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Three Part Question

In a [patient with facial trauma] which [facial views] are necessary for [diagnosing facial fractures]?

Clinical Scenario

An 18 year old man has been assaulted and presents to the emergency department. He has a swollen, tender left zygoma and you would like to exclude an underlying fracture. The radiology department produce 3 views – the OM, OM30 and lateral. You wonder whether all three views are necessary to exclude a fracture.

Search Strategy

Medline 1966-07/04 using the OVID interface.
([Exp Facial bones OR facial.mp OR exp Facial injuries] AND [exp Zygomatic fractures OR exp Fractures OR exp Maxillary fractures OR fracture$.mp] AND [exp X-Rays OR radiograph$.mp OR X ray.mp OR X-ray.mp]) LIMIT to human AND English language.

Search Outcome

Altogether 614 papers were found of which 5 were of some relevance to the clinical question. These 5 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Rogers et al, 1995, UK	All patients referred for facial X-rays over a month 60 of 65 standard OM views taken during one month, viewed by maxillofacial doctors, emergency doctors and radiology staff	Retrospective cohort	Missed fractures	One facial fracture was missed by the radiology consultant, 1/2 maxillofacial doctors, 3/3 emergency doctors and 2/2 PRHOs	Small number of X-rays with only 7 fractures total In 6 of 65 cases, the gold standard used remained undecided whether a fracture existed
Sidebottom et al, 1996, UK	137 patients referred for facial X-rays between Nov 1994 and April 1995 Emergency department SHO's opinion	Prospective cohort	OM 15 view only	Sensitivity 87.5% Specificity 83%	Inherent bias in the study design. The same doctor was relied upon to truthfully comment on the OM15 view before looking at the two additional views Blinding questionable Insufficient information given as to how sensitivity and specificity worked out – my own calculations from the same data do not agree
			OM15 OM30 and lateral view	Sensitivity 87.5% Specificity 97%
Sidebottom et al, 1998, UK	All patients referred for facial X-rays over a year. All patients had only one OM15 view	Prospective cohort	Patient referral to maxillo-facial surgeon	130 referrals, 36 had midfacial fractures	No gold standard employed – if a fracture was not spotted on single film, it would have been missed by the study This makes for a fundamentally flawed study
			Number of maxillo-facial referrals the previous 12 months	131 referrals. Number of fractures unclear
Raby et al, 1998, UK	Facial X-rays of 50 patients with a facial fracture and 50 without Films viewed by 3 radiology doctors, with and without the lateral views	Retrospective cohort	Sensitivity for diagnosis of facial fracture	Sensitivity with and without lateral view remained 90%	Radiology doctors used in study, not emergency doctors Gold standard not described
McGhee et al, 2000, UK	Selection of facial X-rays for 44 patients with a fracture, and 49 patients without a fracture Emergency doctors asked to report	Retrospective cohort	Clinical utility for detection of fractures		Same cohort of doctors reported all 3 cominations of X-rays which introduces bias
			OM15 films only	Sensitivity 89.4% Specificity 82.1%
			OM 30 films only	Sensitivity 88.6% Specificity 84.8%
			Both films together	Sensitivity 90.9% Specificity 94.8% No statistical significance between values

Comment(s)

These studies vary in quality.

Clinical Bottom Line

Requesting one OM view in the emergency department will save cost, time and radiation, however the evidence to date suggests that the emergency doctor may miss an occasional midfacial fracture. At least 2 views should be taken.

References

1. Rogers SN, Bradley S, Michael SP. The diagnostic yield of only one occipito-mental radiograph in cases of suspected medfacial trauma – or is one enough? Br J Oral Maxillofac Surg 1995;33:90-92.
2. Sidebottom AJ, Cornelius P, Allen PE, et al. Routine post-traumatic radiographic screening of midfacial injuries: is one view sufficient? Injury 1996;(5):311-313.
3. Sidebottom AJ, Lord TC. Single view radiographic screening of midfacial trauma. Int J Oral Maxillofac Surg 1998;27:356-357.
4. Raby N, Moore D. Radiography of facial trauma, the lateral view is not required. Clin Radiol 1998;53:218-220.
5. McGhee A, Guse J. Radiography for midfacial trauma: is a single OM 15 radiograph as sensitive as OM15 and OM 30 combined? Br J Radiol 2000;73:883-885.