Background and objectives : Clinical suspicion of mandibular fractures should prompt two radiographs at different angles. The aims of this study were: (a) to audit compliance with this recommendation within our unit; (b) to attempt to identify factors predicting the likelihood of a fracture, and draft a guideline based on these to reduce unnecessary requests.

Methods : A retrospective review was carried out of all patients who attended the Emergency Department (ED) at the Queen Elizabeth Hospital, Birmingham over a four-month period and had plain radiographs taken for suspected mandibular fractures. Univariate analysis was used to identify predictors of the likelihood of fracture and the findings, along with a guideline, were disseminated to all ED physicians. A prospective re-audit was then undertaken over a six-week period to look for improvement.

Results : Failure to request two different radiographic views was seen in 15.6% ( n = 39) of patients in the retrospective audit. Fractures were diagnosed in only 45.2% ( n = 113) of cases where radiographs were taken. Malocclusion (sensitivity 92.7%, p < 0.0001), mental nerve paresthaesia (sensitivity 93%, p < 0.0001), trismus (sensitivity 87.2%, p < 0.0001) and intra-oral bruising (sensitivity 87.2%, p < 0.0001) all emerged as significantly associated with the likelihood of fracture. At least one predictor was present in 97.3% ( n = 110) of fractures, and the remainder were all managed conservatively. Following the introduction of a guideline, only 7.1% ( n = 5) of patients failed to have two diagnostic images taken, although the number of unnecessary radiographs remained high at 58.6% ( n = 41).

Conclusions : There is a tendency towards over-requesting of mandibular radiographs, likely to reflect a well-documented lack of confidence in diagnosing facial fractures among ED physicians. The argument exists for an evidence-based guideline for requests, although greater emphasis on maxillofacial trauma in post-graduate education for ED staff may represent the only realistic route to changing practice in the long term.