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Best X Ray For Orbital Fracture

author
Ava Flores
• Friday, 22 January, 2021
• 14 min read

Orbit involvement is seen in various facial fracture patterns, including zygomaticomaxillary (BMC), naso-orbito-ethmoid (NOE), frontal-sinus, Le Fort II, and Le Fort III fracture patterns. Orbital apex fractures are important to identify because of their association with damage to the neurovascular structures of the superior orbital fissure and optic canal (including traumatic optic neuropathy).

orbital fracture blow ray left wall maxillary sinus floor medial face imaging answer case week facial margin fractured infra emergucate
(Source: www.emergucate.com)

Contents

Optimally, plain radiography of the orbit should include the acquisition of direct frontal (posteroanterior or anteroposterior ), Caldwell, Waters, Town, and lateral views. When clinical suspicion of orbital fracture persists but the plain radiographic findings are equivocal or unremarkable, CT scan study is required for a more definitive assessment of the orbits.

CT scanning is the study of choice for orbital fractures, offering the highest degree of confidence. Thin-section coronal images provide an excellent depiction of all orbital walls, especially the floor and roof.

CT scanning that employs a section thickness of 3 mm or less best illustrates fine bony structures of the midface and orbits. A study by Huang et al. suggests that maxillary heroines (MRS) findings on head CT scans may be used to screen for orbital floor fractures (Offs).

After the intraorbital presence of metal bodies has been excluded, preferably by means of CT scanning, MRI can be used for adjunct characterization of soft-tissue sequela. As with CT scanning, MRI can demonstrate globe injuries, retrobulbar fluid collection (hematoma or other), mucoperiosteal hemorrhage, and hemorrhage along the optic nerve sheath, as well as the proximity of extraocular muscles to the fracture edges.

Ultrasonography requires a dedicated ophthalmologic technician and may not reveal important cranial injuries. Along the visual pathways, trauma in these regions is divided into 4 major locations: intraocular, intraorbital, intracanalicular, and intracranial.

tripod fracture facial fractures orbital ray blowout floor vii chapter
(Source: carpet.vidalondon.net)

Coronal computed tomography scan shows a medial wall blow-out fracture of the right eye. In 1901, Renée Le Fort provided the earliest classification system of maxillary fractures.

His model described “great lines of weakness in the face” caused by low-velocity impact forces directed against cadaver skulls. The Le Fort I, or transverse, fracture extends through the base of the maxillary sinuses above the teeth spices, essentially separating the alveolar processes, palate, and steroid processes from the facial structures above them.

This transverse fracture across the entire lower maxilla separates the alveolus as a mobile unit from the rest of the midface. High-energy injuries may cause a Le Fort I fracture and a split along the palate's midline.

Computed tomography scan showing bilateral fractures of the orbital floor associated with a Le Fort II injury. A Le Fort III fracture, or craniofacial dysfunction, denotes a complete separation of the midface or facial bones from the cranium.

Although still widely used, the Le Fort classification system was developed based on fractures caused by low-speed trauma to the face. Naso-orbito-ethmoid fractures can be classified on the basis of extent of injury to the attachment of the medial central tendon, with possible complications such as nasofrontal duct disruption.

foreign body unusual retained orbital intraorbital superior removal djo
(Source: www.djo.org.in)

Be familiar with the complex anatomy of the orbit and relative soft tissues, as displayed on computed tomography (CT) scans and magnetic resonance images (MRIs) in multiple planes. Be familiar with the plain radiographic and CT scan appearances of traumatic fractures of the orbit.

Orbital radiography should include several views to clearly depict the various parts of the eye without obstruction. Optimally, plain radiography of the orbit should include the acquisition of direct frontal (posteroanterior or anteroposterior ), Caldwell, Waters, Town, and lateral views.

The floor fragment typically remains attached medially, similar to a hinge, with a characteristic lateral sloping. Often, the entire floor fragment can be depressed into the subject maxillary sinus.

Depending on orientation, the depressed floor fragment can appear as a nonanatomic opacity in the maxillary antrum. Indirect findings include asymmetrical, hemorrhage-related opacification of a paranasal sinus adjacent to a particular orbital surface.

For example, an air-fluid level in the maxillary antrum suggests an orbital -floor injury. Unilateral opacification of the ethmoid air cells indicates a possible medial-wall fracture.

orbital fracture emergencies ocular ppt powerpoint presentation assessment eom abnormal movement trauma blunt
(Source: www.slideserve.com)

This pathologic collection of air is seen as a lucency at the anteroposterior aspect of the orbit. Although passage of air into the orbit can theoretically occur via communication with any injured, adjacent paranasal sinus cavity, orbital emphysema detected on plain images is frequently the result of a blow-out fracture of the medial wall.

Fractures of the medial wall and orbital roof are poorly visualized on plain radiographs. When clinical suspicion of orbital fracture persists but the plain radiographic findings are equivocal or unremarkable, CT scan study is required for a more definitive assessment of the orbits.

Infrequently, a maxillary sinus septum occurs near the orbital floor level, mimicking a trapdoor sign. A large polyp or retention cyst at the superior aspect of the maxillary sinus could mimic the appearance of a sunken globe.

However, if the axial CT scan sections are 2-3 mm or thinner, reconstructed images can be obtained in the coronal plane (via computer algorithms). CT scanning allows the direct visualization of disrupted bony contours, fracture fragments, and associated sequela to adjacent soft-tissue structures.

Coronal computed tomography scan shows a medial wall blow-out fracture of the right eye. Axial computed tomography view shows a displaced bony fragment and herniation of orbital fat in the maxillary sinus.

facial caldwell fractures trauma emergencies ent em1 recap studyblue
(Source: studyblue.com)

This computed tomography image shows encroachment on lateral rectus muscle secondary to the lateral-wall fracture. With blow-out fractures of the orbital floor, CT scanning can directly depict the degree of enophthalmos, if any.

Computed tomography scan showing bilateral fractures of the orbital floor associated with a Le Fort II injury. Computed tomography scan demonstrating a fracture of the orbital floor involving both inferior and medial walls, resulting in a depressed fragment.

This computed tomography image shows encroachment on lateral rectus muscle secondary to the lateral-wall fracture. Computed tomography scan depicting fracture of the medial wall of the orbit, with deformity of the lamina panacea.

Note the medial herniation of orbital fat and muscle into the deformity. Coronal computed tomography view from a patient with a fracture of the medial wall of the orbit, with deformity of the lamina panacea and medial herniation of orbital fat and muscle into the deformity.

CT scanning also permits the visualization of globe injuries, such as lens dislocation. With orbital roof fractures, coronal CT scans can display possible associated herniation of intraorbital contents into the frontal sinus or anterior cranial fossa.

fractures maxillofacial fracture fort sutures
(Source: www.slideshare.net)

The development of multidetector-row/multi section (DMS) spiral CT scanning has dramatically increased imaging speed and anatomic coverage. In addition, the development of true volumetric imaging has, in combination with technological progress in virtual reality, led to improved surgical simulation.

Additionally, new generations of software have allowed soft tissues superficial to skeletal structures to be rendered or skin, muscle, and fat layers to be selectively removed to improve visualization of the targeted bones. A complete preoperative plan should be built on a comprehensive clinical examination of the periorbital soft-tissue and bony components, detailed ophthalmic examination, and high-resolution CT scans in the axial, coronal, and reformatted sagittal planes.

Treatment modalities and methods of approach are adapted according to the severity of the orbital deformities. CT scanning is the study of choice for orbital fractures, offering the highest degree of confidence.

Thin-section coronal images provide an excellent depiction of all orbital walls, especially the floor and roof. Axial imaging is good for evaluating fractures of the medial and lateral walls.

However, axial imaging alone is not optimal for evaluating the orbital roof and floor; fractures along those structures and any displaced fragments are commonly in the same section plane and, therefore, are not ideally visualized. MRI has a negligible role in the initial assessment of acute orbital injury because of its poor depiction of subtle bony detail and the overriding requirement that no metallic foreign bodies be present intraorally before exposing the patient to fluctuating magnetic fields.

orbital radiopaedia radiology
(Source: radiopaedia.org)

Such metallic foreign bodies can include bullet fragments or BB pellets left from an acute or previous penetrating trauma. In this case, bringing the patient into the magnetic resonance field is strictly contraindicated, because the individual may have been engaged in an occupation, such as sheet-metal work, that exposed him or her to flying metal debris.

After the intraorbital presence of metal bodies has been excluded, preferably by means of CT scanning, MRI can be used for adjunct characterization of soft-tissue sequela and complications of the above-described fractures. As with CT scanning, MRI can demonstrate globe injuries, retrobulbar fluid collection (hematoma or other), mucoperiosteal hemorrhage, and hemorrhage along the optic nerve sheath, as well as the proximity of extraocular muscles to the fracture edges.

Computed tomography scan of a gross disruption of the right orbit secondary to a gunshot wound (GSW). Coronal computed tomography reconstruction demonstrates a gunshot wound (GSW) involving the superior orbital fracture.

Computed tomography scan in a patient with a gunshot wound (GSW) involving the superior orbital fracture. This image shows metal fragments associated with a ruptured globe.

Computed tomography scan showing a gunshot wound (GSW) to the left lateral orbit with associated bony fractures and metallic fragments in the lateral orbital compartment. Computed tomography scan from a patient with a gunshot wound (GSW) to the left lateral orbit.

orbital radiopaedia radiology
(Source: radiopaedia.org)

Computed tomography scan from a patient with a gunshot wound (GSW) to the left lateral orbit. Selective catheterization of the external carotid arteries is necessary to identify vascular damage or a continued bleeding source caused by facial trauma.

Thus, angiography can be pivotal when orbital trauma, whether internal or external, is related to facial bleeding. Head injuries in which the intravenous carotid artery is torn can result in traumatic carotid-cavernous fistulas (CCS).

Selective angiography of the internal carotid artery (ICA) can clearly display the presence or absence of a CCF. Selective right carotid angiogram from a patient with head trauma and an orbital bruit.

One-month follow-up angiogram in a patient who had head trauma, an orbital bruit, and a small carotid-cavernous fistula. Left internal carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis.

This image shows a feeder of the ophthalmic artery associated with 2 berry aneurysms. Angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms.

orbital floor fracture healing repair surgery implant
(Source: carpet.vidalondon.net)

Selective left external carotid injection in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms. Selective right carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms.

Venous aneurysm is present along the floor of the anterior cranial fossa. Selective right external carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms.

This image shows a large feeder vessel of the right superficial temporal artery and extensive venous drainage. Valencia MRP, Murasaki H, Ito M, et al. Radiological findings of orbital blowout fractures: a review.

Predicting orbital fractures in head injury: a preliminary study of clinical findings. Huang OK, Tu HF, Jiang LD, Chen BY, FM CY.

Evaluation of Concomitant Orbital Floor Fractures in Patients with Head Trauma Using Conventional Head CT Scan: A Retrospective Study at a Level II Trauma Center. Before R. Étude experimental SUR LES fractures DE la macho ire superior.

eye laser glaucoma closure angle iridectomy surgery
(Source: www.slideshare.net)

Brakes MA, Evans T. Evaluation and management of the patient with Before facial fractures. Kelli GJ Jr, Mi lite J, Maker E. Orbital floor fractures: evaluation, indications, approach, and pearls from an ophthalmologist's perspective.

Challah PO, Ekanaykaee K, Bare CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department.

Ski M, Satin I, Device M, Tureen M, Isis S, Singer M. A retrospective analysis of 101 zygotic- orbital fractures. Gómez Rosella E, Quills Granada AM, Arizona Garcia M, Unpair Martí S, Lagoon Sale G, Beltrán Marmot B, et al. Facial fractures: classification and highlights for a useful report.

Murillo JA Jr, Lee HE, Nguyen L. CT of soft tissue injury and orbital fractures. A modification of Her tel's exophthalmometer, using the external auditory canal as a reference point.

Right S, Buffalo P, Guglielmo V, Rossi P, Martina M. Diagnosis and imaging of orbital roof fractures: a review of the current literature. Nunnery WR, Tao JP, John S. Nylon foil “wraparound” repair of combined orbital floor and medial wall fractures.

eye laceration corneoscleral globe injury ruptured penetrating foreign body orbital
(Source: www.slideshare.net)

Surgical treatment of post-traumatic enophthalmos with diced mentor implants through mini-lateral angioplasty incision. Pergola M, Kinsmen I, Aitasalo K. Reconstruction of orbital wall defects with bioactive glass plates.

Kozakiewicz M, Ella M, Lobe P, Kaminski P, Arkuszewski P, Broniarczyk-Loba A, et al. Clinical application of 3D present titanium implants for orbital floor fractures. Carrier S, Prabhakar VC, Davis G, Silva D. Delayed complications of silicone implants used in orbital fracture repairs.

Frisco J, Fuller K, Lee N, Andrew D. Cone beam computed tomography for imaging orbital trauma-image quality and radiation dose compared with conventional multi slice computed tomography. Branch F, Cicada D, Capablanca S, Brig anti F, Brunei L, Folio P. Orbital fractures: role of imaging.

Data FL, Sea bold JE, Brown ML, et al. Procedure guideline for technetium-99 m-HMPAO-labeled leukocyte scenography for suspected infection/inflammation: Society of Nuclear Medicine. Nuclear medicine and infection detection: the relative effectiveness of imaging with 111In-oxine-, 99mTc-HMPAO-, and 99mTc-stannous fluoride colloid-labeled leukocytes and with 67Ga-citrate.

Coronal computed tomography scan shows a medial wall blow-out fracture of the right eye. Axial computed tomography view shows a displaced bony fragment and herniation of orbital fat in the maxillary sinus.

Computed tomography scan showing bilateral fractures of the orbital floor associated with a Le Fort II injury. Computed tomography scan demonstrating a fracture of the orbital floor involving both inferior and medial walls, resulting in a depressed fragment.

This computed tomography image shows encroachment on lateral rectus muscle secondary to the lateral-wall fracture. Computed tomography scan depicting fracture of the medial wall of the orbit, with deformity of the lamina panacea.

Note the medial herniation of orbital fat and muscle into the deformity. Coronal computed tomography view from a patient with a fracture of the medial wall of the orbit, with deformity of the lamina panacea and medial herniation of orbital fat and muscle into the deformity.

Computed tomography scan of a gross disruption of the right orbit secondary to a gunshot wound (GSW). Coronal computed tomography reconstruction demonstrates a gunshot wound (GSW) involving the superior orbital fracture.

Computed tomography scan in a patient with a gunshot wound (GSW) involving the superior orbital fracture. Computed tomography scan showing a gunshot wound (GSW) to the left lateral orbit with associated bony fractures and metallic fragments in the lateral orbital compartment.

Computed tomography scan from a patient with a gunshot wound (GSW) to the left lateral orbit. Computed tomography scan from a patient with a gunshot wound (GSW) to the left lateral orbit.

Selective right carotid angiogram from a patient with head trauma and an orbital bruit. One-month follow-up angiogram in a patient who had head trauma, an orbital bruit, and a small carotid-cavernous fistula.

Left internal carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis. This image shows a feeder of the ophthalmic artery associated with 2 berry aneurysms.

Angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms. Selective left external carotid injection in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms.

Selective right carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms. Venous aneurysm is present along the floor of the anterior cranial fossa.

Selective right external carotid angiogram in a patient with a frontal rural fistula with repeated epistaxis and a feeder vessel of the ophthalmic artery associated with 2 berry aneurysms. This image shows a large feeder vessel of the right superficial temporal artery and extensive venous drainage.

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