Imaging of Facial Trauma
Part 2: Introduction and Anatomy
        Rathachai Kaewlai, MD

         www.RadiologyInThai.com
...
Outline


  Facial fracture epidemiology                         Types of facial fracture
                              ...
Plain Film Radiography


  Can be obtained to screen for facial injury if CT is not immediately
   available

  If plain...
Plain Film Radiography


  Remember: plain film is a 2D image of a 3D object
     Overlapping structures significantly o...
Plain Film Radiography


  Facial series                                      Mandible
     Water’s view (PA view with ...
Water’s View
    The most comprehensive single
    projection display
    Excellent view of
    - Maxilla
    - Maxillary ...
Water’s View
    Key structures
    1 = Frontal sinus
    2 = Maxillary sinus
    3 = Frontal process of
    Zygoma
    4 ...
Line A
    - Begins at inner surface of
    zygomatico-frontal suture,
    follows orbital surface of
    zygoma, maxilla,...
Line C
    - Begins at lateral and inferior
    margins of maxilla, extends
    along lateral wall of
    maxillary sinus ...
Caldwell’s View
     Excellent view of
     - Entire rim of orbit, esp.
     superomedial rim
     - Ethmoid sinus
     - ...
Key structures
         1 = Ethmoid sinuses
         2 = Orbit

         Line A, B, C, D = superior,
2        lateral, inf...
Lateral View
     Excellent view of
     - Frontal sinus: anterior wall
     - Maxillary sinus: anterior
     and posterio...
Key structures
     1 = Frontal sinus
     2 = Maxillary sinus
     3 = Sphenoid sinus
     4 = Hard palate
     5 = Anter...
Line A
     - Connects anterior surface of
     frontal sinus and anterior
     surface of hard palate
     Line B
     - ...
Towne’s View
     Excellent view of
     - Maxillary sinus:
     posterolateral wall
     - Zygomatic arch




15
Key structures
     1 = Zygomatic arch

     Line A = Posterolateral wall
     of maxillary sinus

     Rule:
     - Smoot...
Orthopanthogram or Panorex®
Key structures
R = Temporomandibular joint
13 = Mandible, condyle 14 = Mandible, ramus        ...
8 9

                                                    25 24




Counting the teeth on Orthopanthogram or Panorex®
Ameri...
Oblique View of Mandible
Key structures
R = Temporomandibular joint
13 = Mandible, condyle        14 = Mandible, ramus    ...
Biomechanics
  LeFort described areas of
  relative strength within the
  facial skeleton
     Alveolar process of maxil...
Checklist for Facial
               Radiograph/CT
  Facial structures are quite symmetrical

  Do not stop searching whe...
  To be continued in Part 2 and 3




                              22
  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 2

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Imaging Of Facial Trauma Part 2

  1. 1. Imaging of Facial Trauma Part 2: 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. Plain Film Radiography   Can be obtained to screen for facial injury if CT is not immediately available   If plain film identify a fracture other than a simple nasal bone fracture, further evaluation by CT is indicated   Multiple plain film projections are relative to ‘canthomeatal line’; an imaginary line drawn from outer canthus to external auditory meatus   Proper positioning (of patient’s head), alignment of x-ray beam is critical for evaluation because facial skeletal anatomy is complex 3
  4. 4. Plain Film Radiography   Remember: plain film is a 2D image of a 3D object   Overlapping structures significantly obscure anatomic detail   This problem is solved by standard views (to minimize overlap, allow visualization of important structures, familiarity for interpretation)   Rule of symmetry: two sides of the face are quite symmetrical   Symmetry is usual, and asymmetry is suspect   Multiplicity: fractures of facial bones are frequently multiple. Do not stop looking for others when see one 4
  5. 5. Plain Film Radiography   Facial series   Mandible   Water’s view (PA view with   Oblique view, Towne’s view cephalad angulation)   Caldwell view (PA view)   Orthopanthogram   Towne’s view   Lateral view   Base view   Additional view   Lateral view of the nasal bone (nasal technique) Note: The lecture series are focused on CT scan 5
  6. 6. Water’s View The most comprehensive single projection display Excellent view of - Maxilla - Maxillary sinuses - Zygoma - Zygomatic arches - Rims of orbits, esp. floor - Nasal bones 6
  7. 7. Water’s View Key structures 1 = Frontal sinus 2 = Maxillary sinus 3 = Frontal process of Zygoma 4 = Body of Zygoma (malar eminence) 5 = Temporal process of Zygoma Dotted line = zygomatico- frontal suture Dolan’s lines of reference Line A, B, C Rule: smooth, non-disrupted, same contour on both sides 7
  8. 8. Line A - Begins at inner surface of zygomatico-frontal suture, follows orbital surface of zygoma, maxilla, frontal process of maxilla and arch of nasal bone - If drawn to both sides, the line is similar to lazy ‘W’ or half frame of reading glasses Line B -  egins at lateral and inferior B margin of maxilla and extends along lateral wall of maxillary sinus and inferior surface of zygomatic arch - Ends at glenoid fossa 8
  9. 9. Line C - Begins at lateral and inferior margins of maxilla, extends along lateral wall of maxillary sinus and inferior surface of zygomatic arch - Ends at glenoid fossa “Friendly Line” - Medial half of Line C is the anterolateral wall of the maxillary sinus. - If it is disrupted, the possibilities of fx include 1) Isolated maxillary antrum 2) Zygomatico-maxillary complex (ZMC) 3) LeFort (unilateral or bilateral) 9
  10. 10. Caldwell’s View Excellent view of - Entire rim of orbit, esp. superomedial rim - Ethmoid sinus - Floor of orbit may be well seen in petrous bones are projected below the inferior orbital rim (not in this example) 10
  11. 11. Key structures 1 = Ethmoid sinuses 2 = Orbit Line A, B, C, D = superior, 2 lateral, inferior and medial walls of the orbit, respectively Line E = midline nasal septum and vomer Rule: - Ethmoid sinuses density should be equal, darker than orbit - Smooth non-disrupted orbital walls 11
  12. 12. Lateral View Excellent view of - Frontal sinus: anterior wall - Maxillary sinus: anterior and posterior wall - Sphenoid sinus - Pterygoid plate - Floor of anterior cranial fossa, hard palate - Lateral rim of orbit 12
  13. 13. Key structures 1 = Frontal sinus 2 = Maxillary sinus 3 = Sphenoid sinus 4 = Hard palate 5 = Anterior wall of temporal fossa Between green arrows = Pterygoid plate Line A = Anterior wall of frontal sinus Line B = Anterior cranial fossa Line C = Anterior wall of maxillary sinus Line D = Posterior wall of maxillary sinus 13
  14. 14. Line A - Connects anterior surface of frontal sinus and anterior surface of hard palate Line B - Connects anterior wall of temporal fossa and posterior edge of hard palate Line C - Along planum sphenoidale Line D - Along hard palate Rule: - Line A & B parallel - Line C & D parallel 14
  15. 15. Towne’s View Excellent view of - Maxillary sinus: posterolateral wall - Zygomatic arch 15
  16. 16. Key structures 1 = Zygomatic arch Line A = Posterolateral wall of maxillary sinus Rule: - Smooth, non-disrupted line 16
  17. 17. Orthopanthogram or Panorex® Key structures R = Temporomandibular joint 13 = Mandible, condyle 14 = Mandible, ramus 17 = Mandible, body 18 = Mandible, angle 19 = Mandible, coronoid process 20 = Mandible, symphysis 17
  18. 18. 8 9 25 24 Counting the teeth on Orthopanthogram or Panorex® American Dental Association (ADA) system preferred this system because you will speak same ‘language’ with dentists. Count from midline and go laterally (some individuals may not have #1, #16, #17, and #32) Maxillary Arch ADA#1 - 8 (right), #9-16 (left) Mandibular Arch ADA#32-25 (right), #24-17 (left) 18
  19. 19. Oblique View of Mandible Key structures R = Temporomandibular joint 13 = Mandible, condyle 14 = Mandible, ramus 17 = Mandible, body 18 = Mandible, angle 19 = Mandible, coronoid process 20 = Mandible, symphysis 19
  20. 20. Biomechanics   LeFort described areas of relative strength within the facial skeleton   Alveolar process of maxilla (1)   Frontal process of maxilla (2)   Body of zygoma or malar eminence (3)   Line of fracture tends to avoid these areas 20
  21. 21. Checklist for Facial Radiograph/CT   Facial structures are quite symmetrical   Do not stop searching when see one abnormality   If suspect for more than simple nasal fracture, do CT   Significant (but can be subtle) fractures   Fracture involves the optic foramen which can cause permanent visual loss if not treated promptly   Fracture of the posterior wall of frontal sinus requires neurosurgical evaluation and may require antibiotics prophylaxis   Fracture/dislocation of the TMJ usually missed on initial survey. It can cause significant disability if left untreated   Look for significant soft tissue injuries   Globe rupture, hemorrhage 21
  22. 22.   To be continued in Part 2 and 3 22
  23. 23.   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. 23
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