DR.ANILRAJ K.K, MD,DNB.DMRDPROFESSOR AND HODTDMCH,ALAPUZHA

CRANIO FACIAL TRAUMA –COMMON CLINICAL INDICATION

INTRODUCTION OF MD CT AND ADVANCES IN IMAGE POST PROCESSING PROVIDE CRITICAL ANATOMICAL DETAILS WITH REQUIRED EFFICIENCY

CHALLENGES FOR RADIOLOGIST-DETECT INJURIES AND DEMONSTRATE THOSE INJURIES TO CLINICIAN / SURGEON

CRANIOFACIAL ANATOMY

THREE DIMENSIONS Recognize bony structures Functional dimension in terms of struts

and buttresses General relationship between face and

skull base

Osseous anatomy-supraorbital Continuation of frontal calvarium (orbital

plate of frontal bone on both sides) Frontal sinuses –posterior table fracture

significant NEO REGION-junctional point of frontal

sinus and calverium meet nasal bridge anteriorly and in turn joining with cribriform plate and ethmoid labrynth posteriorly

Union of upper facial skeleton with anterior skull base

ORBIT

ROOF- orbital plate of frontal bone+cribriform plate + lesser wing of sphenoid posteriorly

Supra orbital notch-trigeminal branch MEDIAL WALL-frontal proces of maxilla,lacrimal

bone,orbital plate of ethmoid(LP),sphenoid LATERAL WALL- posteriorly by GWS,anteriorly

by zygoma FLOOR- orbital surface of maxilla and zygoma infra orbital foramen 3 FISSURES/FORAMEN

MID FACE-maxilla, nasal bones,nasal cavity

ZYGOMA- frequently fractured, succesful surgery means reestablishment of normal dimension and contour of zygomatic arch

Inferior margin –maxillary alveolar ridge + teeth along the periphery and hard palate in the centre

MANDIBLE- synphysis,body,angle, ramus,anterior coronoid process and posterior condyle

Vulnerable points- condyle neck,angle, mental foramen,sites of impacted tooth

STRUTS AND BUTTRESES

First described by GENTRY IN 1983 Network of vertically and horizontally

oriented –in all 3 planes 3HORIZONTAL- Superior-orbital roof-cribriform plate-

orbital roof Middle-orbital floor-zygomatic arches Inferior-hard palate 5 VERTICAL- 1 midline-nasal septum 2 medial sagital –medial wall of orbits and

maxillary sinus- pterygoid plates

Struts and buttresses-contd. 2 lateral sagital-lateral wall of orbits

and zygomatic arches 2 CORONAL- Anterior strut- anterior surface of

facial skeleton at NEO region with frontal bone

Posterior strut- posterior walls of maxillary sinuses with pterygoid plates

Site of union between facial skeleton and skull base Roof of orbits- frontal calverium

Midface- frontal process of zygoma- FZS

Temporal process of zygoma- ZTS Most impotant and posterior-

pterygoid plate of sphenoid with posterior wall of maxillary sinuses just above maxillary alveolar ridge and just below the pterygopalatine fossa

classification

By integrating the strut and buttresses concept with understanding of the relationship of facial skeleton with skull base ,a system statifies most fractures into 3 main catogories- also serving a functional framework for the injuries+ fairly well correlating with the theraputic decision making

SOLITARY-simple/single bony wall COPLEX STRUT #- relationship between F.S and

SB partially severed unilaterally or bilaterally,needs open reduction to avoid cosmetic deformity

TRANSFACIAL-

classification

SOLITARY STRUT Isolated orbital floor,medial wall or rim Isolated zygomatic arch Isolated frontal or maxillary sinus wall Nasal arch COMPLEX STRUT Nasoethmoidal-orbital,nasomaxillary Zygomaticomaxillary-ZMC TRANSFACIAL-Lefort I,II,III AND SMASH# MANDIBLE

BLOW OUT FRACTURE

Pure blowout- acute rise in the intra orbital pressue- protective mechanism to maintain integrity of globe

Medial orbital floor,inferior medial wall or combination

Impure- associated with other # -orbital rim ,zygoma,transfacial structures

Clinical- infraorbital nerve injury- numbness of cheek, upper lip and anterior maxillary teeth

Diplopia-entrapment of IR Herniation of fat which may be tetherd to

fat

Blow out fracture-contd 3rd nerve branch injury affecting IO Trauma to IR-impairment of contractility MEDIAL BLOWOUT- Injury /entrapment of MR Associted opacification of ethmoid air cells LATERAL BLOWOUT-/BLOW IN FRACTURE

OF ROOF- Less common –associted with # supra

orbital region. Frontal sinuses and calverium

CORONAL IMAGING

Blow out #-complications

ENOPHTHALMOS- Displacement of orbitalsoft tissues

into maxillary or ethmiod sinus Artophy of orbital fat and scarring

within fat #fragments > 2cm squre area / that

are displaced > 3cm- potential surgical indication

Solitary strut

ISOLATED ZYGOMATIC ARCH-due to focussed trauma

Non displaced /displaced inward or outward Surgery for cosmetic reasons Inward displacement can impinge coronoid

procees-can limit mandibular motion ISOLATED FRONTAL/MAXILLARY SINUS WALL NASAL FRACTYRES- most common ,50% Comminuted or displaced

COMPLEX STRUT#

NEO/NASOMAXILLARY 4 facial struts converge in this region-single

medial and 2 medial paramedian + superior horizontal

Always complex and comminuted Always involve 2 out of 4 struts Involvement of nasal bone +frontal process of

maxilla-free movement 50% unilateral Fragments displaced posteriorly-cribrifom plate Displaced laterally- NLD,NFD,Ocular injuries

COMPLEX STRUT #

ZYGOMATICOMAXILLARY COMPLEX-ZMC Zygoma-inferolateral margin of orbit Point of intersection of lateral

paramedian ,middle horizontal and anterior coronal struts

TRIPOD/TRIMALAR #-dysjunction of zygoma #lateral orbital rim in the vicinity of ZFS #inferior orbital rim+ orbital floor Lateral orbital wall –ZSS #zygomatic arch (ZTS) #anterior and posterior wall of maxillary sinus

ZMC FRACTURES-contd

INCOMPLETE-one of osseous connection intact

NON DISPLACED- incomplete fracturing- ZFS DISPLACED /ROTATED Inferiorly/laterally/posteriorly Exo/enophthalmos if orbital volume affected Displacement at ZFS- open reduction Inferior displacement- distortion of lateral

canthus-cosmetic deformity Infra orbital nerve/IR injury less frequent Impingement of coronoid process

TRANSFACIAL #

RENE LE FORT in early 1900 All are complex –involve multiple struts –

need open reduction and fixation All have potential to result in facial

deformity All represent some degree of

disconnection between facial skeleton and skull base

Single most charecteristic feature is involvement of pterygoid plates

Le Fort type I

Horontally oriented invoving inferior portion of maxillary antra , medial wall of maxillary sinus and inferior nasal septum, posteriorly through pterygoid plates + # hard palate

Palate along with maxillary ridge and alveolus of maxilla- free fragment –FLOATING PALATE

Mid face swelling, echymosis/naso pharyngeal bleed

Le Fort type II

Most common among le fort # Involves orbits and upper nasal cavity

structures 3D triangular configuration –PYRAMID # Apex at nasal bridge +fronto naso

ethmiodal complx Lateral side wall- medial orbital wall,

orbital floor, inferolaterally anterior and posterolateral wall of maxillary sinus terminating to pterygoid plates

Central pyramid displaced posteriorly- DISH FACE DEFORMITY

Le Fort type II-contd

No involvement of medial wall of maxillary sinus,inferiornasal septum,hard palate,lateral orbital wall,zygomatic arches

Severe cosmetic deformity Malocclusisn Infra orbital nerve injury

Lefort type 3

Craniofscial dysjunction Le fort 2 + lateral orbital wall and

zygomatic arches

SMASH FRACTURES High energy injuries causing severe

communition ,usually associted with IC bleed, temporal bone # and cervical spine injuries

MANDIBULAR FRACTURE

50% SOLITRY,50% MULTIPLE SIMPLE-no communication to oral

cavity/skin COMPOUND COMMINUTED-multiple fragments IMPACTED-foreshortening + restricted

movements GREEN STICK- only one side of cortex PATHOLOGIC-underlying osseous disease

Mandibular fracture -contd Commonest site- condyle/sub condylar area INTRA CAPSULAR- less common, in

children,secondary OA changes EXTRACAPSUALR-unilateral> bilateral Unilateral associated with contralateral

angle# Rarely force of impact of condyle

transmitted to temporal bone –carotid canal –ICA injury

1 mm axial ,MPR /curved reformats similar to OPG

Radiological evaluation and interpretation

Plain films –limited role-screening Conventional CT-Direct Coronal

Orbital roof and floor Cribriform plate Plannum sphenoidale Hard palate SPIRAL CT/ MD CT HR images in seconds High quality axial and MPR,curved 2D and 3D

with single tissue(bone) /multiple tissue(bone ,fat and muscle)

IMAGING GOALS

SCREEN FOR INJURY- plain film occipitomental 15

3-5 mm sections CT DETECTING AND DIAGNOSING – high

quality axial, MPR including curved reformats

DEPICTION OF INJURY-3D – surgical planning and

Patient education Advances in 3D- volumetric assessments Advanced volume rendering techniqus Virtual surgery

MDCT- additional sagital and oblique coronal- orbital floor/mandibular #

Curved reformats- condyle /coronoid orocess

NEW HORIZONS INTRA OPERATIVE CT REAL TIME 3D New stabilization /fixation materials –

non metallic and resorbable

SURGEONS PERSPESTIVE

Ct added a 3rd dimension to the craniofascial trauma analysis- ct guided surgery

CT acurately visualizes the fracture Shows comminuted parts Direction of displacement Associted soft tissue injury Catogorized and designated as

low,mid,high velocity Relationship of fracture fragments to

critical soft tissues like optic nerve/extra ocular muscles

Alterd orbital volume

Sublle TM joint effusion or haemoarthrosis

ROLE OF PLAIN RADIOGRAPHY Fractures in proximity to the dentition, Teeth root and related structures Root tip fractures Peri apical pathologies Periodontal/dental pulp diseases Post.op assessment of fixation

CONCLUSION

Craniofascial trauma remains a prevalent condition nowadays and typically requires intense and immediate clinical decision – that is largely dependant on radiologic detection and depiction of injuries

Recent advances in spiral CT and computer post processing technologies made CT to evaluate CFT patients thouroughly and efficiently and become the IMAGING MODALITY OF CHOICE

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