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Most of you know that I read the evening shift for Johns Hopkins Hospital

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and on my shift, which is usually from 4:00 PM to 11:00 PM,

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the predominant abnormalities that I see are related to the emergency department

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and some of the inpatient. We usually don't read the outpatient imaging

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cases. So I see a lot of facial trauma. And the facial trauma

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is usually ruled out fracture or in the scenario of motor vehicle collisions

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where the face is swollen after either hitting the windshield or the steering

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wheel. We see a lot of facial trauma in the elderly who have

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falls, or depending upon the seasonal aspect of it, people who slip and

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fall on the ice or snow and/or those patients who are in altercations

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with their neighbors or maybe not such good neighbors, so lots of fist fights

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that lead to facial trauma. We've dealt with the orbital aspect and the

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orbital fractures and the orbital and ocular trauma, but now we're going

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to deal with the facial trauma that's associated with non orbital pathology.

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Sometimes the patients will present with soft tissue or neck pain in which

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case we're concerned about the possibility of carotid artery or vertebral

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artery dissection. And sometimes we get orders for the "seatbelt sign"

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as the individuals are thrust forward in their seatbelt and they have the

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discoloration and abrasion that is associated with the seatbelt. So let's

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talk about facial fractures. The most common of the facial fractures is

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nasal bone, the nasal bone fractures. Those are very commonly fractured.

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They really have relatively little importance in and of themselves other

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than the cosmetic deformity unless that fracture is leading to airway disruption.

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We talked about orbital wall fractures earlier in the orbital section,

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and then we have our mandibular fracture. In the literature, the

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mandible is the second most common fractured bone after nasal bones.

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In my experience, far and away, the orbital fractures are number two after

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nasal bone fractures. So let's deal initially with nasal bone fractures.

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Here are some schematics of the nasal bone anatomy that we should be

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aware of. So in addition to the nasal bones, we have to look

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at the communication of the nasal bones to the maxilla, and these include

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at the nasomaxillary sutures seen here. Here we have the frontomaxillary

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suture, and here we have the frontonasal suture. So these little irregular

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lines, which are also seen on our skull manifest as the frontonasal suture,

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the frontomaxillary suture, and the nasomaxillary sutures. And these can

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be seen on the axial scans shown as the little communications between the

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nasal bones and the different parts of the maxilla and the frontal bone.

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The anterior nasal spine is another area where we often refer to with

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fractures that affect the anteriormost portion of the face, certainly in

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my case, the nose and the nasal bones.

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So let's look at some examples of these fractures. Here's a fracture of

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the anterior nasal spine, which you could see on the axial scan showing

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these little pointy portions of the nasal process of the maxilla or the

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anterior nasal spine. Here is a fracture involving the nasal bones anteriorly

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with swelling of the nasal cartilage. But you notice also that there is

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a fracture here of the nasal septum. This is very important.

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In fact, one of the most common sources of trainee misses with regard

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to facial bone fractures is the absence of reporting nasal septum fractures.

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And this is a big mistake because the nasal septum actually has a

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relatively precarious vascular system and vascular supply, and therefore

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nasal septum fractures do sometimes lead to avascular necrosis of the nasal

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septum and collapse of the nasal bone inward and that obviously from a

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cosmetic standpoint is very important. Here are fractures involving the

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frontal maxillary process at the junction with the nasal bone, with the

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frontal bone. And here you see fractures also of the nasomaxillary suture.

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All of these are lumped together as nasal bone fractures generally in the

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vernacular of the emergency room, but there are different parts that I've

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laid out here. So again, I want to emphasize this important pearl, nasal

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septum fractures are important to note because the septum obviously maintains

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the integrity of the midline. And because it's vascular supply is tenuous,

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it can lead to avascular necrosis and collapse of the nasal bones and

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the nasal apparatus inward. Cartilaginous fractures are more common than

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bony fractures, but they tend to be less obvious, obviously because we're

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seeing soft tissue rather than the bone where we can see the actual

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break in the bone. This necrosis can lead in its worst situation with

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saddle nose deformity where the nose is actually bent inward in a characteristic

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deformity known as saddle nose deformity.