Abstract and Introduction
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.
In the initial evaluation of a trauma patient, computed tomography (CT) of the head (CTH) is performed to assess for life-threatening intracranial injury. With 25% of all trauma patients sustaining some form of facial injury, many facial fractures are diagnosed, often incidentally, on head CT during the initial evaluation. Whereas maxillofacial CT (CTMF) is widely accepted as the most sensitive method for evaluating facial fractures, it is often not obtained with the initial trauma survey due to limitations in time and information when assessing a critically ill, severely injured patient. Head CT can be used to diagnose facial fractures in some cases, but failure to obtain dedicated imaging can lead to increased costs related to a missed or delayed facial fracture diagnosis, including increased hospital length of stay.
Both types of CT imaging are instrumental in evaluating a trauma patient due to their accuracy, reliability, and wide availability. A routine CTH scan is performed in 5-cm axial cuts parallel to the orbitomeatal line from the foramen magnum to the vertex. By comparison, a CTMF scan incorporates 3-cm axial cuts from the mandible to the frontal sinus and is thus able to provide a better look at the facial bones. The thinner slices and altered axis gives rise to the diagnostic superiority of CTMF.
Previous studies have identified clinical findings associated with the presence of facial fractures and have subsequently developed clinical criteria to guide CTMF use.[2,4,5] There have also been studies analyzing how head and maxillofacial CT are used in conjunction, recognizing that 84% of facial fracture patients receiving initial trauma CTH required CTMF for definitive diagnosis. However, few studies have addressed what specific types of facial fractures are missed on head CT. It is important to note that this study is not insinuating that CTH is an adequate study for the detection of facial fractures.
Because some patients who receive a screening head CT due to trauma are not initially suspected to have a facial fracture or have other critical injuries and do not receive a maxillofacial CT during their initial workup, there are inevitable missed diagnoses. This study seeks to examine what fractures are detected on a head CT (if one is performed prior to CTMF) and what types of fractures would not be detected by reviewing imaging data from patients who presented at a level one trauma center and underwent both head and maxillofacial CT imaging.
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