YBJOM-4229; No. of Pages 5
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years Michael Büttner a,∗ , Fabian Lukas Schlittler a,1 , Chantal Michel b , Aris Konstantinos Exadaktylos c , Tateyuki Iizuka a a b c
Department of Cranio-Maxillofacial Surgery, University Hospital of Bern (Inselspital), CH-3010 Bern, Switzerland University Hospital of Child and Adolescence Psychiatry and Psychotherapy, Bolligenstrasse 111, CH-3000 Bern, Switzerland Department of Emergency Medicine, University Hospital of Bern (Inselspital), CH-3010 Bern, Switzerland
Accepted 26 March 2014
Abstract Orbital blunt trauma is common, and the diagnosis of a fracture should be made by computed tomographic (CT) scan. However, this will expose patients to ionising radiation. Our objective was to identify clinical predictors of orbital fracture, in particular the presence of a black eye, to minimise unnecessary exposure to radiation. A 10-year retrospective study was made of the medical records of all patients with minor head trauma who presented with one or two black eyes to our emergency department between May 2000 and April 2010. Each of the patients had a CT scan, was over 16 years old, and had a Glasgow Coma Score (GCS) of 13–15. The primary outcome was whether the black eye was a valuable predictor of a fracture. Accompanying clinical signs were considered as a secondary outcome. A total of 1676 patients (mean (SD) age 51 (22) years) and minor head trauma with either one or two black eyes were included. In 1144 the CT scan showed a fracture of the maxillofacial skeleton, which gave an incidence of 68.3% in whom a black eye was the obvious symptom. Specificity for facial fractures was particularly high for other clinical signs, such as diminished skin sensation (specificity 96.4%), diplopia or occulomotility disorders (89.3%), fracture steps (99.8%), epistaxis (95.5%), subconjunctival haemorrhage (90.4%), and emphysema (99.6%). Sensitivity for the same signs ranged from 10.8% to 22.2%. The most striking fact was that 68.3% of all patients with a black eye had an underlying fracture. We therefore conclude that a CT scan should be recommended for every patient with minor head injury who presents with a black eye. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Black eye; Orbital fractures; Retrospective study; Clinical predictors; Computed tomography
Introduction A black eye indicates either superficial ecchymosis of the eyelids or a transmitted haemorrhage of a deeper structure to the loose periorbital tissue.1 It can therefore occur on both ∗ Corresponding author at: Department of Cranio-Maxillofacial Surgery, University Hospital of Bern (Inselspital), Freiburgstrasse 10, CH-3010 Bern, Switzerland. Tel.: +41 32 470 99 09 06; fax: +41 31 632 19 90. E-mail address: [email protected] (M. Büttner). 1 Equally contributing author.
sides even though only one side may be affected. Because of the prominent position of the midfacial structures, a black eye is an omnipresent symptom not only in major, but often minor, cases of blunt trauma, the causes of which in industrial countries include assaults, traffic crashes, falls, and sportrelated accidents.2 The aetiology alone does not indicate whether there is an underlying fracture or only soft tissue ecchymosis.3–5 Computed tomography and digital volume tomography are commonly used for the diagnosis of fractures of the thin bones of the facial skeleton. Precise diagnosis has improved
http://dx.doi.org/10.1016/j.bjoms.2014.03.018 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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in recent years with the use of detailed coronal projection, which can complement images obtained with the standard axial view. Coronal views are usually reconstructed from thin axial slices 1–3 mm thick. Considerable exposure to ionising radiation is therefore required to obtain a correct diagnosis of facial fractures.6 When multislice computed tomography (CT) with 1 mm collimation of the face is required, the mean doses of 24.5 mGy (lens) and 1.4 mGy (thyroid gland) are given.7 Other diagnostic tools are often not suitable. For the diagnosis of intracranial haemorrhage after minor head trauma, most trauma centres rely on guidelines such as the Canadian CT Head Rules for patients with minor head injuries.8 Fractures of the midface are commonly missed on axial slices of the neurocranium.9 In many trauma centres the decision to use a facial CT protocol is commonly made according to individual recommendations. More than 10 years ago a consensus was reached in the emergency unit of our university hospital that we would take no further plain radiographs in adults to rule out midfacial fractures. The classic signs of injury, such as diplopia, were then taken to be indicative of a CT scan, as was any history indicating injury to the head. An inadequate diagnosis of facial fracture can lead to appreciable morbidity when treatment is missed or delayed.10 A black eye is a common and obvious sign in minor head injuries. The intention of this study was to find out its value for predicting underlying facial fractures in patients with minor head trauma who had been transferred to a level I trauma centre. For the purpose of statistical analysis, other data, such as mechanism of trauma and secondary clinical signs, were used as secondary outcomes.
fractures of the zygomatico-orbital complex (zygomatic fractures), and fractures of the maxillary sinus.11 Fractures of the central midfacial skeleton were confined to the maxillary and nasal bones. Naso-orbitoethmoid fractures included fractures of the frontal sinus and fractures of the anterior base of skull. The fourth unit was confined to the limits of the mandible. Extraction of data Personal details about age, sex, nationality, and time of admission were extracted. Data on the mechanism of the injury were also reviewed and classified. As a black eye is only one of several features of a facial fracture, the presence or absence of various other signs and symptoms were extracted from the charts. These included: amnesia, anisocoria, diminished sensation in the skin, diplopia, emphysema, epistaxis, facial pain, lacerated facial skin, fracture steps, nausea or vomiting, loss of consciousness, ocular motility disorders, otorrhoea or liquorrhoea, pain on movement of the eyes, and subconjunctival haemorrhage, swelling, and tenderness on palpation. Simultaneous injuries of the upper or lower limp were also recorded. Analysis of data Data were analysed with the aid of the IBM SPSS® statistical package (version 20, IBM Corp, Armonk, NY) and Excel® for Mac version 12.3.4. The significance of differences between incidence and percentages were compared using the chi square test, and those between normally distributed interval data (age) using Student’s t test.
Patients and methods Results Design of study Personal details We retrospectively studied the records of all patients who presented to the emergency department of the University Hospital, Berne, Switzerland during the 10-year period 1 May 2000–30 April 2010. This hospital is a tertiary referral centre for a population of 1.6 million in a mixed urban and rural area. All patients were initially examined by a trained trauma surgeon. CT scans were all reviewed by a specialised neuroradiologist. If a fracture were present, a member of the maxillofacial staff was available 24 h a day to deal with it. Group studied All records were available in digital form, and we included all patients over 16 years of age with a minor head injury (Glasgow Coma Scale 13–15) who had had a CT scan of the facial skeleton. Fractures of the facial skeleton were classified into groups with similar consequences for treatment. Lateral midface fractures included fractures of the bony orbit without its roof,
During the 10-year period, 2255 patients were admitted to our trauma service with either one or two black eyes. Of these 2255 patients, 579 were excluded for the following reasons: 8 patients under 16 years were incorrectly admitted to the adult emergency ward, 143 had been injured more than three days before admission, 287 patients had a Glasgow Coma Score lower than 13, and finally, 141 patients had no CT scan because they did not give informed consent (Fig. 1). The group studied, therefore, included 1676 patients, mean (SD) age 51 (22), range 16–99. There were no significant differences in age, sex or nationality among the groups (Table 1). Incidence of fractures In 1144 of the 1676 patients included (68.3%), CT showed a fracture of the maxillofacial skeleton with a black eye as its most obvious sign. Among patients without a fracture,
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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Table 1 Personal details of patients who were included and excluded. Data are number (%) of patients except where otherwise stated. Variable
Included patients (n = 1676)
Excluded patients (n = 579)
p value
Mean (SD) age (years) Male sex Swiss nationals
51 (22) 1102 (65.8) 1393 (83.1)
49 (22) 382 (66.1) 478 (82.5)
0.124 0.883 0.761
Table 2 Coexisting signs (%). Clinical sign
Sensitivity
Specificity
PPV
NPV
Diplopia Diminished skin sensation Fracture steps Epistaxis Hyposphagma Emphysema
15 22.2 18.5 15.6 16.3 10.7
98.3 96.4 99.8 95.4 90.4 99.6
95.0 93.0 99.5 88.1 78.6 98.4
35.0 36.6 36.3 34.5 33.4 34.2
diplopia or occulomotility disorders (89.3), fracture steps (99.8), epistaxis (95.5), subconjunctival haemorrhage (90.4), and emphysema (99.6). On the other hand, sensitivity for the same signs ranged from only 10.8 to 22.2 (Table 2). No significant differences were found in the incidence of the following symptoms: nausea, vomiting, loss of consciousness, amnesia or facial pain. There was also no significant correlation for the following signs: pain on ocular movement, swelling, tenderness on palpation, anisocoria, facial skin lacerations, otorrhoea or liquorrhoea, or coexisting injuries to the upper or lower limb. Logistic regression found no further significant associations with the presence or absence of a facial fracture. Falls from less than 2 m (including seizures) (p < 0.001) and punches (p = 0.004) were significantly associated with the absence of a fracture. On the other hand, bicycle accidents were highly likely to be associated with the presence of a facial fracture (p < 0.001). However, effect sizes were weak and the mechanism of accident does not improve sensitivity for facial fractures in this large group of patients. Fig. 1. Algorithm of selection of patients.
Implications for treatment 532 (41.5%) were female, which is significantly more than expected, although the effect size was low (Cramer V = 0.1). There were no significant differences in age, nationality, and incidence of fractures. Of the 1144 patients with a black eye and a fracture, 756 had an isolated fracture (66.1%) and 388 had multiple fractures (33.9%). Overall, the distribution of fracture lines showed a clear concentration in the lateral midfacial skeleton (Fig. 2). Mandibular fractures were mainly seen in multiple fractures of the facial skeleton; an isolated mandibular fracture was found in only 11 patients. A black eye in these cases is probably the result of coexisting damage to the soft tissue that did not result in a midfacial fracture. Coexisting symptoms and signs Specificity (%) for facial fractures was particularly high for the following clinical signs: diminished skin sensation (96.4),
All the 1144 patients who presented with one or two black eyes and a maxillofacial fracture were given antibiotic prophylaxis and were instructed not to blow the nose for 2 weeks. A total of 645 patients (56.4%) required open or closed treatment of the fracture. Seventy additional patients (6.1%) needed prolonged bed rest because of an undisplaced fracture of the skull base.
Discussion Midfacial fractures are discovered in 5% of the injuries admitted to emergency departments.12 The black eye is likely to be the main sign of an underlying fracture of the bony orbit when other signs may be camouflaged by swollen soft tissue. Several authors have pointed this out.1,13 Bogusiak and
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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Fig. 2. Distribution of 2945 fractures in 1144 patients (numbers in parentheses indicate subsets).
Arkuszewski2 described periorbital ecchymosis in 90.6% of 468 patients with zygomaticomaxillary complex fractures, Rhim et al. stated that 84.4% of 45 patients with fractures of the orbital floor had a black eye on initial evaluation, and Brasileiro and Passeri found periorbital ecchymosis in 72.4% of 390 patients with fractures of the paranasal sinus at the time of their first attendance.2,10,14 To our knowledge no study has addressed the opposite question: how many patients with a black eye have an underlying fracture? The most salient result of our analysis was that more than two-thirds of all patients included had a facial fracture on CT. All other statistics, including regression analysis, proved to be ineffective in the light of this result. Can we therefore conclude that all patients with blunt facial trauma and minor head injuries who present with a black eye need a CT? Yadav et al. investigated different clinical signs as a predictor for fractures of the facial bones in a similar setting.15 They included patients over 18 years of age with blunt orbital trauma who were due to have an orbital CT scan, and the black eye was one of 15 signs and symptoms related to orbital trauma. Even though this study focused only on blunt trauma to the orbit, the results contradict the findings of our study. Of 2262 patients with blunt orbital trauma, only 1270 presented with periorbital ecchymosis. No more than 271 of these (21.3%) had an underlying fracture of one of the bones constituting the orbit. There are some possible explanations for this. Yadav et al. conducted a prospective study to create a risk score to identify patients at low risk. Nevertheless, these large differences cannot be explained only by differences in the design of the study. The patients selected in our study were all patients with a black eye and with a GCS of 13 or more. Exclusion by GCS score was not mentioned in Yadav’s study. In addition to that, the level of the trauma
centre was different. One must assume that in Switzerland lower level trauma centres and general practitioners manage many patients with mild head injury. For these reasons, the two studies cannot be compared. The fact that 645 (56.4%) of all patients studied had open repair of the orbital floor or other facial fractures emphasises the importance of the accurate diagnosis of such fractures. It is beyond the scope of this paper to describe the indications for all types of facial fractures treated at our centre. In our study minimally displaced fractures of the orbital floor are the most common diagnosis in patients who present with a black eye. There is no clear consensus on the surgical management of these fractures.16 In these cases, the indication for open surgery is often dictated by both clinical and radiological findings.17 We found over a 10-year period that the size of the fracture on CT was increasingly given more weight than clinical signs for decision on the early repair of isolated fractures of the orbital floor. This makes further analysis of the number of cases operated on unreasonable, as it would be a self-fulfilling prophecy. Some authors have postulated that the orbital floor can be repaired up to 12–14 days after injury, when there is no compression of the orbital contents.18,19 This procedure is followed in some trauma centres, and may be a reasonable approach. However, in an acute trauma centre the most common question is whether a protocol of CT of the face should be added to that of a cranial CT or not.9 Another important fact is that there are therapeutic consequences even if the fracture does not need open reduction. All our 1144 patients who presented with one or two black eyes and a maxillofacial fracture were given antibiotic prophylaxis and were instructed not to blow the nose for two weeks. Seventy additional patients needed prolonged bed rest because of an undisplaced fracture
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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of the skull base. That is why we emphasise the importance of a prompt diagnostic CT in patients with minor head trauma presenting as a black eye. Conflicts of interest The authors have no relevant financial information or potential conflicts of interest to disclose. References 1. Key SJ, Dhariwal DK, Patton DW. Beware the black eye. Trauma 2002;4:237–45. 2. Bogusiak K, Arkuszewski P. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 2010;21:1018–23. 3. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398–403. 4. Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers 1980–2000. Otolaryngol Head Neck Surg 2004;130:164–70. 5. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12-year study of 391 patients. J Craniofac Surg 2009;20:1218–23. 6. Abdeen N, Chakraborty S, Nguyen T, et al. Comparison of image quality and lens dose in helical and sequentially acquired head CT. Clin Radiol 2010;65:868–73. 7. Zammit-Maempel I, Chadwick CL, Willis SP. Radiation dose to the lens of eye and thyroid gland in paranasal sinus multislice CT. Br J Radiol 2003;76:418–20.
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8. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6. 9. Holmgren EP, Dierks EJ, Homer LD, Potter BE. Facial computed tomography use in trauma patients who require a head computed tomogram. J Oral Maxillofac Surg 2004;62:913–8. 10. Rhim CH, Scholz T, Salibian A, Evans GR. Orbital floor fractures: a retrospective review of 45 cases at a tertiary health care center. Craniomaxillofac Trauma Reconstr 2010;3:41–7. 11. Spiessl B, Schroll K. The facial skeleton. In: Nigst H, editor. Specific fractures and luxations (in German). Stuttgart: Thieme; 1972. 12. Smith H, Peek-Asa C, Nesheim D, et al. Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center. J Trauma Nurs 2012;19:57–65. 13. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 4: orbital floor and midface fractures. Emerg Med J 2007;24:292–3. 14. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28–34. 15. Yadav K, Cowan E, Haukoos JS, et al. Derivation of a clinical risk score for traumatic orbital fracture. J Trauma Acute Care Surg 2012;73:1313–8. 16. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207–10. 17. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:149–53. 18. Matteini C, Renzi G, Becelli R, Belli E, Ianetti G. Surgical timing in orbital fracture treatment: experience with 108 consecutive cases. J Craniofac Surg 2004;15:145–50. 19. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–40.
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
ARTICLE IN PRESS Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx–xxx
Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years Michael Büttner a,∗ , Fabian Lukas Schlittler a,1 , Chantal Michel b , Aris Konstantinos Exadaktylos c , Tateyuki Iizuka a a b c
Department of Cranio-Maxillofacial Surgery, University Hospital of Bern (Inselspital), CH-3010 Bern, Switzerland University Hospital of Child and Adolescence Psychiatry and Psychotherapy, Bolligenstrasse 111, CH-3000 Bern, Switzerland Department of Emergency Medicine, University Hospital of Bern (Inselspital), CH-3010 Bern, Switzerland
Accepted 26 March 2014
Abstract Orbital blunt trauma is common, and the diagnosis of a fracture should be made by computed tomographic (CT) scan. However, this will expose patients to ionising radiation. Our objective was to identify clinical predictors of orbital fracture, in particular the presence of a black eye, to minimise unnecessary exposure to radiation. A 10-year retrospective study was made of the medical records of all patients with minor head trauma who presented with one or two black eyes to our emergency department between May 2000 and April 2010. Each of the patients had a CT scan, was over 16 years old, and had a Glasgow Coma Score (GCS) of 13–15. The primary outcome was whether the black eye was a valuable predictor of a fracture. Accompanying clinical signs were considered as a secondary outcome. A total of 1676 patients (mean (SD) age 51 (22) years) and minor head trauma with either one or two black eyes were included. In 1144 the CT scan showed a fracture of the maxillofacial skeleton, which gave an incidence of 68.3% in whom a black eye was the obvious symptom. Specificity for facial fractures was particularly high for other clinical signs, such as diminished skin sensation (specificity 96.4%), diplopia or occulomotility disorders (89.3%), fracture steps (99.8%), epistaxis (95.5%), subconjunctival haemorrhage (90.4%), and emphysema (99.6%). Sensitivity for the same signs ranged from 10.8% to 22.2%. The most striking fact was that 68.3% of all patients with a black eye had an underlying fracture. We therefore conclude that a CT scan should be recommended for every patient with minor head injury who presents with a black eye. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Black eye; Orbital fractures; Retrospective study; Clinical predictors; Computed tomography
Introduction A black eye indicates either superficial ecchymosis of the eyelids or a transmitted haemorrhage of a deeper structure to the loose periorbital tissue.1 It can therefore occur on both ∗ Corresponding author at: Department of Cranio-Maxillofacial Surgery, University Hospital of Bern (Inselspital), Freiburgstrasse 10, CH-3010 Bern, Switzerland. Tel.: +41 32 470 99 09 06; fax: +41 31 632 19 90. E-mail address: [email protected] (M. Büttner). 1 Equally contributing author.
sides even though only one side may be affected. Because of the prominent position of the midfacial structures, a black eye is an omnipresent symptom not only in major, but often minor, cases of blunt trauma, the causes of which in industrial countries include assaults, traffic crashes, falls, and sportrelated accidents.2 The aetiology alone does not indicate whether there is an underlying fracture or only soft tissue ecchymosis.3–5 Computed tomography and digital volume tomography are commonly used for the diagnosis of fractures of the thin bones of the facial skeleton. Precise diagnosis has improved
http://dx.doi.org/10.1016/j.bjoms.2014.03.018 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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in recent years with the use of detailed coronal projection, which can complement images obtained with the standard axial view. Coronal views are usually reconstructed from thin axial slices 1–3 mm thick. Considerable exposure to ionising radiation is therefore required to obtain a correct diagnosis of facial fractures.6 When multislice computed tomography (CT) with 1 mm collimation of the face is required, the mean doses of 24.5 mGy (lens) and 1.4 mGy (thyroid gland) are given.7 Other diagnostic tools are often not suitable. For the diagnosis of intracranial haemorrhage after minor head trauma, most trauma centres rely on guidelines such as the Canadian CT Head Rules for patients with minor head injuries.8 Fractures of the midface are commonly missed on axial slices of the neurocranium.9 In many trauma centres the decision to use a facial CT protocol is commonly made according to individual recommendations. More than 10 years ago a consensus was reached in the emergency unit of our university hospital that we would take no further plain radiographs in adults to rule out midfacial fractures. The classic signs of injury, such as diplopia, were then taken to be indicative of a CT scan, as was any history indicating injury to the head. An inadequate diagnosis of facial fracture can lead to appreciable morbidity when treatment is missed or delayed.10 A black eye is a common and obvious sign in minor head injuries. The intention of this study was to find out its value for predicting underlying facial fractures in patients with minor head trauma who had been transferred to a level I trauma centre. For the purpose of statistical analysis, other data, such as mechanism of trauma and secondary clinical signs, were used as secondary outcomes.
fractures of the zygomatico-orbital complex (zygomatic fractures), and fractures of the maxillary sinus.11 Fractures of the central midfacial skeleton were confined to the maxillary and nasal bones. Naso-orbitoethmoid fractures included fractures of the frontal sinus and fractures of the anterior base of skull. The fourth unit was confined to the limits of the mandible. Extraction of data Personal details about age, sex, nationality, and time of admission were extracted. Data on the mechanism of the injury were also reviewed and classified. As a black eye is only one of several features of a facial fracture, the presence or absence of various other signs and symptoms were extracted from the charts. These included: amnesia, anisocoria, diminished sensation in the skin, diplopia, emphysema, epistaxis, facial pain, lacerated facial skin, fracture steps, nausea or vomiting, loss of consciousness, ocular motility disorders, otorrhoea or liquorrhoea, pain on movement of the eyes, and subconjunctival haemorrhage, swelling, and tenderness on palpation. Simultaneous injuries of the upper or lower limp were also recorded. Analysis of data Data were analysed with the aid of the IBM SPSS® statistical package (version 20, IBM Corp, Armonk, NY) and Excel® for Mac version 12.3.4. The significance of differences between incidence and percentages were compared using the chi square test, and those between normally distributed interval data (age) using Student’s t test.
Patients and methods Results Design of study Personal details We retrospectively studied the records of all patients who presented to the emergency department of the University Hospital, Berne, Switzerland during the 10-year period 1 May 2000–30 April 2010. This hospital is a tertiary referral centre for a population of 1.6 million in a mixed urban and rural area. All patients were initially examined by a trained trauma surgeon. CT scans were all reviewed by a specialised neuroradiologist. If a fracture were present, a member of the maxillofacial staff was available 24 h a day to deal with it. Group studied All records were available in digital form, and we included all patients over 16 years of age with a minor head injury (Glasgow Coma Scale 13–15) who had had a CT scan of the facial skeleton. Fractures of the facial skeleton were classified into groups with similar consequences for treatment. Lateral midface fractures included fractures of the bony orbit without its roof,
During the 10-year period, 2255 patients were admitted to our trauma service with either one or two black eyes. Of these 2255 patients, 579 were excluded for the following reasons: 8 patients under 16 years were incorrectly admitted to the adult emergency ward, 143 had been injured more than three days before admission, 287 patients had a Glasgow Coma Score lower than 13, and finally, 141 patients had no CT scan because they did not give informed consent (Fig. 1). The group studied, therefore, included 1676 patients, mean (SD) age 51 (22), range 16–99. There were no significant differences in age, sex or nationality among the groups (Table 1). Incidence of fractures In 1144 of the 1676 patients included (68.3%), CT showed a fracture of the maxillofacial skeleton with a black eye as its most obvious sign. Among patients without a fracture,
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
ARTICLE IN PRESS
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Table 1 Personal details of patients who were included and excluded. Data are number (%) of patients except where otherwise stated. Variable
Included patients (n = 1676)
Excluded patients (n = 579)
p value
Mean (SD) age (years) Male sex Swiss nationals
51 (22) 1102 (65.8) 1393 (83.1)
49 (22) 382 (66.1) 478 (82.5)
0.124 0.883 0.761
Table 2 Coexisting signs (%). Clinical sign
Sensitivity
Specificity
PPV
NPV
Diplopia Diminished skin sensation Fracture steps Epistaxis Hyposphagma Emphysema
15 22.2 18.5 15.6 16.3 10.7
98.3 96.4 99.8 95.4 90.4 99.6
95.0 93.0 99.5 88.1 78.6 98.4
35.0 36.6 36.3 34.5 33.4 34.2
diplopia or occulomotility disorders (89.3), fracture steps (99.8), epistaxis (95.5), subconjunctival haemorrhage (90.4), and emphysema (99.6). On the other hand, sensitivity for the same signs ranged from only 10.8 to 22.2 (Table 2). No significant differences were found in the incidence of the following symptoms: nausea, vomiting, loss of consciousness, amnesia or facial pain. There was also no significant correlation for the following signs: pain on ocular movement, swelling, tenderness on palpation, anisocoria, facial skin lacerations, otorrhoea or liquorrhoea, or coexisting injuries to the upper or lower limb. Logistic regression found no further significant associations with the presence or absence of a facial fracture. Falls from less than 2 m (including seizures) (p < 0.001) and punches (p = 0.004) were significantly associated with the absence of a fracture. On the other hand, bicycle accidents were highly likely to be associated with the presence of a facial fracture (p < 0.001). However, effect sizes were weak and the mechanism of accident does not improve sensitivity for facial fractures in this large group of patients. Fig. 1. Algorithm of selection of patients.
Implications for treatment 532 (41.5%) were female, which is significantly more than expected, although the effect size was low (Cramer V = 0.1). There were no significant differences in age, nationality, and incidence of fractures. Of the 1144 patients with a black eye and a fracture, 756 had an isolated fracture (66.1%) and 388 had multiple fractures (33.9%). Overall, the distribution of fracture lines showed a clear concentration in the lateral midfacial skeleton (Fig. 2). Mandibular fractures were mainly seen in multiple fractures of the facial skeleton; an isolated mandibular fracture was found in only 11 patients. A black eye in these cases is probably the result of coexisting damage to the soft tissue that did not result in a midfacial fracture. Coexisting symptoms and signs Specificity (%) for facial fractures was particularly high for the following clinical signs: diminished skin sensation (96.4),
All the 1144 patients who presented with one or two black eyes and a maxillofacial fracture were given antibiotic prophylaxis and were instructed not to blow the nose for 2 weeks. A total of 645 patients (56.4%) required open or closed treatment of the fracture. Seventy additional patients (6.1%) needed prolonged bed rest because of an undisplaced fracture of the skull base.
Discussion Midfacial fractures are discovered in 5% of the injuries admitted to emergency departments.12 The black eye is likely to be the main sign of an underlying fracture of the bony orbit when other signs may be camouflaged by swollen soft tissue. Several authors have pointed this out.1,13 Bogusiak and
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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Fig. 2. Distribution of 2945 fractures in 1144 patients (numbers in parentheses indicate subsets).
Arkuszewski2 described periorbital ecchymosis in 90.6% of 468 patients with zygomaticomaxillary complex fractures, Rhim et al. stated that 84.4% of 45 patients with fractures of the orbital floor had a black eye on initial evaluation, and Brasileiro and Passeri found periorbital ecchymosis in 72.4% of 390 patients with fractures of the paranasal sinus at the time of their first attendance.2,10,14 To our knowledge no study has addressed the opposite question: how many patients with a black eye have an underlying fracture? The most salient result of our analysis was that more than two-thirds of all patients included had a facial fracture on CT. All other statistics, including regression analysis, proved to be ineffective in the light of this result. Can we therefore conclude that all patients with blunt facial trauma and minor head injuries who present with a black eye need a CT? Yadav et al. investigated different clinical signs as a predictor for fractures of the facial bones in a similar setting.15 They included patients over 18 years of age with blunt orbital trauma who were due to have an orbital CT scan, and the black eye was one of 15 signs and symptoms related to orbital trauma. Even though this study focused only on blunt trauma to the orbit, the results contradict the findings of our study. Of 2262 patients with blunt orbital trauma, only 1270 presented with periorbital ecchymosis. No more than 271 of these (21.3%) had an underlying fracture of one of the bones constituting the orbit. There are some possible explanations for this. Yadav et al. conducted a prospective study to create a risk score to identify patients at low risk. Nevertheless, these large differences cannot be explained only by differences in the design of the study. The patients selected in our study were all patients with a black eye and with a GCS of 13 or more. Exclusion by GCS score was not mentioned in Yadav’s study. In addition to that, the level of the trauma
centre was different. One must assume that in Switzerland lower level trauma centres and general practitioners manage many patients with mild head injury. For these reasons, the two studies cannot be compared. The fact that 645 (56.4%) of all patients studied had open repair of the orbital floor or other facial fractures emphasises the importance of the accurate diagnosis of such fractures. It is beyond the scope of this paper to describe the indications for all types of facial fractures treated at our centre. In our study minimally displaced fractures of the orbital floor are the most common diagnosis in patients who present with a black eye. There is no clear consensus on the surgical management of these fractures.16 In these cases, the indication for open surgery is often dictated by both clinical and radiological findings.17 We found over a 10-year period that the size of the fracture on CT was increasingly given more weight than clinical signs for decision on the early repair of isolated fractures of the orbital floor. This makes further analysis of the number of cases operated on unreasonable, as it would be a self-fulfilling prophecy. Some authors have postulated that the orbital floor can be repaired up to 12–14 days after injury, when there is no compression of the orbital contents.18,19 This procedure is followed in some trauma centres, and may be a reasonable approach. However, in an acute trauma centre the most common question is whether a protocol of CT of the face should be added to that of a cranial CT or not.9 Another important fact is that there are therapeutic consequences even if the fracture does not need open reduction. All our 1144 patients who presented with one or two black eyes and a maxillofacial fracture were given antibiotic prophylaxis and were instructed not to blow the nose for two weeks. Seventy additional patients needed prolonged bed rest because of an undisplaced fracture
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
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of the skull base. That is why we emphasise the importance of a prompt diagnostic CT in patients with minor head trauma presenting as a black eye. Conflicts of interest The authors have no relevant financial information or potential conflicts of interest to disclose. References 1. Key SJ, Dhariwal DK, Patton DW. Beware the black eye. Trauma 2002;4:237–45. 2. Bogusiak K, Arkuszewski P. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 2010;21:1018–23. 3. Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398–403. 4. Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers 1980–2000. Otolaryngol Head Neck Surg 2004;130:164–70. 5. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures: a 12-year study of 391 patients. J Craniofac Surg 2009;20:1218–23. 6. Abdeen N, Chakraborty S, Nguyen T, et al. Comparison of image quality and lens dose in helical and sequentially acquired head CT. Clin Radiol 2010;65:868–73. 7. Zammit-Maempel I, Chadwick CL, Willis SP. Radiation dose to the lens of eye and thyroid gland in paranasal sinus multislice CT. Br J Radiol 2003;76:418–20.
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8. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6. 9. Holmgren EP, Dierks EJ, Homer LD, Potter BE. Facial computed tomography use in trauma patients who require a head computed tomogram. J Oral Maxillofac Surg 2004;62:913–8. 10. Rhim CH, Scholz T, Salibian A, Evans GR. Orbital floor fractures: a retrospective review of 45 cases at a tertiary health care center. Craniomaxillofac Trauma Reconstr 2010;3:41–7. 11. Spiessl B, Schroll K. The facial skeleton. In: Nigst H, editor. Specific fractures and luxations (in German). Stuttgart: Thieme; 1972. 12. Smith H, Peek-Asa C, Nesheim D, et al. Etiology, diagnosis, and characteristics of facial fracture at a midwestern level I trauma center. J Trauma Nurs 2012;19:57–65. 13. Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 4: orbital floor and midface fractures. Emerg Med J 2007;24:292–3. 14. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28–34. 15. Yadav K, Cowan E, Haukoos JS, et al. Derivation of a clinical risk score for traumatic orbital fracture. J Trauma Acute Care Surg 2012;73:1313–8. 16. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 2002;109:1207–10. 17. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:149–53. 18. Matteini C, Renzi G, Becelli R, Belli E, Ianetti G. Surgical timing in orbital fracture treatment: experience with 108 consecutive cases. J Craniofac Surg 2004;15:145–50. 19. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–40.
Please cite this article in press as: Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.018
