Holly B. Hindman
Gillian Lieberman, MD
April 2002
Facial and Orbital Fractures
Holly B. Hindman, Harvard Medical School, Year III
Gillian Lieberman, MD
Holly B. Hindman
Gillian Lieberman, MD
Outline of Discussion
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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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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
Bony Orbit
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 566
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Holly B. Hindman
Gillian Lieberman, MD
Bony Orbit – Medial Wall
Frontal
Ethmoid
Lacrimal
Sphenoid
Vaughan et al. General Ophthalmology, 15th Edition, page 2
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Holly B. Hindman
Gillian Lieberman, MD
Frontal Sinus
Maxillary Sinus
Paranasal Sinuses
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy,
10th Edition, page 606
Ethmoid Sinus
Sphenoid Sinus
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Holly B. Hindman
Gillian Lieberman, MD
Paranasal Sinuses
Plain Film
CT
Frontal
Ethmoid
Maxillary
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 607
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Holly B. Hindman
Gillian Lieberman, MD
Extraocular Muscles
Muscle
Primary
Action
Secondary
Action
Innervation
Lateral Rectus
Abduction
None
CN VI
Medial Rectus
Adduction
None
CN III
Superior Rectus Elevation
Adduction
Intorsion
CN III
Inferior Rectus
Depression
Adduction
Extorsion
CN III
Superior
Oblique
Intorsion
Depression
Abduction
CN IV
Extorsion
Elevation
Abduction
CN III
Inferior
Oblique
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Holly B. Hindman
Gillian Lieberman, MD
Extraocular Muscles
www.eyeplastics.com/ orbital_anatomy.htm
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Holly B. Hindman
Gillian Lieberman, MD
Extraocular Muscles
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 568
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Holly B. Hindman
Gillian Lieberman, MD
Orbital Arteries and Veins
Arteries
Veins
Ophthalmic Artery is the first
intracranial branch of internal
carotid Artery. Accompanies
optic nerve through optic canal
and branches into:
1) Retinal Artery
2) Lacrimal Artery
3) Muscular Branches
4) Long and Short Posterior Ciliary
Arteries
5) Medial Palpebral Arteries
6) Supraorbital and Supratrochlear
Arteries
Vortex 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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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
Nerves of the Orbit
Vaughan et al. General
Ophthalmology, 15th Edition, page 20
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.
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Holly B. Hindman
Gillian Lieberman, MD
The Optic Nerve
Vaughan et al. General Ophthalmology, 15th Edition, page 20
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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Holly B. Hindman
Gillian Lieberman, MD
The Orbital Apex
Entry point of
•Nerves
•Blood vessels
Site of origin of
all EOM, except
inferior oblique
Vaughan et al. General Ophthalmology, 15th Edition, page 3
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Holly B. Hindman
Gillian Lieberman, MD
The Anterior Orbit
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 567
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Holly B. Hindman
Gillian Lieberman, MD
Orbital Contents
Agur AMR and Lee MJ. Grant’s Atlas of Anatomy, 10th Edition, page 571
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Holly B. Hindman
Gillian Lieberman, MD
Putting It All Together
Agur AMR and Lee MJ.
Grant’s Atlas of Anatomy, 10th
Edition, page 611
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Holly B. Hindman
Gillian Lieberman, MD
Causes of Orbital Trauma
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•
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Motor vehicle accidents
High acceleration injuries
Violent crime
Athletic accidents
Industrial accidents
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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
Types of Orbital Fractures
Orbital 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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Holly B. Hindman
Gillian Lieberman, MD
Definitions
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•
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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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Holly B. Hindman
Gillian Lieberman, MD
Le Fort’s Fractures
Le Fort’s fractures are
horizontal fractures that
involve the maxilla
bilaterally.
• 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.
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 247
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Holly B. Hindman
Gillian Lieberman, MD
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, 15
th
Edition, page 2
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Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
Medial Wall Fracture
Coronal CT
blow-out fracture of
medial wall
and
blow-out fracture of
orbital floor
Kanski JK. Clinical Ophthalmology, 4th Edition, page 651
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Holly B. Hindman
Gillian Lieberman, MD
Fracture of the Orbital Floor
Kanski JK. Clinical Ophthalmology, 4th Edition, page 648
• 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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Holly B. Hindman
Gillian Lieberman, MD
Complications of Orbital Floor Fracture
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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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Kanski JK. Clinical Ophthalmology, 4th Edition, page 648
Holly B. Hindman
Gillian Lieberman, MD
Orbital Floor Fracture
CT scan demonstrates
• fracture of the orbital
floor with
displacement of
inferior rectus muscle
through the defect.
Arrowhead = optic nerve sheath
hematoma
Open arrow = downward displacement
of inferior rectus muscle
Mauriello et al. The Radiologic Clinics of North America,
1999, 37:1, page 242
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Holly B. Hindman
Gillian Lieberman, MD
Roof Fractures
Pathogenesis: children have isolated
minor trauma. Adults more likely
to have complicated fractures from
major trauma. May involve frontal
sinus, cribiform plate, and brain.
Kanski JK. Clinical Ophthalmology, 4th Edition, page 652
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
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Holly B. Hindman
Gillian Lieberman, MD
Roof Fractures
Complications
•CSF rhinorrhea: localized
by CT cisternography after
intrathecal contrast
administration
•Pneumocephalus: The
frontal sinus dissipates the
impact and is often
fractured. Violation of
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 244
posterior wall of frontal
sinus require surgical
fracture of posterior wall of frontal sinus
cerebral hemorrhage
repair.
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Holly B. Hindman
Gillian Lieberman, MD
Roof Fractures
Coronal CT of left
orbital roof fracture
demonstrating
pneumo-orbit and
pneumocephalus
(arrow)
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 244
34
Holly B. Hindman
Gillian Lieberman, MD
Lateral Wall Fractures
Lateral 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 Fractures
Involves fracture of three bones:
•Zygomaticofrontal suture superiorly
•Zygomatic arch laterally
•Zygomaticomaxillary suture inferomedially
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Holly B. Hindman
Gillian Lieberman, MD
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.
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 245
36
Holly B. Hindman
Gillian Lieberman, MD
Naso-Ethmoidal Orbital Fractures
www.erlanger.org/craniofacial/ book/Trauma/Trauma_4.htm
•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.
37
Holly B. Hindman
Gillian Lieberman, MD
Naso-Ethmoidal Orbital Fractures
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, page 246
38
Holly B. Hindman
Gillian Lieberman, MD
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
39
Holly B. Hindman
Gillian Lieberman, MD
Orbital Apex Fractures
Intraocular hemorrhage from penetrating injury
intraocular air
intraocular blood
Axial CT of
fracture of ethmoid and medial wall of optic
canal
Axial CT of
nerve sheath hematoma
40
Mauriello et al. The Radiologic Clinics of North America, 1999, 37:1, pages 247-249
Holly B. Hindman
Gillian Lieberman, MD
Complications of Orbital Trauma
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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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Holly B. Hindman
Gillian Lieberman, MD
Foreign Bodies
BB at
orbital apex
Mauriello et al. The Radiologic Clinics of North America,
1999, 37:1, page 243
Plain radiograph
(Waters view)
showing left
foreign body
Kanski JK. Clinical Ophthalmology, 4th
Edition, page 652
B scan Ultrasound shows
intraocular foreign body
Kanski JK. Clinical Ophthalmology, 4th Edition, page 652
42
Holly B. Hindman
Gillian Lieberman, MD
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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Holly B. Hindman
Gillian Lieberman, MD
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
44
Holly B. Hindman
Gillian Lieberman, MD
Fractures of maxilla
Blood in maxillary sinus
Patient P.Q.
Courtesy of Beth Israel Deaconess Medical Center
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Holly B. Hindman
Gillian Lieberman, MD
Fracture of left
zygomatic bone
Patient P.Q.
Blood in sphenoid sinus
Fracture of
lamina papyracea
Blood in ethmoid sinus
Courtesy of Beth Israel Deaconess Medical Center
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Holly B. Hindman
Gillian Lieberman, MD
Patient P.Q.
Blood within
frontal sinus
Courtesy of Beth Israel Deaconess Medical Center
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Holly B. Hindman
Gillian Lieberman, MD
References
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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
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Holly B. Hindman
Gillian Lieberman, MD
Acknowledgements
• Webmasters Larry Barbaras and Cara Lyn
D’amour
• Gillian Lieberman, MD
• Pamela Lepkowski
• Nicole Thobe, MD
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