Sylvia Aparicio, IV

Gillian Lieberman, MD
September 2006

Facial Fractures

Sylvia Aparicio
Harvard Medical School Year IV

Gillian Lieberman, M.D.

Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient

• 82 year old male

• Had a mechanical fall with blunt force to

face

• Taken to BIDMC by ambulance

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Sylvia Aparicio, IV
Gillian Lieberman, MD

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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Sylvia Aparicio, IV
Gillian Lieberman, MD

Facial Fractures

• Analysis of the fractured face requires

• knowledge of normal anatomy
• common fracture patterns in the face

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Sylvia Aparicio, IV
Gillian Lieberman, MD

Anatomy-Frontal View

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http://www.emedicine.com/ent/images/Large/22ent0009-01.jpg
Sylvia Aparicio, IV
Gillian Lieberman, MD

Anatomy-Lateral View

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http://www.bartleby.com/107/
Sylvia Aparicio, IV
Gillian Lieberman, MD

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 7
Sylvia Aparicio, IV
Gillian Lieberman, MD

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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 Sylvia Aparicio, IV

Waters View
Gillian Lieberman, MD

PA with cephalad angulation

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http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas28.html http://www.bcm.edu/oto/studs/nose.html
 Sylvia Aparicio, IV

Caldwell View
Gillian Lieberman, MD

PA

Petrous pyramid

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http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas27.html http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV
Gillian Lieberman, MD

Lateral View

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http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas30.html
 Sylvia Aparicio, IV
Gillian Lieberman, MD

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
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http://www.bcm.edu/oto/studs/nose.html
Sylvia Aparicio, IV
Gillian Lieberman, MD

Facial CT Views

Coronal View Axial View

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http://uuhsc.utah.edu/rad/protocol/fbones.htm
Sylvia Aparicio, IV
Gillian Lieberman, MD

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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Sylvia Aparicio, IV
Gillian Lieberman, MD

Zygomaticomaxillary complex
(tripod fracture)

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www.emedicine.com/ent/topic166.htm http://www.rad.washington.edu/mskbook/facialfx.html
 Sylvia Aparicio, IV
Gillian Lieberman, MD

Orbital Floor Fractures

• "blowout" fracture
• usual mechanism is a
blow to the eye
• common clinical signs
• enophthalmos
• diplopia

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http://www.rad.washington.edu/mskbook/facialfx.html http://www.nature.com/eye/journal/v20/n1/fig_tab/6701801f2.html#figure-title
Sylvia Aparicio, IV
Gillian Lieberman, MD

Le Fort Fractures

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http://www.rad.washington.edu/mskbook/facialfx.html
 Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
Coronal CT
Fracture at naso-frontal suture

Bilateral fractures at
zygomatico-maxillary sutures

Bilateral Le Fort II

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Courtesy of Dr. Handwerker-BIDMC
 Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
Axial CT, Bone Window

Fracture at naso-frontal suture

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Axial view through orbits Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
Axial CT, Bone Window
Fracture of anterior maxillary walls

Aberrant air in subcutaneous

tissues

Fracture of posterior
maxillary walls

Courtesy of
Dr. Handwerker-BIDMC

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Axial view through maxillary sinuses
 Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
Axial Views Through Nasal Bones
Comminuted nasal bone fractures

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Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
3D Reconstruction

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Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
3D Reconstruction

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Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
3D Reconstruction

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Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

Our Patient
3D Reconstruction

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Courtesy of Dr. Handwerker-BIDMC
Sylvia Aparicio, IV
Gillian Lieberman, MD

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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Sylvia Aparicio, IV
Gillian Lieberman, MD

Second Patient

• Post-fixation CT with 3D Reconstruction

slides of another patient with a bilateral
Le Fort Type II fracture

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Sylvia Aparicio, IV
Gillian Lieberman, MD

Second Patient

Courtesy of 28
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD

Second Patient

Courtesy of 29
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD

Second Patient

Courtesy of 30
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Gillian Lieberman, MD

Second Patient

Courtesy of 31
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Gillian Lieberman, MD

Second Patient

Courtesy of 32
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Gillian Lieberman, MD

Second Patient

Courtesy of 33
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Gillian Lieberman, MD

Second Patient

Courtesy of 34
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Gillian Lieberman, MD

Second Patient

Courtesy of 35
Dr. Guo - BWH
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Gillian Lieberman, MD

Second Patient

Courtesy of 36
Dr. Guo - BWH
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Gillian Lieberman, MD

Second Patient

Courtesy of 37
Dr. Guo - BWH
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Gillian Lieberman, MD

Second Patient

Courtesy of 38
Dr. Guo - BWH
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Gillian Lieberman, MD

Second Patient

Courtesy of 39
Dr. Guo - BWH
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Gillian Lieberman, MD

Second Patient

Courtesy of 40
Dr. Guo - BWH
Sylvia Aparicio, IV
Gillian Lieberman, MD

Summary

• Knowing normal • Consider

anatomy and mechanism
common fractures is • Look for asymmetry
important • Look for cortex
• CT-most common interruption
modality used

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Sylvia Aparicio, IV
Gillian Lieberman, MD

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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Sylvia Aparicio, IV
Gillian Lieberman, MD

Acknowledgements

• Atif Zaheer, MD
• Jason Handwerker, MD
• Andrew Hines-Peralta, MD
• Gillian Lieberman, MD
• Pamela Lepkowski
• Larry Barbaras
• Lifei Guo, MD

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