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Before We Start…
• Facial x-ray is overrated
• CT is the current standard for most facial fracture imaging beyond
nasal bone
• Still, we need to learn both XR and CT
• Key for XR: Hazy sinuses, Lines of Dolan
• Key for CT: urgent findings, significant soft tissue injuries, fracture
pattern recognition
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Facial Segments
Upper Face: frontal, superior orbit
(part of skull)
Lower Face : mandible
Mid Face: other orbit, nasal, zygoma,
Le Fort, maxillary sinus,
dentoalveolar, NOE, ZMC
11%
70%
19%
% indicate distribution of facial fractures
Ref: Mundinger et al. J Craniomaxillofac Surg 2014
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About Facial Trauma
• Mundinger J Craniomaxillofac Surg 2014 (n = 8127)
– Male 77.6%
– Right 28%, midline 36%, left 36%
– One fracture pattern 52% (most common = nasal #)
– Panfacial injury 1.1%
– Bilateral fractures 18.9%
– Association:
• C-spine fracture 6.6%
• Skull base fracture 7.6% (greatest in Le Fort II, III or any Le Fort
combinations)
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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
• For obtaining facial CT in multi-trauma patient
• Any 1 of 5 criteria
– 98% sensitive for presence of fracture
– 88% NPV for all fractures
– Reduce CT use by 9%
• Bony stepoff or instability
• Periorbital swelling or contusion
• GCS <14
• Malocclusion
• Tooth absenceSitzman et al. Plast Reconstr Surg 2011
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Airway Compromise:
Nasal Septal Hematoma
• Usually clinically apparent
• Must be identified quickly
– Epistaxis can be life threatening
– May lead to compromised nasal
airway
– Late complications: infection,
abscess, necrosis -> saddle nose
deformity
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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*
– Sensitivity 60-75%
– Specificity 76-100%
• CT to identify foreign bodies
and concomitant injuries
*Romaniuk Emerg Med Clin N Am 2013 Intraocular air and foreign body
Extruded vitreous and intraocular air
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Vision Compromise:
Globe Rupture
• Change of globe contour with
loss of volume “Flat-tire” sign
• Scleral discontinuity
• Intraocular air
• Intraocular foreign body
• Indirect signs: lens
displacement into vitreous
Narrow anterior chamber
Contour abnormality “Flat-tire” sign.
Green arrows = trapped extraocular air
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Vision Compromise:
Orbital Apex Fracture
• Optic canal can be fractured
causing traumatic optic
neuropathy and vision loss
• True emergency if there is
radiological and clinical evidence
of optic nerve impingement
Image from medscape.com
Orbital apex fracture
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Vision Compromise:
Lens Injuries
• Tear of zonular fibers that hold
lens to ciliary muscles
• Luxation
• Dislocation
• Traumatic cataract
• If bilateral, think collagen
vascular disease or
homocysteinuria
Diagram: getsomenbeo.wordpress.com Rt: Lens subluxation. Lt: Lens dislocation
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Vision Compromise:
Ocular Detachments
• Laceration of 3 layers of globe
leading to fluid collections
• Retinal detachment
– Retinal separated from choroid
– Vitreous in subretinal space
– Possibility of non-accidental
trauma in children
– V-form with apex at optic disk and
anterior part at ora serrata
• Choroidal detachment
– Collection in suprachoroidal space
between choroid and sclera
– Biconvex lens shape
Choroidal detachment
Retinal detachment
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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
• Discrete hematoma rarely seen
• Common associated orbital/
facial/cranial injuries
Retrobulbar hemorrhage with medial orbital wall fracture
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Nasal Fracture
• Most common site of facial #
• Frontal blow, lateral blow, blow from below
• Clinical diagnosis
– X-ray misses up to half
– When isolated, XR may be adequate
– X-ray views: laterals and Water
• CT when concern more than mere nasal
fracture
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Nasal Fracture
• What are features of #?
– Unilateral or bilateral
– Simple vs. comminuted
• If comminuted, is there telescoping
or depression?
• Is nasal septum involved?
– Fracture or hematoma or both
• What other fractures does the
patient have?
– Frontal process of maxilla
– ZMC
– NOE
Patel et al. Semin Ultrasound CT MRI 2012
Bilateral nasal bone fractures with comminution and
depression on the right side. No telescoping or
septal involvement
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Le Fort Fractures
• Among the most severe facial fractures
• Progressively severe category from I III
• Separation (partial or complete) of maxilla from remainder face
• All extend through posterior face transecting pterygoid plates
• I, II, III and combined
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 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 III Fracture
• Most severe of all Le Fort
• Separation of facial bones from
skull “craniofacial separation”
– Zygoma separates from
sphenoid
– Nasal bones and medial orbits
separated from frontal bone
Combined Le Fort II and III
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Frontal Sinus Fracture
• Anterior table
– Thicker, require strong force to break
– Cosmetic
• Posterior table
– Dural tear – CSF leak
– Brain injury
• Floor: superior orbital rim & medial
orbital roof
– Nasofrontal duct or frontal recess
www2.aofoundation.org
NFD or frontal recess (dotted lines), a = Agger nasi
http://www.asnr.org/neurographics/Smith/2.shtml
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Frontal Sinus Fracture
• Strong suspicion for NFD injury if:
– # fragments in nasofrontal outflow tract
– Frontal sinus floor #
– # medial wall of anterior table
• Checklist
– Which tables are involved?
– Is there significant displacement or
comminution of either table?
– Are there signs of NFD occlusion?
– Are there associated intracranial
abnormality to suggest dural violation?
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Orbital Fracture
• Can be isolated or with other facial fractures
(NOE, ZMC, Le Fort)
• Blow out vs. blow in
– Blow out: bone displaced away from orbit due
to sudden pressure changes in orbit
– Blow in: bone displaced into orbit from direct
PNS injury
Rad.washington.edu
Blow in fracture
Blow out fracture
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Orbital Fracture:
EOM Entrapment
Normal Hooked Entrapped
Shape of IOM Flat Oval Round
Location of IOM Not in defect Portion lies within
defect
Whole muscle beneath/
within defect
Clinical eye exam required
Easily missed entrapped inferior rectus in
children because fragment springs back
into place “trapdoor”
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ZMC Fracture
• 2 of 4 are orbital structures
– # orbital volume and contents can be
affected
– Globe, nerve, EOM
– Orbital apex
• Can cause impaired mandible
motion esp. if depressed
• Infraorbital nerve foramen
Decreased orbital volume
Compression of temporalis muscle
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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