2017-18 HSC Section 3 Green Book

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T.N. Mansour et al. / American Journal of Emergency Medicine 35 (2017) 112 – 116

BOF >50% Test Predictiveness of Surgery

Average CCD Test Predictiveness of Surgery

Positive Test

Positive Test(>0.8)

Negative Test

Negative Test(<0.8)

5 Number of Subjects

Number of Subjects

Yes

Underwent Surgery

Fig. 2. Test predictiveness of surgery using greater than 50% fl oor fracture size.

Fig. 4. Test predictiveness of surgery using CCD calculation.

0.8 cm, 8 patients underwent surgery, whereas 2 did not, resulting in a speci fi city of 92% and a PPV of 80% ( Fig. 4 ). Given the accuracy in using the CCD to predict the likely need for surgery, interreader variability was measured to assess reproducibility. Using CCD measurements taken individually by both the neuroradiolo- gist and oculoplastic surgeon, the authors were able to con fi dently pre- dict the need for surgery. Taheri prediction resulted in a sensitivity of 100%, speci fi city of 92%, PPV of 80%, and NPV of 100%. Mansour predic- tions resulted in a sensitivity of also 100%, speci fi city of 96%, PPV of 89%, and NPV of 100%. Therefore, both authors were able to accurately pre- dict which patients would not likely require surgery. κ Agreement be- tween Taheri and Mansour with 95% con fi dence interval was noted at 0.9262. Test predictiveness of surgery by both authors is pictorially depicted in the both Figs. 5 and 6 . At the time of the initial clinical examination of the surgical candi- dates, 1 patient exhibited signi fi cant enophthalmos with no other fi nd- ings, 2 exhibited enophthalmos as well as diplopia, and 5 complained of only double vision and were not found to have enophthalmos. It is well established that blunt trauma to the eye results in an anterior-posterior force that causes a buildup in orbital pressure through the orbit [4] . This pressure is subsequently released with the blow-out of one or more of the orbital walls, most commonly the orbital fl oor and then themedial wall. This mechanismprotects the eye and the brain from further injury in many instances. It is also well established that orbital fractures may need surgery within the fi rst 1-2 weeks to avoid dif fi cult repair, further muscle 4. Discussion

damage from ischemia, better functionality, and overall improved aes- thetic results [5-7] . The exact timing has been an ongoing debate and al- though some authors article have advocated early surgery (within 1-2 weeks), others have noted no difference in repair outcomes if per- formed later between 2 and 4 weeks [8] . Proponents of early surgical in- tervention suggest early surgery to prevent scarring or ischemia from playing a factor in outcomes. On the other hand, delayed surgery advo- cates suggest waiting to allow the orbit time to “ decompress ” from the build-up pressure to adequately assess the need for surgery. Only then will adequate clinical judgment be made and perhaps spare the patient unnecessary surgery. However, it is well established that delayed repair (between 2 and 4 weeks) can result in scarring and potentially compli- cate any surgical attempts. Most studies will agree that delayed repair is more technically challenging, albeit generally effective [8] . Previous studies have used CT data to predict delayed onset of enophthalmos [9,10] . Others have attempted to correlate postoperative ocular motility de fi cits after trauma and in the process developed a categorization of fracture types to predict those at greater risk [11] . In- dications of the need for early surgical intervention have also been stud- ied. Banerjee et al [12] looked at the rounding of the IR muscle in the orbital fracture as an indication of periorbital disruption and possibly a predictor for the need for early surgical repair to prevent delayed enophthalmos. Higashino et al [13] looked at orbital fl oor size and orbit- al volume analysis from CT scans to better predict the patients' progno- sis as it relates to enophthalmos primarily. They came up with a treatment algorithm for orbital fractures based on CT scan fi ndings pri- marily looking at the fracture width and the degree of protrusion of the IR muscle into the maxillary sinus [13] . Schouman et al [14] also found

R.T. Test Predictiveness of Surgery

IMS Test Predictiveness of Surgery

Positive Test(IMS inv)

Positive Test

Negative Test

Negative Test(No IMS)

5 Number of Subjects

Number of Subjects

Yes

Underwent Surgery

Fig. 3. Test predictiveness of surgery using ±IMS involvement.

Fig. 5. Reza Taheri test predictiveness of surgery using calculated CCD.

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