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Clinical Decision Rule to Identify Orbital Wall Fracture Among Children

Retrospective Derivation and Validation Study

Paek, So Hyun, MD*; Jung, Jin Hee, MD; Kwak, Young Ho, PhD*; Kim, Do Kyun, PhD*; Lee, Jin Hee, MD; Jung, Jae Yun, MD*; Oh, Sohee, PhD§

doi: 10.1097/PEC.0000000000001300
Original Article: PDF Only

Objectives Head and face injuries are leading causes of emergency department visits in children. There is yet no clinical decision rule on face CT such as pediatric head CT rules. The goal was to develop and validate a clinical decision rule for identifying orbital wall fractures in children with periorbital trauma in the emergency department.

Methods This was a retrospective derivation and validation study. Children younger than 18 years who underwent orbit CT after periorbital trauma were included between January 2011 and December 2013 in 3 emergency centers. Among 16 candidate clinical variables, 13 clinical signs and symptoms were selected as clinical predictors. For the fracture model, these clinical predictors were analyzed by 3-fold cross-validation. Diagnostic performance was assessed using the area under the receiver operating characteristic (AUROC) curve in both cohorts.

Results Four variables (orbital rim tenderness, periorbital ecchymosis, painful extraocular movement, and nausea/vomiting) had the best predictive model with the highest AUROC value. The AUROC values for fracture prediction were 0.793 (95% confidence interval, 0.741–0.844) and 0.809 (95% confidence interval, 0.742–0.877) in the derivation cohort and validation cohort, respectively. The sensitivity and negative predictive values were 96.4% and 93.4%, respectively, in the derivation cohort, and 97.8% and 98.1%, respectively, in the validation cohort. The sum of these scores ranged from 0 to 4. Patients with a sum of scores of 1 or higher showed significantly increased risk for fracture.

Conclusions The 4-variable predictive model can be useful for finding clinically important orbital wall fractures in children.

From the *Department of Emergency Medicines, Seoul National University Hospital, Seoul; †Department of Emergency Medicines, SMG-SNU Boramae Medical Center, and Department of Preventive Medicine, Kangwon National University, School of Medicine, Chuncheon; ‡Department of Emergency Medicines, Seoul National University Bundang Hospital, Seongnam; and §Department of Biostatistics, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.

Disclosure: The authors declare no conflict of interest.

Reprints: Jin Hee Jung, MD, Department of Emergency Medicines, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea (e-mail:

The abstract has been presented at seminars in the American College of Emergency Physicians in 2015 at Boston and the Korean Society of Emergency Medicine in 2015.

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