craniofacial trauma were excluded from the study, since in such cases computerised tomography (CT) scans are the investigation of choice. The A&E doctor assessed the patient clinically and with the aid of the OM15. The treatment options were then: 1) no treatment; 2) refer for further views; or 3) refer for maxillofacial surgical opinion. Any patient where further views were requested or a maxillofacial opinion sought was noted and their further management and final diagnosis was recorded. All radiographs were reviewed by a senior radiologist within 48 hours (as was already standard protocol)
Screening o f midfacial trauma Table 1. Types of midfacial fracture encountered during screening
Type of fracture
Number of incidences
Zygomatic complex Zygomatic arch Nasal bones
30 3 1 (in addition to zygomatic complex) 2 1 2
Orbital floor Le Fort Antral wall
and any patient with an incorrect diagnosis was noted and sent for a further clinical evaluation within a few days of the injury. The referral rates were compared with the same period in 1995/96 when three-view screening was standard protocol (OMI5, OM30, lateral face).
Results
Six hundred and twenty-one patients were referred from A&E for "facial views" during the study period. Of these full data has been obtained on 601, and these comprise the group to be discussed. Six hundred and thirteen radiographs were taken of the latter group of patients; four patients required one further view and four required two further views. Compared with a three-view screening policy this amounts to a saving of 1190 films. One hundred and thirty patients were referred to the maxillofacial team for an opinion. Thirty-six of these had midfacial fractures (Table 1). During the previous 12-month period 591 patients had facial view radiographs of whom 131 were referred to the maxillofacial team. There was no increase in referrals following the introduction of this policy. Two patients had a fracture on radiological review which was not diagnosed by A&E. These patients were reviewed with their radiograph in the maxillofacial department and both had an antral wall fracture which was undisplaced and clinically insignificant. Discussion
Reducing radiographic exposure is part of good clinical practice. This is especially important around the eyes
where radiation exposure may be related to cataract formation and meets with NRPB recommendations on dose limitation. The reduction in patient exposure is 13.5 cGycm 2 of radiation per film for a single facial radiograph. The diagnostic yield of one fracture per 15.8 patients screened highlights the problem of over screening (6.8% fracture rate). One thousand, one hundred and ninety films have been saved, a 66% reduction compared with a three,view policy. The cost of a single facial radiograph is s and this policy has already saved the local Health Authority Trust s on films alone without jeopardising the patients. Additional cost savings include a reduction in radiographer time of approximately 4 minutes per film taken (80 hours in total). This benefit is further appreciated in the drunken or uncooperative patient, who should be asked to return later as these radiographs require patient co-operation to be satisfactory. The missed fractures were clinically insignificant and were diagnosed on routine review by a senior radiologist, which was already hospital policy. Previous reviews on radiographic screening in A&E found missed fracture rates of 0.6-7% s which compares favourably with this study (0.3%). No studies have specifically examined missed facial fractures in A&E. We would not recommend this policy for patients with multiple injuries and severe midfacial or craniofacial trauma. These patients often have cervical spine injuries I which may become unstable during positioning for OM views. CT scans also provide a better assessment of the extent of trauma to both the facial and intracranial structures for these complex injuries. Methods suggested for reducing radiographic exposure have been investigated. A simple poster with guidelines showing when to refer for facial radiographs 4 did not show a significant reduction in referral rates. Recommendations in an A&E manual 6 stating when to refer for facial radiographs has also not reduced referrals. The introduction of a single-view radiographic screening policy for midfacial injuries has proven
357
both a safe and economical method of managing ambulant patients attending A&E following midfacial trauma. This method reduces radiation exposure, saves departmental costs and saves the radiographer's time. In conclusion, single-view radiographic screening of midfacial injuries in A&E attenders maintains high diagnostic efficacy and reduces radiation exposure whilst achieving significant economic benefits. If extrapolated to the United Kingdom as a whole this would save the National Health Service in the region of s 000. Acknowledgments. We would like to thank
the radiology, A&E and maxillofacial departments at the Countess of Chester Hospital, Chester, UK, for their help and wholehearted support. References
1. BmRh'E JC, BUTLER PEM, BRADY FA. Cervical spine injuries in facial trauma. Int J Oral Maxillofac Surg 1995; 24: 26. 2. Ro6ERs SN, BRADLEYS, MICHAEL SP. The diagnostic yield of only one occipitomental radiograph in cases of suspected midfacial trauma - or is one enough? Br J Oral MaxiUofac Surg 1995: 33: 90-2. 3. SmEBOTTOMAJ, CORNELrOSP, ALLENPE, COBBY M, ROGERS SN. Routine posttraumatic radiographic screening of midfacial injuries; is one view sufficient? Injury 1996: 27: 311-3. 4. SIDEBOTTOMAJ, JONESDC, ALLEN PE, ROGERS SN. Reducing radiological exposure following midfacial injury. Br J Oral Maxillofac Surg 1996: 34:267 (abstract). 5. THOMAS HG, MASON AC, SMrrH RM, F~GUSON CM. Value of radiographic audit in an accident service department. Injury 1992: 23: 47-50. 6. WEnSTERK, MALnqSTJ. An audit of facial radiographs taken in an Accident and Emergency Department. Br J Oral Maxillofac Surg 1996: 34:257 (abstract),
Address: Mr A. J. Sidebottom 31, Ravenswood Road Redland Bristol BS6 6B W UK Tel." +44 (0)151 529 5280 (work) +44 (0)117 973 2076 (home) Fax: +44 (0)151 529 5288 (work)