Imaging of Facial Trauma
Part 1: Introduction and Anatomy
        Rathachai Kaewlai, MD

         www.RadiologyInThai.com
...
Outline


  Facial fracture epidemiology                         Types of facial fracture
                              ...
Epidemiology


  Etiology (USA)
     Motor vehicle collision (MVC) most common cause
     Followed by fights, assaults
...
Epidemiology


  Distribution of fracture
     Vary with mechanism of injury
     In general, most common facial fractu...
Epidemiology


  Facial fracture in children
     Less common (< 10% of all facial fractures occur in children)
     Le...
ABC of Trauma


  Initial patient management is to secure airway (A), breathing (B) and
   circulation (C)

  Evaluation...
When to Do
           Imaging of the Face?

  When the patient is stabilized
     Clinically (Airway, Breathing, Circula...
When to Do
         Imaging of the Face?

  Head CT should be thoroughly evaluated in a multi-trauma
  patients
    Sear...
What Imaging to Do?


  Role of imaging
     Identify fractures, fragment displacement and rotation, stable bone
      f...
Normal Anatomy
  Face
    Face (midface) is the region
     from supraorbital rims to
     and including maxillary
     ...
3D CT
        Anterior View

     Major structures
     are labeled in the
     picture.

      Nasofrontal suture
     ...
3D CT
                Left Lateral View


           Nasofrontal suture
           Zygomatico-frontal suture
        ...
3D CT
     Base View




13
Computed Tomography (CT)


  Preferred modality for imaging of the face
     More sensitive for fracture detection
    ...
Computed Tomography (CT)


  CT protocol
     Axial scanning from above the frontal sinus down to below
      hard palat...
• Posterior wall of
                                                                  frontal sinus fracture
             ...





                                                                                   Key structures
                  ...
Key structures
     F = Groove for
     infraorbital nerve
     G = Maxillary sinus,
     posterolateral wall
     5 = Max...
Key structures
     H = Maxillary sinus,
     anterior wall
     I = Maxillary sinus,
     medial wall
     J = Medial pte...
Key structures
     J = Medial pterygoid
     plate
     K = Lateral pterygoid
     plate
     L = Maxilla, spine

     14...
Coronal
    Reformatted Image

Key structures
L = Maxilla, spine
  = Nasomaxillary suture

4 = Nasal bone
5 = Maxilla, fro...
Key structures
     D = Orbit, medial wall
     M = Nasal septum

     5 = Maxilla, frontal process
     15 = Maxilla bone...
Key structures
     M = Nasal septum
     N = Ethmoid bone,
     perpendicular plate
     O = Orbit, roof
     P = Orbit, ...
Key structures
     J = Medial pterygoid
     plate
     K = Lateral pterygoid
     plate
     N = Ethmoid,
     perpendic...
Sagittal Reformatted Image

     Key structures
     R = Temporomandibular joint (TMJ)

     13 = Mandible, condyle
     1...
Key structures
     P = Orbit, floor

     7 = Pterygoid bone
     9 = Maxillary sinus
     15 = Maxilla bone /hard
     p...
Key structures
     3 = Sphenoid sinus
     4 = Nasal bone
     15 = Maxilla bone/
     hard palate




27
CT Orthopanthogram




                     28
Axial                                                Coronal




                                                         ...
  The information provided in this presentation…
    Is intended to be used as educational purposes only.
    Is design...
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Imaging Of Facial Trauma Part 1

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Transcript of "Imaging Of Facial Trauma Part 1"

  1. 1. Imaging of Facial Trauma Part 1: Introduction and Anatomy Rathachai Kaewlai, MD www.RadiologyInThai.com Created: January 2007 1 quot;
  2. 2. Outline   Facial fracture epidemiology   Types of facial fracture   Nasal bone fracture   Initial management   Naso-orbital-ethmoid fracture   Frontal sinus fracture   Imaging: CT versus radiography   Orbital fracture   Zygomatic fracture   Normal anatomy   Maxillary fracture   3D   Mandibular fracture   CT (axial, coronal and sagittal planes)   Radiography   Imaging approach   Biomechanics 2
  3. 3. Epidemiology   Etiology (USA)   Motor vehicle collision (MVC) most common cause   Followed by fights, assaults   Less common: fall, sports activities, industrial accidents, gun shot wounds   Soft tissue injury is more common than fracture   Co-existence of other injury   3-14% of patients with facial fracture have skull fractures   1-4% of patients with facial fracture have cervical spine fractures   20% of patients with cervical spine fractures have facial injury (half soft tissue injuries, half fractures) 3
  4. 4. Epidemiology   Distribution of fracture   Vary with mechanism of injury   In general, most common facial fracture is nasal bone fracture   Most common fracture in admitted patients is zygomatic complex (ZMC) fracture at 40%, followed by complex fractures such as LeFort fracture 4
  5. 5. Epidemiology   Facial fracture in children   Less common (< 10% of all facial fractures occur in children)   Less severe than adults   Most common etiology is fall   Reasons: midface is less prominent, sinuses are less pneumatized, more elasticity of bones   Fractures that are more frequent in children than in adults   Mandibular condyle   Orbital roof 5
  6. 6. ABC of Trauma   Initial patient management is to secure airway (A), breathing (B) and circulation (C)   Evaluation of more serious injuries of the head, chest and abdomen   Avoid blind insertion of endotracheal tube and nasogastric tube   Significance of facial trauma for the initial management   Facial fractures may impinge on oral or nasal airway   Nasal bleeding may be life threatening   Mandible fractures may cause loss of support for tongue, then airway compromise   Facial fractures may compromise vision 6
  7. 7. When to Do Imaging of the Face?   When the patient is stabilized   Clinically (Airway, Breathing, Circulation - stable),   Initial goal is to preserve life - then later restore the form and function of the face   Cervical spine clearance   Radiographically   For cervical spine clearance 7
  8. 8. When to Do Imaging of the Face?   Head CT should be thoroughly evaluated in a multi-trauma patients   Search for critical, emergent finding: some facial injuries may compromise vision if not immediately recognized   In stable patient, face CT can be performed with little additional time when the patient is already in the scanner 8
  9. 9. What Imaging to Do?   Role of imaging   Identify fractures, fragment displacement and rotation, stable bone for use in surgical repair   Identify soft tissue injuries   CT is the imaging modality of choice because   High accuracy for evaluation of both bony and soft tissue injuries   Can be cost-saving screening exam when compared to multiple views of plain film radiography*   Radiation dose is far below the threshold for cataract formation *Turner BG et al. AJR Am J Roentgenol 2004;183:751-754 9
  10. 10. Normal Anatomy   Face   Face (midface) is the region from supraorbital rims to and including maxillary FACE alveolar process   Mandible, including the temporomandibular joints (TMJ), considered separate from the face   This lecture series will include both parts (face and mandible) 10
  11. 11. 3D CT Anterior View Major structures are labeled in the picture.  Nasofrontal suture  Zygomatico- frontal suture  Zygomatico- temporal suture SOF = Superior orbital fissure IOF = Inferior orbital fissure Orbital ‘rim’ is different from the ‘wall’ 11
  12. 12. 3D CT Left Lateral View   Nasofrontal suture  Zygomatico-frontal suture  Zygomatico-temporal suture 12
  13. 13. 3D CT Base View 13
  14. 14. Computed Tomography (CT)   Preferred modality for imaging of the face   More sensitive for fracture detection   Show significant soft tissue injury, especially the globe   Easier to perform, quicker than complete views of plain film radiographs   Pre-surgical planning for complex injuries   Disadvantage of CT   CT can miss subtle tooth fracture along the axial plane, additional orthopanthogram may be helpful to detect tooth fracture 14
  15. 15. Computed Tomography (CT)   CT protocol   Axial scanning from above the frontal sinus down to below hard palate (face), and can be scanned further to include the mandible, if there is a clinical suspicion for fracture of mandible   For helical (spiral) scanner, axial images can be reconstructed to coronal and sagittal planes without the need for direct coronal scanning   Viewing in both bone and soft tissue windows, in 3 planes (axial, coronal and sagittal) 15
  16. 16. • Posterior wall of frontal sinus fracture may co-exist with brain injury • Presence of pneumocephalus signifies dural tear related with the fracture • Inferior part of frontal sinus constitute the medial orbital wall Key structures A = Frontal sinus, anterior wall B = Frontal sinus, posterior wall *Note: The right frontal sinus is not pneumatized in this case. 16
  17. 17.  Key structures D = Orbit, medial wall E = Orbit, lateral wall F = Suture between sphenoid and zygomatic bones = Nasomaxillary suture 1 = Globe 2 = Ethmoid sinus 3 = Sphenoid sinus 4 = Nasal bone 5 = Maxilla, frontal process • Do not misinterpret the suture between nasal bone and frontal process of 6 = Orbit, lateral rim maxilla for a fracture 7 = Sphenoid bone • Look for a piece of fracture in the optic foramen, it is the true emergency of 8 = Optic foramen facial fracture 17
  18. 18. Key structures F = Groove for infraorbital nerve G = Maxillary sinus, posterolateral wall 5 = Maxilla, frontal process 9 = Maxillary sinus 10 = Zygomatic arch 11 = Pterygoid bone 12 = Nasolacrimal duct 13 = Mandible, condyle Clear maxillary sinuses can almost rules out certain fractures such as ZMC, LeFort, blowout fractures 18
  19. 19. Key structures H = Maxillary sinus, anterior wall I = Maxillary sinus, medial wall J = Medial pterygoid plate K = Lateral pterygoid plate 9 = Maxillary sinus 14 = Mandible, ramus Fracture of the pterygoid plates may represent LeFort fracture 19
  20. 20. Key structures J = Medial pterygoid plate K = Lateral pterygoid plate L = Maxilla, spine 14 = Mandible, ramus 15 = Maxilla bone/ hard palate Lucency in midline of the maxilla is a normal finding seen occasionally 20
  21. 21. Coronal Reformatted Image Key structures L = Maxilla, spine = Nasomaxillary suture 4 = Nasal bone 5 = Maxilla, frontal process • Do not confuse nasomaxillary suture for a fracture • Remind yourself that CT can miss subtle tooth fracture, although with the coronal and sagittal reformation. Obtain orthopanthogram or dedicated tooth film when in doubt 21
  22. 22. Key structures D = Orbit, medial wall M = Nasal septum 5 = Maxilla, frontal process 15 = Maxilla bone/ hard palate 16 = Frontal sinus 17 = Mandible, body 22
  23. 23. Key structures M = Nasal septum N = Ethmoid bone, perpendicular plate O = Orbit, roof P = Orbit, floor Q = Maxillary sinus, posterolateral wall  = Zygomatico-frontal suture 1 = Globe 2 = Ethmoid sinus 6 = Orbit, lateral rim 9 = Maxillary sinus 23
  24. 24. Key structures J = Medial pterygoid plate K = Lateral pterygoid plate N = Ethmoid, perpendicular plate 3 = Sphenoid sinus 10 = Zygomatic arch 14 = Mandible, ramus 18 = Mandible, angle 24
  25. 25. Sagittal Reformatted Image Key structures R = Temporomandibular joint (TMJ) 13 = Mandible, condyle 14 = Mandible, ramus 19 = Mandible, coronoid process 20 = Mastoid air cells If patient opens his/her mouth during the scan, there is a normal anterior gliding of the mandibular condyle relative to the glenoid fossa. That can look like subluxation of the TMJ 25
  26. 26. Key structures P = Orbit, floor 7 = Pterygoid bone 9 = Maxillary sinus 15 = Maxilla bone /hard palate • Orbital blowout fracture is best seen in sagittal and coronal images • Facial CT is not completed without image (2D) reformations 26
  27. 27. Key structures 3 = Sphenoid sinus 4 = Nasal bone 15 = Maxilla bone/ hard palate 27
  28. 28. CT Orthopanthogram 28
  29. 29. Axial Coronal Sagittal Right Orbit, soft tissue window Key structures: ON = Optic nerve MR = Medial rectus LR = Lateral rectus IOL = Intra-ocular lens • Globe contour should be smooth • Clean (dark) retro-bulbar fat 29
  30. 30.   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 they be used to establish a legal standard of care.   Thanks, MGH Radiology, for cases I’ve seen and things I’ve learned. R.K. 30
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