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Radiology of Craniofacial Fractures 1

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Until a few years ago, conventional X-rays were the osseous fragments of the skull; (2) indirect fractures
imaging standard for cranio-cerebral and facial trau- identified as opacification of the paranasal sinuses and
mata. Today, however, computed tomography (CT) has soft tissue emphysema. For the facial skeleton, the
become the primary imaging method, along with sig- semi-axial view of the midface is required either in
nificant technical improvements, especially with the occipito-mental or occipito-frontal projections, while
development of multislice CT. fractures of the mandible require the panoramic and the
Conventional X-rays are relatively sensitive to cra- Clementschitsch view.
nial vault fractures, but insensitive to fractures of the The sensitivity of the different exposures for frac-
skull base and facial skeleton. CT enables a precise tures varies depending on fracture type. Some simple
diagnosis of all kind of fractures of the facial skeleton fractures can be well displayed on dedicated X-ray pro-
and skull base, and additionally delivers information jections. On the other hand, complex fractures can only
about intracranial bleeding and injuries to the cere- be partially evaluated because of the overlap of the vari-
brum. In the multi-traumatized patient, CT can be ous structures in the craniofacial skeleton, the complex-
extended to the cervical spine as well as the trunk if ity of which demands considerable expertise in evaluation
necessary. A complete body check for traumatic lesions (Figs. 2.1–2.6).
can be done within a few minutes, including the brain,
spine, bone, and organs. Thus, conventional X-rays of
the skull are no longer used in the case of head traumas
or polytraumatized patients; CT is widely accepted as 2.2  Computed Tomography
the primary imaging method of choice. Nevertheless,
the following provides an overview of all imaging CT is an X-ray imaging method where the X-ray source
methods, including conventional X-rays. rotates around the patient, giving information about the
densitiy of the tissues (attenuation profiles) in the slice
within the X-ray beam. The attenuation profiles of the
2.1  Conventional X-Rays slice are Fourier transformed into a matrix of digital
values representing a digital image of the slice. Every
The standard X-ray exposures for the skull are summa- pixel of the image represents a small volume element
rized in Table 2.1. Standard projections are the anterior/ (voxel) in the patient. There is density averaging within
posterior (AP) and the lateral view of the whole skull. the voxels (partial volume effects), but no superimposi-
These images are sensitive to skull fractures, which fall tion of structures. The thinner the slice, the lesser are
under two general categories: (1) direct fractures identi- partial volume effects and density averaging. CT per-
fiable as fracture lines, fracture gaps and dislocation of mits the analysis of the anatomical structures within the
patient without superimposition of structures, and with
a relatively good tissue density characterization, which
Contributed by Thomas Treumann, Kantonsspital Luzern (CH),
1 can even be improved by the injection of intravenous
Central Institute of Radiology, Luzern, Switzerland. contrast material (CM).

N. Hardt, J. Kuttenberger, Craniofacial Trauma, 15
DOI: 10.1007/978-3-540-33041-7_2, © Springer-Verlag Berlin Heidelberg 2010

2. Sharp lucent line without sclerotic margins in left frontal bone.2  Blow-out fracture of the orbital floor. (a) Indirect fracture sign: total opacification of the right maxillary sinus (asterisks). dento-alveolar traumas Pan-handle X-ray (axial X-ray of the skull) Fractures of the zygomatic arch Unilateral exposure of zygomatic bone Lateral view of nasal bone Fracture of the nasal bone Fig.16 2  Radiology of Craniofacial Fractures Table 2. distant to sutures and vascular channels (arrow) a b ** Fig.1  Conventional X-ray techniques for the skull X-ray Indication Skull X-ray in two planes Cranial fractures Skull occipito-frontal and occipito-mental Fractures of the facial skeleton Occipital exposure (Towne view) Fractures of the occipital bone Mandible (Clementschitsch view) Fractures of the mandible Mandible unilateral in oblique position Fractures of the horizontal branch of the mandible Tilted collum or fracture of the mandibular condyle Panoramic X-ray Collum-condyle-fractures. mandibular fractures. (b) Coronal CT reformatting: depression fracture of the central part of the orbital floor with hematosinus (arrow) .1  Skull fracture on standard X-ray radiographs. 2.

right panel same patient as in Fig. The medial angulation of the right capitulum is well seen in this view (arrow).2  Computed Tomography 17 Fig.2.5  Fracture of the nasal bone with moderate displacement (arrow) Fig. Right paramedian corpus fracture (arrow) Fig.6  X-ray view of both zygomatic arches. The corpus fracture is superimposed by mediasti. 2. 2. 2. Subcapital collum fracture on the right with dislocation of the capitulum (luxation and massive angulation) (arrow) and left neck base fracture without dislocation (arrow).3  Panoramic X-ray: triple fracture of the mandible. 2. Fig. 2.4  Clementschitsch view of the mandible: left panel nor- mal X-ray appearance.3. Fracture of the nal structures and is not seen in this view left zygomatic arch (arrow) .

b) to coronal reformations from thinslice spiral CT thin-section CT scanning allows comfortable patient positioning datasets (c. but put together to form a stack. Scanning is done by continuous with a submillimeter resolution in all three dimen- movement of the patient through the CT gantry in com. 2. in the axial and coronal direction sepa- slices as thin as 0. multiple adjacent body segments can be scanned within a few seconds volumes are acquired. In  the . ago.7  Comparison of direct paracoronal scanning of the images. In MSCT. which in turn can be ana. There is coronal scanning. For the evaluation of the facial skeleton. resulting in a double dose of radiation. d). axial analysis in arbitrary imaging planes. before the MSCT era. The resulting slices are The primary imaging plane of CT images is axial. tooth artifacts superimpose relevant structures (b). Using MSCT. multislice spiral CT (MSCT). sions. with scanned twice. Axial midface (a. and coronal images are mandatory. Until a few years MSCT scanners cover up to 40 mm of patient vol. of the teeth and do not go across relevant structures (d). The scanners become more powerful from year bination with continuous rotation of the X-ray tube. This technique is called ously acquired slices and in the volume per rotation.18 2  Radiology of Craniofacial Fractures To cover larger parts of the body. patient positioning is uncomfortable because no image quality loss between reformatted images and original reclination of the head is required. many structures are more easily analyzed in other imag- lyzed image by image or by reformatting for interactive ing planes. d) has to be tilted leaving less space for the patient (a). with an increase in the number of simultane- resulting in spiral scanning. large rately. to year. split into up to 128 slices. Artifacts remain in the plane with introduction of multislice spiral CT scanners. Direct paracoronal scanning has been abandoned and scanning without gantry tilt (c). the CT gantry paracoronal images (b. In direct para. Furthermore. a b c d Fig. the facial skeleton had to be ume in one rotation.5 mm or less.

but less sensitive In the case of foreign body penetration injuries. such as sensitivity is variable. which must be suspected when tives are valuable for the analysis and visualization of neurologic recovery of the patient is delayed. Whereas glass and metal are seen fluid in the ethmoid cells or sphenoid sinus. 2. These devices are expensive and may not be avail- onal images. carotid-cavernous sinus fistula. On The best. In this case. thus rendering ultrasound imaging a waste of mation from the patient. A workstation can be a CT to be removed from the patient. CSF leak is to inject contrast medium (CM) intrathe- lated within a few seconds. any metal has on a computer workstation. the primary axial CT images are MR angiography are helpful in making the diagnosis. or online from the PACS archive. 2. Ultrasonography is not applicable for adult patients with ments and the position of the osteosynthesis material. which are still open. different density. administration. which should be explored by ence. loaded into a computer program which displays the CT Additional treatment is provided by interventional findings at the site or during surgery (Hassfeld et al. MRI is noninvasive. osseous skull base defects. PACS is the electronic for MRI. 1999. effective in imaging bone than CT. MRI may complex fractures. CT can be used to check and document the repositioned fracture frag. decision. However. method to localize a modern computer workstations. MPR analysis is routinely used to detect or able in every hospital or MR unit. sure the extent of dislocations (Fig. MRI and tion. Gellrich et al. The three-dimensional (3D) perspec. MRI may be used in evaluating post- display (SSD) or volume rendering (VR) algorithms. MR scanning is more exclude fractures of the skull base. MR tomography (MRI. Postoperatively.7). from which conclu.8). . digital image communica.4  Ultrasonography tion in medicine). CT is used In addition to MPR. where all metal equipped today. posttraumatic period. als. In most very well and detected without prior knowledge of their cases. The images have to be loaded in DICOM format from a CD. palate. wood and plastic are difficult to detect and nasal sinuses and skull base will be sufficient to identify special attention must be given for their possible pres.3  Magnetic Resonance Imaging (MRI) tanels. 2003). rather than X-rays. but difficult and invasive. Because of these limiting characteristics. The patient has to be placed in time (Fig. which is the standard format used in medicine (DICOM. 2. Cardiac pacemakers and workstation or a picture archiving and communication other implanted electronic devices are contraindications system (PACS) workstation.9). a noncontrast-enhanced low-dose CT of the para- presence. as well as to mea. 3D views can be calcu. and is much less floor.2. DVD. The image quality of the reconstructed elements are manufactured out of nonmagnetic materi- coronal images is similar to that of directly acquired cor. making 3D visualization a cally and to perform CT scans before and after CM practicable routine diagnostic add-on. CT datasets can be used for naviga. For this purpose. angiography and coil placement (Fig. A rare complication of skull base trauma is a Intraoperatively. Sonographic imaging of the brain in young children is possible through the fon- 2. and mandible. fragments and relevant dislocations. the high spatial resolu- tion of ultrasound allows skull fractures to be detected. three-dimensional views of the rather than MRI when initially examining a trauma scanned object can be calculated using shaded surface patient. to gain infor. which are a diagnostic problem after skull base injuries. from the axial images by multi­planar reformatting (MPR) Before placing the patient in the chamber. CT is a necessity for treatment that uses radiowaves. orbital time-consuming than CT scanning. sions about the trauma mechanism can be drawn. 1998. maxilla. MRT) is an imaging method As for the facial skeleton. The a high-magnetic-field chamber so as to localize the coronal images and any other planes are reconstructed ­origin of the radiowaves within the patient’s body. Also.4  Ultrasonography 19 only a single dataset in the axial plane is required. inasmuch as it lends itself for VR images are color coded and give an impressive view easy detection of shearing injuries of the brain in the of the anatomy. operative complications. CT because detection is based on indirect signs. They give an overview over the main be also used to look for cerebrospinal fluid (CSF) leaks. Wood appears like air and plastic materials have the surgeon. but may be the method of choice for evaluation in children. 2. Anesthetic monitoring requires dedicated image database system with which most hospitals are equipment with special medical devices. optic canal. trauma to the head and face.

5  Diagnostic Algorithm and hard tissue damage is reliably demonstrated and a first fast overview of the images can be done to iden- tify relevant lesions requiring immediate surgery. CT is widely managed by the trauma team. such 2. although it is sensitive . (a) Ultra­sound image with cleavage in the tabula externa (arrow). The CT datasets can then be analyzed thoroughly in an off- Conventional X-ray is no longer the standard in radio. line situation at the computer workstation. (d.20 2  Radiology of Craniofacial Fractures Fig. patient is brought to the operating room or otherwise this is now carried out by CT imaging. 2. (a-c) CT after head trauma demonstrating fis.9  Ultrasonography of a scull fracture. e) MRI demonstrates multiple a b Fig. injuries (arrow).8  Illustration of the high sensitivity of MRI for shearing small foci of low intensity representing hemorrhage in shearing injuries and SDH. 2. MRI is not the primary available and allows fast scanning of the patient.5. (f) Coronal FLAIR image shows distincly a sural fracture of right orbital roof (arrow) with frontal sinus small SDH covering both frontal lobes (arrow) involvement and pneumatocele. (b) Corresponding X-ray image with evidence of a discrete fracture line on the left parietal bone cranial to the lambdoid suture (arrow) 2. Soft imaging modality after trauma.1  General Considerations as intracranial hemorrhage or splenic rupture. while the logical imaging for cranio-facial trauma detection.

The usual trauma algorithms for CT respect this issue. or ICP monitoring. Is there parenchymal bleeding? Are cerebral aneurysms. If there is 2. Hemorrhagic contusions are usually small in the rachnoid hemorrhage is detected and a cerebral artery initial CT. skull base or over the edge of the temporal bone during enhanced CT is added only if. for brain injury and bear the risk of delayed bleeding.v. a contrast- The primary structure of observation in the initial head enhanced arterial phase CT should be added to look for CT is the brain. Typical 2003). Subarachnoid hemorrhages (SAH) may be present. the basal cisterns are not visible. CT should be The initial CT scan is usually focused on the neuro. locations are the frontal and temporal poles. 1989. and may require head without repositioning the patient. 2. 2001. In these patients. Intravenous of the frontal and temporal lobes. Diffuse brain damage facial trauma is to exclude space-occupying intracranial must be suspected if the basal ganglia and cortical hemorrhage or increased intracranial pressure (ICP) structures have the same density as the white matter. ate or delayed decompression by craniectomy. especially if The first important issue to be resolved after cranio.2. In polytraumatized patients. ing or absence of the external and internal CSF spaces. the contrast administration is contraindicated since it can brain collides with the bone or glides over the rough obscure small intraparenchymal hemorrhages. There may be epidural or subdural hematomas extended to the thorax and the abdomen. 1991).2  Craniocerebral Trauma ruptured cerebral artery aneurysm. based on the NECT scan. However. It is. brain swelling can develop. Contrast. Bull et al. of the head. CT is rhage. CM is injected. CM to exclude dissection of a The second thing to look for is extracerebral hemor- vertebral artery. The excluded. the lateral Technically.5. This includes evac.v. Fractures of the cervical spine must be excluded in large hematomas or massive cerebellar swelling in the any major cranio-facial trauma. This is not a problem with modern CT systems. In these regions. however. Bowley areas of the brain and at the brain surface. and the rupture of the aneurysm can be the cause for the trauma. Lehmann et al. albeit of elevated ICP? Elevated ICP is indicated by narrow- this question is raised later after trauma. deceleration. and the basal surfaces noncontrast-enhanced (NECT) scanning. Brain swelling may require immedi- apex. requiring neurosurgical intervention. matic situation (Yokata et al. the CT technician should be depends on the initial CT findings and is managed by advised to scan the head completely from the chin to the the neurosurgeon. The second point is to assess bone injury (Schneider and Cerebral hemorrhage usually occurs at the polar Tölly 1984. but nonetheless always indicate significant aneurysm must be excluded.10). Large hematomas with a significant mass effect out with i. ventricular drainage (Fig. CM injection. Still. If there is no aneurysm on CT. if significant trauma to the facial need for ICP monitoring by a surgically placed probe skeleton is suspected. Shearing inju. first NECT scanning so-called “blooming-up” of contusional hemorrhages. The maxilla is not patients on anticoagulant drugs. repeated 6–24 h after trauma. advisable to apply i. however. followed by scanning other parts of the body. cere- there signs of diffused brain damage? Are there signs bral angiography should be discussed. one should be aware that a SAH may be caused by a 2. but almost never require inter- vention since they generally resolve spontaneously. the primary CT after trauma is done as contours of the temporal lobes.1  The Initial CT After Trauma significant spread of the SAH in the typical regions around the basal arteries in the basal cisterns. The cervical spine can posterior fossa can result in obstruction of the fourth be scanned immediately after the NECT scan of the ventricle and cause hydrocephalus. and the mandible is usually CT should be repeated earlier.2. The risk of continuing cranium and usually covers the region from the foramen hemorrhage and significant hematomas is high in magnum to the apex of the skull. This is referred to as “absence of the normal medullo- uation of hematoma. absent spaces are never normal. require immediate surgery. However. craniectom. identifying and classifying fractures. usually after 4–6 h. the CT of the cervical spine and trunk. As a further complication. Narrow spaces may be physiological in young patients. cortical differentiation”. also carried (SDHs). . an intracranial tumor is suspected or if significant suba. the completely included. ries are of little significance in the primary posttrau. In order not to miss these complications. In the long term. Also.5.5  Diagnostic Algorithm 21 for the detection of shearing injuries to the brain.

Multiple or combined hemorrhages in differ. Singular trauma. Location and size of the hemorrhage represent a typical hyperten- sive bleeding (arrow) and not a superficial contusion injury SAH may cause CSF malresorption and hydrocephalus 12–24 h has already been mentioned. 2. Compression of the external CSF spaces especially in the tentorial area.11–2.11  Intracerebral hemorrhage (ICH) and midface fracture (left orbital floor): which was first? In this case. 2.15).22 2  Radiology of Craniofacial Fractures Fig. The need for fur- weeks to months after trauma and require ventricular ther follow-up CTs will depend on the patient’s clinical drainage. course (Figs. the ICH was first and led to collapse of the patient with midface fracture. ent areas indicate semi-severe to severe cranio-cerebral The third thing to look for is fractures.10  Signs of brain swelling after severe trauma. Little subarachnoid hemorrhage in the insular cisterne on the left side Fig. 2. The need for a “second look” CT scan after undisplaced skull fractures are of little clinical .

2. the first step is to define the • Sphenoid sinus. parietal.) Left subdural hematoma and zygomatico-orbital osteosynthesis (right) (SDH) (arrow) with midline shift to the right (d.5  Diagnostic Algorithm 23 Fig. optic canal and affected bone structures: clivus . Depressed and displaced fractures with gaps • Anterior and/or posterior wall of the frontal sinus and steps between fragments may require surgery. • Ethmoid (roof. temporal.2. Large right-anterior craniofacial skull fragment. occipital) (EDH). 2. sphenoid wing.12  Large supraorbital EDH (arrow) after complex left cranio-orbito-zygomatic fracture a b c d e f Fig. (c. (a) right ethmoid and orbit (arrow) into the anterior wall of the right Large right-anterior craniofacial skull fragment (b) Left fron. lateral wall) In describing a fracture.13  Major burst fracture of the skull after compression of the frontal bone continues through the planum sphenoidale. maxillary sinus (f) Postoperative result after craniotomie (left) toparietal skull impression fracture. e) The fracture significance unless they cause epidural hematomas • Calvarial bones (frontal. inju­ry.

orbital optic canal) floor) • Nasal bone • Maxilla (alveolar process. • Maxillary sinus (anterior and lateral walls. teeth.24 2  Radiology of Craniofacial Fractures Fig. medial wall.14  Complex bilateral midface fracture and cranio-frontal fracture with little displacement (arrow). CSF circulation is blocked by the clot in the fourth ventricle leading to slight widening of the temporal horns of the ventricles Fig.15  Typical hemorrhagic contusions in both frontal lobes (arrow) after midface trauma. pterygoid process) • Zygoma and zygomatic arch and palate . Frontobasal and right temporo-polar contusion hemorrhages (arrow). 2. lateral pillar. Fracture of the left zygomatic arch and lateral zygomatico-maxillary complex • Orbit (roof. but massive brain injury. Intraventricular hemorrhage with hydrocephalus (arrow). orbital floor. 2.

perform an Angio-CT Open brain injury and discuss cerebral angiography Indicates dural laceration Parenchymal hemorrhage (contusional hemorrhage) Indicates fracture of temporal bone at the skull base Common in mid-severe and severe cerebral trauma Look for: At surface and on the poles of the brain   Frontal skull base fracture May “bloom up”   Sphenoid sinus fracture Require additional CT scan (within next 24 h)   Mastoid fracture May be accompanied by brain swelling and require   Temporal bone fracture ­decompression surgery Foreign bodies Signs of space occupying hemorrhage   Following penetration injuries Compressed external CSF spaces on the side of the   Glass: Most often superficial in skin hemorrhage   Wood: Difficult to detect. because of appearance like air/ Compresssed lateral ventricle on the hemorrhage side emphysema Displacement of the midline to the contralateral side   Metal: May cause artifacts • Mandible 2. one should check the following • The high coincidence of facial skeletal fractures (Table 2. • Zygoma For example. • Supraorbital margin • Infraorbital margin Fracture of the skull base can be the direct extension of • Lateral orbital wall skull fractures or orbital fractures into the skull base. pneumatocephalus) If there is a suspicion of an aneursysm. skull base fractures. Check the trauma history Intracranial air (pneumatocele. 2001. and malalignments of the relevant structures. The skull base is mostly affected overlaps. In the CT analysis.5. in the frontobasal and fronto-ethmoidal regions.5  Diagnostic Algorithm 25 Table 2.16): and frontobasal and fronto-ethmoidal injuries in • Skull contours midfacial traumas requires a CT scan to evaluate • Nasion the skull base (Joss et al.2. 2.2  Radiological findings in trauma CT Epidural hematoma Compressed tentorial and basal cisterns Lens shaped between dura and tabula interna Compressed fourth ventricle (if hemorrhage is in the posterior Usually stops at skull sutures fossa) Requires surgery dependent on size Hydrocephalus (when the fourth ventricle is compressed) Subdural hematoma Brain swelling Crescent-shaped Compressed external CSF spaces over the swollen brain Along the cranial vault parenchymal area Along the falx Narrow ipsilateral ventricle Along the tentorium Mid-line displacement Exceeds the skull sutures Asymmetry of the tentorial cisterns Requires surgery dependent on size Signs of increased ICP Traumatic SAH Compression of external CSF spaces Blood in the external CSF spaces (sulci or basal cisterns) Narrowed ventricles Traumatic SAH is common in severe cranio-cerebral injuries Compression of the tentorial and basal cisterns: Ambiens Clinical significance is low cistern (lateral to the midbrain) and quadrigeminal cistern (dorsal to the quadrigeminal lamina) Nontraumatic SAH Foramen magnum filled out with brain parenchyma (cerebellar In each SAH: should think about the possibility of a ruptured tonsils) cerebral artery aneurysm.2.3  Skull Base Fractures • Temporal bone and mastoid There is a high coincidence of midface fractures and The second step is to define dislocations: impressions. a frontal bone fracture can • Anterior nasal spine radiate into the orbital roof. ethmoid and sphenoid. Fig. a temporal bone fracture can extend into • Zytomatic arch the temporal skull base. A rupture may be the cause for the trauma. or . Bowley 2003).

magnum. Anterior head trauma can result in complex Clinical symptoms are otic hemorrhage.16  Radiological – diagnostic procedure in craniocerebral trauma – flow chart an occipital fracture can radiate down into the foramen cause hemorrhage in the mastoid cells and tympanon. the Another mechanism leading to skull base fractures clivus and the sella. and may extend into the roof of the sphenoid sinus. 2. Temporal bone fractures can radi.26 2  Radiology of Craniofacial Fractures Craniocerebral trauma History Course of accident Unconsciousness Vertigo Vomitting Conscious behaviour / GCS / Amnesia Haziness / Unconsciousness / GCS Clinic Pupils Reaction to light Reaction to pain Neurology Normal Pathological X-Ray: AP and lateral view of the skull Fractures? CT (axial/coronal) Intracranial air ? Increased intracranial pressure? Cerebral edema? Space consuming hemorrhage? Compression fracture? Foreign body? Cerebral pressure monitoring Surgical decompression Fig. is the indirect energy transmission from the mid-face ate into the petrous bone and mastoid process and to the skull base through the main vertical pillars. This . otic liquor- fractures of the frontal skull base and ethmoid bone rhea and hearing loss.

Intracranial air collections visualize muscle entrapment in fractures of the orbital can be demonstrated in 25–30% of skull base fractures floor. 1998.5. To exclude undisplaced skull maxillary region (Terrier et al. the peri. MPR is also required Pfeifer 1987. the orbits. Vast air collections (pneumocephalus) CT permits a differentiated fracture assessment and occur after destructive fractures of the frontal sinus and provides evidence of injury in anatomically difficult ethmoid roof.Liquorscintigraphy + Pneumocephalus Neurosurgical Revision CT Fracture gap >3 mm Dislocated base fractures Fig. anterior-posterior direction (nasion. Schneider and Tölly 1984. maxilla). 1984.17). for analysis of the extent of displacement of skull base 1990. In addition. ning and intraoperative navigation are based on CT.Clinic Definite signs Questionable signs CT CT Frontal sinus .and retroorbital skull base and the retro- be analyzed thoroughly. 3. MPR is required. 2. . 2. Small air ­collections are ated by the CT technician. Oblique tures. fractures.. according to the structed from the axial image set by the CT technician’s classification systems outlined in Chap.5  Diagnostic Algorithm 27 Skull base fractures History . Indirect signs are intracranial the inferior rectus muscle of the orbit may be helpful to air collections and liquorrhea. if available. CT images in the axial and cor- fractures in the region of the foramen magnum and the onal planes are obligatory to differentiate fracture risk of a burst fracture of the first cervical vertebra types and to define the extent of the fracture. The sagit- (atlas ring burst fracture). tal plane may be helpful to assess dislocations in the There are direct and indirect signs of skull base frac.2.Transferrin + Sphenoid bone . Rother 2000). fracture gaps and sagittal images parallel to the optic nerve or parallel to steps between fragments.4  Midface Fractures Not associated with mid-face fractures are skull base fractures after axial head trauma from the vertex with For midface fractures. surgical plan- team (Fig. Whitaker et al.axial 4 mm Na – Fluoreszin + Jonotrast. the primary axial images areas. sphenoid sinus.g. Coronal images should be routinely recon. the naso-orbito-ethmoidal com- are most helpful to detect skull base fractures and must plex.coronal 2 mm B . Manson et al. Direct signs are fracture lines. e. In the CT dataset.17  Radiological – diagnostic procedure in skull base fractures – flow chart mainly affects the temporal skull base and the ethmoid. Classification of midface fractures. Schwenzer and base fractures. 2.axial 2 mm Rhinoliquorrhea ? Ethmoid bone . analysis can be regularly seen with fractures of the temporal bone and done interactively in a PACS viewer. The required series of images should be gener- (Probst and Tomaschett 1990).

Orthopantomogram Bone trauma CT obligatory Soft tissue injuries MRT facultative Fig. 2. Schmelzeisen R (1999).18): • Fracture of the medial orbital wall (blow-out fracture) • Depressed fractures of the anterior and posterior • Ocular lens luxation or rupture of the ocular bulb frontal sinus walls • Fracture and dislocation of the nasal bone • Displacement of the nasal bone into the ethmoid • Fractures of the maxillary sinus with hematosinus • Depressed fracture of the maxilla • Hematosinus without apparent wall fracture may • Sella fractures (rare) indicate fracture of the orbital floor • Fractures of the anterior lateral walls of the maxil- lary sinus are associated with inward rotational dis- location of the zygoma References • Fracture of the zygomatic arch • Fracture of the alveolar crest of the maxilla and of Bowley NB (2003).und Gesichtsschädels. Schirmer M (1989). Gruentzig J. skull base) The value of computer-aided planning and intraoperative . Schmelzeisen R (eds).Axial view . Radiographic Assessment. • Fractures of the orbital and ethmoid roofs (frontal Gellrich NC./occipito-mental/occipito-frontal views . the palate bone Eppley BL.Lateral view . Traumatologie des Hirn. Ganzer U. Particular to detection in the coronal images are: Bull HG.28 2  Radiology of Craniofacial Fractures Midface fractures Clinical presentation Malocclusion Instability Dislocation Craniofacial bleeding Liquorrhea Computed tomography Roentgenograms . Urban und • Fractures of the orbital floor Schwarzenberg: München.18  Radiological – diagnostic procedure in midface fractures – flow chart Axial images should be scrutinized for: • Fracture of the hard palate • Fractures of the anterior and posterior walls of the • Fracture of the pterygoid process frontal sinus • Mandibular collum or condyle fractures • Fracture of the lateral orbital wall Sagittal CT-scan display (Fig. In: PW Booth. Hammer B. Schramm A. Maxillofacial trauma • Mandibular fractures (ramus) and aesthetic facial reconstruction.p.a. Churchill Livingstone: Edinburgh.Clementschitsch view . 2.

basal fractures. Terrier F. Tomaschett C (1990). Krettek C (2001). Unfallchirurg 104. Akt Gellrich NC. traumatic frontobasal spinal fluid fistulas (1982–1986). Burckhardt B (1984). Traumatologie. Mund Kiefer Gesichtschir 2: 20–24. Dias PS (1998).References 29 navigation in orbital reconstruction. Abbasi KH. Kurowa A. Clinical Traumatol 20. Kiefer. Schneider G. 5: 391–399. Possibilities and devel. Thieme: Stuttgart. Radiologische Diagnostik des pp 215–228. Int J Oral Maxillofac Probst C. BL Eppley. Ann Radiol (Paris) 27. Early definitive surgical management acute head injury. Lehmann U. Joss U. In: P Ward-Booth. Rickels E. Bildgebende Untersuchungs­ opments of intraoperative image-guided surgery in craniofa. Zahn- posttraumatic deformities. Hassfeld S. 2: 202–212. Maxillofacial trauma and esthetic Urban und Fischer: München. of long bone fractures. Piffko J. In: F Sitzmann (ed). Yaremchuk M anterior cranial base fractures classification using computer- (1990). Otsuka T (1991). Gesichtsschädels. Thieme: Stuttgart. Krebs Al. Behandlung von frontoba. Mirvis S. Mund Kiefer Gesichtschir phy and computed tomography for the diagnosis of fronto- 5: 86–93. application of computer-assisted reconstruction in complex Rother UJ (2000). Plast ized to mograph scanning as a basis for selection of patients Reconstr Surg 85.und Gesichtschirurgie. Conventional tomogra- salen Traumen und Polytraumen. verfahren in der Mund-. Meyer U (2001). J Trauma 1: 351–357. Multiple trauma with Yokata H. Toward CT-based facial fracture treatment. Schwenzer N. J Neurosurg 88: 471–478. . Dunham M. 5: 217–225. Tölly E (1984). Fortschr Kiefer Gesichtschir 32. Schramm A. Schmelzeisen R (2003). Pfeifer G (1987). Whitaker KW. The neurosurgical treatment of Surg 28 (Suppl 1): 52. 3: 196–209. Significance of MRI in craniocerebral trauma. Mühling J. Raveh J. Schmelzeisen (eds). for dural repair. Compound Manson PN. Zöller J (1998). Markowitz B. Churchill Livingstone: Edinburgh. R Mund-Kieferkrankheiten Atlas der bildgebenden Diagnostik. facial reconstruction. cial surgery.