Sylvia Aparicio, IV Gillian Lieberman, MD
September 2006
Facial Fractures
Sylvia Aparicio Harvard Medical School Year IV Gillian Lieberman, M.D.
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient
• 82 year old male • Had a mechanical fall with blunt force to face • Taken to BIDMC by ambulance 2
Sylvia Aparicio, IV Gillian Lieberman, MD
Facial Fractures • Most common mechanism is auto accidents • 70 % of auto accidents produce some type of facial injury, although most are limited to soft tissue
• The face is a target in fights or assaults • Remainder of facial fractures produced by falls, sports, industrial accidents and gunshot wounds 3
Sylvia Aparicio, IV Gillian Lieberman, MD
Facial Fractures
• Analysis of the fractured face requires • knowledge of normal anatomy • common fracture patterns in the face
4
Sylvia Aparicio, IV Gillian Lieberman, MD
Anatomy-Frontal View
5 http://www.emedicine.com/ent/images/Large/22ent0009-01.jpg
Sylvia Aparicio, IV Gillian Lieberman, MD
Anatomy-Lateral View
6 http://www.bartleby.com/107/
Sylvia Aparicio, IV Gillian Lieberman, MD
Imaging Studies • Plain Film • universally available • quickly obtained • economical
• CT • more accurate • 3D reconstruction very useful • fractures involving multiple planes • fracture displacement • assessment of facial symmetry
• assess fractures, soft tissue injuries, and intracerebral hemorrhage simultaneously
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Sylvia Aparicio, IV Gillian Lieberman, MD
Standard Views for Plain Films • • • •
Waters view (PA view with cephalad angulation) Caldwell view (PA view) lateral view submentovertex view
• Non-traumatized patient • should be obtained with the patient erect and all frontal projections with the central-beam PA
• Patients with facial trauma • obtained with the patient supine • cervical spine must be cleared 8
Sylvia Aparicio, IV Gillian Lieberman, MD
Waters View PA with cephalad angulation
9 http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas28.html
http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Caldwell View PA
Petrous pyramid
10 http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas27.html
http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Lateral View
11 http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas30.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Submentovertex View • a-zygomatic arch • b-maxillary sinus • c-anterior wall, maxillary sinus
http://www.uth.tmc.edu/radiology/test/er_primer/face/images/subment02.html
12 http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Facial CT Views
Coronal View
Axial View 13 http://uuhsc.utah.edu/rad/protocol/fbones.htm
Sylvia Aparicio, IV Gillian Lieberman, MD
Key Points for Assessing Fractures • Look at orbits carefully • Involved in 60 - 70 % of all facial fractures
• Look for most common fracture patterns • Bilateral symmetry can be very helpful. • Normal radiopacities are usually bilateral. Abnormal ones are usually unilateral.
• Look for aberrant air 14
Sylvia Aparicio, IV Gillian Lieberman, MD
Zygomaticomaxillary complex (tripod fracture)
15 www.emedicine.com/ent/topic166.htm
http://www.rad.washington.edu/mskbook/facialfx.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Orbital Floor Fractures • "blowout" fracture • usual mechanism is a blow to the eye • common clinical signs • enophthalmos • diplopia
16 http://www.rad.washington.edu/mskbook/facialfx.html
http://www.nature.com/eye/journal/v20/n1/fig_tab/6701801f2.html#figure-title
Sylvia Aparicio, IV Gillian Lieberman, MD
Le Fort Fractures
17 http://www.rad.washington.edu/mskbook/facialfx.html
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient Coronal CT
Fracture at naso-frontal suture Bilateral fractures at zygomatico-maxillary sutures
Bilateral Le Fort II
18 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient Axial CT, Bone Window
Fracture at naso-frontal suture
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Axial view through orbits
Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient Axial CT, Bone Window Fracture of anterior maxillary walls Aberrant air in subcutaneous tissues
Fracture of posterior maxillary walls
Courtesy of Dr. Handwerker-BIDMC
Axial view through maxillary sinuses
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Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient
Axial Views Through Nasal Bones Comminuted nasal bone fractures
21 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient 3D Reconstruction
22 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient 3D Reconstruction
23 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient 3D Reconstruction
24 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
Our Patient 3D Reconstruction
25 Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV Gillian Lieberman, MD
3D Reconstruction • CT 3D reconstruction can often be used to plan surgical management • Can also be used to evaluate facial skeleton post-surgically
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Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
• Post-fixation CT with 3D Reconstruction slides of another patient with a bilateral Le Fort Type II fracture
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Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
28 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
29 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
30 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
31 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
32 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
33 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
34 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
35 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
36 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
37 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
38 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
39 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Second Patient
40 Courtesy of Dr. Guo - BWH
Sylvia Aparicio, IV Gillian Lieberman, MD
Summary • Knowing normal anatomy and common fractures is important • CT-most common modality used
• Consider mechanism • Look for asymmetry • Look for cortex interruption
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Sylvia Aparicio, IV Gillian Lieberman, MD
Resources • • • • • • • • • • •
Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery. Nose and Paranasal Sinuses 21 May 2006. 12 Sept. 2006 . Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences. Gross Anatomy 2005. 12 Sept. 2006 . Gray H. Anatomy of the Human Boday. Gray’s Anatomy. 12 Sept. 2006 . Harris J and Troetscher T. Emergency Radiology Primer 2000. 12 Sept.2006 . Jahan-Parwar B. Facial Bone Anatomy. eMedicine 17 Oct. 2005. 12 Sept. 2006 . Mauriello Jr JA, Lee HJ, Nguyen L. CT of Soft Tissue Injury and Orbital Fractures. Radiologic Clinics of North America 1999; 37: 241-252. Mullins RJ. The Influence of Imaging on the Trauma Surgeon’s Initial Evaluation of Seriously Injured Patients. Seminars in Roentgenology 2006; 41: 159-167. Rhea JT, Rao PM, Novelline RA. Helical CT and Three-Dimensional CT of Facial and Orbital Injury. Radiologic Clinics of North America 1999; 37: 489-513. Richardson M. Facial and Mandibular Fractures 24 Jan. 2001. 12 Sept. 2006 . Vose M, Maloof A, and Leatherbarrow B. Orbital floor fracture: an unusual late complication. Eye (2006) 20, 120–122. Wiggins R. Facial Bones CT Protocol 2002. 12 Sept. 2006 .
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Sylvia Aparicio, IV Gillian Lieberman, MD
Acknowledgements • • • • • • •
Atif Zaheer, MD Jason Handwerker, MD Andrew Hines-Peralta, MD Gillian Lieberman, MD Pamela Lepkowski Larry Barbaras Lifei Guo, MD 43
