CT of Maxillofacial Fracture Patterns. CT of Maxillofacial Fracture Patterns

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1 CT of Maxillofacial Fracture Patterns CT of Maxillofacial Fracture Patterns Stuart E. Mirvis, M.D., FACR Department of Radiology University of Maryland School of Medicine Viking MGS 2001 Technology changes the diagnosis

2 Technologic Evolution Highlights of Facial Anatomy - Orbit Orbital sutures and thin orbital bony plates allow suture diastasis and fractures of thin bone to absorb impacting energy. This mechanism plus orbital fat and muscles cushions the globe and preserves vision in high-energy impacts to the orbit.

3 Orbital blow-in fracture Orbital Blow-out Fractures: Significant Imaging Features Evidence of muscle or fat entrapment -rare Pure or impure fracture (?intact inferior orbit rim) Orbital hematoma (up to 24% orbital injuries) Complications: enopthalmous, diplopia, hypoesthesia Size (area) of floor defect or associated fractures Calculations of blow-out fractures of the orbital floor by 3D-CT and 2D-CT method are accurate for assessing the area of fracture and the volume of herniated tissue * * Ploder O, 2D- and 3D-based measurements of orbital floor fractures from CT scans. J Craniomaxillofac Surg. 2002

4 Orbit Blow-out Fracture Orbit Blow-out Fracture

5 Medial orbital wall fracture Isolated or associated 20-40% with floor fracture More common to cause orbital emphysema Rarely surgically repaired Complications: Horizontal gaze palsy, enopthalmous, epistaxis Medial Orbital Blow-out out Fractures

6 Medial orbital wall fractureemphysema Medial wall fracture - entrapment

7 Medial blow-out with herniation Orbital Blow-in fracture

8 Orbital Blow-in fracture: MRI with brain herniation Orbital Blow-up fracture Rare Orbital roof fragments explode into frontal lobe Typical dural tears and CSF leak Frontal sinus involvement common

9 Orbital blow-up fracture Orbital Blow-up fracture

10 Naso-orbital-ethmoid Complex Nasal bridge, lower frontal sinus, medial orbits Comminution, depression, and lateral spread of bones Soft tissue injury; medial canthal ligament, lacrimal drainage, nasofrontal sinus Usually associated fracture patterns Naso-orbital Ethmoid Fractures N= 21 Clinical findings: Widened intercanthal distance (71%) Increased nasofrontal angle (28%) Epistaxis (100%) Visual disorder (62%) Cerebrospinal rhinorrhea (33%) Enophthalmos (23%) Facial paralysis (14%)

11 Naso-orbital-ethmoid Complex Naso-orbital-ethmoid Complex

12 NOE and repair Nasomaxillary Fracture Kicked by horse

13 Sagittal mid-face pattern Zygomatic-maxillary Complex (ZMC) Impact on malar eminence 4- point fracture Displaces posterior and medially Simple type vs. hi-grade variant

14 Zygomaticmaxillary Complex (ZMC) Always involves orbital floor May involve medial orbit wall Lateral canthal ligamant and inferior orbital nerve Coronoid process impact Zygomatic-maxillary Complex (ZMC) hi-grade

15 Zygomatic-maxillary Complex (ZMC) Higrade Complex ZMC

16 Orbital Apex Syndrome Orbital Apex Syndrome Optic neuropathy and ophthalmoplegia Loss of cranial nerves II, III, IV, opthalmic division of V, and VI Blindness, fixed dilated pupils, proptosis, ptosis Causes: inflammatory, infectious neoplastic, iatrogenic/traumatic, and vascular conditions LeFort Fracture Patterns Described as symmetric mid-face lines of weakness - experimental Often asymmetric clinically and combined with ZMC, NOE Always involves pterygoid plate fractures Higher energy usually leads to higher grade

17 LeFort Fracture Patterns LeFort Fracture 1 Fracture all 6 walls of maxillary sinuses Floating palate Typically: nasal septum & maxillary nasal spine Airway compromise - rare

18 LeFort Fracture I + LeFort II Fracture Patterns Mobile nose and maxilla Fx. Lateral maxillary sinus, medial orbital floor, nasal bridge, pterygoids (pyramidal) Soft tissues: medial orbit, infraorbital nerve

19 LeFort 2 LeFort Fracture II

20 Lefort II and NOE LeFort Fracture III

21 LeFort Fracture III LeFort Fracture III and NOE

22 Lefort II/III: highly comminuted

23 Combined LeFort Fracture Pattern - Smash

24

25 Mandibular Fractures Mandibular Fractures Fracture Type Prevalence Body % Angle % Condyle % Symphysis 7-15 % Ramus 3-9 % Alveolar 2-4 % Coronoid process 1-2 %

26 Mandibular Angle Fracture

27

28 ORIF angle/body fx oops! Minimally displaced bilateral fractures

29 Mandibular Fracture Dislocation Mandibular Fracture - Dislocation

30 Mandible fracturedislocation (sagittal split) LeFort I/II/III: Comminuted mandible fractures

31 Attempted suicide: Bit blasting cap GSW: Facial explosion

32 That s All Folks

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