This document provides an outline and overview of imaging of facial trauma, focusing on nasal fractures and naso-orbital-ethmoidal fractures. It describes the relevant anatomy, mechanisms of injury, diagnostic imaging techniques including CT and x-rays, clinical findings, and complications. Radiologic examples are provided to demonstrate nasal septum fractures and NOE fractures from frontal blows. The goal is to aid in the diagnosis and management of these types of facial fractures.
This presentation covers routinely used intraoral & extraoral plain radiographs used in assessment of maxillofacial trauma patients with extended coverage on occlusal radiographs. This PPT is echanced with addition of images for all radiographs
Facial bone fractures: an overview
Dr. Ahmed M. Adawy
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
The bone and soft tissues of the face are able to absorb the energy from impact forces. Force to the bone in the elastic range causing the deformation and after force removal, bone returns to its previous state, but if the force be greater than the elasticity of bone, a permanent displacement occurs and be irreversible. Furthermore, when these forces exceed the strength of these tissues, a variety of fractures can occur. The buttress theory proposes that the midfacial region is like a framework that is stabilized by horizontal and vertical buttresses. The most common causes of maxillofacial trauma are traffic accidents, injuries from fights, sport accidents or falls. The Le Fort’s classification is based on low-velocity trauma, and does not completely reflect the breadth of high-velocity fractures encountered in modern practice. Currently, facial fractures are classified into central midface fractures, lateral midface fractures and mandibular fractures. Nasal, nasoethmoidal, Zygomatic bone, and orbital fractures are presented. Today, surgical techniques have been moving away from delayed closed reduction with internal wires suspension to early open reduction and internal plate fixation. Different treatment approaches exist to restore the facial skeleton using the different facial buttresses as landmarks.
A slideshow of 'Imaging of Head Trauma: Part I' describes nature, mechanism, significance of head trauma, indications and choices of imaging in patients with head trauma, and normal anatomy of the brain with emphasis on CT.
Naso-orbital-ethmoid (NOE) fractures: Management principles, options and rec...Dibya Falgoon Sarkar
Comprehensive discussion on diagnosis and management of NOE fractures. Surgical anatomy and approaches to NOE region is also discussed. Reconstruction of NOE complex is discussed. Recent advances in management of NOE fractures are also highlighted in this presentation
This presentation covers routinely used intraoral & extraoral plain radiographs used in assessment of maxillofacial trauma patients with extended coverage on occlusal radiographs. This PPT is echanced with addition of images for all radiographs
Facial bone fractures: an overview
Dr. Ahmed M. Adawy
Professor Emeritus, Dept. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
The bone and soft tissues of the face are able to absorb the energy from impact forces. Force to the bone in the elastic range causing the deformation and after force removal, bone returns to its previous state, but if the force be greater than the elasticity of bone, a permanent displacement occurs and be irreversible. Furthermore, when these forces exceed the strength of these tissues, a variety of fractures can occur. The buttress theory proposes that the midfacial region is like a framework that is stabilized by horizontal and vertical buttresses. The most common causes of maxillofacial trauma are traffic accidents, injuries from fights, sport accidents or falls. The Le Fort’s classification is based on low-velocity trauma, and does not completely reflect the breadth of high-velocity fractures encountered in modern practice. Currently, facial fractures are classified into central midface fractures, lateral midface fractures and mandibular fractures. Nasal, nasoethmoidal, Zygomatic bone, and orbital fractures are presented. Today, surgical techniques have been moving away from delayed closed reduction with internal wires suspension to early open reduction and internal plate fixation. Different treatment approaches exist to restore the facial skeleton using the different facial buttresses as landmarks.
A slideshow of 'Imaging of Head Trauma: Part I' describes nature, mechanism, significance of head trauma, indications and choices of imaging in patients with head trauma, and normal anatomy of the brain with emphasis on CT.
Naso-orbital-ethmoid (NOE) fractures: Management principles, options and rec...Dibya Falgoon Sarkar
Comprehensive discussion on diagnosis and management of NOE fractures. Surgical anatomy and approaches to NOE region is also discussed. Reconstruction of NOE complex is discussed. Recent advances in management of NOE fractures are also highlighted in this presentation
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Imaging of Facial Trauma
Part 2: Pathology
Rathachai Kaewlai, MD
Specialized in Body Imaging and Emergency Radiology
rathachai@gmail.com
January 2007
The author is willing to receive any input, comments and corrections,
Please do not hesitate to contact at the email address provided above. 1
Emergency Radiology: Imaging of Facial Trauma
3. Nasal Fractures
• Most common fracture of the facial bone
• Etiology: motor vehicle collisions (MVC) most common, followed
by assaults
• Relevant anatomy: Nasal pyramid consists of
– Nasal bones
• Inferior part of nasal bones is thinner than superior, more prone to fx
– Frontal processes of maxilla
– Nasal septum (superior = perpendicular plate of ethmoid, inferior =
vomer, anterior = quadrangular cartilage)
– Lateral cartilages (upper and lower lateral cartilages)
3
Emergency Radiology: Imaging of Facial Trauma
4. Nasal Fractures
• Pattern of nasal fractures depend on direction of force
– Frontal direction (frontal blow)
• May cause a simple nasal fx
• Can be more severe with flattening of nose, septum and more
complicated fx such as nasoorbitalethmoidal fx
– Lateral direction (lateral blow)
• May cause depression of ipsilateral nasal bone
• May also fracture contralateral nasal bone
• Interlocking of nasal bone and cartilage may occur; requiring open
reduction for adequate cosmetic result
– Inferior direction (blow from below)
• Usually with septum (quadrilateral cartilage, bony septum) fx and
dislocation
4
Emergency Radiology: Imaging of Facial Trauma
5. Nasal Fractures
• Diagnosis:
– Made based on physical examination findings
• Visible bony deformity in displaced fx
• Laceration, ecchymosis, hematoma, mucosal tear and epistaxis in the
inner surface of the nasal cavity strongly suggest fx
– Presence of epistaxis and septal hematoma requires prompt
diagnosis and treatment
• Epistaxis can be life threatening
• Septal hematoma may lead to cartilage necrosis and resultant saddle
nose deformity
– Telecanthus is an indication of more severe injury, further
workup including CT scan is required
5
Emergency Radiology: Imaging of Facial Trauma
6. Nasal Fractures
• Plain film radiography
– Plain film can miss up to nearly half of the patients with nasal
fractures
– Nasal bone series:
• Lateral nasal views (soft tissue technique)
• Water’s view
• CT
– CT better depicts fx, especially frontal process of maxilla.
Depressed fx of frontal process of maxilla can lead to facial
deformity if left untreated
– CT should be performed if there is more than a simple nasal
fracture on xray
– Presence of telecanthus prompts CT workup
6
Emergency Radiology: Imaging of Facial Trauma
7. Nasal Fractures,
frontal blow
39yoman (cop vs.
robber) was punched from
the front
Comminuted bilateral
nasal bone fractures (red
arrows) with displaced
fragments.
N = nasal bone
M = Frontal process of maxilla
Black arrow = Intact
nasomaxillary suture
7
Emergency Radiology: Imaging of Facial Trauma
8. Nasal Septum
Fractures
33yoman was
punched by a right
handed person
S = Bony nasal septum
E = Ethmoid sinus
Sp = Sphenoid sinus
= Orbital emphysema
(in this case, from
maxillary sinus fracture)
Fractures of the left frontal process of maxilla (red arrow) and right nasal bone (green
arrow) are noted. The fractures are displaced to the right, indicating the force of impact
from the left. The righthanded person hit the left side of the nose of the victim.
8
Emergency Radiology: Imaging of Facial Trauma
9. Nasal Septum
Fractures
67yoman involved in
a motor vehicle
collision
S = Bony nasal septum
E = Ethmoid sinus
Blue arrows = Frontal
process of maxilla
= Trapped air in
preseptal region
(anterior to the globe)
Deformity of the nose pointing toward the left. Angulation of the cartilagenous portion of
the nasal septum (red arrows). Blood in the nasal cavity is present as soft tissue density.
9
Emergency Radiology: Imaging of Facial Trauma
10. Nasoorbitalethmoidal (NOE)
Fractures
• Etiology:
– Forceful frontal blow to the central aspect of midface.
– Most common from motor vehicle collisions (MVC), followed by
assaults
• NOE fractures involve the central upper face, disrupting the
medial orbit, nose and ethmoid sinuses
• NOE fractures are distinguished from simple nasal
fractures by
– Posterior disruption of medial canthal region, ethmoids and
medial orbital walls
10
Emergency Radiology: Imaging of Facial Trauma
11. Nasoorbitalethmoidal (NOE)
Fractures
• Relevant anatomy:
– NOE complex consists of nasal, frontal, maxillary,
ethmoid, lacrimal and sphenoid bones
– Superior to NOE complex is anterior cranial fossa
– Lateral to NOE complex is globe
– Deep to NOE complex is optic canal and sphenoid
bone
– Center of NOE complex is interorbital space,
consisting of ethmoid sinuses, lacrimal drainage
system, nasofrontal ducts
– NOE fractures can injure significant
surrounding structure
11
Emergency Radiology: Imaging of Facial Trauma
12. Nasoorbitalethmoidal (NOE)
Fractures
• Relevant anatomy
– Medial canthal tendon
• A crucial soft tissue component of NOE complex
• Medial portion of orbicularis oculi, inserting to the medial orbital wall
• Acts as a suspensory sling for the globe and ensure close apposition of
the eyelid
• In NOE fractures, medial canthal tendon pulls the fragment laterally, or
(rarely) torn, causing telecanthus
• Helpful clinical signs to detect traumatic telecanthus
– Intercanthal distance > interpalpebral distance of the eyes
– Intercanthal distance more than onehalf of interpupillary distance
– Clinically, the most obvious deformity is loss of nasal
projection in profile and apparent telecanthus
12
Emergency Radiology: Imaging of Facial Trauma
13. Nasoorbitalethmoidal (NOE)
Fractures
• Three types of NOE fractures
– Type I: Large fragment of medial orbit, medial canthal insertion is
intact
– Type II: Comminution of bones, fracture line does not extend into
area of medial canthal insertion
– Type III: Comminution of bones, fracture line extends into area of
medial canthal insertion
13
Emergency Radiology: Imaging of Facial Trauma
14. Nasoorbitalethmoidal (NOE)
Fractures
• Pertinent radiologic information
– Degree of comminution of medial orbital wall, especially in the
lacrimal fossa where medial canthus attaches
– Involvement of nasofrontal ducts require surgical obliteration of
frontal sinus to prevent frontal mucocele
– Extension
• Posterior extension to the optic canal
• Superior extension to the frontal sinus, intracranial structures
• Complications
– Persistent telecanthus
– Injury to lacrimal system
– Nasofrontal duct impingement
14
Emergency Radiology: Imaging of Facial Trauma
15. NOE Fractures,
bilateral, type II or III
21yoman was assaulted
E = Ethmoid
M = Maxillary sinus
Sp = Sphenoid sinus
= Orbital emphysema
A Frontal blow to the nasion results
in a comminuted fracture
involving the medial walls of both
orbits (green circle), nasal bones
(green arrow) and frontal
processes of maxillae (red arrows)
as shown in image A. Blue arrows
indicate the attachment sites for
medial canthal tendons. Posterior
displacement (depression) of the
nasion is noted in image B.
B
15
Emergency Radiology: Imaging of Facial Trauma
16. C D
3D images better depict degree of displacement and depression of the NOE fractures. The
fractures also extend to frontal sinuses (F). Comminuted fractures of bilateral nasal bones
(N) and frontal processes of maxillae (M). Small images on right lower corners represent
normal anatomy in the same projections. From radiological perspective, type II and II NOE
fractures may not be differentiated.
Radiologic description should comment on degree of comminution of medial orbital
wall especially in the region of lacrimal fossa, where the medial canthus attaches and
nasofrontal ducts locate.
16
Emergency Radiology: Imaging of Facial Trauma
17. Frontal Sinus Fractures
• Etiology: motor vehicle collision (most common), followed by
highimpact sport related injuries
• Clinical
– Gross depression or laceration over supraorbital ridge,
glabella or lower forehead (most common finding on clinical
exam)
– Ophthalmologic evaluation may be necessary because up to
half of patients have orbital trauma
• Classification of fractures
– Location: anterior wall, posterior wall, or both
– Appearance: linear, comminuted, depressed or nondisplaced
• Isolated anterior wall fracture is most common
17
Emergency Radiology: Imaging of Facial Trauma
18. Frontal Sinus Fractures
• Relevant anatomy
– Frontal sinus first appear 68yrs, fully pneumatized in adolescence.
– It can be asymmetric/partial incomplete pneumatized up to
20% of population
– Frontal sinus drainage via either nasofrontal duct located
posteriomedially in the sinus (the only drainage pathway of frontal
sinus may be absent in general population) or in conjunction with
anterior ethmoid air cells. The nasofrontal duct, if present and
fractured, can be obstructed leading to chronic drainage
complication
– Frontal sinus is closed to dura, frontal lobe, crista galli and
cribiform plate
18
Emergency Radiology: Imaging of Facial Trauma
19. Frontal Sinus Fractures
• Indication for surgery
– Fracture potentially injures nasofrontal duct (fx involves base of
frontal sinus, medial to supraorbital notch)
– Depressed anterior wall cosmetic deformity
– Posterior table fx with gross CSF leak, more than one table width
displacement
• Pertinent radiologic information
– Status of nasofrontal duct, posterior wall, frontal lobe injury
• Complication
– Early complication: frontal sinusitis (retained FB in sinus) leading to
meningitis, osteomyelitis, orbital abscess or brain abscess
– Late complication: mucocele, mucopyocele, delayed CSF leak
19
Emergency Radiology: Imaging of Facial Trauma
20. Frontal Sinus Fractures
Two examples. Young
patients who were
assaulted.
Above: Isolated anterior
wall fracture (red arrows)
with hemosinus. Intact
posterior wall (blue arrow).
This type of depressed
fracture causes cosmetic
deformity
Below: Both anterior and
posterior table fractures
(red and green arrows),
which are nondepressed.
Pneumocephalus (white
arrow)
20
Emergency Radiology: Imaging of Facial Trauma
21. Frontal Sinus Fractures
Scout CT: Asymmetrical haziness of the left frontal sinus (normal frontal sinus on
AP skull radiograph should have same density to the orbit) indicates hemosinus (red
arrow).
Axial CT: Fracture of the posterior wall of the left frontal sinus (green arrows) is
demonstrated. There is displacement of the fracture fragments into the sinus. Small
pneumocephalus is noted deep to the fracture. The patient also has anterior wall
fracture (not shown). Isolated posterior wall fracture is rare.
21
Emergency Radiology: Imaging of Facial Trauma
22. Orbital Fractures
• Plain film radiography has false negative rate of 730%
• CT in axial, and coronal planes are essential to determine
presence of fractures and status of intraocular muscle
– Axial: medial, lateral wall fracture, entrapment of medial rectus
muscle
– Coronal: floor, roof fracture, entrapment of inferior rectus muscle,
fracture involving nasolacrimal duct
– Both are helpful for fx of optic canal, retroorbital hematoma
• Two main types
– Blowout fractures
– Blowin fractures
22
Emergency Radiology: Imaging of Facial Trauma
23. Orbital Fractures
• Blowout fractures
– Bone is displaced away from the orbit
– May involve the roof, floor, and medial or lateral walls of the orbit
• Most common = floor
– If orbital rim is intact = ‘pure’ blowout fracture (classic fx)
– Up to 30% have ocular injury
– Two proposed mechanism of injury
• Hydraulic mechanism: pressure on eyeball increases intraorbital
pressure, then the orbit ruptures at its weakest point (thin floor)
• Buckling mechanism: blow to orbital rim results in fx of orbital wall
– Clinical
• Enophthalmos, diplopia and hypoesthesia (infraorbital nerve
distribution). This can be obscured due to swelling
23
Emergency Radiology: Imaging of Facial Trauma
24. Orbital Fractures
• Blowout fractures
– Pertinent radiologic information
• Appearance of inferior rectus muscle on coronal images
– Normal = oval shape
– Abnormal = round shape
• Location of inferior rectus muscle
– Abnormal = located below the expected level of orbital floor
• Abnormal inferior rectus can be
– Entrapped: muscle lies completely beneath or within the defect and
appears round on coronal images
– Hooked: portion of muscle lies within the defect
– Entrapment of inferior rectus in children can be easily missed, since
flexible bone springs back into place like a trap door, looking normal
at CT except for entrapped muscle beneath it
• This requires urgent Rx within 2472 hours to minimize motility problem
24
Emergency Radiology: Imaging of Facial Trauma
25. Orbital Blowout Fractures
Middle age patient involved in
motor vehicle collision
Coronal images (in bone and soft
tissue windows) show the defect
(red arrow) in the floor of the right
orbit with a small hematoma in the
right maxillary sinus (green arrow).
Light blue arrows point to the inferior
rectus muscle, where its inferior
portion (blue arrow) is hooked to the
defect. Clinically, the patient does
not have entrapment
O = Optic nerve
= Facial soft tissue edema
Clinical ophthalmologic
exam is required to confirm
or rule out evidence of
intraocular muscle
entrapment.
25
Emergency Radiology: Imaging of Facial Trauma
26. Orbital Blowout Fractures
81yearold woman fell from stairs
Intraorbital fat herniation (green arrow) through the defect in the floor of the left orbit. The
inferior rectus (blue arrow) is far from the site of fracture. 3D image shows intact orbital
rim (red arrows) indicative of ‘pure’ blowout fracture.
O = Optic nerve, H = Hemosinus
26
Emergency Radiology: Imaging of Facial Trauma
27. Orbital Fractures
• Blowin fractures
– Bone is displaced into the orbit, intraorbital volume is decreased
– May involve the roof, floor, and medial or lateral walls of the orbit
– If orbital rim is intact = ‘pure’ blowin fractures
– Clinical
• Exophthalmos (due to decreased orbital volume)
• Decreased visual acuity (eyeball trauma, optic neuropathy, fracture of
optic canal)
27
Emergency Radiology: Imaging of Facial Trauma
28. Orbital Blowin Fractures
80yearold man fell onto his face.
Fractures of the floor of the left orbit (red arrow) displace superiorly into the
orbit. The medial rectus muscle (blue arrows) is pushed upward by the
fracture fragment. Intraorbital volume is further decreased by retroorbital
hematoma (blue star).
H = Hemosinus
28
Emergency Radiology: Imaging of Facial Trauma
29. Orbital Fractures
• Orbital floor fractures
– Most common portion of orbit to sustain a fracture
– Usually associated with other complex midface fractures (ZMC,
LeFort II and LeFort III fractures)
– Can be linear, comminuted, or segmental
– Herniation of intraorbital contents
• Best seen in coronal projection
• What determines chance of herniation, entrapment?
– Size of fragment, degree of depression
• Inferior rectus muscle can be free, hooked, or entrapped
– Indications for surgery
• Involvement > 50% of the floor, combined floor and medial wall fx with
soft tissue herniation, significant enophthalmos (> 2mm), significant
diplopia
29
Emergency Radiology: Imaging of Facial Trauma
30. Orbital Fractures
• Medial wall fractures
– Usually associated with other complex midface fractures
– Risk of medial rectus herniation (either hooked or entrapped)
relatively rare
• Orbital roof fractures
– Risk of brain herniation into the orbit (better seen with coronal
reformatted CT or MRI)
• Orbital apex fractures
– Emergent surgical cases if there is radiologic and clinical
evidence of optic nerve impingement
– May be associated with blindness
– May be associated with carotid artery injury (cavernous portion)
30
Emergency Radiology: Imaging of Facial Trauma
31. Orbital Fractures
• Soft tissue injuries of the orbit
– Eyeball rupture
• Usually there is extrusion of vitreous (normal intraocular pressure is
higher than intraorbital pressure) leading to ‘flat tire’ sign and
‘deepening’ of anterior chamber sign seen in CT
– Lens injury: subluxation, dislocation, traumatic cataract
• Zonular fibers hold lens in place to ciliary muscle. If torn (partial or
complete), subluxation or dislocation occurs
• Traumatic cataract (acute lens edema): affected lens has density 30HU
less than normal side
– Intraorbital hemorrhage
– Intraorbital foreign body
31
Emergency Radiology: Imaging of Facial Trauma
32. Globe Rupture and Vitreous Hemorrhage
21yearold man was assaulted.
Right globe rupture is evident by flattening of the posterior wall of the globe “flat tire
sign” (red arrow) and narrowing of the space between cornea and lens “deepening of
anterior chamber” (red line). = Vitreous hemorrhage
32
Emergency Radiology: Imaging of Facial Trauma
33. Hemorrhage: Preseptal, Vitreous and Choroidal
Preseptal hemorrhage = bleeding in the space anterior to the globe (green arrows, line)
Vitreous hemorrhage = bleeding in the posterior chamber of the globe (red star), usually making
‘obtuse’ angle with the surrounding vitreous
Choroidal hemorrhage = bleeding in the choroid (white stars) along the wall of the globe
Blue arrows represent subcutaneous edema/hemorrhage.
33
Emergency Radiology: Imaging of Facial Trauma
34. Traumatic Lens Dislocation
60yearold man was found down.
Traumatic left lens dislocation (red arrow) is noted. Dislocation occurs due to tear of
zonular fibers normally surrounding the lens. Blue arrows point to normal lens at the
locations of zonular fiber attachment. The patient also has diffuse subarachnoid
hemorrhage (red stars) and multiple facial fractures.
34
Emergency Radiology: Imaging of Facial Trauma
35. Zygomatic Fractures
• Two types of zygomatic fractures
– Zygomatic complex fracture
– Isolated zygomatic arch fracture
• Relevant anatomy
– Malar eminence = surface anatomy of the
body of zygoma
– Zygomatic fractures can cause limitation
of mandibular motion, especially when the
fractures are depressed
• Masseter muscle arises from zygomatic arch
• Coronoid process is located underneath the
zygomatic arch
35
Emergency Radiology: Imaging of Facial Trauma
36. Zygomatic Fractures
• Zygomatic complex fractures
– AKA ZMC fracture, trimalar fracture, malar eminence fracture
– Tripod fracture is a misnomer (zygoma actually has 2 attachments
to cranium and 2 to maxilla)
– Principal lines involve 3 components
• Orbital process of zygoma
• Inferior rim of orbit
• Zygomatic arch
– Main fragment is zygoma, which has become separated from
its three areas of attachment
36
Emergency Radiology: Imaging of Facial Trauma
37. Zygomatic Fractures
• Zygomatic complex fractures
– Fractures almost invariably traverse the infraorbital nerve foramen
(located in the orbital floor), causing impaired sensation of the
cheek and a portion of the upper lip. However in majority of cases,
the nerve is usually intact
– Pertinent radiologic information
• Alignment of zygoma (depressed, rotated)
• Lateral orbital wall alignment (posterior relationship of zygoma and
sphenoid bones)
– Angulation of the wall results in increased orbital volume and enophthalmos
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Emergency Radiology: Imaging of Facial Trauma
38. Zygomatic Fractures
• Isolated zygomatic arch fracture
– Etiology: direct blow by small object
– Commonly consists of 3 fractures:
• One at each extremity
• Third in the center with depression of fracture fragment
– Limited motion of mandible may occur if the fracture impinges on
coronoid process or simply because the masseter muscle arises
from zygomatic arch
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Emergency Radiology: Imaging of Facial Trauma
39. Zygomatic Complex Fractures
60yearold man fell onto the left cheek.
Axial and coronal reformatted CT images show typical left ZMC fractures:
anterior/posterior walls of maxillary sinus including rim (red arrows), zygomatic arch
(green arrow), and orbital process of zygoma (blue arrow). Left orbital floor ‘blowout’
fracture with intraorbital fat herniation is seen in coronal image. Orbital floor fracture is
commonly associated with ZMC fractures.
H = Hemosinus, = Soft tissue emphysema due to communication with fractured sinus
39
Emergency Radiology: Imaging of Facial Trauma
40. Zygomatic
Complex Fractures
Same patient as in
previous page
3D image shows all
components of left
ZMC fractures
including the inferior
orbital rim (red
arrows), zygomatico
frontal separation
(blue arrow),
zygomatic arch
(green arrow).
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Emergency Radiology: Imaging of Facial Trauma
41. Isolated Zygomatic Arch Fractures
23yearold man was punched by a lefthanded.
Classic zygomatic arch fractures occur in three sites along the arch. The
middle fracture causes fracture fragment depression. The depressed
fragments impinge on masseter muscle and can limit jaw movement.
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Emergency Radiology: Imaging of Facial Trauma
42. • The information provided in this presentation…
– Does not represent the official statements or views of the Thai
Association of Emergency Medicine.
– 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.
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Emergency Radiology: Imaging of Facial Trauma