HMSD 6010

Theory of Axial Image

Interpretation

(Part 1 - Facial Bones)

Gail Jefferson / Craig Anderson

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 Today’s session
Aim
• To provide basic image evaluation and fracture
detection skills of the Facial Skeleton.

Intended learning Outcomes

At the end of this session you should be able:

• To evaluate images for signs of bony injury

• To be able to recognise normal and abnormal
appearances and apply a ‘red-dot’
• To accurately exclude normal variants.
• To be able to communicate simple written
findings to the referring clinician. 2
 Bony Structure
1. The human skull is unique in
the overlapping of the face by
the skull

2. The bones of the face have

evolved to resist the forces
of mastication as well as to
protect certain organs such
the eyes.

3. There are sagittal and

coronal struts or buttresses 3
McGrigors Lines

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 McGrigors Lines - 1
► Fronto-zygomatic
suture, Supra-orbital
margin and frontal
sinus
► Look for;
► Fractures
► Widening of suture
► Fluid level in frontal
sinus

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 McGrigor’s lines - 2
► Superior border of
zygomatic arch, body of
zygoma, infra-orbital
margin, nasion, opposite
side
► Look for;
► #’s of zygomatic arch
► #’d Infra-orbital rim
► Soft tissue shadow in roof
of maxillary antrum

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 McGrigor’s lines - 3
► Inferior margin of
zygomatic arch, lateral wall
of maxillary antrum, inf
margin of antrum, across
maxilla (inc. roots of the
teeth), same structures on
opposite side

► Look for;
► #’s of zygoma and lateral
maxillary antrum
► Fluid level in maxillary
sinus

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Dolan’s Lines – alternative
assessment method

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 The orbital region
► Look at the orbits carefully, since 60 - 70 %
of all facial fractures involve the orbit in
some way.
► The exceptions:
 local nasal bone fracture
 zygomatic arch fracture
 LeFort I fracture.

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Indirect signs to look for

¨ Soft tissue swelling or haematoma

¨ Soft tissue emphysema

¨ Soft tissue displacement

¨ Para nasal sinus fluid or blood

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 Le Fort Fracture (1)
► Le Fort fractures classify
those of the mid third of
the face
► Rene LeFort 1901
► Dropped corpses off a
tavern roof to assess facial
fractures!
► Can have type 1 on one
side and type 2 on the
other.
► High impact trauma.
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Le Fort fracture (2)

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Le Fort Fracture (3)

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 Zygomatic Arch fracture
► Isolated fracture of
zygomatic arch =
common due to
prominent position

► More complicated tripod

fracture involves:
1. Widening of fronto-
zygomatic suture
2. Zygomatic arch fracture
3. Fracture of body of
zygoma.
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Zygomatic arch & infra-orbital rim
fracture

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Normal Modified SMV “Jug handles”

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 Tripod Fracture
R

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Tripod Fracture

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 BLOW OUT FRACTURES
 Results from strike with object too big to enter the orbit

 The orbital rim transmits the force to the orbital floor

 The increased pressure drives the contents downwards

 Usually the orbital rim and globe are undamaged

 Diplopia is the most frequent complaint but does not imply

muscle entrapment

 Medial orbital wall fractures can be present in up to 50% but is

very hard to see on plain film

 Orbital emphysema is usually caused by medial orbital wall

fracture
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Blow Out Fracture

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Orbital Emphysema

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Fluid levels

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Inferior Nasal
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Spine
 NASAL FRACTURES
►Commonest fractures of the facial skeleton

►50% are isolated

►Radiography not recommended for routine work

►There is poor correlation between plain film

appearance and need for surgical reduction

►Fractures usually run transversely through superior

nasal spine.

►Inferior Nasal spine should be included on

radiograph.
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Mandibular fractures ► ‘Contrecoup’ injury
common
► Coronoid process #’s
rare and single
► Fractures of neck
often transverse and
associated with
dislocation of TMJ on
same side
► OPG and PA mandible
together often
provide higher
accuracy
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 OPG – Step by Step

► 1- Trace outline of mandible - ? Cortical Steps

► 2 – Check TMJ’s - ? Dislocation
► 3 – Check common fracture areas
 Symphyseal ; Para-symphyseal areas; Body; Angle and Condylar neck
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What about skull projection
Radiography?
► Limited use of skull imaging as
the norm is now CT for trauma
patients
► Still used forensically for NAI
and myeloma skeletal surveys
► Occasionally tangential soft
tissue projections to look for
foreign bodies
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 www.nice.org.uk/guidance/cg176/
resources/guidance-head-injury-pdf
For adults who have sustained a head injury and have any of the
following risk factors,
► perform a CT head scan within 1 hour of the risk factor being
identified:
► GCS less than 13 on initial assessment in the emergency department.
► GCS less than 15 at 2 hours after the injury on assessment in the
emergency department.
► Suspected open or depressed skull fracture.
► Any sign of basal skull fracture (haemotympanum, 'panda' eyes,
cerebrospinal fluid leakage from the ear or nose, Battle's sign).
► Post-traumatic seizure.
► Focal neurological deficit.
► More than one episode of vomiting.

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 Your Turn!
► Look at the following three cases:
► Write a short (Red Dot) comment on each
image.
► Is there a fracture, dislocation or other
significant feature?
► Or – is it normal??
 Case 1 –fall on concrete, banged head on right
side, right sided black eye and large laceration right
mandible ?underlying fracture

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Case 2 – fell onto face 4/7 ago. Tender over right
cheek with some altered sensation

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Case 3 – Punch to face. Tender left lower
orbit

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 Case 1 – Explanation & Suggested answer:

► Fracture of right inferior

orbital margin, lateral wall of
maxillary antrum and fronto-
zygomatic suture
► Fluid level right maxillary
antrum (sinus)

► Red dot? – YES

► Comment: Fracture of right

maxilla with widening of
fronto-zygomatic suture. Fluid
level in maxillary sinus.
 Case 2 – Explanation & Suggested answer:

► There is a soft tissue

opacity seen within
the upper right
maxillary antrum,
abutting the inferior
orbital margin.

► Most likely
represents a ‘blow-
out’ type fracture.

► Red dot? – YES

► Comment: Blow out
fracture right
maxillary sinus.
 Case 3 – Explanation & Suggested answer:

► There is an oblique fracture

running through the left
lateral wall of the maxillary
antrum
► Associated fluid level.
► Probable blow out fracture
left orbital floor

► Red dot? – YES

► Comment: Fluid level in left
maxillary sinus. Probable
blow out fracture.
 Summary -Facial Bone &
Mandible Interpretation
► Importance of ► Finally – Think Quality!
anatomical knowledge
► Use a systematic
► Poor facial bone and
interpretation method
Mandible images are
(Lines)
difficult to interpret
► Identify common
and easy to miss a
fracture patterns fracture………
► Be aware of subtle
fractures (Blow out)
► Understand soft tissue
signs of trauma. 46