le fort fractures
TRANSCRIPT
Sylvia Aparicio, IVGillian Lieberman, MD
Facial Fractures
Sylvia Aparicio Harvard Medical School Year IV
Gillian Lieberman, M.D.
September 2006
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Our Patient
• 82 year old male
• Had a mechanical fall with blunt force to face
• Taken to BIDMC by ambulance
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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
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Facial Fractures
• Analysis of the fractured face requires• knowledge of normal anatomy• common fracture patterns in the face
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Anatomy-Frontal View
http://www.emedicine.com/ent/images/Large/22ent0009-01.jpg
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Anatomy-Lateral View
http://www.bartleby.com/107/
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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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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
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Waters View PA with cephalad angulation
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas28.html http://www.bcm.edu/oto/studs/nose.html
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Caldwell View PA
Petrous pyramid
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas27.html http://www.bcm.edu/oto/studs/nose.html
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Lateral View
http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas30.html
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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
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Facial CT Views
http://uuhsc.utah.edu/rad/protocol/fbones.htm
Coronal View Axial View
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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
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Zygomaticomaxillary complex (tripod fracture)
http://www.rad.washington.edu/mskbook/facialfx.htmlwww.emedicine.com/ent/topic166.htm
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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-titlehttp://www.rad.washington.edu/mskbook/facialfx.html
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Le Fort Fractures
http://www.rad.washington.edu/mskbook/facialfx.html
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Our Patient Coronal CT
Courtesy of Dr. Handwerker-BIDMC
Bilateral Le Fort II
Fracture at naso-frontal suture
Bilateral fractures at zygomatico-maxillary sutures
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Our Patient Axial CT, Bone Window
Courtesy of Dr. Handwerker-BIDMC
Fracture at naso-frontal suture
Axial view through orbits
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Courtesy of Dr. Handwerker-BIDMC
Fracture of anterior maxillary walls
Fracture of posterior maxillary walls
Aberrant air in subcutaneoustissues
Axial view through maxillary sinuses
Our Patient Axial CT, Bone Window
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Our Patient Axial Views Through Nasal Bones
Courtesy of Dr. Handwerker-BIDMC
Comminuted nasal bone fractures
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Our Patient 3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
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Our Patient 3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
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Our Patient 3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
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Our Patient 3D Reconstruction
Courtesy of Dr. Handwerker-BIDMC
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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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Second Patient
• Post-fixation CT with 3D Reconstruction slides of another patient with a bilateral Le Fort Type II fracture
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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Second Patient
Courtesy of Dr. Guo - BWH
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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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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. Gray’s 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>.• Jahan-Parwar B. Facial Bone Anatomy. eMedicine 17 Oct. 2005. 12 Sept. 2006
<http://www.emedicine.com/ent/topic9.htm>.• 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
<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,
120–122. • Wiggins R. Facial Bones CT Protocol 2002. 12 Sept. 2006 <http://uuhsc.utah.edu/rad/protocol/fbones.htm>.
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Acknowledgements
• Atif Zaheer, MD• Jason Handwerker, MD• Andrew Hines-Peralta, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Lifei Guo, MD