Facial and Orbital Fractures - Lieberman's...

$: Facial and Orbital Fractures - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/central/Hindman.pdf · various facial and orbital fractures ... psuedoaneurysms, lacrimal$
Holly B. Hindman

Gillian Lieberman, MD

Holly B. Hindman, Harvard Medical School, Year IIIGillian Lieberman, MD

April 2002

Facial and Orbital Fractures

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Outline of Discussion

• Introduction to our patient• Orbital anatomy• Recommended imaging studies• Presentation and radiological findings of

various facial and orbital fractures• Potential complications of orbital fractures• Revisiting our patient

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Patient Presentation – P.Q.

CC: Trauma patient, s/p fall from 70 feet.HPI: brought to E.R. s/p fall from 70 feet with

multiple injuries including facial and orbital fractures.

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Defining the Orbital Walls

• Medial Wall: ethmoid bone (paper thin), lacrimal bone, body of spenoid (posteriorly), frontal bone (superiorly), maxilla (inferiorly)

• Lateral Wall: zygomatic bone anteriorly, greater wing of sphenoid bone posteriorly.

• Roof: frontal bone, lesser wing of sphenoid bone containing optic canal

• Floor: maxilla and zygomatic bone anteriorly, palatine bone posteriorly

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Bony Orbit

Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 566

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Bony Orbit – Medial Wall

Vaughan et al. General Ophthalmology, 15th Edition, page 2

Frontal

Lacrimal

Ethmoid

Sphenoid

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Paranasal SinusesFrontal Sinus Ethmoid Sinus

Sphenoid SinusMaxillary Sinus Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 606

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Paranasal SinusesPlain Film CT

Frontal

Ethmoid

Maxillary


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Extraocular MusclesMuscle Primary

ActionSecondary Action Innervation

Lateral Rectus Abduction None CN VI

Medial Rectus Adduction None CN III

Superior Rectus ElevationAdductionIntorsion

CN III

Inferior Rectus DepressionAdductionExtorsion

CN III

Superior Oblique Intorsion

DepressionAbduction

CN IV

Inferior Oblique Extorsion

ElevationAbduction

CN III

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Extraocular Muscles

www.eyeplastics.com/ orbital_anatomy.htm

http://www.eyeplastics.com/orbital_anatomy.htm

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Extraocular Muscles


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Orbital Arteries and VeinsArteries

Ophthalmic Artery is the first intracranial branch of internal carotid Artery. Accompanies optic nerve through optic canal and branches into:

1) Retinal Artery2) Lacrimal Artery3) Muscular Branches4) Long and Short Posterior Ciliary

Arteries5) Medial Palpebral Arteries6) Supraorbital and Supratrochlear

Arteries

VeinsVortex veins, anterior ciliary veins,

and central retinal vein drain into superior and inferior ophthalmic veins

Superior ophthalmic vein passes through superior orbital fissure and communicates with cavernous sinus

Inferior ophthalmic vein passes through inferior orbital fissure to communicate with pterygoid plexus

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Nerves of the Orbit

Oculomotor Nerve (CN III): enters via superior orbital fissure•Superior Division: levator palpebrae, superior rectus muscle•Inferior Division: medial and inferior recti, inferior oblique muscles, parasympathetic fibers to ciliary ganglion

Trochlear Nerve (CN IV): enters via superior orbital fissure • innervates superior oblique muscle

Abducens Nerve (CN VI): enters via the superior orbital fissure•Innervates lateral rectus muscle.

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Nerves of the Orbit

Trigeminal Nerve (CN V):•Ophthalmic Branch: enters via superior orbital fissure

1) lacrimal nerve: provides sensory innervation to lacrimal gland

2) frontal nerve: divides into supraorbital and supratrochlear nerves and provides sensation to brow and forehead

3) nasociliary nerve: sensation to cornea, iris, and ciliary body

•Maxillary Branch: enters via inferior orbital fissure becomes the infraorbital nerve and exits via the infraorbital foramen provide sensory innervation to lower lid and cheek

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Nerves of the Orbit

Optic Nerve (CN II):•contains axons of ~ 1 million retinal ganglion cells.•80% is composed of visual fibers that travel to the visual cortex via the lateral geniculate body.•20% is composed of pupillary fibers that terminate in the pretectal area.•Exits via the optic canal.Vaughan et al. General

Ophthalmology, 15th Edition, page 20

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The Optic Nerve

The optic nerve is ensheathed with fibrous wrappings which are continuous with the outer layers of the eye and the meninges.


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The Orbital Apex

Entry point of •Nerves•Blood vessels

Site of origin of all EOM, except inferior oblique


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The Anterior Orbit


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Orbital Contents


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Putting It All Together

Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th

Edition, page 611

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Causes of Orbital Trauma

• Motor vehicle accidents• High acceleration injuries• Violent crime• Athletic accidents• Industrial accidents

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Imaging Studies• Plain Films in patients who show no neurological

abnormalities or in patients who have suspected foreign body. Use Caldwell and Waters views.

• High resolution axial CT is primary imaging modality using both axial and coronal views.

• CT angiogography if there is concern for vascular injury such as carotid cavernous fistula.

• MR useful for evaluating vascular injuries and psuedoaneurysms, lacrimal drainage injury, motility disorders, and for surgical planning. Contraindicated until metallic foreign body ruled out.

• US can detect intraocular foreign bodies, globe rupture, suprachoroidal hemorrhage, and retinal detachment.

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Types of Orbital FracturesOrbital fractures are often associated with optic nerve

injuries, paranasal sinus injuries, and/or intracranial injuries.

Types of orbital fractures include:• Le Fort Fractures• Medial Orbital Fractures• Orbital Floor Fractures• Orbital Roof Fractures• Lateral (Zygomatic, Tripod) Fractures• Naso-Ethmoidal Orbital Fractures• Orbital Apex Fractures

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Definitions• Blow-out Fracture:• outward fracture of involved orbital bones.• Usually involves medial wall and floor. • Results in increased intraorbital volume and

enophthalmos.

• Blow-in Fracture:• fracture of orbital bones inward into the orbital

space. • Results in decreased orbital volume and proptosis.

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Le Fort’s Fractures• Le Fort I: no orbital

involvement.• Le Fort II: medial orbital

wall affected. Fracture of nasal, lacrimal, and maxillary walls. May involve nasolacrimal duct

• Le Fort III: medial and lateral walls and floor affected. Craniofacial dysjunction. May involve optic canal.

Le Fort’s fractures are horizontal fractures that involve the maxilla bilaterally.

Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 247

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Medial Wall Fractures

• Involves maxilla, lacrimal, and ethmoid bones.

• Associated with orbital floor fracture, depressed nasal bridge, traumatic telecanthus.

• Can get blow-out and prolapse of tissues into ethmoid and sphenoid sinuses. Vaughan et al. General Ophthalmology, 15th Edition, page 2

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Medial Wall Fracture

Signs and Complications•Periorbital emphysema which develops when patient blows nose•Defective motility: involving abduction and adduction because of medial rectus entrapment.•Severe epistaxis if ethmoidal artery is damaged•CSF rhinorrhea•Lacrimal system injury

Kanski JK. Clinical Ophthalmology, 4th Edition, page 651

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Medial Wall Fracture


Coronal CTblow-out fracture of medial wall andblow-out fracture of orbital floor

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Fracture of the Orbital Floor

• Caused by sudden increase in orbital pressure by small object.

• Floor fractures anteriorly through the maxillary bone and posteriorly along the thin bone covering the infraorbital canal.

• Orbital contents may prolapse and become entrapped in maxillary sinus.


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Complications of Orbital Floor Fracture

• ecchymosis and edema• Infraorbital nerve anesthesia:

due to involvement of infraorbital canal

• Diplopia: caused by hemorrhage or edema, mechanical entrapment within the fracture, or direct injury to extraocular muscle

• Ocular damage • Enophthalmos• Globe ptosis• Orbit and lid emphysema


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Orbital Floor Fracture

CT scan demonstrates• fracture of the orbital

floor with displacement of inferior rectus muscle through the defect.

Arrowhead = optic nerve sheath hematomaOpen arrow = downward displacement of inferior rectus muscle


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Roof Fractures

Signs:•Hematoma of the upper lids and periocular ecchymosis•Inferior or axial globe displacement•Pulsation of the globe may be seen in large fractures•Supraorbital hypesthesia•Ptosis•Limited elevation and depression of the eye


Pathogenesis: children have isolated minor trauma. Adults more likely to have complicated fractures from major trauma. May involve frontal sinus, cribiform plate, and brain.

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Roof FracturesComplications

•CSF rhinorrhea: localized by CT cisternography after intrathecal contrast administration•Pneumocephalus: The frontal sinus dissipates the impact and is often fractured. Violation of posterior wall of frontal sinus require surgical repair.

fracture of posterior wall of frontal sinuscerebral hemorrhage


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Roof Fractures

Coronal CT of left orbital roof fracture demonstrating pneumo-orbit and pneumocephalus (arrow)


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Lateral Wall FracturesLateral Wall Fractures•Bone is more solid•Associated with extensive facial damage •Fractures rarely occur alone •Frequently part of a complex tripod or Le Fort III fracture.

Tripod FracturesInvolves fracture of three bones:•Zygomaticofrontal suture superiorly•Zygomatic arch laterally•Zygomaticomaxillary suture inferomedially

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Combined Fractures – Tripod Fracture• A: coronal spiral CT

shows separated frontozygomatic suture

• B: 3D reformatted spiral CT shows lateral displacement of lateral orbital wall

• C: 3D reformatted spiral CT shows downward displacement of trimalar complex.


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Naso-Ethmoidal Orbital Fractures•Often caused by MVA in which patient strikes the nose on the dashboard.•Thick anterior bones cause telescoping of posterior thinner bones.•Usually cause a blow-in fracture but occasionally cause blow-out into ethmoid sinus of medial wall.

www.erlanger.org/craniofacial/ book/Trauma/Trauma_4.htm

http://www.erlanger.org/craniofacial/book/Trauma/Trauma_4.htm

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Naso-Ethmoidal Orbital Fractures


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Orbital Apex Fractures• Usually in association with other facial fractures• May involve optic canal and superior orbital fissure and

cause injury to nerves in the area• Optic nerve injury may be caused by mechanical tearing or

laceration, stretching, torsion, contusion, compression, ischemia, hemorrhage, or thrombosis

• Must look for foreign bodies• Complications:

1) CSF leaks 2) carotid-cavernous fistula 3) loss of vision

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Orbital Apex Fractures

Intraocular hemorrhage from penetrating injury intraocular airintraocular blood

Axial CT of fracture of ethmoid and medial wall of optic canal

Axial CT of nerve sheath hematoma

Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, pages 247-249

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Complications of Orbital Trauma

• Foreign bodies (Radiographs, US, CT, NOT MRI)• Diplopia from muscle entrapment• Globe rupture• Suprachoroidal hemorrhage (US)• Retinal detachment (US)• Carotid cavernous fistula (CT, MRI,

arteriography)• Lens dislocation (US)• enophthalmos

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Foreign Bodies



Plain radiograph (Waters view) showing left foreign body

BB at orbital apex

Kanski JK. Clinical Ophthalmology, 4th

Edition, page 652

B scan Ultrasound shows intraocular foreign body

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Other Complications

Carotid Cavernous Fistula

Suprachoroidal Hemorrhage

Friedman et al The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 1998, page 5

Kanski JK. Clinical Ophthalmology, 4th

Edition, page 652

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Patient D.W.

Findings on CT: contiguous axial images from the foramen magnum through the cranial vertex

• Multiple comminuted fractures involving the bilateral maxillary sinuses and ethmoid air cells

• Fracture of lamina papyracea bilaterally• Fracture of the left zygomatic arch• Extensive blood and soft tissue density within

maxillary, ethmoid, sphenoid, and frontal sinuses as well as mastoid air cells

• No gross abnormalities of the brain

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Patient P.Q.Fractures of maxilla Blood in maxillary sinus

Courtesy of Beth Israel Deaconess Medical Center

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Fracture of left zygomatic bone

Blood in sphenoid sinus Blood in ethmoid sinus

Fracture of lamina papyracea


Patient P.Q.

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Blood within frontal sinus


Patient P.Q.

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References• Agur AMR, Lee MJ. Grant’s Atlas of Anatomy, 10th Edition. Lippincott Williams and Wilkins, 1999.• Coleman DJ, Silverman RH, Daly SM, Rondeau MJ. Advances in Ophthalmic Ultrasound. Radiologic

Clinics of North America, 1998; 36:6, 1073-1082.• Ettl A, Salmonowitz E, Koornneef L, Zonnefeld FW. High Resolution MR Imaging – Anatomy of the

Orbit. The Radiologic Clinics of North America, 1998; 36:6, 1021-1045.• Friedman NJ, Pineda R, Kaiser PK. The Massachusetts Eye and Ear Infirmary Illustrated Manual of

Ophthalmology. W.B. Saunders Company, 1998.• Kanski JK. Clinical Ophthalmology. 4th Edition. Butterworth-Heinemann, 2000.• Koornneef L, Zonneveld FW. The Role of Direct Multiplanar High-Resolution CT in the Assessment

and Management of Orbital Trauma. Radiologic Clinics of North America, 1987; 25:4, 753-766.• Mauriello JA, Lee HJ, Nguyen L. CT of Soft Tissue Injury and Orbital Fractures. Radiologic Clinics

of North America 1999; 37:1, 241-252.• Novelline, RA. Squire’s Fundamentals of Radiology, 5th Edition. Butterworth-Heinemann, 2000.• Vaughan D, Asbury T, Riordan-Eva P. General Ophthalmology, 15th Edition. McGraw-Hill, 1999.• www.eyeplastics.com/ orbital_anatomy.htm• www.erlanger.org/craniofacial/ book/Trauma/Trauma_4.htm

http://www.eyeplastics.com/orbital_anatomy.htm

http://www.erlanger.org/craniofacial/book/Trauma/Trauma_4.htm

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Acknowledgements

• Webmasters Larry Barbaras and Cara Lyn D’amour

• Gillian Lieberman, MD • Pamela Lepkowski• Nicole Thobe, MD

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