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1.chapter 8 - Diagnostic Imaging of Injuries PDF
1.chapter 8 - Diagnostic Imaging of Injuries PDF
Injuries
By: Sam Caruso
samrcaruso@gmailcom | 847.542.8131
Nice to meet you!
“A buttress is an architectural
structure built against or projecting
from a wall which serves to support
or reinforce the wall. “
- Wikipedia
Anatomy - Facial Buttresses
Facial butresses
Basics…?
Multi Detector-CT
● Gets submillimeter axial cuts and reformats to coronal and sagittal cuts
CT Angiography
3D Imaging - Two types Shaded Surface Display (SSD) & Volume Rendering (VR)
SSD
Facial Frac / tures
● Zygomaticomaxillary
● Orbital
● Le Fort
Zygomaticomaxillary
~ Two major buttresses are upper
transverse & lateral vertical maxillary ~
● Airway
○ Although apparent, MDCT offers excellent evaluation of crush and penetrating airway
injuries
○ Look for: Pneumomediastinum, Trauma, or Resulting Abscess
● Esophagus
○ Optimal radiographic study is single contrast fluoroscopic esophagram
○ Look for secondary injuries: pneumomediastinum, hematoma and paraesophageal
stranding
● Neurologic
○ Imaging is the gold standard for deciphering operative vs. non-operative repair of the
brachial plexus
○ Look for: Postganglionic injuries which constitute as operative
■ (Preganglionic are non-operative)
Mandibular & Dentoalveolar Imaging
● Mandibular Series
○ Historically the standard analysis. Phased out ~2003/2004~
○ Bilateral Lateral Obliques (Condyle, Ramus, Coronoid, Body, Angle, Limited to no parasymphyseal)
○ Posterior-Anterior (preferable) or AP projection (shows entire mandible, except condyles)
○ Towne’s View (condylar & subcondylar region, also shows medio-lateral displacement)
○ Lateral View (Optional: Rarely balanced, has good imagery. Shows alveolar fractures & condylar neck well)
○ Negative: In traumatized patient it may not be possible to complete a series & distinct crossover of imagery
● Supplemental
○ Nondisplaced Parasymphyseal not shown well with mandibular series, may only present with gingival
laceration and ecchymosis of the floor of the mouth. Consider Panoramic or Periapical film upon suspicion.
○ Occlusal Films very useful in identifying anterior fractures. Central ray directed 55 degrees to the midline
● Panoramic (Orthopanogram)
○ Superior, but noted to miss symphyseal & parasymphyseal fractures
○ May not be readily available, or in the case of trauma, a patient may not be able to sit upright
● CT
○ 3D Computed imaging, absence of distinct detail. Prior to technical advancements, were only used when
film did not suffice
Mandibular Fractures
● At least 50% of head and neck injuries have at least one fracture in the
mandible
● Ellis found of patients with midface fractures 33% had associated mandible
fractures
● The condyle is the smallest portion, associated with other fractures
● The angle, the largest and thickest portion, is disadvantages including
trabeculae direction change, presence of impacted teeth.
● Diagnostic imaging varies (Intraoral, Pan, CT)
** Fracture Types ** (Take Home Slide)
1. Simple - do not communicate with the outside environment (Ramus or Condylar)
2. Compound - communicate through laceration or tooth socket
3. Comminuted - Two or more fractures at fracture site; signifies greater force
4. Complicated - Either directly or indirectly produce injuries to surrounding nerves,
vessels, or joints. (IAN Bundle coursing through the mandible makes almost all
fractures complicated)
5. Impacted - Where segments interlock so there is little to no movement at fracture site
(rare)
6. Greenstick - One cortex broken, opposite cortex bent (mostly pediatric subcondylar)
7. Pathologic - Occuring in a region weakened by pre-existing disease (infection, tumor,
metastasis)
Greenstick Fractures
Condylar & Subcondylar
● Most Common accounting for 25-40% of fractures
● Unilateral more common than bilateral, and are frequently associated with contralateral angle fractures
● Bilateral normally occur resulting a blow to the ching
● Intracapsular/intra-articular fractures are rare, normally occurring in children who take a direct blow to the chin
● Anterio-medial dislocation of the condylar head often occurs
○ Cortical Ring Sign - Well corticated density seen over the condylar neck on lateral views
○ Townes view is/was useful to determine this anterio-medial dislocation
Coronoid
Ramus
● Composes 16-36%
● Highest incidence patients involved in MVAs
● Primarily from a direct blow
● All fractures (except our edentulous patients without laceration) qualify as
compound fractures
● USUALLY, muscle pull reduces the fracture (favorable) but an oral airway
should be readily available
Symphysis & Parasymphysis
● 11.7-24% of fractures
● Again, difficult to see on films
● Commonly angulated obliquely
● Bilateral fractures is an airway risk due to muscle strain of the suprahyoids
Dentoalveolar
Scenario 1:
You are out to a consult at your other hospital across town and you get a call from the
trauma bay. They want advice on stabilizing the patient. What is the significance of determining
if your fracture is Simple vs Compound.
The Rx of Antibiotics - if the fracture is compound its exposed to the outside world
Also consider:
- NPO Status
- Pain Control
**Pop Quiz**
Scenario 2:
You are out getting slammed by consults at your other hospital across town and you get a
call from the children’s hospital trauma bay. They want advice on consulting a patient. To reduce
radiation to the patient they took a mandibular series which showed no fractures to the clinicians
at the hospital . What clinical evaluation should you suggest to consider CT imaging?
What is the most commonly post operatively infected site of the mandible?
The Angle
1. Presence of third molars
2. Dependant area (pooling of food)
3. Function - more likely to flex & move
Thank You & Questions?
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