Sylvia Aparicio, IV

Gillian Lieberman, MD
Facial Fractures
Sylvia Aparicio
Harvard Medical School Year IV
Gillian Lieberman, M.D.
September 2006
Sylvia Aparicio, IV
Gillian Lieberman, MD
2
Our Patient
82 year old male
Had a mechanical fall with blunt force to
face
Taken to BIDMC by ambulance
Sylvia Aparicio, IV
Gillian Lieberman, MD
3
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
Sylvia Aparicio, IV
Gillian Lieberman, MD
4
Facial Fractures
Analysis of the fractured face requires
knowledge of normal anatomy
common fracture patterns in the face
Sylvia Aparicio, IV
Gillian Lieberman, MD
5
Anatomy-Frontal View
http://www.emedicine.com/ent/images/Large/22ent0009-01.jpg
Sylvia Aparicio, IV
Gillian Lieberman, MD
6
Anatomy-Lateral View
http://www.bartleby.com/107/
Sylvia Aparicio, IV
Gillian Lieberman, MD
7
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
Sylvia Aparicio, IV
Gillian Lieberman, MD
8
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
Sylvia Aparicio, IV
Gillian Lieberman, MD
9
Waters View
PA with cephalad angulation
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas28.html http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
10
Caldwell View
PA
Petrous pyramid
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas27.html http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
11
Lateral View
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas30.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
12
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
http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
13
Facial CT Views
http://uuhsc.utah.edu/rad/protocol/fbones.htm
Coronal View Axial View
Sylvia Aparicio, IV
Gillian Lieberman, MD
14
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
Sylvia Aparicio, IV
Gillian Lieberman, MD
15
Zygomaticomaxillary complex
(tripod fracture)
http://www.rad.washington.edu/mskbook/facialfx.html
www.emedicine.com/ent/topic166.htm
Sylvia Aparicio, IV
Gillian Lieberman, MD
16
Orbital Floor Fractures
"blowout" fracture
usual mechanism is a
blow to the eye
common clinical signs
enophthalmos
diplopia
http://www.nature.com/eye/journal/v20/n1/fig_tab/6701801f2.html#figure-title http://www.rad.washington.edu/mskbook/facialfx.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
17
Le Fort Fractures
http://www.rad.washington.edu/mskbook/facialfx.html
Sylvia Aparicio, IV
Gillian Lieberman, MD
18
Our Patient
Coronal CT
Courtesy of Dr. Handwerker-BIDMC
Bilateral Le Fort II
Fracture at naso-frontal suture
Bilateral fractures at
zygomatico-maxillary sutures
Sylvia Aparicio, IV
Gillian Lieberman, MD
19
Our Patient
Axial CT, Bone Window
Courtesy of Dr. Handwerker-BIDMC
Fracture at naso-frontal suture
Axial view through orbits
Sylvia Aparicio, IV
Gillian Lieberman, MD
20
Courtesy of
Dr. Handwerker-BIDMC
Fracture of anterior maxillary walls
Fracture of posterior
maxillary walls
Aberrant air in subcutaneous
tissues
Axial view through maxillary sinuses
Our Patient
Axial CT, Bone Window
Sylvia Aparicio, IV
Gillian Lieberman, MD
21
Our Patient
Axial Views Through Nasal Bones
Courtesy of Dr. Handwerker-BIDMC
Comminuted nasal bone fractures
Sylvia Aparicio, IV
Gillian Lieberman, MD
22
Our Patient
3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD
23
Our Patient
3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD
24
Our Patient
3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD
25
Our Patient
3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD
26
3D Reconstruction
CT 3D reconstruction can often be used
to plan surgical management
Can also be used to evaluate facial
skeleton post-surgically
Sylvia Aparicio, IV
Gillian Lieberman, MD
27
Second Patient
Post-fixation CT with 3D Reconstruction
slides of another patient with a bilateral
Le Fort Type II fracture
Sylvia Aparicio, IV
Gillian Lieberman, MD
28
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
29
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
30
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
31
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
32
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
33
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
34
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
35
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
36
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
37
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
38
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
39
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
40
Second Patient
Courtesy of
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD
41
Summary
Knowing normal
anatomy and
common fractures is
important
CT-most common
modality used
Consider
mechanism
Look for asymmetry
Look for cortex
interruption
Sylvia Aparicio, IV
Gillian Lieberman, MD
42
Resources
Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery. Nose and Paranasal Sinuses 21
May 2006. 12 Sept. 2006 <http://www.bcm.edu/oto/studs/nose.html>.
Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences.
Gross Anatomy 2005. 12 Sept. 2006 <http://anatomy.uams.edu/anatomyhtml/gross.html>.
Gray H. Anatomy of the Human Boday. Grays Anatomy. 12 Sept. 2006 <http://www.bartleby.com/107/>.
Harris J and Troetscher T. Emergency Radiology Primer 2000. 12 Sept.2006
<www.uth.tmc.edu/radiology/test/er_primer/face/images/subment02.html>.
J ahan-Parwar B. Facial Bone Anatomy. eMedicine 17 Oct. 2005. 12 Sept. 2006
<http://www.emedicine.com/ent/topic9.htm>.
Mauriello J r J A, 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 Surgeons Initial Evaluation of Seriously Injured
Patients. Seminars in Roentgenology 2006; 41: 159-167.
Rhea J T, 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 J an. 2001. 12 Sept. 2006
<http://www.rad.washington.edu/mskbook/facialfx.html>.
Vose M, Maloof A, and Leatherbarrow B. Orbital floor fracture: an unusual late complication. Eye (2006) 20,
120122.
Wiggins R. Facial Bones CT Protocol 2002. 12 Sept. 2006 <http://uuhsc.utah.edu/rad/protocol/fbones.htm>.
Sylvia Aparicio, IV
Gillian Lieberman, MD
43
Acknowledgements
Atif Zaheer, MD
J ason Handwerker, MD
Andrew Hines-Peralta, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras
Lifei Guo, MD