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- 1. Maxillofacial Trauma Rathachai Kaewlai, MD Division of Emergency Radiology, Ramathibodi Hospital, Bangkok, Thailand 25 Sep 2016 10:40-11:00 Society of Emergency Radiology (SER) India
- 2. Quick Facts Men two times more than women Concomitant C-spine fracture 7% Concomitant skull base fracture 8% Mundinger J Craniomaxillofac Surg 2014 (n=8127)
- 3. Role of Imaging Detection of soft tissue and bony injuries Characterization of soft tissue and bony injuries Surgical planning CT preferred over radiography Much more accurate Easier to perform in multi-trauma patients Might be performed concurrently on other body parts
- 4. Who Needs Facial Imaging? Wisconsin Criteria used for obtaining facial CT Multi-trauma patients with any 1 of 5 criteria: 98% sensitive for frx, 88% NPV Bony stepoff or instability Periorbital swelling or contusion GCS <14 Malocclusion Tooth absence Sitzman et al. Plast Reconstr Surg 2011
- 5. CT Techniques Different from brain/head CT Frontal sinuses to mandible, nose to mandibular condyles Thin collimations, bone algorithm Routine 2D and 3D reconstructions
- 6. First Thing First Do not get distracted by facial injuries Are there intracranial or C-spine injuries?
- 7. Imaging Approach: CT Specifically search for critical findings Yes No Nasal Zygomatic arch Mandible Dento-alveolar Le Fort I, II, III ZMC, frontal Maxillary Orbit NOE Airway Vision NoYes Clear paranasal sinus? Pterygoid plates fracture?
- 8. Critical Facial Injuries Airway Flail mandible Nasal septal hematoma Vision Retrobulbar hemorrhage Orbital apex frx Globe injuries
- 9. Flail Mandible Fractures of symphysis + bilateral condyles, rami or angles Potentially compromise airway 2/2 pharyngeal hematoma, tongue not maintained
- 10. Nasal Septal Hematoma Potentially compromise nasal airway Life-threatening epistaxis
- 11. Retrobulbar Hemorrhage Proptosis, tented posterior sclera and stretched optic nerve Bleeding from infraorbital or ethmoidal arteries 0.5-3% of all facial trauma had vision problem
- 12. Orbital Apex Fracture Impingement on optic nerve Traumatic optic neuropathy and vision loss Image from medscape.com
- 13. Globe Rupture Full thickness tear of sclera or cornea Anterior surface common but posterior occult on clinical exam CT helps diagnosis (SE60-75, SP76-100), FB, other injuries
- 14. Globe Rupture Flat-tire sign, scleral discontinuity Intra-ocular air, FB Lens displacement
- 15. Lens Injuries Zonular fiber tear causing luxation or dislocation Traumatic cataract = acute lens edema (30 HU lower than normal side)
- 16. Ocular Detachments Retina separated from choroid = V-shaped apex at optic disc retinal detachment Choroid separated from sclera = lens shaped choroidal detachment
- 17. Fracture Patterns: Facts Right 28%, midline 36%, left 36% Bilateral fractures 19% One fracture pattern 52% Panfacial injury 1% Mundinger J Craniomaxillofac Surg 2014 (n=8127)
- 18. Fracture Patterns: Facts 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
- 19. Fracture Patterns: Facts Nasal – Naso-orbital-ethmoidal – Nasal spine Zygomatic arch – Zygomatic complex (ZMC) Maxillary sinus – Lefort – Dento-alveolar Frontal sinus Mandible Orbit
- 20. Facial Buttresses: 4 Vertical
- 21. Facial Buttresses: 5 Transverse 1 superior orbital rim 2 inferior orbital rim 3 maxillary alveolar rim 4 mandibular alveolar rim 5 inferior border of mandible
- 22. CT Clear Sinus Sign “Absence of paranasal sinus fluid after facial trauma is a highly reliable criterion to exclude fractures involving paranasal sinus walls” Screening tool in head CT Lambert DM et al. J Oral Maxillofac Surg 1997;55:1207 DDx Remote traumatic deformity Normal anatomy mimicking fracture Fractures of nasal bone, zygomatic arch, dentoalveolar structures or mandible
- 23. Imaging Approach: CT Specifically search for critical findings Yes No Nasal Zygomatic arch Mandible Dento-alveolar Le Fort I, II, III ZMC, frontal Maxillary Orbit NOE Airway Vision NoYes Clear paranasal sinus? Pterygoid plates fracture?
- 24. Imaging Approach: CT Specifically search for critical findings Yes No Nasal Zygomatic arch Mandible Dento-alveolar Le Fort I, II, III ZMC, frontal Maxillary Orbit NOE Airway Vision NoYes Clear paranasal sinus? Pterygoid plates fracture?
- 25. Nasal Fracture Unilateral v bilateral, simple v comminuted If comminuted, telescoping or depression? Septum involved? Hematoma?
- 26. Fracture of Frontal Process of Maxilla Part of more complex fracture?
- 27. Zygomatic Arch Fracture Three fracture lines, depressed middle fragment Limit motion of mandible by impinging on coronoid process or massetter origins
- 28. Mandible Fracture Typically bilateral injury (U-shaped mandible) Often displaced because of muscle traction CT better choice than XR
- 29. Dento-alveolar Fracture Any portion of alveolar process Malaligned and displaced tooth Tooth injuries: luxation, subluxation and fracture
- 30. Imaging Approach: CT Specifically search for critical findings Yes No Nasal Zygomatic arch Mandible Dento-alveolar Le Fort I, II, III ZMC, frontal Maxillary Orbit NOE Airway Vision NoYes Clear paranasal sinus? Pterygoid plates fracture?
- 31. Pterygoid Plate Fracture • 90-100% Le Fort # • Isolated pterygoid plate fracture very rare • Absence of pterygoid plate # rules out Le Fort
- 32. Le Fort Fractures Among the most severe facial fractures Progressively severe category from I III Separation (partial or complete) of maxilla from remainder face Hopper RA, et al. Radiographics 2006
- 33. Le Fort I Fracture Transverse fracture of inferior maxillae (all walls of maxillary sinuses except superior walls), anterolateral margins of nasal fossa, nasal septum and pterygoid plates “Floating palate”
- 34. Le Fort II Fracture Pyramid shaped Fractures of maxillary sinuses (anterior, lateral wall), inferior orbital rim, orbital floor, nasofrontal suture “Floating maxilla”
- 35. Le Fort III Fracture Fractures of nasofrontal suture, maxillofrontal suture, orbital wall and zygomatic arch/zygomaticofrontal suture “Floating face”
- 36. Imaging Approach: CT Specifically search for critical findings Yes No Nasal Zygomatic arch Mandible Dento-alveolar Le Fort I, II, III ZMC, frontal Maxillary Orbit NOE Airway Vision NoYes Clear paranasal sinus? Pterygoid plates fracture?
- 37. Zygomaticomaxillary Complex (ZMC) # 4 principle fracture lines: lateral orbital rim, zygomatic arch, zygomaticomaxillary buttress, inferior orbital rim Diagrams from Buchanan EP, et al. Plast Reconstr Surg
- 38. Zygomaticomaxillary Complex (ZMC) # Orbital volume, globe, nerve, EOM, orbital apex (# two orbital rims) Impaired mandible motion (#zygomatic arch) Infraorbital nerve foramen (# inferior orbital rim)
- 39. Maxillary Sagittal Fracture Anterior wall fracture only Normal pterygoid plate and zygomatic arch
- 40. Masticator Space Blowout Fracture Segmental fracture in posterolateral aspect of maxillary sinus Medial displacement of fragment Herniation of masticator space fat and/or muscle into sinus Erly WK et al. Emerg Radiol 2016; 23:439.
- 41. Orbital Fracture: Blow-in v Blow-out Blow-in = bone displaced into orbital cavity from direct PNS injury Blow-out = bone displaced away from orbit due to sudden pressure change inside orbit Rad.washington.edu
- 42. Orbital Fracture: Pure v Impure Pure if orbital rim is intact
- 43. Orbital Fracture: EOM Entrapment Clinical eye exam required CT can assist in Dx by showing herniated muscle through # defect Easily missed entrapped inferior rectus in children because fragment springs back into place “trapdoor”
- 44. 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
- 45. Orbital Floor Fracture Size of # defect (>1 sq.cm) Fascial sling: intact or compromised Infraorbital foramen: sensory function Soft tissue herniation: diplopia Abnormal fascial sling Normal fascial sling
- 46. Orbital Fracture: Floor Infraorbital foramen involvement results in sensory dysfunction Diagram from http://emedicine.medscape.com/article/82660-overview Fracture through RIGHT infraorbital nerve foramen Normal LEFT foramen
- 47. Orbital Fracture: Medial Wall Entrapment of medial rectus results in horizontal motility restriction Loss of normal posteromedial bulge of orbit Check for NOE # and NFD disruption
- 48. Orbital Roof Fracture High energy impact common with other injuries: 65% neuro, 47% eye Easily missed on axial images
- 49. Frontal Sinus Fracture Anterior table: cosmetic Posterior table: dural tear (CSF leak), brain injury Floor: nasofrontal duct or frontal recess injury
- 50. Frontal Sinus Fracture: NFD Injury Suggested if # base of frontal sinus and/or anterior ethmoid complex Fragments in nasofrontal outflow tract, floor #, medial wall of anterior table Ravindra VM et al. Surg Neurol Int 2015; 6:141 Harris L et al. Radiology 1987; 165:195
- 51. Naso-orbital-ethmoidal (NOE) Fracture Fractures of medial orbit, nose and ethmoid sinuses Medial canthal tendon: disrupted v non-disrupted Medial canthal tendon Gray’s Anatomy
- 52. Panfacial Injuries At least one fracture in all of 3 facial thirds
- 53. Conclusions Always check intracranial & C-spine injuries first Two critical facial findings – airway and vision Systematic evaluation Clear paranasal sinuses ? Pterygoid plate fracture ? Try to fit all fractures into one or few patterns Look for potential complications
Notas do Editor
- A total of 366 CT scans of the face were performed during the study. Among them, 180 scans (49%) were identified that showed no evidence of free paranasal fluid. Twenty-two (12%) of these 180 CT studies showed isolated nasal fractures (n = 13) or zygomatic arch fractures (n = 9). No patient without free paranasal sinus fluid had any midfacial fracture involving a parana- sal sinus wall (P < .OOl by Fischer exact test).
- X-ray misses up to half When isolated, XR may be adequate X-ray views: laterals and Water
- Types of maxillary sinus fractures: Maxillary sagittal, palate, alveolar process, Le Fort
- Transient increase in pressure in masticator space (space confined by floor of middle cranial fossa, central skull base and maxillary sinus, temporal bone)
- Fascial sling Likely intact if inferior rectus in correct position and flat Likely compromised if inferior rectus round, displaced
- Roof = frontal bone and lesser wing of sphenoid bone Neurologic injuries 65%* ICH Pneumocephalus CSF leak Ophthalmologic injuries 47%* CN palsy (VII, III, VI, II) Retrobulbar hemorrhage
- Floor is actually = orbital roof & rim
- Correlation between NFD injury and frontal sinus fx pattern: base of frontal sinus = 83%; anterior ethmoid complex = 67%; both = 89%
- Lacrimal system, nasofrontal duct, persistent telecanthus