Diagnostic accuracy of the tongue blade test combined with clinical signs to detect maxillary and mandibular fractures in the emergency department

doi:10.5847/wjem.j.1920-8642.2023.032

Abstract

Abstract:

BACKGROUND: To evaluate the diagnostic accuracy of clinical signs combined with the tongue blade test (TBT) to detect maxillary and mandibular fractures.

METHODS: A cross-sectional study enrolled patients with maxillary and mandibular injuries in the emergency department. Physical examination and the TBT were performed, followed by radiological imaging (facial X-ray or computed tomography [CT]). The diagnostic accuracy was calculated for individuals and a combination of clinical findings at predicting maxillary and mandibular fractures.

RESULTS: A total of 98 patients were identified, of whom 31.6% had maxillary fractures and 9.2% had mandibular fractures. The combination of malocclusion, tenderness on palpation and swelling with positive TBT had 100% specificity to detect maxillary and mandibular fractures. In the absence of malocclusion, the combination of tenderness on palpation and swelling with positive TBT produced a specificity of 97.8% for maxillary fracture and a specificity of 96.2% for mandibular fracture. A clinical decision tool consisting of malocclusion, tenderness on palpation, swelling and TBT revealed a specificity of 100% and a positive predictive value of 100%.

CONCLUSION:The clinical decision tool is potentially useful to rule out mandibular fractures, thus preventing unnecessary radiation exposure.

Key words: Maxillary fractures, Mandibular fractures, Tongue blade test, Diagnostic accuracy, Clinical decision tool, Emergency department

Jee Yen Kuck, Abdul Muhaimin Noor Azhar, Neena Wee, Rishya Manikam. Diagnostic accuracy of the tongue blade test combined with clinical signs to detect maxillary and mandibular fractures in the emergency department[J]. World Journal of Emergency Medicine, 2023, 14(2): 122-127.

Figures/Tables 5

Table 1.

Table 2.

Table 3.

Diagnostic accuracy of clinical examinations for fracture, maxillary fracture and mandibular fracture

Physical examinations	Sensitivity (%) (95% CI)	Specificity (%) (95% CI)	PPV (%) (95% CI)	NPV (%) (95% CI)	+LR (95% CI)	-LR (95% CI)
Fracture
Swelling	85.0 (70.2-94.3)	37.9 (25.5-51.6)	48.6 (42.6-54.6)	78.6 (62.0-89.2)	1.4 (1.1-1.7)	0.4 (0.2-0.9)
Malocclusion	12.5 (4.2-26.8)	100 (93.8-100)	100 (46.3-100)	62.4 (59.6-65.1)	∞	0.9 (0.8-0.9)
Facial asymmetry	12.5 (4.2-26.8)	89.7 (78.8-96.1)	45.5 (21.4-71.8)	59.8 (56.2-63.2)	1.2 (0.4-3.7)	1.0 (0.8-1.1)
Laceration	20.0 (9.1-35.7)	72.4 (59.1-83.3)	33.3 (19.2-51.4)	56.8 (51.3-62.1)	0.7 (0.3-1.5)	1.1 (0.9-1.3)
Tenderness on palpation	95.0 (83.1-99.4)	25.9 (15.3-39.0)	46.9 (42.8-51.1)	88.2 (64.5-96.9)	1.3 (1.1-1.5)	0.2 (0.1-0.8)
Ecchymosis and bruises	52.5 (36.1-68.5)	51.7 (38.2-65.1)	42.9 (33.5-52.7)	61.2 (51.2-70.4)	1.1 (0.7-1.6)	0.9 (0.6-1.4)
Abrasion	50.0 (33.8-66.2)	44.8 (31.7-58.5)	38.5 (29.8-47.9)	56.5 (46.0-66.5)	0.9 (0.6-1.3)	1.1 (0.7-1.7)
TBT	42.5 (27.0-59.1)	93.1 (83.3-98.1)	81.0 (60.7-92.1)	70.1 (64.1-75.6)	6.2 (2.2-16.9)	0.6 (0.5-0.8)
Malocclusion + tenderness on palpation + TBT	12.5 (4.2-26.8)	100 (93.8-100)	100 (46.3-100)	62.4 (59.6-65.1)	∞	0.9 (0.8-1.0)
Maxillary fracture
Swelling	83.9 (66.3-94.6)	31.1 (18.2-46.7)	45.6 (39.5-51.9)	73.7 (52.9-87.5)	1.2 (1.0-1.6)	0.5 (0.2-1.3)
Malocclusion	6.5 (0.8-21.4)	100 (92.1-100)	100 (19.8-100)	60.8 (58.6-63.0)	∞	0.9 (0.9-1.0)
Facial asymmetry	6.5 (0.8-21.4)	86.7 (73.2-95.0)	25.0 (6.7-60.7)	57.4 (53.7-60.9)	0.5 (0.1-2.2)	1.1 (0.9-1.3)
Laceration	12.9 (3.6-29.8)	73.3 (58.1-85.4)	25.0 (10.6-48.4)	55.0 (49.5-60.4)	0.5 (0.2-1.4)	1.2 (1.0-1.5)
Tenderness on palpation	93.5 (78.6-99.2)	20.0 (9.6-34.6)	44.6 (40.4-48.9)	81.8 (51.0-95.1)	1.2 (1.0-1.4)	0.3 (0.1-1.4)
Ecchymosis and bruises	64.5 (45.4-80.8)	44.4 (29.6-60.0)	44.4 (35.6-53.7)	64.5 (50.5-76.4)	1.2 (0.8-1.7)	0.8 (0.5-1.4)
Abrasion	54.8 (36.0-72.7)	37.8 (23.8-53.5)	37.8 (29.1-47.3)	54.8 (41.5-67.6)	0.9 (0.6-1.3)	1.2 (0.7-2.1)
TBT	29.0 (14.2-48.0)	93.3 (81.7-98.6)	75.0 (46.9-91.1)	65.6 (60.1-70.8)	4.4 (1.3-14.8)	0.8 (0.6-1.0)
Malocclusion + tenderness on palpation + TBT	6.5 (0.8-21.4)	100 (92.1-100)	100 (19.8-100)	60.8 (58.6-63.0)	∞	0.9 (0.9-1.0)
Tenderness on palpation + swelling + TBT	19.4 (7.5-37.5)	97.8 (88.2-99.9)	85.7 (43.2-97.9)	63.8 (59.6-67.8)	8.7 (1.1-68.8)	0.8 (0.7-1.0)
Tenderness on palpation + TBT	29.0 (14.2-48.0)	93.3 (81.7-98.6)	75.0 (46.9-91.1)	65.6 (60.1-70.8)	4.4 (1.3-14.8)	0.8 (0.6-1.0)
Mandibular fracture
Swelling	88.9 (51.8-99.7)	34.6 (17.2-55.7)	32.0 (24.7-40.4)	90.0 (56.8-98.4)	1.4 (1.0-2.0)	0.3 (0.1-2.2)
Malocclusion	33.3 (7.5-70.1)	100 (86.8-100)	100 (31.0-100)	81.3 (73.2-87.3)	∞	0.7 (0.4-1.1)
Facial asymmetry	33.3 (7.5-70.1)	92.3 (74.9-99.1)	60.0 (22.9-88.4)	80.0 (71.3-86.6)	4.3 (0.9-21.9)	0.7 (0.5-1.2)
Laceration	44.4 (13.7-78.8)	61.5 (40.6-79.8)	28.6 (14.3-49.0)	76.2 (62.4-86.1)	1.2 (0.5-2.8)	0.9 (0.5-1.7)
Tenderness on palpation	100 (66.4-100)	38.5 (20.2-59.4)	36.0 (29.3-43.3)	100 (65.5-100)	1.6 (1.2-2.2)	1/∞
Ecchymosis and bruises	11.1 (0.3-48.3)	61.5 (40.6-79.8)	9.1 (1.5-40.3)	66.7 (57.7-74.6)	0.3 (0.0-2.0)	1.4 (1.0-2.1)
Abrasion	33.3 (7.5-70.1)	46.2 (26.6-66.6)	17.6 (7.4-36.6)	66.7 (51.8-78.8)	0.6 (0.2-1.7)	1.4 (0.8-2.7)
TBT	88.9 (51.8-99.7)	92.3 (74.9-99.1)	80.0 (50.9-93.9)	96.0 (79.0-99.4)	11.6 (3.0-44.6)	0.1 (0.0-0.8)
Malocclusion + tenderness on palpation + TBT	33.3 (7.5-70.1)	100 (86.8-100)	100 (31.0-100)	81.3 (73.2-87.3)	∞	0.7 (0.4-1.1)
Tenderness on palpation + swelling + TBT	77.8 (40.0-97.2)	96.2 (80.4-99.9)	87.5 (49.8-98.0)	92.6 (78.6-97.7)	20.2 (2.9-142.6)	0.2 (0.1-0.8)
Tenderness on palpation + TBT	88.9 (51.8-99.7)	92.3 (74.9-99.1)	80.0 (50.9-93.9)	96.0 (92.3-99.8)	11.6 (3.0-44.6)	0.1 (0.0-0.8)

Table 3.

Figure 1.

Figure 2.

References 10

[1]	Al-Hassani A, Ahmad K, El-Menyar A, Abutaka A, Mekkodathil A, Peralta R, et al. Prevalence and patterns of maxillofacial trauma: a retrospective descriptive study. Eur J Trauma Emerg Surg. 2022; 48(4):2513-9. doi: 10.1007/s00068-019-01174-6
[2]	Rahman RA, Hussaini HM, Rahman NA, Rahman SR, Nor GM, Ai Idrus SM, et al. Facial fractures in Kajang Hospital, Malaysia: a 5-year review. Eur J Trauma Emerg Surg. 2007; 33(1):90-5. doi: 10.1007/s00068-007-5154-5
[3]	Qiu M, Barberi A, Lee K. Facial trauma: epidemiology, demographics and fracture patterns. Int J Oral Maxillofac Surg. 2017; 46:234-5.
[4]	Caputo ND, Raja A, Shields C, Menke N. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? J Emerg Med. 2013; 45(1):8-12. doi: 10.1016/j.jemermed.2012.11.078 pmid: 23490109
[5]	Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J Emerg Med. 1995; 13(3):297-304. pmid: 7673618
[6]	Malhotra R, Dunning J. The utility of the tongue blade test for the diagnosis of mandibular fracture. Emerg Med J. 2003; 20(6):552-3. pmid: 14623851
[7]	Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue blade bite test predicts mandible fractures. Craniomaxillofac Trauma Reconstr. 2016; 9(2):121-4. doi: 10.1055/s-0035-1567812 pmid: 27162567
[8]	Schwab RA, Genners K, Robinson WA. Clinical predictors of mandibular fractures. Am J Emerg Med. 1998; 16(3):304-5. pmid: 9596439
[9]	Rozema R, El Moumni M, de Vries GT, Spijkervet FKL, Verbeek R, Kleinbergen JYJ, et al. REDUCTION study group. A clinical decision aid to discern patients without and with midfacial and mandibular fractures that require treatment (the REDUCTION-II study): a prospective multicentre cohort study. Eur J Trauma Emerg Surg. 2022; 48(4):2547-58. doi: 10.1007/s00068-022-01892-4
[10]	Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform. 2014; 48:193-204. doi: 10.1016/j.jbi.2014.02.013 pmid: 24582925

Characteristics	Values
Age, years, median (IQR)	32 (23.00-50.25)
Gender, n (%) Male Female	74 (75.5) 24 (24.5)
Occupation, n (%) Professional Non-professional Unemployed	26 (26.5) 42 (42.9) 30 (30.6)
Mechanism of injury, n (%) Road traffic accident Fall Assault Struck by object Burn/explosion	63 (64.3) 25 (25.5) 6 (6.1) 3 (3.1) 1 (1.0)
Location of facial injury, n (%) Maxillary region Mandibular region Both region	Fracture	Soft tissue injury
	31 (31.6) 9 (9.2) 0 (0.0)	32 (32.7) 13 (13.3) 13 (13.3)
Referral to OMFS, n (%) Maxillary fracture Mandibular fracture Soft tissue injury	31 (100) 9 (100) 23 (39.7)

Clinical findings	Fracture (n=40)	STI (n=58)	OR	P-value
Total
Swelling	34	36	3.46	0.014**
Malocclusion	5	0	18.13	0.006*
Facial asymmetry	5	6	1.24	0.740**
Laceration	8	16	0.66	0.391**
Tenderness on palpation	38	43	6.63	0.007**
Ecchymosis and bruises	21	28	1.18	0.681**
Abrasion	20	32	0.81	0.614**
TBT	17	4	9.98	<0.001**
Malocclusion + tenderness on palpation + TBT	5	0	18.13	0.006*
Maxillary region	(n=31)	(n=45)
Swelling	26	31	2.35	0.138**
Malocclusion	2	0	7.71	0.084*
Facial asymmetry	2	6	0.45	0.337*
Laceration	4	12	0.41	0.148*
Tenderness on palpation	29	36	3.63	0.099**
Ecchymosis and bruises	20	25	1.45	0.435**
Abrasion	17	28	0.74	0.520**
TBT	9	3	5.73	0.009*
Malocclusion + tenderness on palpation + TBT	2	0	7.71	0.084*
Tenderness on palpation + swelling + TBT	6	1	10.56	0.011*
Tenderness on palpation + TBT	9	3	5.73	0.009*
Tenderness on palpation + swelling	24	25	2.74	0.290*
Mandibular region	(n=9)	(n=26)
Swelling	8	17	4.24	0.179**
Malocclusion	3	0	28.54	0.002**
Facial asymmetry	3	2	6.00	0.058*
Laceration	4	10	1.28	0.752*
Tenderness on palpation	9	16	12.09	0.028**
Ecchymosis and bruises	1	10	0.20	0.128*
Abrasion	3	14	0.43	0.289*
TBT	8	2	96.00	<0.001*
Malocclusion + tenderness on palpation + TBT	3	0	28.54	0.002*
Tenderness on palpation + swelling + TBT	7	1	87.50	<0.001*
Tenderness on palpation + TBT	8	2	96.00	<0.001*
Tenderness on palpation + swelling	8	13	8.00	0.040*

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