Upcoming Events
Log In
Pricing
Free Trial

Clinical Scenario 2 - Facial/Neck Trauma - Video Introduction

HIDE
PrevNext

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.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

© 2024 Medality. All Rights Reserved.

Contact UsTerms of UsePrivacy Policy