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BACKGROUND: Facial trauma is common, with over 150,000 patients presenting to the emergency room annually. While it is common practice to use CT scan as a preliminary tool to diagnose facial skeletal injury, the physical exam remains an important component of the patient evaluation. In patients where imaging is not available or must be delayed, knowing the predictive value of exam findings can allow for improved triage and planning. A prospective clinical study was undertaken to assess the predictive value of physical exam findings in detecting maxillofacial fracture in trauma patients.
METHODS: From June 2013 to April 2014, the plastic surgery and oral and maxillofacial services examined patients admitted with facial trauma to the emergency department of Stony Brook University Hospital. Patients were excluded if their trauma had occurred greater than one day prior to admission, if they had active facial infection at the time of examination, were intubated, had temporal or frontal bone fracture diagnosed at an outside facility, or if consent was not obtainable. The evaluating physician completed a standardized physical exam evaluation form, prior to the CT scan, indicating the type and location of the physical findings. If a CT Scan had been performed, the examiner was blinded to the results. Corresponding CT scans were then reviewed and findings recorded by a plastic surgeon who was blinded to the results of the forms and had not evaluated any of the patients. Sensitivity, specificity, and predictive values of physical exam findings in the six major fracture areas were determined using radiographic findings as control.
RESULTS: A total of 53 patients met our inclusion criteria. There were 40 male and 13 female patients. The sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV] of grouped physical exam findings were determined in major areas (Table 1). In further analysis, specific exam findings with n >/= 9 are reported in Table 2.
CONCLUSIONS: The physical exam findings of dental malocclusion, subconjunctival hemorrhage, and cheek flatness are more likely to indicate underlying fracture with PPV all >75%. Based on the high NPV for all the major fracture areas (Mandible, Maxilla, Nasoethmoidal, Nose, Orbital Floor, Zygoma), the data indicates that routine imaging to diagnose facial fractures should be reconsidered. These findings justify further collection of data in the hopes of improving the power of the study, as well as to assess inter-rater reliability of the physical exam evaluation form in the use of diagnosing or excluding possible facial fractures in trauma patients.

Table 1: The Incidences and Predictive Values of Grouped Physical Exam Findings for Major Areas

Grouped Positive Findings: Major Area	Physical Exam Incidence	CT Negative: n (%)	CT Positive: n (%)	PPV	NPV	Sensitivity	Specificity
Mandible	26 (49.1%)	12 (30.8%)	14 (100%)	53.8%	100.0%	100.0%	69.2%
Maxilla	3 (5.7%)	2 (4.26%)	1 (20%)	33.3%	91.8%	20.0%	95.7%
Nasoethmoidal	3 (5.7%)	2 (3.85%)	1 (100%)	33.3%	100.0%	100.0%	96.2%
Nose	14 (24.5%)	6 (13.3%)	7 (87.5%)	53.8%	97.5%	87.5%	86.7%
Orbital Floor	20 (37.7%)	6 (18.8%)	17 (81%)	73.9%	86.7%	81.0%	81.3%
Zygoma	18 (34.0%)	14 (37.8%)	14 (87.5%)	50.0%	92.0%	87.5%	62.2%

Table 2: The Incidences and Predictive values of High Frequency Physical Exam Findings

Major Area	Positive Physical Exam Findings	Physical Exam Incidence: n (%)		CT Negative: n (%)	CT Positive: n (%)	PPV	NPV	Sensitivity	Specificity
Mandible	Dental Malocclusion	17 (32.1%)		4 (10.3%)	13(92.9%)	76.5%	97.2%	92.9%	89.7%
Mandible	Intraoral Gingival Laceration	11 (20.8%)		4 (10%)	7(50.0%)	63.6%	83.3%	50.0%	89.7%
Mandible	Tenderness	19 (35.8%)		5 (13%)	14(100.0%)	73.7%	100.0%	100.0%	87.2%
Nasal	Tenderness	12 (22.6%)		5 (11.1%)	7(87.5%)	58.3%	97.6%	87.5%	88.9%
Orbital Floor	Subconjunctival Hemmorrhage	20 (37.7%)		4 (12.5%)	16(76.2%)	80.0%	84.8%	76.2%	87.5%
Orbital Floor	V2 Para/Anesthesia	9 (17.3%)		3 (9.7%)	6 (28.6%)	66.67%	65.12%	28.57%	90.32%
Zygoma	Cheek Flatness	14 (26.4%)		2 (5.4%)	12(75.0%)	85.7%	89.7%	75.0%	94.6%
Zygoma	Subconjunctival Hemmorrhage	20(37.7%)		12 (32.4%)	8(50.0%)	40.0%	75.8%	50.0%	67.6%
Zygoma	V2 Para/Anesthesia	9 (17.3%)		4 (11.1%)	5 (31.3%)	55.6%	74.4%	31.3%	88.9%