Predictive Value of Wisconsin Criteria in Trauma

Predictive Value of Wisconsin Criteria in Trauma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictive Value of Wisconsin Criteria in Trauma Ugur Guloksuz, Okan Gunaydin, Huseyin Koray Kilic, Huseyin Avni Demir, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9382777/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Introduction: Maxillofacial injury is seen in 20–25% of trauma patients and has an important role in trauma-induced morbidity and mortality. The aim of this study is to define the effectiveness of Wisconsin Criteria in our country to determine the need for computed tomography (CT) in maxillofacial traumas. Methods The data of 782 trauma patients who applied to our Emergency Departmant between July 2010 and July 2015, and who underwent maxillofacial and cranial CT, were retrospectively evaluated. Of these patients, 439 met the criteria and were included in the study. Results The median age of the patients was 37 years and 73.3% were male. The maxillofacial fracture was found in 62.6% (n = 275). There was a significant difference in terms of gender, loss of consciousness, limited gaze, and tenderness over the zygoma between patients with and without fracture as a result of CT imaging (p < 0.05 for each comparison). When evaluated for the Wisconsin Criteria for maxillofacial fractures; its sensitivity was 78.1%, its specificity was 70.7%, its PPV was 78.5%, and its NPV was 70.3%. Conclusions In our study, we examined clinical markers that would guide the determination of maxillofacial CT indications in maxillofacial trauma patients. We believe that the revision of Wisconsin Criteria’s should be considered by addition of clinical findings such as loss of consciousness, limited gaze, and tenderness over the zygoma, which were found to be statistically significant in our study. Also, our study is a validation study of the Wisconsin Criteria for the Turkish population. Maxillofacial computed tomography maxillofacial trauma Wisconsin Criteria INTRODUCTION Maxillofacial injury has an important role in trauma-induced morbidity and mortality ( 1 , 2 ). Maxillofacial injury is seen in 20–25% of trauma patients ( 3 , 4 ). They can be isolated or associated with cranial, cervical, or other serious injuries. These patients should be rapidly evaluated in emergency departments, and diagnostic imaging should be performed in patients with suspected maxillofacial trauma ( 5 – 7 ). Due to the complex anatomy of the maxillofacial region, not only it is difficult to evaluate with plain X-rays but also they have low sensitivity. Maxillofacial Computed Tomography (CT) is the gold standard for the diagnosis of maxillofacial fracture ( 8 – 10 ). The use of CT causes long-term side effects, increased cost, and workload due to radiation exposure ( 11 ). There are no validated evidence-based guidelines for identifying who should undergo maxillofacial CT when evaluating patients with maxillofacial trauma. Therefore, unnecessary CT scans may be performed or pathologies may not be detected ( 12 ). The Wisconsin Criteria (periorbital swelling or contusion, Glasgow Coma Scale (GCS) < 14, cascading or instability, malocclusion, and tooth loss), established in the study of Sitzman et al. seems useful ( 13 ). These five physical examination findings in the criteria; was determined based on retrospective studies that found a relationship between these findings and facial fractures. However, it is not clear whether the criteria are generalizable outside of Wisconsin ( 14 ). The aim of this study is to determine the effectiveness of the Wisconsin Criteria in our country to determine the need for CT in maxillofacial trauma and to evaluate the relationship between other clinical findings and maxillofacial CT results. In this respect, our study is a validation study of the Wisconsin Criteria for the Turkish population. METHODS This study was planned as a retrospective clinical study and was carried out in a university emergency department between 16/07/2010-15/07/2015 after obtaining the approval of the local ethics committee. All patients who were admitted to the emergency department with maxillofacial trauma and evaluated by CT were included in the study. Those who were referred from another center, patients under the age of 18, patients with missing database records, and penetrating injuries were not included in the study. Patients' age, gender, blood alcohol level, GCS ( 15 ), AVPU (Alert-Verbal-Painless-Unresponsive) scale ( 16 ), intubation status on arrival, mechanism of injury, history of previous cranial-cervical operation or injury, loss of consciousness, whether or not using seat belt and helmet, physical examination findings and maxillofacial, cranial and cervical CT results were recorded in the study form. In maxillofacial CT, sections were taken in the caudocranial direction from the inferior of orbita to the apex of the cranium for cranial CT and from the inferior of the mandible to the superior of frontal sinus for maxillofacial CT. The section thickness of serial axial images in tomography was 0.625 mm. Multiplanar; axial, sagittal, and coronal images were interpreted and reported by Gazi University Faculty of Medicine, Radiology Department faculty academic members. During the five-year study period, the number of patients who applied to our emergency department due to trauma and underwent maxillofacial and cranial CT was 782. Of these patients, 439 met the criteria and were included in the study. According to the Wisconsin criteria, if the patient does not meet any of the criteria, there is no need for imaging, while if he meets even one, he should be evaluated with maxillofacial CT. In our study, we examined the Wisconsin criteria and other clinical findings to predict pathologies and if they can reduce unnecessary imaging. Statistical Analysis: Statistical analyses were performed using the SPSS software version 16. The variables were investigated using visual (histograms, probability plots) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk’s test) to determine whether or not they are normally distributed. Descriptive analyses were presented using means and standard deviations for normally distributed variables, medians, and range for the non-normally distributed and ordinal variables, frequencies for the categorical variables. In the comparisons between groups, the Student's t-test was used for normally distributed variables, the Mann-Whitney U test for non-normally distributed variables and ordinal variables, and the Chi-square or Fisher tests for categorical variables were used. A 2x2 table was used to calculate sensitivities, specificities, negative predictive values (NPV), and positive predictive values (PPV) of the Wisconsin criteria, and other clinical findings in the detection of facial fractures were calculated against maxillofacial CT as the gold standard. A p-value of less than 0.05 was considered to show a statistically significant result. RESULTS The median age of the patients included in the study was 37 years (range, 19–94), and 73.3% of the patients were male. Considering the mechanism of patient injury; while the most common ones were interpersonal violence with 31.7% and falling from a height with 29.8%, the least common were motorcycle and bicycle accidents (0.9%) (Table 1 ). Table 1 Distribution of Descriptive and Clinical Characteristics of the Patients Age (year) n (%) Mean±Standard Deviation 43,21 ± 18,34 Median (min-max) 37 (19–94) Gender Male 322 (73,3) Female 117 (26,7) Injury Mechanism Beat 139 (31,7) Falling from high 131 (29,8) Motor vehicle accident 97 (22,1) Pedestrian 34 ( 7 , 7 ) Workplace accident 17 ( 3 , 9 ) Sport accident 9 ( 2 , 1 ) Motorcycle accident 8 ( 1 , 8 ) Bicycle 4 (0,9) Values are given in numbers and percentages n (%) The maxillofacial fracture was found in 62.6% of the patients (n = 275). The orbital fracture was the most common with 34.9% (n = 153) and maxillary sinus fracture with 30.1% (n = 132) among simple fractures. Considering the complex fractures; while 3.2% (n = 14) of the patients had nasofrontoethmoidal fractures and only 1 (0.2%) had Le Fort II fracture, no Le Forte I and III fractures were found. Isolated nasal bone and maxillary sinus fractures were detected in 224 (51%) patients, and these patients were excluded because they did not require maxillofacial CT in the treatment management. Subsequent evaluations were made on 224 patients with fractures requiring maxillofacial CT (Table 2 ). Table 2 Distribution of Maxillofacial Fractures by Computed Tomography Results Simple Fractures n (%) Orbital fracture 153 (34,9) Maxillary sinus fracture 132 (30,1) Nasal arch fracture 101 (23,0) Zygomatic arch fracture 63 ( 14 , 4 ) Frontal sinus fracture 42 ( 9 , 6 ) Alveolar bone fracture 18 ( 4 , 1 ) Complex Fractures Nasofrontoethmoidal fracture 14 ( 3 , 2 ) Zygomaticomaxillary complex fracture 6 ( 1 , 4 ) Orbital roof and ring fracture 6 ( 1 , 4 ) Nasomaxillary junction fracture 4 (0,9) Le Forte Fractures 1 0 2 1 (0,2) 3 0 Mandible Fractures 41 ( 9 , 3 ) Others 21 ( 4 , 8 ) Fractures in CT 275 (62,6) Fractures Requiring CT* 224 (51,0) * Direct radiography is considered sufficient for the diagnosis of isolated nasal arch and maxillary sinus fractures and/or CT does not affect the treatment approach. Therefore, the number and percentage of patients after excluding these fractures are given. Values are given in numbers and percentages n (%) CT: Computed Tomography Some descriptive and clinical features were evaluated according to the fracture detection status in maxillofacial CT. Among the patients included in the study, there was a significant difference in terms of gender (p < 0.001) and loss of consciousness (p = 0.049) between patients with and without fracture as a result of CT imaging. The percentage of men and those with loss of consciousness among patients with fractures as a result of CT was significantly higher than those without fractures. On the other hand, age (p = 0.946), mechanism of injury (p = 0.065), presence of intubation at presentation (p = 0.998), alcohol status (p = 0.488), and blood alcohol levels (p = 0.520) of patients with and without fractures were similar, there was no statistically significant difference. The GCS < 14 patients were more frequently detected with fracture when compared with GCS ≥ 14 patients (p = 0.012). When the examination findings were evaluated, fracture was more frequent in patients with a positive physical examination finding of bone cascading or instability (p < 0.001), malocclusion (p = 0.001), eye movement disorder (p = 0.028), zygomatic (p = 0.007), nasal (p < 0.001) and maxillary tenderness (p = 0.040), laceration in the nasal (p = 0.015), malar (p = 0.001) and perioral (p = 0.004) regions, presence of contusion in the periorbital or any region (p < 0.001). On the other hand, there was no statistically significant difference was found in patients with or without fracture in terms of hemorrhage (p = 0.905), hematoma (p = 0.156), tooth loss (p = 0.242), facial numbness (p = 0.998), diplopia (p = 0.655), open fracture (0.655), change in vision (p = 0.162), and epistaxis (p = 0.302) (Table 5 ). Table 5 Distribution of Physical Examination Findings According to Any Fracture Detection in Computed Tomography Physical Examination Findings (n = 439) Any Fracture in Computed Tomography p value Yes (n = 275) No (n = 164) n (%*) n (%*) AVPU Score 0,061 Mean±Standard Deviation 1,14 ± 0,52 1,01 ± 0,08 Median (min-max) 1 ( 1 – 4 ) 1 ( 1 – 2 ) GCS Score 0,082 Mean±Standard Deviation 14,53 ± 1,86 14,96 ± 0,27 Median (min-max) 15 ( 3 – 15 ) 15 ( 12 – 15 ) GCS Group 0,012 < 14 14 ( 5 , 1 ) 1 (0,6) ≥ 14 261 (94,9) 163 (99,4) Any Tenderness in Physical Examination 105 (38,2) 69 (42,1) 0,420 Zygomatic 27 ( 9 , 8 ) 31 ( 18 , 9 ) 0,007 Nasal 50 ( 18 , 2 ) 5 (3,0) < 0,001 Maxillary 23 ( 8 , 4 ) 24 ( 14 , 6 ) 0,040 Mandibular 27 ( 9 , 8 ) 18 (11,0) 0,699 Any Laceration in Physical Examination 113 (41,1) 73 (44,5) 0,483 Periorbital 49 ( 17 , 8 ) 21 ( 12 , 8 ) 0,165 Forehead 37 ( 13 , 5 ) 14 ( 8 , 5 ) 0,120 Scalp 20 ( 7 , 3 ) 14 ( 8 , 5 ) 0,632 Nasal 25 ( 9 , 1 ) 5 (3,0) 0,015 Malar 9 ( 3 , 3 ) 18 (11,0) 0,001 Perioral 7 ( 2 , 5 ) 14 ( 8 , 5 ) 0,004 Mandible 10 ( 3 , 6 ) 5 (3,0) 0,743 İntraoral 6 ( 2 , 2 ) 6 ( 3 , 7 ) 0,377 a Any Contusion in Physical Examination 168 (61,1) 63 (38,4) < 0,001 Periorbital 148 (53,8) 39 (23,8) < 0,001 Malar 20 ( 7 , 3 ) 14 ( 8 , 5 ) 0,632 Forehead Nasal 15 ( 5 , 5 ) 11 (4,0) 8 ( 4 , 9 ) 2 ( 1 , 2 ) 0,739 0,144 a Skalp 2 (0,7) 6 ( 3 , 7 ) 0,057 a Mandibular 4 ( 1 , 5 ) 1 (0,6) 0,655 a Zygomatic 1 (0,4) 0 0,998 a Bone cascading or instability 58 ( 21 , 1 ) 4 ( 2 , 4 ) < 0,001 Subconjunctival hemorrhage 16 ( 5 , 8 ) 10 ( 6 , 1 ) 0,905 Malocclusion 23 ( 8 , 4 ) 1 (0,6) 0,001 Tooth loss 15 ( 5 , 5 ) 5 (3,0) 0,242 Hematoma 3 ( 1 , 1 ) 5 (3,0) 0,156 a Eye movement disorder 8 ( 2 , 9 ) 0 0,028 a Facial numbness 5 ( 1 , 8 ) 2 ( 1 , 2 ) 0,998 a Diplopia 4 ( 1 , 5 ) 1 (0,6) 0,655 a Open fracture 4 ( 1 , 5 ) 1 (0,6) 0,655 a Change in Vision 5 ( 1 , 8 ) 0 0,162 a Epistaxis 4 ( 1 , 5 ) 0 0,302 a Face swelling 1 (0,4) 1 (0,6) 0,998 a Ear injury 1 (0,4) 0 0,998 a *Column percentage; a Fisher's Final Test, Statistically significant P -values are written in bold GCS: Glasgow Coma Scale When the sensitivities of the physical examination findings of the patients were evaluated, the ones with the highest sensitivities were any contusion and periorbital contusion with 64.3% and 57.6%, respectively. When the specificities of the physical examination findings were examined, the two most specific findings were malocclusion and GCS < 14 with a rate of 99.4%. When the PPV of the physical examination findings were examined, the highest ones were malocclusion, GCS < 14 and bone cascading and instability with 95.8%, 93.3%, 93.2%, respectively. Considering the NPV of the physical examination findings, the highest ones were periorbital contusion with 56.8% and any contusion with 55.8%. When evaluated for the Wisconsin Criteria for maxillofacial fractures; its sensitivity was 78.1%, its specificity was 70.7%, its PPV was 78.5%, and its NPV was 70.3% (Table 3 ). Table 3 Sensitivity, Specificity, Positive and Negative Predictive Values of Some Physical Examination Findings for Facial Fractures Physical Examination Finding Sensitivity (%) Specificity (%) PPV (%) NPV (%) Face Numbness 2,2 98,8 71,4 42,5 Any Laceration 43,3 55,5 57,1 41,7 Any Contusion 64,3 61,6 69,6 55,8 Cascading or instability 24,6 97,6 93,2 48,6 Malocclusion 10,3 99,4 95,8 44,8 Tooth Loss 6,3 97,0 73,7 43,1 Periorbital Contusion 57,6 76,2 76,8 56,8 GCS < 14 6,3 99,4 93,3 43,7 Wisconsin Criteria 78,1 70,7 78,5 70,3 * PPV: Positive Predictive Value; NPV: Negative Predictive Value GCS: Glasgow Coma Scale The rate of reduction of maxillofacial CT scans if they were taken according to the examination findings and the rate of failure to detect clinically important pathologies were examined. If maxillofacial CT had been taken according to the Wisconsin Criteria, the CT rate would have decreased by 29.9% (n = 116). On the other hand, if CT had been performed according to the Wisconsin Criteria, 12.6% (n = 49) of the maxillofacial fractures would not have been detected. In case of applying the Wisconsin Criteria, 34.7% (n = 17) of the patients whose fractures could not be detected were hospitalized and operated (Table 4 ). Table 4 Reduction Rate of Physical Examination Findings in Computed Tomography and Distribution of Undetected Fractures Physical Examination Findings (n = 388) CT Reduction Rate Undetected Fractures n (%) n (%) Face Numbness 162 (41,8) 219 (56,4) Any Laceration 91 (23,4) 127 (32,7) Any Contusion 101 (26,1) 80 ( 20 , 6 ) Cascading or instability 160 (41,2) 169 (43,6) Malocclusion 163 (42,1) 201 (51,8) Tooth Loss 159 (41,0) 210 (54,1) Periorbital contusion 125 (32,2) 95 (24,5) GKS < 14 163 (42,1) 210 (54,1) Wisconsin Criteria 116 (29,9) 49 ( 12 , 6 ) GCS: Glasgow Coma Scale Values are given in numbers and percentages n (%) DISCUSSION Maxillofacial injury has an important place in trauma-induced morbidity and mortality ( 1 , 2 ). Maxillofacial injuries are seen in a significant proportion of trauma patients, and it is very important to evaluate these patients quickly and appropriately in the emergency department ( 13 , 17 ). Diagnostic imaging is frequently used in emergency departments in patients with suspected maxillofacial trauma. Maxillofacial CT is considered as gold standard in the diagnosis of maxillofacial fractures ( 9 ). However, the issue of which patients should receive CT is still controversial, and there are no globally accepted algorithms on this subject. Therefore, clinical decision guidelines are needed to prevent unnecessary CT scans without missing clinically important pathologies in patients with maxillofacial trauma. The Glasgow Coma Score is the most commonly used scoring system for monitoring the consciousness of trauma patients at the time of admission and afterward. The GCS guides the grading of traumatic brain injury and which patients should undergo brain CT. Sitzman et al. ( 13 ) conducted a study to establish a clinical decision marker for whom maxillofacial CT should be performed in maxillofacial trauma. According to the Wisconsin Criteria, they created in this study, it is stated that GCS can be used among decision markers for determining the indication of imaging in maxillofacial trauma patients. In our study, the role of GCS in determining the requirement of maxillofacial CT in maxillofacial trauma patients were examined, and statistically significant correlation was found between GCS < 14 and maxillofacial fracture. One of the Wisconsin Criteria, GCS < 14, is a guide for maxillofacial CT in maxillofacial trauma, and the results of our study also support this. Low GCS and loss of consciousness at presentation are important markers of maxillofacial injury in trauma patients. All these are also markers of severe trauma, and clinicians need to be careful and keep the examination threshold low in terms of cranial, cervical, and other injuries in addition to maxillofacial injury in these patients ( 18 ). Although there are some single-center studies ( 18 ) showing that loss of consciousness is an important clinical marker in showing maxillofacial fracture, to our humble knowledge there has been no multicenter randomized controlled studies. Similarly, in our study, the relationship between loss of consciousness and maxillofacial fracture was found to be statistically significant. Since the loss of consciousness and low GCS value reduce the reliability of examination findings, the imaging threshold should be kept low for maxillofacial injuries in these cases. In line with the results of this project, loss of consciousness at presentation might be a guide in maxillofacial CT in maxillofacial trauma patients. In a prospective study conducted by Exadaktylos et al. ( 19 ) to establish a clinical decision-maker about who should undergo orbital CT in trauma patients, the sensitivity of periorbital swelling and contusion was 68.6%. In another study on this subject, it was reported that the most common examination finding in patients with maxillofacial fractures was periorbital ecchymosis (68.3%) ( 20 ). In a retrospective study on zygomaticomaxillary complex fractures which was included 468 patients, had been showed that 90.6% of zygomaticomaxillary complex fracture patients had periorbital ecchymosis ( 21 ). It is stated in these three studies that periorbital ecchymosis is a guide for maxillofacial CT in maxillofacial trauma. In our study, periorbital contusion was found in 53.8% of patients with maxillofacial fractures, and the sensitivity of this physical examination finding in detecting maxillofacial fracture is 57.6%. On the other hand, when all physical examination findings were examined, contusion sensitivity anywhere in the maxillofacial region was the examination finding with the highest sensitivity, and the presence of only periorbital contusion was found to be the second most sensitive physical examination finding in terms of showing maxillofacial fracture. The rate of patients with fractures in the absence of periorbital contusion was 24.5%. Examination findings with high sensitivity are preferred to create clinical decision marker and may be a guide for maxillofacial CT in maxillofacial trauma patients with periorbital contusion. Among the physical examination findings, bone cascading or instability in the orbital bones is one of the most specific findings in terms of detecting orbital fractures, and studies have reported that the rate of not detecting orbital fractures is around 45% ( 19 ). Similar to the literature data in our study, the specificity of this finding was 97.6%, and the rate of failure to detect the injury was 43%. Among the other physical examination findings, malocclusion and tooth loss have a high specificity (99.4% and 97%, respectively), and the rate of not detecting orbital fracture is around 50%. When all maxillofacial bone fractures were examined, although there was a significant relationship between bone cascading or instability, malocclusion and maxillofacial fractures, no significant relationship was found with tooth loss. In the light of these data, bone cascading or instability and malocclusion may be a guide for maxillofacial CT for patients with maxillofacial trauma. Sitzman et al ( 17 ) developed Wisconsin Criteria’s in 2015 and reported the sensitivity and NPV of these Criteria’s were 98.2% and 87.8% respectively. They stated that using the Wisconsin Criteria’s could reduce the maxillofacial CT scan by 9.3% in patients presenting with maxillofacial trauma, and clinically significant pathology could not be detected in only 1.8% patients. None of the patients without pathology required surgical treatment. In our study, the sensitivity of the Wisconsin Criteria was 78.1%, while the NPV was found to be 70.3%. In case of using these Criteria’s, the rate of maxillofacial CT withdrawal decreased by 29.9%, while the rate of failure to detect clinically important pathologies was found to be 12.6% (n = 49). Of 49 patients with clinically significant pathological findings that could not be detected according to the Wisconsin Criteria, 34% (n = 17) were treated surgically. Therefore, due to its’ low sensitivity and the inability to detect clinically important pathologies in a significant number of patients (with a rate of 12.6%), using the Wisconsin Criteria’s alone in determining the indication of maxillofacial CT in maxillofacial trauma patients would not be sufficient. In conclusion, in this study, we examined clinical markers that would guide the determination of maxillofacial CT indications in maxillofacial trauma patients. The presence of loss of consciousness at the time of admission is an important guide for maxillofacial CT. GCS < 14, which is one of the Wisconsin Criteria, guides the maxillofacial CT scan for bone cascading or instability, malocclusion, and periorbital contusion. Tooth loss, which is one of the Wisconsin Criteria, was not found to be statistically associated with maxillofacial fracture, and it might be more appropriate to use other findings such as limited gaze or tenderness over the zygoma. Although all Wisconsin Criteria except tooth loss are guiding in maxillofacial CT, the use of Wisconsin Criteria alone does not seem appropriate not only due to its’ low sensitivity but also its’ inability to detect clinically important pathologies. The revision of Wisconsin Criteria’s should be considered by addition of clinical findings such as loss of consciousness, limited gaze, and tenderness over the zygoma, which were found to be statistically significant in our study. In this way, the sensitivity of the Wisconsin Criteria can be increased and missing of clinically important pathologies can be avoided. The results of these studies should be validated with prospective and multicenter studies where the mentioned limitations can be eliminated and their usability as a clinical decision-maker should be evaluated. The most important limitation of this study is that it is a retrospective study and therefore the accuracy of the examination findings cannot be evaluated clearly. As with all retrospective studies, the quality of findings and records might have been affected the results of the study. The exclusion of patients with missing records and penetrating trauma in our study might have caused inevitable selection bias. Another important limitation is that our study was conducted in a single center and the emergency department of a university hospital. Therefore, generalizing the results of the study to all maxillofacial trauma patients and/or other emergency services would not be appropriate. Declarations Author contributions Dr U.G. and Dr M.A.K.designed and conceptualized the study. Dr U.G., Dr O.G., Dr S.U., Dr H.A.D. and Dr S.G. collected and analyzed the data. Dr H.K.K. interpreted the images of tomographies. Dr U.G. and Dr M.A.K. drafted and revised the manuscript for intellectual content. All the authors approved the article to be published. All the authors participated sufficiently in the work to take public responsibility for appropriate portions of the content. The authors alone are responsible for its contents and writing of the article. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Availability of data and materials The data underlying this article will be shared on reasonable request to the corresponding author. Informed consent Written informed consent was not required by research ethics committee as this is a retrospective study without patient intervention and no identifiable patient data have been included in the manuscript. Ethical approval The protocol of the study was approved by the Gazi University Ethics Committee with the number 79/23.11.2015. 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J Craniofac Surg. 2010 Jul;21(4):1018–23. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 May, 2026 Reviews received at journal 11 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviews received at journal 11 May, 2026 Reviewers agreed at journal 02 May, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers invited by journal 30 Apr, 2026 Editor invited by journal 21 Apr, 2026 Editor assigned by journal 17 Apr, 2026 Submission checks completed at journal 17 Apr, 2026 First submitted to journal 10 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9382777","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":636421893,"identity":"09263cbb-73b1-4a6e-be6c-c9362398645e","order_by":0,"name":"Ugur Guloksuz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYPACCwYJEPUBiNnYidMiAdbCOAOkhZkULcw8IDYhLQbn15h9/NomISfZf8b4s82vbfJ8zAyMHz7m4NFy443xbNk2CWNpiRwD49y+24ZtzAzMkjO34dNyxphZsk0icZ4Ej0Fybs9tRqAWNmZeorTwnzE4bNlz256wlvM9xowfgVpmM+QYNjP8uJ1IUIvkDbZiZoZzEsaSM9KKGXsbbie3MTM24/UL3/nDmxl/lNnISQAZH378uW07v7354IePeLQwSCRAowMEGNvAZAMe9UDAf4CB8Qec9we/4lEwCkbBKBiZAACLKkyGGCY1NgAAAABJRU5ErkJggg==","orcid":"","institution":"Ufuk University","correspondingAuthor":true,"prefix":"","firstName":"Ugur","middleName":"","lastName":"Guloksuz","suffix":""},{"id":636421894,"identity":"e3dedff0-63da-4632-b9f1-266066c6083f","order_by":1,"name":"Okan Gunaydin","email":"","orcid":"","institution":"Etlik City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Okan","middleName":"","lastName":"Gunaydin","suffix":""},{"id":636421897,"identity":"d59669c8-45b5-4e6d-8bde-5dbc6cd5f4fb","order_by":2,"name":"Huseyin Koray Kilic","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Huseyin","middleName":"Koray","lastName":"Kilic","suffix":""},{"id":636421904,"identity":"e51490a2-506d-4208-afde-5339f86b6f61","order_by":3,"name":"Huseyin Avni Demir","email":"","orcid":"","institution":"Mehmet Akif İnan Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huseyin","middleName":"Avni","lastName":"Demir","suffix":""},{"id":636421907,"identity":"5eb0016f-e12c-4d99-9b8e-6edbe06b39a5","order_by":4,"name":"Sami Ulusal","email":"","orcid":"","institution":"Edremit State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sami","middleName":"","lastName":"Ulusal","suffix":""},{"id":636421912,"identity":"645ebe79-a1c5-48f3-a5f7-6d8397ee71c4","order_by":5,"name":"Selahattin Guru","email":"","orcid":"","institution":"Ankara City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Selahattin","middleName":"","lastName":"Guru","suffix":""},{"id":636421916,"identity":"02380d5d-8438-463a-ac57-655a20b96947","order_by":6,"name":"Mehmet Akif Karamercan","email":"","orcid":"","institution":"Gazi University","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Akif","lastName":"Karamercan","suffix":""}],"badges":[],"createdAt":"2026-04-10 19:53:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9382777/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9382777/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108814929,"identity":"a7ac5779-fda6-4e7a-9c36-320c2112e825","added_by":"auto","created_at":"2026-05-08 16:20:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":456218,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9382777/v1/da0b16fb-8e7f-4d63-a5e9-2242510088e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePredictive Value of Wisconsin Criteria in Trauma\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMaxillofacial injury has an important role in trauma-induced morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Maxillofacial injury is seen in 20\u0026ndash;25% of trauma patients (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). They can be isolated or associated with cranial, cervical, or other serious injuries. These patients should be rapidly evaluated in emergency departments, and diagnostic imaging should be performed in patients with suspected maxillofacial trauma (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDue to the complex anatomy of the maxillofacial region, not only it is difficult to evaluate with plain X-rays but also they have low sensitivity. Maxillofacial Computed Tomography (CT) is the gold standard for the diagnosis of maxillofacial fracture (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The use of CT causes long-term side effects, increased cost, and workload due to radiation exposure (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e There are no validated evidence-based guidelines for identifying who should undergo maxillofacial CT when evaluating patients with maxillofacial trauma. Therefore, unnecessary CT scans may be performed or pathologies may not be detected (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Wisconsin Criteria (periorbital swelling or contusion, Glasgow Coma Scale (GCS)\u0026thinsp;\u0026lt;\u0026thinsp;14, cascading or instability, malocclusion, and tooth loss), established in the study of Sitzman et al. seems useful (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These five physical examination findings in the criteria; was determined based on retrospective studies that found a relationship between these findings and facial fractures. However, it is not clear whether the criteria are generalizable outside of Wisconsin (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The aim of this study is to determine the effectiveness of the Wisconsin Criteria in our country to determine the need for CT in maxillofacial trauma and to evaluate the relationship between other clinical findings and maxillofacial CT results. In this respect, our study is a validation study of the Wisconsin Criteria for the Turkish population.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e This study was planned as a retrospective clinical study and was carried out in a university emergency department between 16/07/2010-15/07/2015 after obtaining the approval of the local ethics committee. All patients who were admitted to the emergency department with maxillofacial trauma and evaluated by CT were included in the study. Those who were referred from another center, patients under the age of 18, patients with missing database records, and penetrating injuries were not included in the study.\u003c/p\u003e \u003cp\u003ePatients' age, gender, blood alcohol level, GCS (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), AVPU (Alert-Verbal-Painless-Unresponsive) scale (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), intubation status on arrival, mechanism of injury, history of previous cranial-cervical operation or injury, loss of consciousness, whether or not using seat belt and helmet, physical examination findings and maxillofacial, cranial and cervical CT results were recorded in the study form.\u003c/p\u003e \u003cp\u003eIn maxillofacial CT, sections were taken in the caudocranial direction from the inferior of orbita to the apex of the cranium for cranial CT and from the inferior of the mandible to the superior of frontal sinus for maxillofacial CT. The section thickness of serial axial images in tomography was 0.625 mm. Multiplanar; axial, sagittal, and coronal images were interpreted and reported by Gazi University Faculty of Medicine, Radiology Department faculty academic members.\u003c/p\u003e \u003cp\u003eDuring the five-year study period, the number of patients who applied to our emergency department due to trauma and underwent maxillofacial and cranial CT was 782. Of these patients, 439 met the criteria and were included in the study.\u003c/p\u003e \u003cp\u003eAccording to the Wisconsin criteria, if the patient does not meet any of the criteria, there is no need for imaging, while if he meets even one, he should be evaluated with maxillofacial CT. In our study, we examined the Wisconsin criteria and other clinical findings to predict pathologies and if they can reduce unnecessary imaging.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the SPSS software version 16. The variables were investigated using visual (histograms, probability plots) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk\u0026rsquo;s test) to determine whether or not they are normally distributed. Descriptive analyses were presented using means and standard deviations for normally distributed variables, medians, and range for the non-normally distributed and ordinal variables, frequencies for the categorical variables. In the comparisons between groups, the Student's t-test was used for normally distributed variables, the Mann-Whitney U test for non-normally distributed variables and ordinal variables, and the Chi-square or Fisher tests for categorical variables were used. A 2x2 table was used to calculate sensitivities, specificities, negative predictive values (NPV), and positive predictive values (PPV) of the Wisconsin criteria, and other clinical findings in the detection of facial fractures were calculated against maxillofacial CT as the gold standard. A p-value of less than 0.05 was considered to show a statistically significant result.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe median age of the patients included in the study was 37 years (range, 19\u0026ndash;94), and 73.3% of the patients were male. Considering the mechanism of patient injury; while the most common ones were interpersonal violence with 31.7% and falling from a height with 29.8%, the least common were motorcycle and bicycle accidents (0.9%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Descriptive and Clinical Characteristics of the Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026plusmn;Standard Deviation\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43,21\u0026thinsp;\u0026plusmn;\u0026thinsp;18,34\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedian (min-max)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (19\u0026ndash;94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e322 (73,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (26,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInjury Mechanism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBeat\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (31,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFalling from high\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (29,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMotor vehicle accident\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (22,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePedestrian\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWorkplace accident\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSport accident\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMotorcycle accident\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBicycle\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eValues are given in numbers and percentages n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe maxillofacial fracture was found in 62.6% of the patients (n\u0026thinsp;=\u0026thinsp;275). The orbital fracture was the most common with 34.9% (n\u0026thinsp;=\u0026thinsp;153) and maxillary sinus fracture with 30.1% (n\u0026thinsp;=\u0026thinsp;132) among simple fractures. Considering the complex fractures; while 3.2% (n\u0026thinsp;=\u0026thinsp;14) of the patients had nasofrontoethmoidal fractures and only 1 (0.2%) had Le Fort II fracture, no Le Forte I and III fractures were found. Isolated nasal bone and maxillary sinus fractures were detected in 224 (51%) patients, and these patients were excluded because they did not require maxillofacial CT in the treatment management. Subsequent evaluations were made on 224 patients with fractures requiring maxillofacial CT (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Maxillofacial Fractures by Computed Tomography Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eSimple Fractures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOrbital fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153 (34,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMaxillary sinus fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132 (30,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNasal arch fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (23,0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eZygomatic arch fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFrontal sinus fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAlveolar bone fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplex Fractures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNasofrontoethmoidal fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eZygomaticomaxillary complex fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOrbital roof and ring fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNasomaxillary junction fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLe Forte Fractures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMandible Fractures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOthers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFractures in CT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e275 (62,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFractures Requiring CT*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e224 (51,0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e* Direct radiography is considered sufficient for the diagnosis of isolated nasal arch and maxillary sinus fractures and/or CT does not affect the treatment approach. Therefore, the number and percentage of patients after excluding these fractures are given.\u003c/p\u003e \u003cp\u003eValues are given in numbers and percentages n (%)\u003c/p\u003e \u003cp\u003eCT: Computed Tomography\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSome descriptive and clinical features were evaluated according to the fracture detection status in maxillofacial CT. Among the patients included in the study, there was a significant difference in terms of gender (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and loss of consciousness (p\u0026thinsp;=\u0026thinsp;0.049) between patients with and without fracture as a result of CT imaging. The percentage of men and those with loss of consciousness among patients with fractures as a result of CT was significantly higher than those without fractures. On the other hand, age (p\u0026thinsp;=\u0026thinsp;0.946), mechanism of injury (p\u0026thinsp;=\u0026thinsp;0.065), presence of intubation at presentation (p\u0026thinsp;=\u0026thinsp;0.998), alcohol status (p\u0026thinsp;=\u0026thinsp;0.488), and blood alcohol levels (p\u0026thinsp;=\u0026thinsp;0.520) of patients with and without fractures were similar, there was no statistically significant difference. The GCS\u0026thinsp;\u0026lt;\u0026thinsp;14 patients were more frequently detected with fracture when compared with GCS\u0026thinsp;\u0026ge;\u0026thinsp;14 patients (p\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003cp\u003eWhen the examination findings were evaluated, fracture was more frequent in patients with a positive physical examination finding of bone cascading or instability (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), malocclusion (p\u0026thinsp;=\u0026thinsp;0.001), eye movement disorder (p\u0026thinsp;=\u0026thinsp;0.028), zygomatic (p\u0026thinsp;=\u0026thinsp;0.007), nasal (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and maxillary tenderness (p\u0026thinsp;=\u0026thinsp;0.040), laceration in the nasal (p\u0026thinsp;=\u0026thinsp;0.015), malar (p\u0026thinsp;=\u0026thinsp;0.001) and perioral (p\u0026thinsp;=\u0026thinsp;0.004) regions, presence of contusion in the periorbital or any region (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). On the other hand, there was no statistically significant difference was found in patients with or without fracture in terms of hemorrhage (p\u0026thinsp;=\u0026thinsp;0.905), hematoma (p\u0026thinsp;=\u0026thinsp;0.156), tooth loss (p\u0026thinsp;=\u0026thinsp;0.242), facial numbness (p\u0026thinsp;=\u0026thinsp;0.998), diplopia (p\u0026thinsp;=\u0026thinsp;0.655), open fracture (0.655), change in vision (p\u0026thinsp;=\u0026thinsp;0.162), and epistaxis (p\u0026thinsp;=\u0026thinsp;0.302) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Physical Examination Findings According to Any Fracture Detection in Computed Tomography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhysical Examination Findings (n\u0026thinsp;=\u0026thinsp;439)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAny Fracture in Computed Tomography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;275)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;164)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%*)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%*)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAVPU Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026plusmn;Standard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,14\u0026thinsp;\u0026plusmn;\u0026thinsp;0,52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,01\u0026thinsp;\u0026plusmn;\u0026thinsp;0,08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,082\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026plusmn;Standard Deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,53\u0026thinsp;\u0026plusmn;\u0026thinsp;1,86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14,96\u0026thinsp;\u0026plusmn;\u0026thinsp;0,27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian (min-max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e261 (94,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (99,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Tenderness in Physical Examination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e105 (38,2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e69 (42,1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0,420\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZygomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNasal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (11,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Laceration in Physical Examination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e113 (41,1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e73 (44,5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0,483\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriorbital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForehead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNasal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (11,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,743\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eİntraoral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,377\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Contusion in Physical Examination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e168 (61,1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e63 (38,4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriorbital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (53,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (23,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForehead\u003c/p\u003e \u003cp\u003eNasal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e11 (4,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,739\u003c/p\u003e \u003cp\u003e0,144\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkalp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,057\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,655\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZygomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,998\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cascading or instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubconjunctival hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,905\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalocclusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTooth loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,156\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye movement disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,028\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacial numbness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,998\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,655\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,655\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in Vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,162\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpistaxis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,302\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFace swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,998\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEar injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,998\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Column percentage; \u003csup\u003ea\u003c/sup\u003eFisher's Final Test, Statistically significant \u003cem\u003eP\u003c/em\u003e-values are written in bold\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eGCS: Glasgow Coma Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen the sensitivities of the physical examination findings of the patients were evaluated, the ones with the highest sensitivities were any contusion and periorbital contusion with 64.3% and 57.6%, respectively. When the specificities of the physical examination findings were examined, the two most specific findings were malocclusion and GCS\u0026thinsp;\u0026lt;\u0026thinsp;14 with a rate of 99.4%. When the PPV of the physical examination findings were examined, the highest ones were malocclusion, GCS\u0026thinsp;\u0026lt;\u0026thinsp;14 and bone cascading and instability with 95.8%, 93.3%, 93.2%, respectively. Considering the NPV of the physical examination findings, the highest ones were periorbital contusion with 56.8% and any contusion with 55.8%. When evaluated for the Wisconsin Criteria for maxillofacial fractures; its sensitivity was 78.1%, its specificity was 70.7%, its PPV was 78.5%, and its NPV was 70.3% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity, Specificity, Positive and Negative Predictive Values of Some Physical Examination Findings for Facial Fractures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Examination Finding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFace Numbness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Laceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCascading or instability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalocclusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTooth Loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeriorbital Contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS\u0026thinsp;\u0026lt;\u0026thinsp;14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWisconsin Criteria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* PPV: Positive Predictive Value; NPV: Negative Predictive Value\u003c/p\u003e \u003cp\u003eGCS: Glasgow Coma Scale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe rate of reduction of maxillofacial CT scans if they were taken according to the examination findings and the rate of failure to detect clinically important pathologies were examined. If maxillofacial CT had been taken according to the Wisconsin Criteria, the CT rate would have decreased by 29.9% (n\u0026thinsp;=\u0026thinsp;116). On the other hand, if CT had been performed according to the Wisconsin Criteria, 12.6% (n\u0026thinsp;=\u0026thinsp;49) of the maxillofacial fractures would not have been detected. In case of applying the Wisconsin Criteria, 34.7% (n\u0026thinsp;=\u0026thinsp;17) of the patients whose fractures could not be detected were hospitalized and operated (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReduction Rate of Physical Examination Findings in Computed Tomography and Distribution of Undetected Fractures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePhysical Examination Findings\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;388)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCT Reduction Rate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUndetected Fractures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFace Numbness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162 (41,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e219 (56,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Laceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (23,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (32,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny Contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (26,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCascading or instability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (41,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169 (43,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMalocclusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (42,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e201 (51,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTooth Loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e159 (41,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (54,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeriorbital contusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (32,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (24,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGKS\u0026thinsp;\u0026lt;\u0026thinsp;14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (42,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (54,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWisconsin Criteria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (29,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGCS: Glasgow Coma Scale\u003c/p\u003e \u003cp\u003eValues are given in numbers and percentages n (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMaxillofacial injury has an important place in trauma-induced morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Maxillofacial injuries are seen in a significant proportion of trauma patients, and it is very important to evaluate these patients quickly and appropriately in the emergency department (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Diagnostic imaging is frequently used in emergency departments in patients with suspected maxillofacial trauma. Maxillofacial CT is considered as gold standard in the diagnosis of maxillofacial fractures (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the issue of which patients should receive CT is still controversial, and there are no globally accepted algorithms on this subject. Therefore, clinical decision guidelines are needed to prevent unnecessary CT scans without missing clinically important pathologies in patients with maxillofacial trauma.\u003c/p\u003e \u003cp\u003eThe Glasgow Coma Score is the most commonly used scoring system for monitoring the consciousness of trauma patients at the time of admission and afterward. The GCS guides the grading of traumatic brain injury and which patients should undergo brain CT. Sitzman et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) conducted a study to establish a clinical decision marker for whom maxillofacial CT should be performed in maxillofacial trauma. According to the Wisconsin Criteria, they created in this study, it is stated that GCS can be used among decision markers for determining the indication of imaging in maxillofacial trauma patients. In our study, the role of GCS in determining the requirement of maxillofacial CT in maxillofacial trauma patients were examined, and statistically significant correlation was found between GCS\u0026thinsp;\u0026lt;\u0026thinsp;14 and maxillofacial fracture. One of the Wisconsin Criteria, GCS\u0026thinsp;\u0026lt;\u0026thinsp;14, is a guide for maxillofacial CT in maxillofacial trauma, and the results of our study also support this.\u003c/p\u003e \u003cp\u003eLow GCS and loss of consciousness at presentation are important markers of maxillofacial injury in trauma patients. All these are also markers of severe trauma, and clinicians need to be careful and keep the examination threshold low in terms of cranial, cervical, and other injuries in addition to maxillofacial injury in these patients (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Although there are some single-center studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) showing that loss of consciousness is an important clinical marker in showing maxillofacial fracture, to our humble knowledge there has been no multicenter randomized controlled studies. Similarly, in our study, the relationship between loss of consciousness and maxillofacial fracture was found to be statistically significant. Since the loss of consciousness and low GCS value reduce the reliability of examination findings, the imaging threshold should be kept low for maxillofacial injuries in these cases. In line with the results of this project, loss of consciousness at presentation might be a guide in maxillofacial CT in maxillofacial trauma patients.\u003c/p\u003e \u003cp\u003eIn a prospective study conducted by Exadaktylos et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) to establish a clinical decision-maker about who should undergo orbital CT in trauma patients, the sensitivity of periorbital swelling and contusion was 68.6%. In another study on this subject, it was reported that the most common examination finding in patients with maxillofacial fractures was periorbital ecchymosis (68.3%) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In a retrospective study on zygomaticomaxillary complex fractures which was included 468 patients, had been showed that 90.6% of zygomaticomaxillary complex fracture patients had periorbital ecchymosis (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). It is stated in these three studies that periorbital ecchymosis is a guide for maxillofacial CT in maxillofacial trauma. In our study, periorbital contusion was found in 53.8% of patients with maxillofacial fractures, and the sensitivity of this physical examination finding in detecting maxillofacial fracture is 57.6%. On the other hand, when all physical examination findings were examined, contusion sensitivity anywhere in the maxillofacial region was the examination finding with the highest sensitivity, and the presence of only periorbital contusion was found to be the second most sensitive physical examination finding in terms of showing maxillofacial fracture. The rate of patients with fractures in the absence of periorbital contusion was 24.5%. Examination findings with high sensitivity are preferred to create clinical decision marker and may be a guide for maxillofacial CT in maxillofacial trauma patients with periorbital contusion.\u003c/p\u003e \u003cp\u003eAmong the physical examination findings, bone cascading or instability in the orbital bones is one of the most specific findings in terms of detecting orbital fractures, and studies have reported that the rate of not detecting orbital fractures is around 45% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Similar to the literature data in our study, the specificity of this finding was 97.6%, and the rate of failure to detect the injury was 43%. Among the other physical examination findings, malocclusion and tooth loss have a high specificity (99.4% and 97%, respectively), and the rate of not detecting orbital fracture is around 50%. When all maxillofacial bone fractures were examined, although there was a significant relationship between bone cascading or instability, malocclusion and maxillofacial fractures, no significant relationship was found with tooth loss. In the light of these data, bone cascading or instability and malocclusion may be a guide for maxillofacial CT for patients with maxillofacial trauma.\u003c/p\u003e \u003cp\u003eSitzman et al (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) developed Wisconsin Criteria\u0026rsquo;s in 2015 and reported the sensitivity and NPV of these Criteria\u0026rsquo;s were 98.2% and 87.8% respectively. They stated that using the Wisconsin Criteria\u0026rsquo;s could reduce the maxillofacial CT scan by 9.3% in patients presenting with maxillofacial trauma, and clinically significant pathology could not be detected in only 1.8% patients. None of the patients without pathology required surgical treatment. In our study, the sensitivity of the Wisconsin Criteria was 78.1%, while the NPV was found to be 70.3%. In case of using these Criteria\u0026rsquo;s, the rate of maxillofacial CT withdrawal decreased by 29.9%, while the rate of failure to detect clinically important pathologies was found to be 12.6% (n\u0026thinsp;=\u0026thinsp;49). Of 49 patients with clinically significant pathological findings that could not be detected according to the Wisconsin Criteria, 34% (n\u0026thinsp;=\u0026thinsp;17) were treated surgically. Therefore, due to its\u0026rsquo; low sensitivity and the inability to detect clinically important pathologies in a significant number of patients (with a rate of 12.6%), using the Wisconsin Criteria\u0026rsquo;s alone in determining the indication of maxillofacial CT in maxillofacial trauma patients would not be sufficient.\u003c/p\u003e \u003cp\u003eIn conclusion, in this study, we examined clinical markers that would guide the determination of maxillofacial CT indications in maxillofacial trauma patients. The presence of loss of consciousness at the time of admission is an important guide for maxillofacial CT. GCS\u0026thinsp;\u0026lt;\u0026thinsp;14, which is one of the Wisconsin Criteria, guides the maxillofacial CT scan for bone cascading or instability, malocclusion, and periorbital contusion. Tooth loss, which is one of the Wisconsin Criteria, was not found to be statistically associated with maxillofacial fracture, and it might be more appropriate to use other findings such as limited gaze or tenderness over the zygoma. Although all Wisconsin Criteria except tooth loss are guiding in maxillofacial CT, the use of Wisconsin Criteria alone does not seem appropriate not only due to its\u0026rsquo; low sensitivity but also its\u0026rsquo; inability to detect clinically important pathologies. The revision of Wisconsin Criteria\u0026rsquo;s should be considered by addition of clinical findings such as loss of consciousness, limited gaze, and tenderness over the zygoma, which were found to be statistically significant in our study. In this way, the sensitivity of the Wisconsin Criteria can be increased and missing of clinically important pathologies can be avoided. The results of these studies should be validated with prospective and multicenter studies where the mentioned limitations can be eliminated and their usability as a clinical decision-maker should be evaluated.\u003c/p\u003e \u003cp\u003eThe most important limitation of this study is that it is a retrospective study and therefore the accuracy of the examination findings cannot be evaluated clearly. As with all retrospective studies, the quality of findings and records might have been affected the results of the study. The exclusion of patients with missing records and penetrating trauma in our study might have caused inevitable selection bias. Another important limitation is that our study was conducted in a single center and the emergency department of a university hospital. Therefore, generalizing the results of the study to all maxillofacial trauma patients and/or other emergency services would not be appropriate.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr U.G. and Dr M.A.K.designed and conceptualized the study. Dr U.G., Dr O.G., Dr S.U., Dr H.A.D. and Dr S.G. collected and analyzed the data. Dr H.K.K. interpreted the images of tomographies. Dr U.G. and Dr M.A.K. drafted and revised the manuscript for intellectual content. All the authors approved the article to be published. All the authors participated sufficiently in the work to take public responsibility for appropriate portions of the content. The authors alone are responsible for its contents and writing of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was not required by research ethics committee as this is a retrospective study without patient intervention and no identifiable patient data have been included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol of the study was approved by the Gazi University Ethics Committee with the number 79/23.11.2015. Our study was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAzevedo AB, Trent RB, Ellis A. Population-based analysis of 10,766 hospitalizations for mandibular fractures in California, 1991 to 1993. J Trauma. 1998 Dec;45(6):1084\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eAtilgan S, Erol B, Yaman F, Yilmaz N, Ucan MC. Mandibular fractures: a comparative analysis between young and adult patients in the southeast region of Turkey. J Appl Oral Sci. 2010 Feb;18(1):17\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eMcGoldrick DM, Fragoso-I\u0026ntilde;iguez M, Lawrence T, McMillan K. Maxillofacial injuries in patients with major trauma. British Journal of Oral and Maxillofacial Surgery. 2018 Jul;56(6):496\u0026ndash;500.\u003c/li\u003e\n\u003cli\u003eAmerican College of Surgeons. National Trauma Data Bank 2009 Annual Report. In.\u003c/li\u003e\n\u003cli\u003eWong EC, Marshall GN, Shetty V, Zhou A, Belzberg H, Yamashita D-DR. Survivors of violence-related facial injury: psychiatric needs and barriers to mental health care. Gen Hosp Psychiatry. 2007 Apr;29(2):117\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eThornton B, Ryckman RM. Relationship between physical attractiveness, physical effectiveness, and self-esteem: a cross-sectional analysis among adolescents. J Adolesc. 1991 Mar;14(1):85\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eGlynn SM, Shetty V, Elliot-Brown K, Leathers R, Belin TR, Wang J. Chronic posttraumatic stress disorder after facial injury: a 1-year prospective cohort study. J Trauma. 2007 Feb;62(2):410\u0026ndash;8; discussion 418.\u003c/li\u003e\n\u003cli\u003eCole P, Kaufman Y, Hollier L. Principles of facial trauma: orbital fracture management. J Craniofac Surg. 2009 Jan;20(1):101\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eFinkle DR, Ringler SL, Luttenton CR, Beernink JH, Peterson NT, Dean RE. Comparison of the diagnostic methods used in maxillofacial trauma. Plast Reconstr Surg. 1985 Jan;75(1):32\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eRoth FS, Kokoska MS, Awwad EE, Martin DS, Olson GT, Hollier LH, et al. The identification of mandible fractures by helical computed tomography and panorex tomography. J Craniofac Surg. 2005 May;16(3):394\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBlackmore CC. Clinical prediction rules in trauma imaging: who, how, and why? Radiology. 2005 May;235(2):371\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eHolmgren 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 Aug;62(8):913\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSitzman TJ, Hanson SE, Alsheik NH, Gentry LR, Doyle JF, Gutowski KA. Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients. Plast Reconstr Surg. 2011 Mar;127(3):1270\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHarrington AW, Pei KY, Assi R, Davis KA. External Validation of University of Wisconsin\u0026rsquo;s Clinical Criteria for Obtaining Maxillofacial Computed Tomography in Trauma. J Craniofac Surg. 2018 Mar;29(2):e167\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eKompanje EJ. [The Glasgow coma scale]. Tijdschr Ziekenverpl. 1982 Feb 16;35(4):107\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eCarmont MR. The Advanced Trauma Life Support course: a history of its development and review of related literature. Postgraduate Medical Journal. 2005 Feb 1;81(952):87\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eSitzman TJ, Sillah NM, Hanson SE, Gentry LR, Doyle JF, Gutowski KA. Validation of Clinical Criteria for Obtaining Maxillofacial Computed Tomography in Patients With Trauma. J Craniofac Surg. 2015 Jun;26(4):1199\u0026ndash;202.\u003c/li\u003e\n\u003cli\u003eWhitesell RT, Steenburg SD, Shen C, Lin H. Facial Fracture in the Setting of Whole-Body CT for Trauma: Incidence and Clinical Predictors. AJR Am J Roentgenol. 2015 Jul;205(1):W4-10.\u003c/li\u003e\n\u003cli\u003eExadaktylos AK, Sclabas GM, Smolka K, Rahal A, Andres RH, Zimmermann H, et al. The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma center. J Trauma. 2005 Feb;58(2):336\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eB\u0026uuml;ttner M, Schlittler FL, Michel C, Exadaktylos AK, Iizuka T. 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 Jul;52(6):518\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBogusiak K, Arkuszewski P. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg. 2010 Jul;21(4):1018\u0026ndash;23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maxillofacial computed tomography, maxillofacial trauma, Wisconsin Criteria","lastPublishedDoi":"10.21203/rs.3.rs-9382777/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9382777/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eMaxillofacial injury is seen in 20\u0026ndash;25% of trauma patients and has an important role in trauma-induced morbidity and mortality. The aim of this study is to define the effectiveness of Wisconsin Criteria in our country to determine the need for computed tomography (CT) in maxillofacial traumas.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe data of 782 trauma patients who applied to our Emergency Departmant between July 2010 and July 2015, and who underwent maxillofacial and cranial CT, were retrospectively evaluated. Of these patients, 439 met the criteria and were included in the study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe median age of the patients was 37 years and 73.3% were male. The maxillofacial fracture was found in 62.6% (n\u0026thinsp;=\u0026thinsp;275). There was a significant difference in terms of gender, loss of consciousness, limited gaze, and tenderness over the zygoma between patients with and without fracture as a result of CT imaging (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for each comparison). When evaluated for the Wisconsin Criteria for maxillofacial fractures; its sensitivity was 78.1%, its specificity was 70.7%, its PPV was 78.5%, and its NPV was 70.3%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn our study, we examined clinical markers that would guide the determination of maxillofacial CT indications in maxillofacial trauma patients. We believe that the revision of Wisconsin Criteria\u0026rsquo;s should be considered by addition of clinical findings such as loss of consciousness, limited gaze, and tenderness over the zygoma, which were found to be statistically significant in our study. Also, our study is a validation study of the Wisconsin Criteria for the Turkish population.\u003c/p\u003e","manuscriptTitle":"Predictive Value of Wisconsin Criteria in Trauma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 15:33:01","doi":"10.21203/rs.3.rs-9382777/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-14T12:25:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T19:24:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141931460809970117955055120524518148903","date":"2026-05-11T18:27:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85551715845961832956540299661745533103","date":"2026-05-11T12:45:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T04:40:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211653302996653983050707050801983191106","date":"2026-05-03T00:20:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195789634940832983344927510242023102078","date":"2026-04-30T14:09:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-30T13:31:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-21T06:47:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-17T11:39:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-17T11:39:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-04-10T19:47:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"717f77ec-5bb3-4a1a-8d84-6ef84fcb9d33","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-14T12:25:26+00:00","index":96,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T19:24:22+00:00","index":94,"fulltext":""},{"type":"reviewerAgreed","content":"141931460809970117955055120524518148903","date":"2026-05-11T18:27:45+00:00","index":93,"fulltext":""},{"type":"reviewerAgreed","content":"85551715845961832956540299661745533103","date":"2026-05-11T12:45:44+00:00","index":92,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T04:40:45+00:00","index":91,"fulltext":""},{"type":"reviewerAgreed","content":"211653302996653983050707050801983191106","date":"2026-05-03T00:20:20+00:00","index":68,"fulltext":""},{"type":"reviewerAgreed","content":"195789634940832983344927510242023102078","date":"2026-04-30T14:09:39+00:00","index":58,"fulltext":""},{"type":"reviewersInvited","content":"61","date":"2026-04-30T13:31:16+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T15:33:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 15:33:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9382777","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9382777","identity":"rs-9382777","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}