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20160925 ser dr.rathachai kaewlai
- 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 twotimes more than women Concomitant C-spine fracture 7% Concomitant skull base fracture 8% Mundinger J Craniomaxillofac Surg 2014 (n=8127)
- 3. Role of Imaging Detectionof 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 FacialImaging? 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 frombrain/head CT Frontal sinuses to mandible, nose to mandibular condyles Thin collimations, bone algorithm Routine 2D and 3D reconstructions
- 6. First Thing First Donot get distracted by facial injuries Are there intracranial or C-spine injuries?
- 7. Imaging Approach: CT Specificallysearch 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 Flailmandible Nasal septal hematoma Vision Retrobulbar hemorrhage Orbital apex frx Globe injuries
- 9. Flail Mandible Fractures ofsymphysis + bilateral condyles, rami or angles Potentially compromise airway 2/2 pharyngeal hematoma, tongue not maintained
- 10. Nasal Septal Hematoma Potentiallycompromise nasal airway Life-threatening epistaxis
- 11. Retrobulbar Hemorrhage Proptosis, tentedposterior 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 Impingementon optic nerve Traumatic optic neuropathy and vision loss Image from medscape.com
- 13. Globe Rupture Full thicknesstear 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 fibertear causing luxation or dislocation Traumatic cataract = acute lens edema (30 HU lower than normal side)
- 16. Ocular Detachments Retina separatedfrom choroid = V-shaped apex at optic disc retinal detachment Choroid separated from sclera = lens shaped choroidal detachment
- 17. Fracture Patterns: Facts Right28%, 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 UpperFace: 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: 4Vertical
- 21. Facial Buttresses: 5Transverse 1 superior orbital rim 2 inferior orbital rim 3 maxillary alveolar rim 4 mandibular alveolar rim 5 inferior border of mandible
- 22. CT Clear SinusSign “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 Specificallysearch 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 Specificallysearch 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 vbilateral, simple v comminuted If comminuted, telescoping or depression? Septum involved? Hematoma?
- 26. Fracture of FrontalProcess of Maxilla Part of more complex fracture?
- 27. Zygomatic Arch Fracture Threefracture lines, depressed middle fragment Limit motion of mandible by impinging on coronoid process or massetter origins
- 28. Mandible Fracture Typically bilateralinjury (U-shaped mandible) Often displaced because of muscle traction CT better choice than XR
- 29. Dento-alveolar Fracture Any portionof alveolar process Malaligned and displaced tooth Tooth injuries: luxation, subluxation and fracture
- 30. Imaging Approach: CT Specificallysearch 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 Amongthe 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 IFracture 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 IIFracture Pyramid shaped Fractures of maxillary sinuses (anterior, lateral wall), inferior orbital rim, orbital floor, nasofrontal suture “Floating maxilla”
- 35. Le Fort IIIFracture Fractures of nasofrontal suture, maxillofrontal suture, orbital wall and zygomatic arch/zygomaticofrontal suture “Floating face”
- 36. Imaging Approach: CT Specificallysearch 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 Anteriorwall fracture only Normal pterygoid plate and zygomatic arch
- 40. Masticator Space BlowoutFracture 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-inv 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: Purev Impure Pure if orbital rim is intact
- 43. Orbital Fracture: EOMEntrapment 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 NormalHooked 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 Sizeof # 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 Infraorbitalforamen 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: MedialWall 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 Highenergy impact common with other injuries: 65% neuro, 47% eye Easily missed on axial images
- 49. Frontal Sinus Fracture Anteriortable: 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 Fracturesof medial orbit, nose and ethmoid sinuses Medial canthal tendon: disrupted v non-disrupted Medial canthal tendon Gray’s Anatomy
- 52. Panfacial Injuries At leastone 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
Editor's Notes
- #23 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).
- #26 X-ray misses up to half When isolated, XR may be adequate X-ray views: laterals and Water
- #41 Types of maxillary sinus fractures: Maxillary sagittal, palate, alveolar process, Le Fort
- #42 Transient increase in pressure in masticator space (space confined by floor of middle cranial fossa, central skull base and maxillary sinus, temporal bone)
- #47 Fascial sling Likely intact if inferior rectus in correct position and flat Likely compromised if inferior rectus round, displaced
- #50 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
- #51 Floor is actually = orbital roof & rim
- #52 Correlation between NFD injury and frontal sinus fx pattern: base of frontal sinus = 83%; anterior ethmoid complex = 67%; both = 89%
- #53 Lacrimal system, nasofrontal duct, persistent telecanthus