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A Shattered Face:

Radiologic and Surgical Reconstruction


of Complex Craniofacial Trauma
Kapil

Verma, Harvard Medical School Year IV
Gillian Lieberman, MD
May 2010
Beth Israel Deaconess Medical Center
Harvard Medical School
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Background:
Epidemiology of craniofacial trauma
Approximately 50% of the 12 million annual traumatic wounds
treated in emergency rooms across the United States involve the
head and neck
Common causes of craniofacial trauma include:
-

Motor vehicle accidents (community setting)
-

Assault (urban setting)
-

Sports injuries and falls
-

Domestic violence
Among level-1 trauma centers, facial trauma is managed by:
-

Plastic surgeons (40%)
-

Oral and maxillofacial surgeons (36%)
-

Otolaryngologists/head and neck surgeons (23%)
-

General surgery and Oculoplastics

(~0.5%)
Singer, Hollander, Quinn
Aksoy, Unlu, Sensoz

Bagheri

et al
Holmes
Background:

Why recognition and management of craniofacial
trauma is crucial
The face contains crucial specialized systems needed to see,
hear, smell, breathe, eat, and speak
Vital structures within the head and neck are intimately
associated
Several facial injuries may be life threatening:
- Hemorrhage
-

Airway obstruction
- Aspiration
The psychological impact of facial disfigurement can be
devastating
Manson et al
Lee et al
Background:

Clinical exam findings in the recognition of
craniofacial trauma
Facial asymmetry
Pain upon palpation
Facial instability
Cortical step-offs
Periorbital

edema
Periorbital

crepitus
Infraorbital

numbness
Epistaxis
Epiphora
Exopthalmus
Enopthalmus
Telecanthus
Orbital muscle/nerve
entrapment
Many more
Manson et al
Background:

Limitations of the clinical exam in the recognition of
craniofacial trauma
Clinical evaluation of the facial skeleton in
trauma patients is difficult:
-

Facial features are often obscured and
distorted by endotracheal

and gastric tubes
and tapes that hold them in place. Thus,
evaluation of facial instability is difficult
-

Response to painful stimuli is blunted. Thus,
evaluation of localized pain secondary to
fractures is difficult
Rehm, Rhos
Background:

The crucial role of radiologic imaging in the
recognition of craniofacial trauma
Up to

60% of facial fractures may be missed
clinically

(lack of step-offs, instability, orbital
entrapment, telecanthus, etc) and are later detected
by CT
Of

those 60% of clinically unsuspected facial
fractures later detected on CT, approximately 50%
require subsequent surgical repair
As a result, though plastic surgeons and
maxillofacial surgeons primarily manage
craniofacial trauma, the radiologist plays a crucial
role in diagnosis

to guide management
Rehm, Rhos
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Normal craniofacial skeletal anatomy:

The skull consists of cranial and

facial

bones
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:

Components of both cranial and

facial

bones form the
orbit

-

colloquially known as the eye socket
Normal craniofacial skeletal anatomy:

Lateral view of the 22 bones of the skull,
8 cranial bones and 14 facial bones
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
8 cranial bones:
1 x Frontal
2 x Parietals
1 x Sphenoid
2 x Temporals
1 x Ethmoid
1 x Occipital
14 facial bones
2 x Lacrimals
2 x Inferior Nasal Conchae
1 x Vomer
2 x Nasals
2 x Zygomatics
2 x Palatines
2 x Maxillae
1 x Mandible
7 orbital bones
Frontal
Sphenoid
Ethmoid
Palatine
Lacrimal
Zygomatic
Maxillary
Normal craniofacial skeletal anatomy:
Anterior view of the facial bones and orbit
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
14 facial bones
2 x Lacrimals
2 x Nasals
1 x Vomer
2 x Inferior Nasal Conchae
2 x Maxillae
2 x Palatines
2 x Zygomatics
1 x Mandible
Cranial
Facial
Normal craniofacial skeletal anatomy:
Skeletal anatomy of the orbit
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
http://www.ophthobook.com/wp-content/uploads/2007/12/an-orbitbone.jpg
7 orbital bones
Frontal
Sphenoid
Ethmoid
Palatine
Lacrimal
Zygomatic
Maxillary
Cranial
Facial
Normal craniofacial skeletal anatomy:
Anatomy of the mandible
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
http://www.face-and-emotion.com/dataface/anatomy/facialbones.jsp
Coronoid

process
Condylar process
Ramus
Angle Body Symphysis
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Shattered Anatomy: Intro to Patient AA
History
37M unhelmeted

bicycle rider struck by a car, propelled
head first through windshield
Widely opened multiple cranial and facial fractures

with
visible brain material, otherwise (remarkably) no other
no traumatic injury to the chest, abdomen, or pelvis
Intubation initially difficult secondary to multiple facial
fractures
Unable to immediately assess for clinical signs of orbital
entrapment secondary to patients waning mental status
Shattered Anatomy: Intro to Patient AA
Initial 3D Facial CT Reconstruction Anterior View
NORMAL OUR PATIENT, AA
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstructions of the face
Normal patient on the left. Our patient AA on the right
Shattered Anatomy: Intro to Patient AA

Initial 3D Facial CT Reconstruction Oblique view
NORMAL
OUR PATIENT, AA
GE Vitrea

3D Workstation, MGH
Oblique 3D-reformatted CT reconstructions of the face
Normal patient on the left. Our patient AA on the right.
Severely comminuted, complex
frontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort

II fractures
Comminuted fractures of the
ethmoid

and sphenoid sinuses,
nasal bone fractures
OUR PATIENT, AA
Shattered Anatomy: Intro to Patient AA

List of craniofacial injuries (to be revisited)
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Menu of radiologic tests:

Traditional facial radiograph series-

outdated in the
evaluation of facial trauma
Traditional facial radiographic series
include those such as the Waters
view,

Caldwell view,

Towne view

and submentovertex

view
Such views are outdated

in
evaluation of facial trauma:
-

difficulty of interpretation

amongst non-radiologist
physicians
-

inability to assess soft tissues
in detail
-

advent of CT and 3D CT
reformatting
Chen, Ng, Whaites
http://www.ispub.com/journal/the_internet_journal_of_otorhi
nolaryngology/volume_5_number_2_21/article/inter_observ
er_and_intra_observer_variability_in_the_assessment_of_t
he_paranasal_sinuses_radiographs.html
Menu of radiologic tests:

Facial Multidetector

CT -

the imaging gold standard
Facial Multidetector

CT without contrast with axial
and coronal sections is the gold standard

in the
evaluation of facial trauma
Fast
Bone windows may evaluate for fractures
Soft tissue windows may simultaneously evaluate for
secondary soft tissue swelling (including extra-ocular
muscles, nerves, and globe) and hematomas
Coronal sections are superior to radiographs in
showing orbital floor fractures
Subsequent 3D CT reformatting is possible
Tanrikulu, Erol
Menu of radiologic tests:

CT with 3D reformatting -

Background
Contiguous 2D CT slices are obtained via
normal CT protocol
These series of tomographs

are analyzed by
a 3D software program
The computer essentially uses one of two
rendered techniques to obtain a 3D image:
1-

Threshold/Surface Rendering
2-

Volume Rendering
Kung, Fung
Menu of radiologic tests:

CT with 3D reformatting

Surface rendering and
volume rendering
Principle behind threshold/surface rendering is based on
the Hounsfield scale (quantitative scale for radiodensity

in
CT using Hounsfield Units = HU)
Can select CT attenuation value of +150 HU as

threshold,
and thus all soft tissues (below +150 HU) excluded in final
3D CT image, and only bone (and other structures with
HU > +150) included
Volume rendering performs a similar algorithm using
summation
-1000 HU: Air -100-30 HU: Fat 0 HU: Water +30+100 HU: Soft tissue +1000 HU: Cortical Bone
Kung, Fung
Menu of radiologic tests:

CT with 3D reformatting -

Conceptually simplified
Combine with
coronal sections
Apply rendering
algorithms
using HU
thresholds
to subtract
soft tissues
Axial CT sections obtained from PACS BIDMC; stacked graphic created independently
3D CT Face reconstruction image obtained from GE Vitrea 3D Workstation, MGH
Menu of radiologic tests:

CT with 3D reformatting -

useful for the surgeon
Surgeons generally think in 3D

vs.
radiologists with specialized training in
3D interpretation of 2D imaging
3D reformatting may aid in pre-surgical
planning
3D reformatting may aid in the design of
custom facial prosthetics
Reuben, Watt-Smith, Dobson, et al
Alder, Deahl, Matteson
Menu of radiologic tests:

Panorex
2D panoramic x-ray (radiograph) of the upper and
lower teeth and mandible
Displays the mandible as a flat structure
Combined with CT, picks up virtually all fractures
of the mandible
When used alone, often misses parasymphysial

fractures

of the mandible
Romeo, Pinto, Cappabianca, et al
Menu of radiologic tests:

Panorex


may miss mandibular

fractures if used alone
Panorex

film of the mandible, upper and lower teeth
AGFA, MGH
-This patient was initially

noted to only have 1 left nondisplaced

fracture at the

junction of the mandibular

ramus

and condylar

process

from this Panorex
Menu of radiologic tests:

Panorex


may miss mandibular

fractures if used alone
Panorex

film of the mandible, upper and lower teeth
AGFA, MGH
-This patient was initially

noted to only have 1 left nondisplaced

fracture at the

junction of the mandibular

ramus

and condylar

process

from this Panorex
Menu of radiologic tests:

Panorex


should be used in conjunction with CT for
the evaluation of mandibular

fractures
-

On subsequent CT, however, in addition to known left mandibular

fracture, she was found to have 2 additional mandibular

fractures: a
right

condylar

process fracture, and a parasymphysial

fracture
AGFA, MGH
Coronal C-

CT sections through mandible
Menu of radiologic tests:

Panorex


should be used in conjunction with CT for
the evaluation of mandibular

fractures
-

On re-evaluation of original Panorex, the 2 additional fractures seen on
CT became apparent, though still difficult to assess on Panorex

alone
Panorex

film of the mandible, upper and lower teeth
AGFA, MGH
The patient subsequently had arch bar placement and
wire fixation of her maxillary and mandibular

teeth
Panorex

film of the mandible, upper and lower teeth; post arch bar placement and wire fixation of upper
and lower teeth
AGFA, MGH
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Severely comminuted, complex
frontal bone fractures
OUR PATIENT, AA
Patient AA revisited:
Frontal bone fractures
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Patient AA revisited:
Frontal bone fractures on CT
AGFA, MGH
Axial C-

CT through the level of the frontal bone; bone window
Patient AA revisited:
Frontal bone fractures on CT, Findings
AGFA, MGH
Axial C-

CT through the level of the frontal bone; bone window
Numerous severely
comminuted fractures of
the frontal bone
Low attenuation areas of
subcutaneous emphysema
High attenuation foreign
objects, likely lead-

containing glass
fragments (as patient was
projected head first
through windshield)
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
OUR PATIENT, AA
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Patient AA revisited:
Orbital rim, wall, and floor fractures
Patient AA revisited:
Orbital fractures on CT
Coronal C-

CT through the level of the orbits; bone window Sagittal

C-

CT through the level of left orbit; bone window
AGFA, MGH
Patient AA revisited
Orbital fractures on CT, Findings
Non-orbital fracture seen: Depressed
skull fragment of frontal bone (on soft
tissue window seen to cause cerebral
edema, necessitating subsequent
craniectomies

and ventriculostomy)
Complex displaced fracture of the right
superior lateral orbital rim
Non-displaced fracture of the left lateral
orbital wall
Bilateral comminuted orbital floor
fractures
Depressed orbital floor fracture on the
right
Coronal C-

CT through the level of the orbits; bone window
Sagittal

C-

CT through the level of left orbit; bone window
AGFA, MGH
Patient AA revisited:
Orbital injury on CT, soft tissue window
Coronal C-

CT through the level of the orbits; soft tissue window AGFA, MGH
Patient AA revisited:
Orbital injury on CT, soft tissue window findings
Coronal C-

CT through the level of the orbits; soft tissue window
Extra-ocular muscles within
orbit
Downward herniation

of
perioribital

fat (HU: -60)
into right maxillary sinus
Blood

in bilateral maxillary
sinuses
No evidence of optic nerve
or extraocular

muscle
entrapment seen on
subsequent clinic exam
(PERRL; negative forced
duction

test)
* *
AGFA, MGH
Bilateral LeFort

II fractures
OUR PATIENT, AA
Patient AA revisited:
Bilateral LeFort

II fractures
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Patient AA revisited:
Bilateral LeFort

II fractures on CT
AGFA, MGH
Axial C-

CT through the level of sphenoid; bone window Coronal C-

CT through the level of the maxilla; bone window
Patient AA revisited:
Bilateral LeFort

II fractures on CT,

Findings
Bilateral fractures of the
pterygoid

processes of
the sphenoid (defines all
LeFort

maxillary
fractures)
Bilateral medial orbital
wall fractures

resulting
in pyramidal pattern of
the LeFort

II fracture
Coronal C-

CT through the level of the maxilla
Axial C-

CT through the level of sphenoid
AGFA, MGH
Comminuted fractures of the
ethmoid

and sphenoid sinuses,
nasal bone fractures
OUR PATIENT, AA
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Patient AA revisited:

Comminuted fractures of the ethmoid

and sphenoid
sinuses, nasal bone fractures
Patient AA revisited:

Comminuted fractures of the ethmoid

and sphenoid
sinuses, nasal bone fractures on CT
Axial C-

CT through the level of the ethmoid

and sphenoid sinuses Axial C-

CT through the level of the nasal bones
Bone window

Bone window
Patient AA revisited:

Comminuted fractures of the ethmoid

and sphenoid

sinuses, nasal bone fractures on CT, Findings (with
blood

in both sinuses)
Axial C-

CT through the level of the ethmoid

and sphenoid sinuses Axial C-

CT through the level of the nasal bones
Bone window

Bone window
*
*
AGFA, MGH
Severely comminuted, complex
frontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort

II fractures
Comminuted fractures of the
ethmoid

and sphenoid sinuses,
nasal bone fractures
OUR PATIENT, AA
Patient AA revisited:

Summary of all fractures
GE Vitrea

3D Workstation, MGH
Anterior 3D-reformatted CT reconstruction
of the face
Patient AA revisited:

Follow-up
Anterior 3D-reformatted CT reconstruction of the face
post bifrontal

craniectomies

with ventriculostomy

tube
placement, and ORIF of comminuted frontal sinus fractures
OUR PATIENT, AA POST-OP
GE Vitrea

3D Workstation, MGH
Due to elevated
intracranial
pressure, underwent
bifrontal

craniectomies
Left ventriculostomy

tube was placed
ORIF of frontal sinus
fracture
Patient AA revisited:

Post craniectomies

and ventriculostomy

tube imaging
Oblique 3D-reformatted CT reconstruction of the face
post bifrontal

craniectomies

with ventriculostomy

tube
placement
Sagittal

C-

CT Head post bifrontal

craniectomies

with
ventriculostomy

tube placement
GE Vitrea

3D Workstation, MGH
AGFA, MGH
Patient AA revisited:

List of subsequent craniofacial reconstructive
procedures
Bilateral arch bar placement with intermaxillary

fixation
ORIF of right zygomaticofrontal

suture
ORIF

of right orbital floor fracture with
reconstruction of the floor with alloplastic

implant
ORIF

of bilateral LeFort

II fractures
Closed reduction of the nasal fractures
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Agenda
Background
Normal craniofacial skeletal anatomy
Shattered anatomy: Intro to patient AA
Menu of radiologic tests
Patient AA revisited
Conclusions
Conclusions
Craniofacial trauma can be devastating

if not acutely
recognized and managed
The recognition of craniofacial trauma depends heavily on
radiologic imaging since the clinical exam is unreliable (60%
of facial fractures are missed clinically)
Facial CT is the gold standard in the evaluation of facial
trauma: facial radiographs are outdated, except for Panorex

which

still has utility when used in conjunction with CT in the
evaluation of mandibular

fractures
3D CT reconstructions provide

useful information in surgical
planning
Acknowledgments
Gillian Lieberman, MD
Yoon S. Chun, MD
Hillary Kelly, MD
Gregory Czuczman, MD
David Li, MD
Maria Levantakis
Linda Burke
References
1-

Singer AJ, Hollander JE, Quinn JV: Evaluation and management of

traumatic lacerations. N Engl

J Med.
1997; 337:1142
2-

Bagheri

SC, Dimassi

M, Shahriari

A, et al. Facial Trauma Coverage Among Level-1 Trauma Centers of the
United States. J Oral Maxillofac

Surg. 2008; 66(5):963-7
3-

Holmes S. Facial Trauma

who should provide care? Br J Oral Maxillofac

Surg. 2009; 47:179-81
4-

Aksoy

E, Unlu

E, Sensoz

O. A retrospective study on epidemiology and treatment of maxillofacial
fractures. J Craniofac

Surg. 2002; 13(6):772-5
5-

Manson P, Clark N, Robertson B, Crawly W. Comprehensive management of pan facial fractures. J
Craniomaxillofac

Trauma. 1995; 11:43-56
6-

Lee SS, Huang SH, Wu SH, et al. A Review of Intraoperative

Airway Management for Midface

Facial Bone
Fracture Patients. Ann Plast

Surg. 2009;63(2):162-166
7-

Rehm

CG, Ross SE. Diagnosis of Unsuspected Facial Fractures on Routine Head Computerized
Tomographic

Scans in the Unconscious Multiply Injured Patient. J Oral Maxillofac

Surg.1995;53:522-54
8-

Chen TW, Ng SY, Whaites

EJ. Interpretation of skull radiographs for facial fractures by

medical staff
working in UK emergency departments: a pilot study. Dentomaxillofac

Radiol. 2003;32(3):166-72
9-

Tanrikulu

R and Erol

B. Comparison of computed tomography with conventional radiography for midfacial

fractures. Dentomaxillofac

Rad. 2001; 30:141-146
10-

Reuben AD, Watt-Smith R, Dobson D, et al. A comparative study of evaluation of radiographs, CT and 3D
reformatted CT in facial trauma: what is the role of 3D? Br J Radiol

2005; 78:198201
11-

Alder ME, Deahl

ST, Matteson SR. Clinical Usefulness of Two-Dimensional Reformatted and Three-

Dimensionally Rendered Computerized Tomographic

Images: Literature Review and a Survey of
Surgeons' Opinions. J Oral Maxillofac

Surg. 1995; 53(4):375-86
12-

Romeo A, Pinto A, Cappabianca

S, et al. Role of multidetector

row computed tomography in the
management of mandible traumatic lesions. Semin

Ultrasound CT MRI. 2009; 30:174-180
13-

Wolfe SA, Ghurani

R, Podda

S, et al. An examination of posttraumatic, postsurgical orbital

deformities:
conclusions drawn for improvement of primary treatment. Plast

Reconst

Surg. 2008; 122(6):1874