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Lucy Shen, 2004 Gillian Lieberman, MD Orbital Trauma Lucy Shen Harvard Medical School Year IV Gillian Lieberman, MD March, 2004

Orbital Trauma - Lieberman's eRadiology Learning Sites

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Lucy Shen, 2004Gillian Lieberman, MD

Orbital Trauma

Lucy ShenHarvard Medical School Year IV

Gillian Lieberman, MD

March, 2004

Lucy Shen, 2004Gillian Lieberman, MD

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Orbital Trauma

• Causes: high acceleration, MVA, violent crimes, industrial accidents

• Orbital fractures• Soft tissue injuries

Lucy Shen, 2004Gillian Lieberman, MD

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Imaging Modalities for Orbital Trauma

• Plain radiograph

• CT

• MRI

• US

Conventional

HelicalIV contrastno IV contrast

Lucy Shen, 2004Gillian Lieberman, MD

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Primary Imaging Modality: Helical CT

• Rapid and high resolution• Reformatted coronal and 3-D images• Accurate for diagnosing fractures and soft

tissue injuries• Helpful for planning corrective surgeries• CTA assesses traumatic vascular anomalies• Radiation exposure: 0.02 – 0.03 Gy, similar to

orbital plain films

Lucy Shen, 2004Gillian Lieberman, MD

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Other Imaging Modalities

• Plain radiograph: difficult to interpret due to superimposition of bony structures.

• MRI: can evaluate vascular injuries and the optic nerve.contraindication: metal foreign body.

• US: limited use, can assess intraocular foreign body and other structures (retina).

Lucy Shen, 2004Gillian Lieberman, MD

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Bones of the Orbit (Left)

frontal b.lesser wing of sphenoid b.

orbital roof lateral wallfrontal b.zygomatic b.greater wing of sphenoid b.

orbital floorpalatine b.zygomatic b.maxilla

medial wallmaxilla

lacrimal b.ethmoid b.

(lamina papyracea) body of sphenoid b.(posterior to ethmoid b.)

Netter FH, Atlas of Human Anatomy, East Hanover, NJ:Novartis, 1997.

Lucy Shen, 2004Gillian Lieberman, MD

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Bones of the Orbit on Coronal CT

orbital roof

medial wall (ethmoid b.)

orbital floor

lateral wall(zygomatic b.)

ethmoid sinus

maxillary sinus

Hofer M, CT Teaching Manual, New York, NY:Thieme, 2000.

Lucy Shen, 2004Gillian Lieberman, MD

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Bones of the Orbit on Axial CT

sphenoid sinus

body of sphenoid b.

zygomatic bone

lacrimal b.

ethmoid b.

Novelline RA, Squire LF, Living Anatomy, Philadelphia, PA:Hanley & Belfus, 1987.

Lucy Shen, 2004Gillian Lieberman, MD

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Frontal Sinus on Axial CT

frontal sinus

Novelline RA, Squire LF, Living Anatomy, Philadelphia, PA:Hanley & Belfus, 1987.

Lucy Shen, 2004Gillian Lieberman, MD

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Anatomy of Extraocular Muscles (Left Eye)

Yanoff M, Ophthalmology, 2nd ed, Mosby Inc, 2004.

sup oblique

levator palp sup

med rectus

inf rectus

lat rectus

sup rectus

inf obliqueannulus of Zinn

Lucy Shen, 2004Gillian Lieberman, MD

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Extraocular Muscles on CT Coronal View (Left Eye)

optic nerve

sup ophth veinsup rectus

lat rectus

inf rectus

med rectus

sup oblique

levator palp sup

Yanoff M, Ophthalmology, 2nd ed, Mosby Inc, 2004.

Lucy Shen, 2004Gillian Lieberman, MD

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Soft Tissues of the Orbit: CT Axial View

lens

globe of the eye

optic nervemedial rectus

lateral rectus

Yanoff M, Ophthalmology, 2nd ed, Mosby Inc, 2004.

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 1: Orbital Floor FractureHx: 74 yo F, fell on left face, hitting left eye

air pockets in the orbit

soft tissue swelling and air

blood in left max sinus

fx of orbital floor

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Blow-Out Fractures

• Patient 1 suffered a blow-out fracture.• Definition: blunt trauma to the orbit displacing the

fragmented bones outward. The globe can be pushed inward.

• Fracture often involves the medial wall or the orbital floor or both. Muscle entrapment may occur.

• The following slide illustrates a blow-out fracture.

Lucy Shen, 2004Gillian Lieberman, MD

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Blow-Out Fractures

Kanski JJ, Illustrated Tutorials in Clinical Ophthalmology, Boston, MA:Butterworth-Heinemann, 2001.

Lucy Shen, 2004Gillian Lieberman, MD

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Pt 2: Blow-Out Fx with Muscle Herniation

Hx: 79 yo M, fell on right face at home

fx of medial wall

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Pt 2: Blow-Out Fx with Muscle Herniation

blood in max sinus

orbital fat in max sinus

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Pt 2: Blow-Out Fx with Muscle Herniation

blood in ethmoid sinus

orbital floor

fracture

Lat displaced globe

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Pt 2: Blow-Out Fx with Muscle Herniation

blood in max sinus

orbital fat in max sinus

herniated inf rectus

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Diagnosing Muscle Entrapment Associated with Blow-Out Fx

• Ophthalmoplegia and diplopia in upward and downward gaze

• Secondary over-reaction of the unaffected eye• Muscle entrapment is a clinical diagnosis. On radiology,

only muscle herniation can be seen.

Kanski JJ, Illustrated Tutorials in Clinical Ophthalmology, Boston, MA:Butterworth-Heinemann, 2001.

Lucy Shen, 2004Gillian Lieberman, MD

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Surgical Treatment for Blow-Out Fx

1. subcilliary incision

2. free entrapped tissues

3. repair bony defect with alloplastic implant

alloplastic implant

Kanski JJ, Illustrated Tutorials in Clinical Ophthalmology, Boston, MA:Butterworth-Heinemann, 2001.

Lucy Shen, 2004Gillian Lieberman, MD

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Interim Summary of Orbital Fractures

• Orbital floor and medial wall fx’s

• Orbital roof fx• Lateral wall fx• Tripod fx (displaced

zygoma)• Naso-ethmoidal orbital fx• Le Fort III fx• Le Fort II fx

Cummings CW, Otolaryngology: Head and Neck Surgery, 3nd ed: Mosby Inc, 1998.

Lucy Shen, 2004Gillian Lieberman, MD

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Soft Tissue Injuries

• Ruptured globe

• Foreign body

Rhea JT, et al, Radiol Clin North Am, 1999 May;37(3):489-513.

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Pan-Facial TraumaHx: 22 yo M, working with a cement truck, when the boom of the truck swung around and hit him on the right side of the face.

Bird’s eye view of patient’s head

Boom of the truck

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Axial CT

orbital fat ant. to fx’d nasal b.

extruded & lat. displaced globe (not ruptured)lateral wall fx, zygomatic b.

medial wall fx

edema, hemorrhage, subcutaneous air

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Coronal CT

fx’d and displaced mandible

OG tube

ETT

orbital floor fx

fx’d and displaced

zygomatic b.

courtesy of Dr. N. Nelson, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: 3D CT

PACS, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Findings on 3D CT

• Fractures of all 4 orbital walls• Orbital rim was shattered to > 8 pieces• Le Fort I fracture of the maxilla• Fractured and displaced mandible

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Hospital Course

• Patient was hospitalized in the trauma ICU.• He underwent tracheostomy and extensive

facio-reconstructive surgeries.• The next 2 slides are from a CT taken after

his first major facial surgery.

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: 10 Days Later, Coronal CT

lat. displaced globe

right maxilla and mandible in near alignment

extensive fx’s of right facial bones

soft tissue edema and hematoma

PACS, BIDMC

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: 10 Days Later, 3D CT

PACS, BIDMC

reconstructed inf orbital rim

Lucy Shen, 2004Gillian Lieberman, MD

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Patient 3: Hospital Course cont’d

• Patient was discharged on hospital day 14.• Many of the facial fractures have been

repaired, although he will have additional surgeries as an outpatient.

• His trach was removed.• His vision in right eye was 20/400 five days

after the injury. He was able to read.

Lucy Shen, 2004Gillian Lieberman, MD

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Orbital Trauma: in Summary

• Helical CT is the primary imaging test• Reconstructed coronal and 3D images help

with diagnosis and surgery planning• Medial wall is the most commonly fx site• Blindness occurs in 3% of facial fx’s• Don’t forget ABC: mandibular fx can

obstruct the airway

Lucy Shen, 2004Gillian Lieberman, MD

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References

• Cummings CW, Otolaryngology: Head and Neck Surgery, 3nd ed: Mosby Inc, 1998. • Grainger RG, Allison A, Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed:

Churchill Livingstone, Inc, 2001.• Hofer M, CT Teaching Manual, New York, NY:Thieme, 2000. • Kanski JJ, Illustrated Tutorials in Clinical Ophthalmology, Boston, MA:Butterworth-

Heinemann, 2001.• Mauriello JA, Lee HJ, Nguyen L, CT of soft tissue injury and orbital fractures.

Radiol Clin North Am. 1999 Jan;37(1):241-52.• Netter FH, Atlas of Human Anatomy, East Hanover, NJ:Novartis, 1997. • Novelline RA, Squire LF, Living Anatomy, Philadelphia, PA:Hanley & Belfus, 1987.• Rhea JT, Rao PM, Novelline RA, Helical CT and three-dimensional CT of facial and

orbital injury. Radiol Clin North Am, 1999 May;37(3):489-513. • Yanoff M, Ophthalmology, 2nd ed, Mosby Inc, 2004.

Lucy Shen, 2004Gillian Lieberman, MD

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Acknowledgements

• Nicole Nelson, MD• Steve Reddy, MD• Loren Borud, MD• Larry Barbaras, our webmaster• Gillian Lieberman, MD• Pamela Lepkowski