0:01

This was a young child who fell out of a stroller

0:05

and landed and hit the facial structures.

0:08

And this case will demonstrate some of the

0:12

more unusual types of orbital fractures.

0:16

So I'm just going to focus on the axial CT scans

0:20

and point out a few findings.

0:23

So obviously,

0:24

first thing we will see is the air fluid level in the

0:28

right maxillary antrum and the left maxillary antrum.

0:31

We see that the patient has nasal bone fractures,

0:34

which we'll discuss in a moment.

0:36

But let's focus on the orbit.

0:38

So as we come up further superiorly on the right side,

0:42

focusing there,

0:45

we see some air at the foramen rotundum.

0:51

We see some air coursing to the superior orbital fissure,

0:56

and we see some air cutting across the

1:00

anterior clinoid process.

1:02

This is a fracture which is crossing the orbital apex.

1:05

Here is the optic nerve canal, the optic canal.

1:10

And the fracture goes just above the optic canal

1:15

with small areas of air seen in that location.

1:19

You notice that it communicates across to the

1:24

medial orbital wall at its posterior most portion.

1:29

This is a very unusual location for

1:31

a fracture at the orbital apex.

1:34

But it points out what the risk factor is, that this

1:37

can then, at this narrowest portion of the orbit,

1:41

lead to a compression of the optic nerve

1:44

when you have a hematoma there.

1:46

Although we will talk a little bit

1:48

more about this case later on

1:49

when we're talking about the other types of fractures.

1:53

I do want to point out that this patient also has

1:56

a fracture which goes across the top of the

2:00

orbit. So orbital roof fractures.

2:02

These are usually when there is a big pressure in the

2:06

orbital space that drives the fracture generally

2:10

superiorly into the intracranial compartment.

2:13

So we have to be very careful here about our coronal images.

2:18

I want to point out that these are the thin section,

2:21

0.75 millimeter thick sections. I've shown you

2:25

previously coronal and sagittal reconstructions.

2:27

You notice that the coronal and sagittal reconstructions

2:30

are two millimeter or three millimeter

2:32

in some of the examples I gave you.

2:34

It is not uncommon for me to make my own coronal and

2:38

sagittal reconstructions from the 0.75 mm.

2:42

So that way I have even thinner section than what is

2:44

provided to me by the technologists or

2:46

the scanner that are two to 3 mm.

2:50

So if you need that higher resolution,

2:52

take those thin sections at 0.75 and

2:55

reconstructive and coronal, and sagittal also in thin section.

3:00

Here we can see a large laceration with a foreign body

3:02

over the forehead. Let's look at the coronal reconstruction.

3:06

So in this example, you can see the orbital roof fracture,

3:11

which is shearing off a portion of the anterior clinoid

3:15

process, and we are... here is the optic canal.

3:19

So in point of fact,

3:20

the fracture doesn't actually cross the optic canal.

3:23

It's just in close proximity to it.

3:25

But we do see the fracture involving the roof

3:28

of the orbit. Note the small amount of air.

3:31

I'll magnify that for you.

3:33

So here's the small amount of air.

3:35

Again, whenever I see that,

3:36

I'm going to be very suspicious of an adjacent

3:40

fracture. And here that fracture is.

3:43

And the next thing we want to do is

3:44

to look at the soft tissue windows.

3:46

Why do we want to look at the soft tissue windows?

3:49

We want to look of the orbital apex to see whether this optic

3:53

nerve is being compressed at all by adjacent

3:56

hemorrhage associated with the fracture.

4:00

And this is about as good as you're going to see symmetry

4:03

from side to side in the orbital apex.

4:06

So, in point of fact,

4:07

there isn't a large hematoma associated with this fracture

4:10

that was involved in the interclinoid and the

4:13

soft tissues just adjacent to the optic canal.