Interactive Transcript
0:00
Most of you know that I read the evening shift for Johns Hopkins Hospital
0:06
and on my shift, which is usually from 4:00 PM to 11:00 PM,
0:11
the predominant abnormalities that I see are related to the emergency department
0:15
and some of the inpatient. We usually don't read the outpatient imaging
0:21
cases. So I see a lot of facial trauma. And the facial trauma
0:25
is usually ruled out fracture or in the scenario of motor vehicle collisions
0:31
where the face is swollen after either hitting the windshield or the steering
0:37
wheel. We see a lot of facial trauma in the elderly who have
0:41
falls, or depending upon the seasonal aspect of it, people who slip and
0:46
fall on the ice or snow and/or those patients who are in altercations
0:52
with their neighbors or maybe not such good neighbors, so lots of fist fights
0:56
that lead to facial trauma. We've dealt with the orbital aspect and the
1:00
orbital fractures and the orbital and ocular trauma, but now we're going
1:03
to deal with the facial trauma that's associated with non orbital pathology.
1:09
Sometimes the patients will present with soft tissue or neck pain in which
1:12
case we're concerned about the possibility of carotid artery or vertebral
1:16
artery dissection. And sometimes we get orders for the "seatbelt sign"
1:22
as the individuals are thrust forward in their seatbelt and they have the
1:28
discoloration and abrasion that is associated with the seatbelt. So let's
1:34
talk about facial fractures. The most common of the facial fractures is
1:38
nasal bone, the nasal bone fractures. Those are very commonly fractured.
1:42
They really have relatively little importance in and of themselves other
1:47
than the cosmetic deformity unless that fracture is leading to airway disruption.
1:53
We talked about orbital wall fractures earlier in the orbital section,
1:58
and then we have our mandibular fracture. In the literature, the
2:03
mandible is the second most common fractured bone after nasal bones.
2:08
In my experience, far and away, the orbital fractures are number two after
2:13
nasal bone fractures. So let's deal initially with nasal bone fractures.
2:18
Here are some schematics of the nasal bone anatomy that we should be
2:22
aware of. So in addition to the nasal bones, we have to look
2:26
at the communication of the nasal bones to the maxilla, and these include
2:31
at the nasomaxillary sutures seen here. Here we have the frontomaxillary
2:38
suture, and here we have the frontonasal suture. So these little irregular
2:44
lines, which are also seen on our skull manifest as the frontonasal suture,
2:49
the frontomaxillary suture, and the nasomaxillary sutures. And these can
2:55
be seen on the axial scans shown as the little communications between the
3:00
nasal bones and the different parts of the maxilla and the frontal bone.
3:06
The anterior nasal spine is another area where we often refer to with
3:10
fractures that affect the anteriormost portion of the face, certainly in
3:13
my case, the nose and the nasal bones.
3:16
So let's look at some examples of these fractures. Here's a fracture of
3:20
the anterior nasal spine, which you could see on the axial scan showing
3:26
these little pointy portions of the nasal process of the maxilla or the
3:31
anterior nasal spine. Here is a fracture involving the nasal bones anteriorly
3:38
with swelling of the nasal cartilage. But you notice also that there is
3:43
a fracture here of the nasal septum. This is very important.
3:47
In fact, one of the most common sources of trainee misses with regard
3:54
to facial bone fractures is the absence of reporting nasal septum fractures.
4:00
And this is a big mistake because the nasal septum actually has a
4:04
relatively precarious vascular system and vascular supply, and therefore
4:09
nasal septum fractures do sometimes lead to avascular necrosis of the nasal
4:15
septum and collapse of the nasal bone inward and that obviously from a
4:20
cosmetic standpoint is very important. Here are fractures involving the
4:24
frontal maxillary process at the junction with the nasal bone, with the
4:28
frontal bone. And here you see fractures also of the nasomaxillary suture.
4:33
All of these are lumped together as nasal bone fractures generally in the
4:39
vernacular of the emergency room, but there are different parts that I've
4:43
laid out here. So again, I want to emphasize this important pearl, nasal
4:47
septum fractures are important to note because the septum obviously maintains
4:51
the integrity of the midline. And because it's vascular supply is tenuous,
4:57
it can lead to avascular necrosis and collapse of the nasal bones and
5:02
the nasal apparatus inward. Cartilaginous fractures are more common than
5:09
bony fractures, but they tend to be less obvious, obviously because we're
5:12
seeing soft tissue rather than the bone where we can see the actual
5:16
break in the bone. This necrosis can lead in its worst situation with
5:22
saddle nose deformity where the nose is actually bent inward in a characteristic
5:28
deformity known as saddle nose deformity.
© 2024 Medality. All Rights Reserved.