Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients

Background: Over 150,000 patients present with maxillofacial trauma annually to emergency rooms in the United States. Although maxillofacial computed tomography is a sensitive screening tool for identifying facial fractures, indiscriminate use leads to unnecessary radiation exposure and substantial costs. A decision instrument is needed to ensure computed tomographic evaluation of patients at high risk for facial fracture and limit computed tomography use in low-risk patients. Methods: A retrospective review was conducted of all patients evaluated at a Level I trauma center over a 3-year period. Inclusion criteria were maxillofacial examination on presentation, maxillofacial computed tomography, and head computed tomography. A total of 525 patients met the enrollment criteria. Results: Injury to the maxillofacial skeleton occurred in 332 patients (63.2 percent). The presence of any of the following five physical examination criteria identified patients at high risk for facial fracture: bony stepoff or instability, periorbital swelling or contusion, Glasgow Coma Scale score less than 14, malocclusion, or tooth absence. These criteria identified all but six of the 332 patients with a facial fracture (sensitivity, 98.2 percent; 95 percent confidence interval, 96.5 to 99.1 percent). The negative predictive value was 87.8 percent (95 percent confidence interval, 76.3 to 94.2 percent). No patient determined by these criteria to be at low risk for a facial fracture required surgical treatment. If these criteria had been applied to the study population, radiographic imaging could have been avoided in 9.3 percent of patients. Conclusions: A decision instrument based on clinical criteria can ensure appropriate screening of patients at high risk for facial facture. Application of this instrument may reduce unnecessary maxillofacial imaging.