Facial Trauma ASHNR. Disclosures: Acknowledgments: None. Edward P. Quigley, III, MD PhD University of Utah

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1 Disclosures: Facial Trauma ASHNR Edward P. Quigley, III, MD PhD University of Utah None Acknowledgments: Dr. Rebecca Cornelius Dr. Ilona M. Schmalfuss Dr. Richard Wiggins III Dr. Yoshimi Anzai Dr. Lindell Gentry Dr. Blair Winegar Dr. H Ric Harnsberger Dr. H Christian Davidson Dr. J Scott McNally

$Overview Anatomy and physiology Maxillofacial fractures Mandible fracture$ Craniocervical Anatomy and Physiology Hopper, Salemy, and Sze 2006 Osseous and

Craniocervical Anatomy and Physiology Hopper, Salemy, and Sze 2006 Osseous and

Sphenoid and Skull base Hyoid, Thyroid, Cricoid Mechanical models Buttress, struts,

Sequential failures Patterns Limited Strut Transfacial LeFort Smash Winegar et al.

2 Overview Anatomy and physiology Maxillofacial fractures Mandible fracture dislocation Oral cavity and dental Complications Skull base, Temporal Bone, Craniocervical Anatomy and Physiology Hopper, Salemy, and Sze 2006 Osseous and cartilaginous anatomy Orbits Sinuses and nasal cavity Maxilla, Mandible Zygoma, Sphenoid and Skull base Hyoid, Thyroid, Cricoid Mechanical models Buttress, struts, and arches Conical orbits and Tetrahedral sinuses Force Weak breaks first Sequential failures Patterns Limited Strut Transfacial LeFort Smash Winegar et al Vascular injuries Hematoma Dissection Pseudoaneurysm AV fistulae Cavernous carotid fistula Courtesy S. McNally

$Maxillofacial fractures$ Oral cavity and dental Skull

$floor fracture Lateral$ $fracture Terson syndrome$ Anterior chamber Small

3 Outline Anatomy and physiology Vascular injuries Maxillofacial fractures Mandible fracture dislocation Oral cavity and dental Skull base, Temporal Bone, Craniocervical Supraglottic neck, larynx, infraglottic neck Penetrating globe injury Retinal detachment/ Lens Dislocation Post septal and orbital apex hematoma Orbit floor fracture Lateral orbital wall Lamina papyrecea Orbital roof, frontal sinus fracture Terson syndrome Anterior chamber Small anterior compartment Large anterior compartment posterior globe Lens Dislocation Subluxation Vitreous Hemorrhage Retina detachment Optic Nerve Avulsion

4 Post septal hematoma Compartment syndrome Optic nerve injury Orbital apex hematoma Orbital Floor Muscular/Fat entrapment Infraorbital foramen Enophthalmos Medial wall Lamina papyrecea May be component of medial compartment fx Can involve nasolacrimal canal Musculotendinous entrapment Orbital Roof Apex hematoma Fracture into frontal sinus or anterior fossa High energy Delayed complication, meningitis Orbital Roof Apex hematoma Fracture into frontal sinus or anterior fossa High energy Delayed complication, meningitis

Facial smash plus orbit Lateral wall of orbit

$fracture result in vergence limitation?$ Fat adhesive syndrome: Wright and Speigel

Extraconal fat fascicle adhesion Tenon s

Maxilloalveolar buttress Lateral midface ZMC

$Nasal septal Mandibular fracture and TMJ$

5 Facial smash plus orbit Lateral wall of orbit High energy May be component of sphenotemporal buttress complex How does minimal orbital floor fracture result in vergence limitation? Fat adhesive syndrome: Wright and Speigel Pediatric Ophthalmology Fat adhesive syndrome Extraconal fat fascicle adhesion Tenon s capsule becomes scarred and trapped Maxillofacial Fractures Transfacial: Transfacial LeFort (I, II, III), LeFort +ZMC Complex strut Central midface Nasofrontoethmoidal Nasomaxillary buttress Maxilloalveolar buttress Lateral midface ZMC Sphenotemporal buttress Simple strut Nasal arch Isolated maxillary wall Isolated orbital rim Nasal septal Mandibular fracture and TMJ dislocation Common features of LeFort Fx of pterygoid plates or root of pterygoids

$Pyramidal fracture$ frontonasal Most common

6 Transfacial: Le Fort I Guerin Floating palate Maxilla, medial and lateral, nasal septum Direct force on maxilla Transfacial Le Fort II Pyramidal fracture Inferomedial orbit, frontonasal Most common Midface separation Transfacial: Le Fort III Craniofacial disassociation Floating face Frontonasal, medial lateral orbit, malar zygoma, pterygoids Complex: LeFort III + ZMC

$Complex strut fractures Central midface Nasofrontoethmoidal Nasomaxillary$ $Nasoorbitoethmoidal fractures Medial Maxillary Buttress Fracture Nasal bones,$ effect Telecanthus from splaying the medial canthal tendon CSF leak from

effect Telecanthus from splaying the medial canthal tendon CSF leak from

$strut fractures Maxilloalveolar buttress Central midface Nasofrontoethmoidal$ $are the stress riser or fulcrum Complications: Considered an open fracture$

7 Complex strut fractures Central midface Nasofrontoethmoidal Nasomaxillary buttress Maxilloalveolar buttress Lateral midface ZMC Sphenotemporal buttress Nasoorbitoethmoidal fractures Medial Maxillary Buttress Fracture Nasal bones, ethmoid sinuses, medial orbital walls Complications: Exoophthalmos from mass effect Telecanthus from splaying the medial canthal tendon CSF leak from cribriform plate NOE Markowitz and Manson Complex strut fractures Central midface Nasofrontoethmoidal Nasomaxillary buttress Maxilloalveolar buttress Lateral midface ZMC Sphenotemporal buttress Hopper et al RG 2006 Complex strut fractures Maxilloalveolar buttress Central midface Nasofrontoethmoidal Nasomaxillary buttress Maxilloalveolar buttress Lateral midface ZMC Sphenotemporal buttress Alveolar process is the most common maxillary fracture Teeth are the stress riser or fulcrum Complications: Considered an open fracture Fractured dentition

$Complex strut: Lateral Midface Zygomaticomaxillary complex fracture Complex strut:$ with fx at zygomaticomaxillary suture and zygomaticotemporal Tripod= maxillary sinus and

with fx at zygomaticomaxillary suture and zygomaticotemporal Tripod= maxillary sinus and

$buttress Winegar et al 2013 Complex strut fractures Central midface Nasofrontoethmoidal$ $buttress Isolated simple strut fractures Nasal arch Isolated frontal bone Complication:$ Obstruction and mucocele Isolated maxillary wall Complication: dacrocystitis Isolated

Obstruction and mucocele Isolated maxillary wall Complication: dacrocystitis Isolated

$Inferior alveolar nerve Oral cavity and dental Tongue laceration Dental fractures Foreign$ objects Usually clinically obvious On obtunded patients always evaluate for dental

objects Usually clinically obvious On obtunded patients always evaluate for dental

8 Complex strut: Lateral Midface Zygomaticomaxillary complex fracture Complex strut: Lateral Midface Zygomaticomaxillary complex fracture Arch/ring rules Depressed fragment with fx at zygomaticomaxillary suture and zygomaticotemporal Tripod= maxillary sinus and lateral orbital wall Tripod/Quadripod Zygomaticofrontal Zygomaticomaxillary Zygomaticotemporal Zygomaticosphenoid Lateral maxillary buttress and transverse maxillary buttress Winegar et al 2013 Complex strut fractures Central midface Nasofrontoethmoidal Nasomaxillary buttress Maxilloalveolar buttress Lateral midface ZMC Sphenotemporal buttress Isolated simple strut fractures Nasal arch Isolated frontal bone Complication: Obstruction and mucocele Isolated maxillary wall Complication: dacrocystitis Isolated orbital rim Nasal septal Complications Hematoma, perforation Mandible Trauma Arch and ring mechanics TMJ dislocation Body>angle>condyle >symphysis>ramus> coronoid process Inferior alveolar nerve Oral cavity and dental Tongue laceration Dental fractures Foreign objects Usually clinically obvious On obtunded patients always evaluate for dental foreign objects, bridges, partials in the hypopharynx or supraglottis (iatrogenic) C. M. Cadogan Radiology image database Lifeinthefastlane.com

Skull base, Temporal Bone, and Craniocervical

$petrous portion ~80% of TB fractures More likely$ to involve ossicles CHL ~20% facial nerve injury

portion More likely to involve bony labyrinth SNHL

complications Post Traumatic complications

entrapment, Eno/Exophthalmos, Diplopia Maxillary

injury, dissection, AV fistula, pseudoaneurysm,

Summary Common mechanisms of force predict injury

9 Skull base, Temporal Bone, and Craniocervical injuries Often visible on Maxillofacial CT or C-spine CT. Corners of the film AJR May 2002 Temporal Bone Trauma Fractures Longitudinal Along long axis of petrous portion ~80% of TB fractures More likely to involve ossicles CHL ~20% facial nerve injury Transverse Perpendicular to long axis of petrous portion More likely to involve bony labyrinth SNHL ~50% facial nerve injury Mixed Post traumatic complications Post Traumatic complications Infection Meningitis Cerebritis Ocular muscular entrapment, Eno/Exophthalmos, Diplopia Maxillary mandibular malocclusion TMJ disfunction Vascular injury, dissection, AV fistula, pseudoaneurysm, occlusion Concluding questions: Do the mechanics of injury predict the facial trauma? Which buttresses are involved? What are the possible complications? Have you considered more than the osseous injury? Summary Common mechanisms of force predict injury patterns Face is crumple zone Orbit and Maxillofacial patterns of injury Mandible and zygoma obey arch mechanics Do not ignore soft tissues, cartilage, vascular, airway injury

References: Rene LeFort 1869-1951 Diagnosis of Midface Fractures with CT: What the Surgeon Needs to Know Richard A.

$Winegar, MD, Horacio Murillo, MD, PhD, and Bundhit Tantiwongkosi, MD Maxillofacial fractures and craniocerebral injuries stress propagation from face$

10 References: Rene LeFort Diagnosis of Midface Fractures with CT: What the Surgeon Needs to Know Richard A. Hopper, MD, Shahram Salemy, MD, and Raymond W. Sze, MD Radiographics 26:3 Spectrum of Critical Imaging Findings in Complex Facial Skeletal Trauma Blair A. Winegar, MD, Horacio Murillo, MD, PhD, and Bundhit Tantiwongkosi, MD Maxillofacial fractures and craniocerebral injuries stress propagation from face to neurocranium in a finite element analysis Heike Huempfner-Hierl, Andreas Schaller, and Thomas Hierl Facial Fractures: beyond Le Fort euroimaging Clin N Am May;12(2):

Head and Neck Trauma. Disclosures: Acknowledgments: Introductory case. None

Head and Neck Trauma. Disclosures: Acknowledgments: Introductory case. None Head and Neck Trauma None Disclosures: Edward P. Quigley III MD PhD Radiology and Imaging Sciences University of Utah Dr. Richard Wiggins III Dr. Yoshimi Anzai Dr. Lindell Gentry Dr. Blair Winegar Dr.