How To Read Facial Bone X-Rays By Peter Andre Soltau -Jan2015

This presentation was created for educational purposes. It was initially presented at the Accident & Emergency Residents Meeting In January 2015.

1. How to read Facial Bone Xrays (45 mins) Dr Peter Andre Soltau 3rd year A&E Resident UWI Mona [email protected]

2. Epidemiology Incidence : 20 -50% of cases admitted to traumatic emergency room Etiology: 1) M.V.A (up to 80%) 2) Direct Force e.g Fights (up to 60%) 3) Falls (up to 25%) 4) Sports (up to 10%) 5) Industrial accidents

3. Facial Fractures Soft tissue injury is more common Co-existence of other injuries: 3 - 14% have skull fractures 1 - 4% have c-spine fractures 20% of patients with c- spince fractures have facial injury

4. Facial Fractures M ost common is nasal bone fracture S ite vary based on mechanism on injury I n admitted patients, most common fracture is of the ZMC (40%) followed by complex fractures L ess common in children <10% (mid-face less prominent , sinuses less pneumatized , elasticy of bones )

5. Imaging Why: Identify fractures, fracture displacement and rotation, stable bone Identify soft tissue injury CT is the modality of choice !!! high accuracy (soft tissue and bone detail) cost saving versus multiple view plain radiography easier quicker pre-op planning

6. Imaging Plain Film Radiography can be obtained if CT not available must have proper patient positioning of the head alignment of x-ray beam is critical multiple projections obtained relative to " canthomeateal line" (outer canthus to EA meatus overlapping obscures anatomic detail if a fracture is identified other than a simple nasal bone fracture - CT is required

7. Anatomy Familiarity with facial bone anatomy is required for accurate interpretation Face is defined as that area which is bounded by superiorly - supra-orbital rims inferiorly - maxillary alveolar process

8. Plain X-rays Views Water's View (P.A view with cephalad angulation) Caldwell View (P.A view) Towne View Lateral View Submentovertex / Basal Additional view: lateral nasal bone view

9. Adult Facial Bones - PA Caldwell

10. Adult Facial Bones - Occipito Mental (OM) (Waters) View

11. Adult Facial Bones - PA 30° ( Modified Parietocanthial )

12. Adult Facial Bones - Occipito Mental 30° (OM30) View

13. Adult Facial Bones - Lateral View

14. Adult Facial Bones - Submentovertex (SMV) / Slit Basal / Jughandles View

15. Adult Facial Bones - Slit Townes

16. Pearls Rule of symmetry : symmetry is usual, asymmetry is suspect Facial fractures usu occur in multiples

17. Radiographic signs of facial fractures Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a "double-density" asymmetry of face Indirect Signs soft tissue swelling periorbital or intracranial air fluid in a paranasal sinus

18. Dolan Lines Three anatomic contours best seen on the Waters view of the face, and they were first popularized by Dolan et al . As you can see, the 3 lines of Dolan lead the eye along some facially important structures. Lee Rogers pointed out that the 2nd and 3rd lines together form the profile of an elephant.

19. Line 1: Look for widening of the zygomatico -frontal sutures Fractures of the superior rim of the orbits “Black-Eyebrow” sign due to orbital emphysema Opacification / air-fluid level in the frontal sinuses Line 2: Look for fractures of the superior aspect of the zygomatic arch Fractures of the inferior rim of the orbits Soft tissue shadow in the superior maxillary antrum Fractures of the nasoethmoid bones and medial orbits Line 3: Look for fractures of the inferior aspect of the zygomatic arch Fractures of the lateral maxillary antrum Opacification / air-fluid level in the maxillary sinuses Fractures of the alveolar ridge Compare the injured side with the uninjured side.

20. McGrigor -Campbell interpretation lines Facial bone fractures result from direct trauma and usually follow one of only a small number of patterns. ' McGrigor -Campbell' lines can be used as a simple aid to interpretation. The eye follows these lines to check for these common fracture patterns.

21. Facial fractures Most common facial fractures: Nasal bone fracture Isolated zygomatic arch fracture Tripod or zygomaticomaxillary complex fracture( involves separation of all three major attachments of the zygoma to the rest of the face) Orbital "blowout" fractures

22. Fracture Type Prevalence: Zygomaticomaxillary complex (tripod fracture) - 40 % LeFort I - 15 % II - 10 % III - 10 % Zygomatic arch - 10 % Alveolar process of maxilla - 5 % Smash fractures - 5 % Other - 5 %

23. Isolated zygomatic arch fracture

24. 'Tripod' fractures

25. Maxillary antrum fluid level

26. Orbital 'blowout' fractures Trauma to the orbit may lead to increased pressure in the orbit such that the thin bone of the orbital floor bursts. This manifests as the 'teardrop' sign which is due to herniation of orbital contents into the maxillary antrum.

27. Orbital 'blowout' fracture- Teardrop sign

28. Orbital emphysema Occasionally a 'tripod' or 'blowout' fracture will cause a leak of air from the maxillary antrum into the orbit. This can have the appearance of a dark 'eyebrow'.

29. Fractures of the Maxilla The classification of maxilla fractures again follows the concept of areas of relative strength within the facial skeleton There are three principal fracture lines which correspond to relative areas of weakness, and these are referred to as LeFort fractures By definition, these fractures must transect the pterygoid process of the sphenoid bone.

30. LeFort I This is a transverse fracture through the inferior maxillary antra , which separates off the alveolar process of the maxilla. The LeFort I is demonstrated on the OM view with fractures through the medial and lateral walls of the maxillary antra , and the nasal septum

31. LeFort II This is a pyramidal fracture, which separates off the central portion of the face. The OM film identifies the LeFort II with fractures through the lacrimal bones, medial orbital walls, infra-orbital rim and lateral walls of the maxillary antra .

32. LeFort III This fracture is characterised by separation of the entire facial skeleton from the skull. The posterior aspect of the fracture extends down the posterior maxillary sinus walls. Fracture lines will be visible on the OM view extending from the medial orbits and nasoethmoid region across the ethmoids posteriorly. The orbits appear elongated with wide diastasis of the zygomatico-frontal sutures, or fractures of the orbital process of the zygoma.

33. Pathology Spotters

34. Pathology Spotters

35. Pathology Spotters

36. Pathology Spotters

37. Summary Analysis of the fractured face requires a knowledge of not only normal anatomy, but also of common fracture patterns in the face The workup and treatment of facial fractures is often properly delayed until more pressing problems have been addressed, such as the establishment of an adequate airway, hemodynamic stabilization, and the evaluation and treatment of other more serious injuries Know the most common patterns of facial fractures and look for them Symmetry is frequent, asymmetry is suspect

38. Summary Plain film is a 2D representation of a 3D object Always utilise a systematic approach Correlate radiological findings with clinical features

39. References http://www.wikiradiography.net/page/Facial+Bones+Radiographic+Anatomy http:// radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_face_fracture.html#top_first_img http:// www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/facial-and-mandibular-fracture http :// www.imageinterpretation.co.uk/face.html *NONE OF THE IMAGES IN THIS PRESENTATION ARE MINE, IF YOU WOULD LIKE TO HAVE YOUR IMAGE REMOVED, CONTACT ME!