Published on October 6, 2008
Imaging of Facial Trauma Part 1: Introduction and Anatomy Rathachai Kaewlai, MD www.RadiologyInThai.com Created: January 2007 1 quot;
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
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
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
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
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
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
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
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
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
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
3D CT Left Lateral View Nasofrontal suture Zygomatico-frontal suture Zygomatico-temporal suture 12
3D CT Base View 13
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
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
• 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
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
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
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
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
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
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
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
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
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
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
Key structures 3 = Sphenoid sinus 4 = Nasal bone 15 = Maxilla bone/ hard palate 27
CT Orthopanthogram 28
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
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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