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Updated May 2014
Before We Start…
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Facial Bones
http://encyclopedia.lubopitko-bg.com/Axial_Skeleton.html
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Facial Buttresses: 4 Vertical
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Facial Buttresses: 5 Transverse
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5 inferior border of mandible
Facial Segments
11%
Upper Face: frontal, superior orbit
(part of skull)
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Role of Imaging
• Detection of soft tissue and bony injuries
• Characterization of soft tissue and bony injuries
• Surgical planning
• CT preferred over x-ray
– Much more accurate than x-ray
– Easier to perform in multi-trauma, non-cooperative patients
– If patients going to have CT for other indications
– If you think of injury other than simple nasal fracture
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Wisconsin Criteria
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Standard X-ray Projections
• Facial trauma series
– AP/PA
– Caldwell’s
– Water’s
– Towne’s
– Lateral a
– (+/- base)
5-6 views
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Standard X-ray Projections
• Mandible trauma series
– AP
– Lateral
– Towne’s
– Both obliques
5 views
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Interpreting Facial X-rays
• Hazy PNS
Water view is the cornerstone
• Lines of Dolan
– AKA: Elephant head (Lee Rogers)
– Water’s view
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Don’t Rely on X-rays Too Much,
Use CT Liberally
• Smaller FOV
• Frontal sinus to mandible
• Nose to mandibular condyles
• Thinner collimation
– 1 mm bone
– 2 mm soft tissue
• 2D (coronal and sagittal) reformats,
and 3D shaded surface display --
routine
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Imaging Approach: CT
Specifically search for urgent findings
Airway
Vision
Clear paranasal sinus?
Yes No
Pterygoid plates?
Nasal
Zygomatic arch
Mandible Fracture No fracture
Dento-alveolar ZMC, frontal
Le Fort I, II, III
Maxillary
Orbit
NOE
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Airway Compromise:
Nasal Septal Hematoma
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Airway Compromise:
Flail Mandible
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Vision Compromise:
Globe Rupture
• Full-thickness scleral or
corneal wound
• Common at anterior surface of
eye but can be clinically occult
in posterior
• CT to assist in diagnosis* Extruded vitreous and intraocular air
– Sensitivity 60-75%
– Specificity 76-100%
• CT to identify foreign bodies
and concomitant injuries
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*Romaniuk Emerg Med Clin N Am 2013 Intraocular air and foreign body
Vision Compromise:
Globe Rupture
• Change of globe contour with
loss of volume “Flat-tire” sign
• Scleral discontinuity
• Intraocular air
• Intraocular foreign body Contour abnormality “Flat-tire” sign.
Green arrows = trapped extraocular air
• Indirect signs: lens
displacement into vitreous
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Narrow anterior chamber
Vision Compromise:
Orbital Apex Fracture
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Choroidal detachment
Vision Compromise:
Retrobulbar Hemorrhage
• Increased IOP transmits to optic
nerve and globe compression
of retinal vessels retinal
ischemia loss of vision in
60-100 min
• “Orbital compartment syndrome”
• Arterial bleeding from infraorbital
or ethmoidal arteries
• Severe proptosis, tented
posterior sclera and stretched
optic nerve
Retrobulbar hemorrhage with medial orbital wall fracture • Discrete hematoma rarely seen
• Common associated orbital/
facial/cranial injuries
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Nasal Fracture
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Nasal Fracture
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Mandible Fracture
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*Murray et al. Emerg Med Clin N Am 2013
Mandible Fracture
Gray’s Anatomy
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Mandible Fracture
• X-ray
– PA view: rami, body
– Towne view: condyles, rami, TMJ
– Lateral & oblique views: body, angle
• Panoramic x-ray
– Rami and condyles
– Tooth
– Not always available in emergency
setting
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Mandible Fracture
http://www.simplestepsdental.com/i/D/DNTKnowUnivNumSys.gif
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Dentoalveolar Fracture
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Maxillary dentoalveolar process fracture
Imaging Approach: CT
Specifically search for urgent findings
Airway
Vision
Clear paranasal sinus?
Yes No
Pterygoid plates?
Nasal
Zygomatic arch
Mandible Fracture No fracture
ZMC, frontal
Le Fort I, II, III
Maxillary
Orbit
NOE
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Pterygoid Plate Fracture
• 90-100% Le Fort #
• Isolated pterygoid plate
fracture very rare
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Le Fort Fractures
Hopper RA, et al. Radiographics 2006
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Le Fort I Fracture
• Transverse fracture of inferior
maxillae (involving all walls of
maxillary sinus except superior
walls), nasal septum and
pterygoid plates
• Free-floating hard palate
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Le Fort I Fracture
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Le Fort II Fracture
• Pyramid-shaped
• Fractures of
– Maxillary sinuses anterolateral
wall
– Inferior orbital rim
– Orbital floor
– Nasofrontal suture
• Free-floating midface
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Le Fort II Fracture
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Le Fort III Fracture
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Combined Le Fort II and III
Le Fort III Fracture
(with I & II)
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Imaging Approach: CT
Specifically search for urgent findings
Airway
Vision
Clear paranasal sinus?
Yes No
Pterygoid plates?
Nasal
Zygomatic arch
Mandible Fracture No fracture
Frontal
Le Fort I, II, III
NOE
Orbit
ZMC
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Maxillary
Hazy Sinus + Intact Pterygoid Plates:
DDx
• Frontal sinus fractures
• Naso-orbital-ethmoidal (NOE) fractures
• Orbital fractures
• Zygomaticomaxillary complex (ZMC) fractures
• Maxillary sinus fractures
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Frontal Sinus Fracture
• Anterior table
– Thicker, require strong force to break
– Cosmetic
• Posterior table
– Dural tear – CSF leak
– Brain injury
www2.aofoundation.org
• Floor: superior orbital rim & medial
orbital roof
– Nasofrontal duct or frontal recess
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NFD or frontal recess (dotted lines), a = Agger nasi
http://www.asnr.org/neurographics/Smith/2.shtml
Frontal Sinus Fracture
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Naso-orbital-ethmoidal
(NOE) Fracture
Gray’s Anatomy
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Orbital Fracture
Rad.washington.edu
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Blow out fracture
Clinical eye exam required
Orbital Fracture: Easily missed entrapped inferior rectus in
EOM Entrapment children because fragment springs back
into place “trapdoor”
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Orbital Fractures
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Orbital Fracture: Medial Wall
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Orbital Fracture: Checklist
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Zygomaticomaxillary Complex (ZMC)
Fracture
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ZMC Fracture
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ZMC Fracture
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Maxillary Sagittal Fractures:
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Multiple Patterns
• Nasal + NOE
• Nasal + ZMC
• Nasal + frontal process of
maxilla
• ZMC + orbit
• Le Fort + ZMC
• Le Fort + NOE
• etc...
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Panfacial
Injuries
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Conclusion
• Facial fracture concomitant with mandible fracture 6-10%; facial CT
must include mandible and vice versa
• Two critical areas – airways and orbits
• Sinus haziness important sign on x-ray
• CT useful if suspected more than nasal fracture
• Clear sinus?
• Pterygoid fracture?
• Pattern recognition
• Try to fit all fractures into one pattern (if possible) in the conclusion
of the report
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Disclaimer
• The information provided in this presentation...
– Is intended to be used as educational purposes only
– Is designed to assist emergency practitioners in providing appropriate
radiologic care for patients
– Is flexible and not intended, nor should be used to establish a legal
standard of care
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