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Trauma face radiology Mats O. Beckman

Radiology Karolinska Solna

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Radiology and facial trauma

2012 Nordter Helsinki

Mats O.Beckman

Traumasection

Diagnostic Radiology

Alas, poor Yorick! (ur Hamlet)

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Eugene Delacroix

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ATLS standards A Airways and Cervical spine control

B Breathing

C Circulation

D Disability ( Neurological symptoms)

E Exposure

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Brå “Assault and severe assault". 50-talet 60-talet 70-talet 80-talet 90-talet 8.000 11.800 20.400 31.400 45.900

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Face fractures incidence

Maxilla - Mandibula 1 : 4.

men 77% - women 23%. Causes:

Battery 40% Traffic 29%

Fall 21%

Sport 4% Work 4%

Others 2% (Lund)

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The Trauma Team

Anesthesiologist

General Surgeon ER Nurse

Radiologist Radiology

Nurse

OR Nurse Assistants

Operation Nurse

Trauma Bay area

Anesthetic nurse

Prehospital Staff

Ortopedic Surgeon

Trauma leader Surgeon

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Radiological methods Xray

•  OPG Computed tomography,

•  Multislice Ultrasound

Magnetic resonans tomography, MRT

Scintigraphy

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Ortopantomogram, OPG Great overwiew!

Only one projection- fractures can be hidden

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Computed tomography, CT, MSCT More and thinner slices result in higher spatial resolution

Reformations in any plane •  sagittal, coronal, oblique

3D and ”volume rendering”

PACS availability

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CT or conventional X-ray?

CT Multitrauma

Comminut fractures

Orbita

Canalis opticus

Ears

Foreign body

3D/4D

X-Ray Isolated Zygoma

Mandibula if OPG

Only stable patient!

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Irradiation risks Lens dose

•  Brain CT 50 mGy •  Face, C-spine 0,5 mGy

Cancer death

•  5*10-2 Sv-1 Face MSCT 0,6 mSv

•  1 cancer death in 30 000 exams

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Lens ? The adult lens can tolerate a total dose of 5 Gy during a

fractionated course of supervoltage radiation therapy without showing any changes. Doses of 16.5 Gy or higher will almost invariably lead to visual impairment. The dose which causes a 50% probability of visual impairment is approximately 15 Gy.

Int J Radiat Oncol Biol Phys. 1993 Apr 2;25(5):815-20. Links

Radiation dose to the lens and cataract formation. Henk JM, Whitelocke RA, Warrington AP, Bessell EM.

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Lens ? 100 brain CT may start causing cataracts.

300 brain CT will give 50% of the patients cataract.

30 000 face CT will do the same.

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Dose reduction in MSCT Adapt mAs/kV to examined organ

Adaptation to demands •  High contrast or low contrast resolution?

As high table speed as possible

Reconstruct as many images as your computer time allows, with overlap

Combination with other examinations to avoid double exposure

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Doses full facial CT Initial examination DLP ca 100-150 mGycm

Postoperative examination DLP 20 mGycm

with noise reduction algorithms

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Normal vs low dose face CT DLP 15 DLP 96

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Axial,sagittal and coronal reformation max 1x1x1mm

Bone Soft

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Anatomical resistances

6=low resistance

1=high resistance 1

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6 5

2

2 4

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Fractures

Isolated fracture lines

Zygomatic Complex frakturer ”ZMC”

LeFort I, II,III midface fractures

NOE complex

Mandibula

Fractures extending into the neurocranium/ scull base fractures

Orbit fractures

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Fracture Types Zygomatic 40%

LeFort 1 15%

LeFort 2 10%

LeFort 3 10%

Arch 10%

Alveolar 5%

Crush 5%

Accordion fractures

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Multislice CT

Standard of face fracture diagnosis

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Bones of the skull

Anatomy

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Pillars

Pillars, vertical &horisontal

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Pillars, surgically marked

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Regioner- mediala, laterala

”Våningar”- caudala, mellersta, övre

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Zygomatic complex ”Tripod” fracture

•  Sutura frontozygomatica, lateral orbit wall •  Margo orbitalis inferior •  Lateral maxillary sinus wall •  Arcus zygomaticus •  Orbital floor ?? Association to blow-out fracture.

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Elephant lines

Dolans lines

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Classic Zygomatic fracture

OBS! Orbital floor???

Direction of dislocation

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Zygomaticus 4D

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Zygomatic axial

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René Le Fort (1869 – 1951) was a French army surgeon from Lille Etude expérimental sur les fractures de la machoire supérieure 1901

Published book on mediastinum war trauma 1918, accomplished front line war surgeon!!

http://www.sciencedirect.com/science/article/pii/S0266435609005397

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Le Fort

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LeFort-fractures

I Alveolar process and hard palate

II Maxilla

III Maxilla and both zygomatic

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LeFort fractures

I, II, and III

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LeFort 1

LeFort 2

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LeFort III

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Pterygoid lamellae always fractured with LeFort

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LeFort 1

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NOE complex

Naso Orbito Ethmoidal

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Mandibula Anatomy

•  corpus, angulus, ramus, processus coronoideus (muscularis), collum, caput, alveolar process.

•  Foramen mentale

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Mandibula

Directions: •  Mesial, distal •  lingual, buccal

Mesial

Distal

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Muscles add traction to fragments . Closers:: 1. m. Temporalis

2. m. masseter

3. m. pterygoideus medialis

•  Openers: 4. m. geniohyoideus

5. m. digastricus

•  Translation: 6. m. pterygoideus lateralis

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Mandibula fractures

Collum 36%

Ramus 4%

Angulus 20%

Corpus 40%

Alveolar, muscular process, caput, teeth…

40% 20%

4%

36%

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Type fractures mandibula Corpus, angulus

Collum

Intracapsular caput fractures

Combination of corpus and contralateral collumfracture

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Mandibula

Same patients , fractures Window!!!

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Comminute fracture Lefort +Zygomatic

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Blowout Op if > 1 cubic cm fat herniated.

OBS muscular entrapment •  rectus inferior •  rectus medialis/ obliqus sup if

medial lamina papyracea fracture

•  Relationship to optic canal??? •  Orbital hematoma?? Intraconal?

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Entrapment. A surgical emergency!

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Case entrapment

Case entrapment  

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Entrapment – Trapdoor fracture

Entrapment of m rectus inferior : children, ”green-stick” fracture

Vasovagala symptoms – occulocardial reflex

Surgical emergency (< 24 timmar)

•  Trapdoor fracture of the orbit in a pediatric population - Grant 2002 •  Underestimation of soft tissue entrapment by computed tomography in

orbital floor fractures in the pediatric population – Parbhu 2008

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Bulb Oil treatment ! For retinal detachment

The welding equipment blew up..

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Trauma dx, blind

Small blowout fx. Optic contusion??

Visus

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Fuzzy sight?

Loss of red?

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Trauma Dx. Bulb deformation Retrobulbar heamtoma

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Exophtalmus

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Liquor leakage

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Eye foreign body MVC; glas in the eye

lead

air

Bulbform

Other damage?

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Optic canal

Comminute fractures increase risk for optic damage

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Lacrimal canal

Fractures may cause tear flow problems

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Associated damages Airway

Bleeding

Intracranial bleedings

C-spine fractures

Bulb, optic nerve

Neck arteries

Hyoid Larynx

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Hyoid Hyoid fracture

Bicycle accident

Associated neck fractures and Le Fort face fractures

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Hyoid fracture Strangulation

Rare in other trauma

Associated with airway compromise, seen in forensics……

Am Surg. 1999 Sep;65(9):877-80

http://www.ncbi.nlm.nih.gov/pubmed/10484094

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Neck vessels

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Contusions High energy trauma!

Risk for IC bleeding > 1% in face fracture and no IC symtoms

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Puck

Hockey fan; Early 3D

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Comminute facial trauma Make a complete exam at first show

Face trauma team includes

ENT, reconstructive surgeons, Neuro, Jaw surgeons, Radiology

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Comminute fracture 2 Le Fort 1 och 3

NOE complex

Frontal sinus

Caput mand dx

Orbita floor sin

Cerebral contusions

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Comminute fracture 3 Missing tooth Fr canalis opticus

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Optic canal

Comminute fractures increase risk for optic damage

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Frontal sinus Posterior wall of frontal sinus??

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Postoperative evaluation Implants well visible, no artifacts

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3D in real time

Teeth

Teeth bone algorithm

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Tooth infection

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Combinations of injuries US 2002-2006 2.7 million reported traumas.

Mulligan JTrauma 2010

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The incidence of facial fracture was 3.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury.

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The incidence of facial fracture was 3.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury.

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Computed tomography Nobel Price 1979 in medicine

Allan M. Cormack USA

Sir Godfrey Hounsfield

England

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The Beatles

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Thank you!

The speaker who would rather be flying over middle earth country (Queenstown NZ)