Themes Key landmarks Clinically relevant Gotcha injuries
Easy-to-miss, land you in trouble Simplify approaches to
classification, where possible Differentiating one fracture pattern
from another
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Of Processes and Terminology
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Temporal Bone Frontal Bone Maxillary Bone
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Of Processes and Terminology Temporal Bone Frontal Bone
Maxillary Bone Frontal process of zygomatic bone
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Of Processes and Terminology Temporal Bone Frontal Bone
Maxillary Bone Zygomatic process of frontal bone
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Of Processes and Terminology Temporal Bone Frontal Bone
Maxillary Bone Maxillary process of zygomatic bone
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Of Processes and Terminology Temporal Bone Frontal Bone
Maxillary Bone Zygomatic process of maxillary bone
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Clinical Relevance of Fracture Diagnosis Fracture repair timing
Ideally
Frontal Sinus Fractures Direct blow to supraorbital region High
force injury (>800 lbs) Anterior wall Forms the frontal bar
Contributes to facial projection Foundation for vertical buttresses
Posterior wall Separates sinus from cranial vault Projection
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Frontal Sinus Fractures Key landmark: nasofrontal duct Duct
dysfunction may lead to mucocele formation Frontal sinus
obliterated prophylactically Mucosa stripped and sinus packed with
bone or fat Coronal CT: Frontal Mucocele 36M Facial injury ten
years ago Coronal CT: Normal Example 59F Normal Normal Duct
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Nasal Bone Fracture 61M Pedestrian struck Axial CT: Simple
Nasal Bone Fracture Common 50% of all facial fractures Watch for:
Septal hematoma Saddle nose deformity Anterior nasal spine fracture
Chronic pain Involvement of medial orbital wall
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Nasal Bone Fracture Common 50% of all facial fractures Watch
for: Septal hematoma Saddle nose deformity Anterior nasal spine
fracture Chronic pain Involvement of medial orbital wall Axial CT:
Paraseptal Hematoma * Photo credit: http://images.rheumatology.org
Saddle Nose* 22M Blunt trauma to face
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Nasal Bone Fracture Common 50% of all facial fractures Watch
for: Septal hematoma Saddle nose deformity Anterior nasal spine
fracture Chronic pain Involvement of medial orbital wall 3D SSD:
Anterior Nasal Spine 31M Punch to face Lateral View: Anterior Spine
Fracture 31M Drunk, fell
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Nasal Bone Fracture Common 50% of all facial fractures Watch
for: Septal hematoma Saddle nose deformity Anterior nasal spine
fracture Chronic pain Involvement of medial orbital wall Axial CT:
Naso-Orbital Ethmoidal Fracture 66M Gunshot wound
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NOE Fractures Fractures involve: Nasal bones Frontal process of
maxilla Medial canthal region Ethmoid sinus and walls Strongly
associated with: Cribiform plate injury Intracranial injury Dural
tears Globe injury Nasal bone Maxilla Lacrimal bone Orbital plate
of ethmoid
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NOE Fracture 61M Pedestrian struck Fractured medial wall
Associated open frontal sinus fracture Associated orbital roof
blowout Fractured nasal bones
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NOE Fractures Key landmark: lacrimal fossa Medial canthal
tendon inserts around fossa Formerly ligament Complex structure
intimately related to orbicularis oculi Fracture may cause:
Telecanthus Globe malposition Look for nasolacrimal duct to find
the lacrimal fossa
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NOE Fractures Key landmark: lacrimal fossa Medial canthal
tendon inserts around fossa Fracture may cause: Telecanthus Globe
malposition Look for nasolacrimal duct to find the lacrimal fossa *
Photo credit: Pham et al. Computer Modeling and Intraoperative
Navigation in Maxillofacial Surgery. Otolaryngology 137(4):
624-631.
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NOE Fractures Key landmark: lacrimal fossa Medial canthal
tendon inserts around fossa Fracture may cause: Telecanthus Globe
malposition Look for nasolacrimal duct to find the lacrimal fossa
59F Normal study Coronal CT: Normal Nasolacrimal Duct Coronal CT:
Normal Lacrimal Fossa
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NOE Fracture Classification Markowitz-Manson Classification:
Type I Fractured piece is large Medial canthal tendon intact
Fixation of bony fragment restores canthal anatomy Type II
Comminution Canthus tendon is attached to a small bone fragment
Type III Comminution with avulsion of medial canthal tendon Cannot
reliably differentiate from Type II on imaging * Hopper et al.
Diagnosis of Midface Fractures with CT: What the Surgeon Needs to
Know. Radiographics. 2006 May-Jun;26(3):783-93
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NOE Fracture Classification 38M Fell off bike onto face 3D SSD:
Manson Type IAxial: Fractured Nasal Bones & Medial Walls
Coronal CT: Fractured Medial Wall and Floor Nasolacrimal Duct
Lacrimal Fossa
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NOE Fracture Classification * Hopper et al. Diagnosis of
Midface Fractures with CT: What the Surgeon Needs to Know.
Radiographics. 2006 May-Jun;26(3):783-93 Markowitz-Manson
Classification: Type I Fractured piece is large Medial canthal
tendon intact Fixation of bony fragment restores canthal anatomy
Type II Comminution Canthus tendon is attached to a small bone
fragment Type III Comminution with avulsion of medial canthal
tendon Cannot reliably differentiate from Type II on imaging 3D
SSD: Manson Type II 63F Massive blunt force trauma
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NOE Fracture Classification * Hopper et al. Diagnosis of
Midface Fractures with CT: What the Surgeon Needs to Know.
Radiographics. 2006 May-Jun;26(3):783-93 Markowitz-Manson
Classification: Type I Fractured piece is large Medial canthal
tendon intact Fixation of bony fragment restores canthal anatomy
Type II Comminution Canthus tendon is attached to a small bone
fragment Type III Comminution with avulsion of medial canthal
tendon Cannot reliably differentiate from Type II on imaging 3D
SSD: Manson Type III 53M Gunshot wound
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NOE Fracture Classification * Hopper et al. Diagnosis of
Midface Fractures with CT: What the Surgeon Needs to Know.
Radiographics. 2006 May-Jun;26(3):783-93 Always comment on: The
degree of comminution Bilateral involvement Nasofrontal ducts
likely disrupted Risk of mucocele formation Frontal sinuses are
surgically obliterated
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Zygoma Cornerstone bone Attachments to frontal, temporal,
sphenoid bones of skull base Forms large portions of the orbital
floor and lateral orbital wall Attachment to maxilla Contributes to
projection, width & height Accurate diagnosis and reduction is
crucial for: Restoring orbital volume Restoring facial projection,
height, width Serving as reference for maxilla in Le Fort-type
injuries
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Zygoma Fractures Tripod fractures Region of zygomaticofrontal
suture Region of zygomaticotemporal suture Region of
zygomaticomaxillary suture Tetrapod fractures Zygomaticosphenoid
suture Often involves lateral maxillary wall Often the zygoma
itself is intact Weaker bones and suture lines fracture around
zygoma 24M Assaulted 3D SSD
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Zygoma Fractures Tripod fractures Region of zygomaticofrontal
suture Region of zygomaticotemporal suture Region of
zygomaticomaxillary suture Tetrapod fractures Zygomaticosphenoid
suture Often involves lateral maxillary wall Often the zygoma
itself is intact Weaker bones and suture lines fracture around
zygoma
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Tetrapod 42M Punch to face SSD: Fourth Attachment DisruptedSSD:
Three of Four Attachments Disrupted
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Zygoma Fractures Tripod fractures Region of zygomaticofrontal
suture Region of zygomaticotemporal suture Region of
zygomaticomaxillary suture Tetrapod fractures Zygomaticosphenoid
suture Often involves lateral maxillary wall Often the zygoma
itself is intact Weaker bones and suture lines fracture around
zygoma 25M Car tire blew up in face 3D SSD: Comminuted Zygomatic
Body
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Zygoma Fractures Preferred Term: Zygomaticomaxillary complex
fracture Spectrum of zygomatic Injuries : Isolated zygomatic arch
TripodTetrapod Comminution of zygoma Amount of Force
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ZMC Fracture Rotation around the zygomaticosphenoid suture is
possible even if the upper transverse and lateral vertical
maxillary buttresses are fixed Implications: Report suture
disruption Review carefully on follow up imaging Transaxial CT:
Zygomaticosphenoid Suture Disruption
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Le Fort Fractures Complex, multi-strut Dissociation of face
from skull base at anchor points Universally involve: Nasal
apparatus Pterygoid processes Classic Le Fort injuries are uncommon
Oversimplification but useful to communicate and to conceptualize
injury * Picture credit: Rosario Van Tulpe under GNU Free
Documentation License v1.2 1 2 3
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Simplified Approach Fractured StructureSignificance Pterygoid
processLe Fort almost always present Lateral margin of nasal
fossaUnique to Le Fort I Inferior orbital rimUnique to Le Fort II
Zygomatic archUnique to Le Fort III * Rhea and Novelline. How to
Simplify the CT Diagnosis of Le Fort Fractures. AJR Am J
Roentgenol. 2005 May; 184(5):1700-5
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Simplified Approach Fractured StructureSignificance Pterygoid
processLe Fort almost always present Lateral margin of nasal
fossaUnique to Le Fort I Inferior orbital rimUnique to Le Fort II
Zygomatic archUnique to Le Fort III * Rhea and Novelline. How to
Simplify the CT Diagnosis of Le Fort Fractures. AJR Am J
Roentgenol. 2005 May; 184(5):1700-5 63M Fall Coronal CT: Pterygoid
Plate FracturesTransaxial CT: Pterygoid Plate Fractures Fractured
StructureSignificance Pterygoid processLe Fort almost always
present Lateral margin of nasal fossaUnique to Le Fort I Inferior
orbital rimUnique to Le Fort II Zygomatic archUnique to Le Fort
III
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Simplified Approach Fractured StructureSignificance Pterygoid
processLe Fort almost always present Lateral margin of nasal
fossaUnique to Le Fort I Inferior orbital rimUnique to Le Fort II
Zygomatic archUnique to Le Fort III * Rhea and Novelline. How to
Simplify the CT Diagnosis of Le Fort Fractures. AJR Am J
Roentgenol. 2005 May; 184(5):1700-5 Coronal CT: Pterygoid Plate
FractureCoronal CT: Nasal Fossa FractureSSD: Le Fort I
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Simplified Approach Fractured StructureSignificance Pterygoid
processLe Fort almost always present Lateral margin of nasal
fossaUnique to Le Fort I Inferior orbital rimUnique to Le Fort II
Zygomatic archUnique to Le Fort III * Rhea and Novelline. How to
Simplify the CT Diagnosis of Le Fort Fractures. AJR Am J
Roentgenol. 2005 May; 184(5):1700-5 Coronal CT: Pterygoid Plate
FracturesCoronal CT: Inferior Orbital Rim Fracture
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Simplified Approach Fractured StructureSignificance Pterygoid
processLe Fort almost always present Lateral margin of nasal
fossaUnique to Le Fort I Inferior orbital rimUnique to Le Fort II
Zygomatic archUnique to Le Fort III * Rhea and Novelline. How to
Simplify the CT Diagnosis of Le Fort Fractures. AJR Am J
Roentgenol. 2005 May; 184(5):1700-5 Coronal CT: Pterygoid Plate
Fractures Coronal CT: Zygomatic Arch Fractures
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Le Fort Fractures: Pitfalls Unilateral Requires a sagittal
split of hard palate Results in widened maxillary arch Combined Le
Fort types Same side Different sides Dont stop searching 27M
Post-op internal fixation Coronal: Left Pterygoid Plate Fracture
Coronal: Palate FractureCoronal: Nasal Fossa Fracture SSD:
Unilateral Le Fort I & II
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Le Fort Fractures: Pitfalls 61M Fall, head injury Coronal CT:
Fractures Lateral Nasal Fossa Walls Axial CT: Fractures of
Pterygoid Plates I I II SSD: Fracture of Orbital Rim Unilateral
Requires a sagittal split of hard palate Results in widened
maxillary arch Combined Le Fort types Same side Different sides
Dont stop searching
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Smash Fractures High energy fractures Severe comminution
Multiple fracture planes Multiple fracture patterns Often
associated with: Intracranial injury Temporal bone fractures
C-spine injury 66M Self-inflicted gunshot wound 3D SSD: Facial
Smash
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65M Attacked by grizzly bear Elements of: Zygomaticomaxillary
Complex Fracture
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65M Attacked by grizzly bear Elements of: Naso-orbital
Ethmoidal Fractures
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65M Attacked by grizzly bear Elements of: Orbital Blow Out
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65M Attacked by grizzly bear Elements of: Le Fort
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LandmarkSignificance Medial orbital wall in simple nasal
fractures Likely NOE complex fracture Nasofrontal duct Dysfunction
leads to mucoceles May require frontal sinus obliteration Lacrimal
fossa Landmark for medial canthal tendon attachment
Zygomaticosphenoid suture Watch out for rotatory deformity
Pterygoid plates Marker for transfacial injury Next look at lateral
walls nasal fossa, inferior orbital rims, zygomatic arches Orbital
soft tissues Widen windows Look for foreign material