Imaging of Facial Trauma

Part 1: Introduction and Anatomy

Rathachai Kaewlai, MD
www.RadiologyInThai.com Created: January 2007

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Outline

Facial fracture epidemiology Initial management Imaging: CT versus radiography Normal anatomy

3D CT (axial, coronal and sagittal planes) Radiography

Types of facial fracture Nasal bone fracture Naso-orbital-ethmoid fracture Frontal sinus fracture Orbital fracture Zygomatic fracture Maxillary fracture Mandibular fracture Imaging approach

Biomechanics

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)

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

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

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

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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

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

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 alveolar process

Mandible, including the

FACE

temporomandibular joints (TMJ), considered separate from the face This lecture series will include both parts (face and mandible)
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3D CT Anterior View Major structures are labeled in the picture.

Nasofrontal suture Zygomaticofrontal suture Zygomaticotemporal suture SOF = Superior orbital fissure IOF = Inferior orbital fissure Orbital rim is different from the wall

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3D CT Left Lateral View

Nasofrontal suture Zygomatico-frontal suture Zygomatico-temporal suture

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3D CT Base View

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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
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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)
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Key structures

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

A = Frontal sinus, anterior wall B = Frontal sinus, posterior wall *Note: The right frontal sinus is not pneumatized in this case.

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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 6 = Orbit, lateral rim 7 = Sphenoid bone 8 = Optic foramen

Do not misinterpret the suture between nasal bone and frontal process of maxilla for a fracture Look for a piece of fracture in the optic foramen, it is the true emergency of facial fracture
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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
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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

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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

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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

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Key structures
D = Orbit, medial wall M = Nasal septum 5 = Maxilla, frontal process 15 = Maxilla bone/ hard palate 16 = Frontal sinus 17 = Mandible, body

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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

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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

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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
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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

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Key structures
3 = Sphenoid sinus 4 = Nasal bone 15 = Maxilla bone/ hard palate

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CT Orthopanthogram

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Axial

Coronal

Sagittal

Right Orbit, soft tissue window

Key structures:
ON = Optic nerve LR = Lateral rectus MR = Medial rectus IOL = Intra-ocular lens

Globe contour should be smooth Clean (dark) retro-bulbar fat

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 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 Ive seen and things Ive

learned.
R.K.
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