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Imaging Orbit/Periorbital Injury
Stuart E. Mirvis, M.D., FACR
Department of Radiology
University of Maryland School of Medicine
9th Nordic Trauma Radiology Course 2016
Fireworks
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Struts and buttresses
Orbital fractures
Periorbital injuries
Orbital cranial nerves
Soft tissue globe injury
Topics to Cover
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Facial Struts Posterior coronal struts consisting of posterior wall of maxillary sinus (1) and pterygoid plates (2)
Anterior coronal struts consisting of frontal (1), zygomaticofrontal (2), nasofrontal (3), anterior maxillary (4), anterior alveolar (5) components.
Sagittal struts consisting of median (1 ), parasagittal(2), and lateral (3) parts
Horizontal struts superior (1), middle (2), and inferior (3) parts.
Gentry LR, et al. High-Resolution CT
Analysis of Facial Struts in Trauma:
1. Normal Anatomy. AJR 140:523-
532, March 1983
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Concept of Facial Buttresses
Major support for facial skeleton to maintain form and function (I-beams)
Attach directly or indirectly to skull base
or cranium 3 vertical and 3 horizontal Buttresses accommodate screw fixation Maintain facial width and height Establish functional support (orbits and
teeth)
Hopper RA, Salemy S, Sze RW. Diagnosis of Midface
Fractures with CT: What the Surgeon Needs to Know.
RadioGraphics 2006; 26:783–793
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Highlights of Facial Anatomy - Orbit
Orbital sutures and thin orbital bony plates
allow suture diastasis and fractures of thin
bone to absorb impacting energy.
This anatomy plus orbital fat and muscles
cushions the globe and preserves vision in
high-energy impacts to the orbit.
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Orbital Blow-out Fractures:
Significant Imaging Features
Evidence of muscle or fat entrapment (position/shape of muscle) Pure or impure fracture (?intact inferior orbit rim) Orbital hematoma (up to 24% orbital injuries) Complications: enopthalmous, diplopia, hypoesthesia Size (area) of floor defect or associated fractures Calculations of blow-out fractures of the orbital floor by 3D-CT
and 2D-CT method are accurate for assessing the area of fracture and the volume of herniated tissue*
*Ploder O, 2D- and 3D-based measurements of orbital floor fractures
from CT scans. J Craniomaxillofac Surg. 2002
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Orbital blow-out fracture
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Orbit Blow-out Fracture
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Orbit Blow-out Fracture
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Herniated Inferior Rectus
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Herniated and
entrapped inferior rectus
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Round inferior rectus – torn
supportive tissues
Rounding of the inferior rectus muscle on
initial coronal CT scan is predictive of the
development of late enophthalmos
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Medial orbital wall fracture
Isolated or associated 20-40% with floor
fracture
More common to cause orbital emphysema
Rarely surgically repaired
Complications: Horizontal gaze palsy,
enopthalmous, epistaxis
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Isolated or associated 20-40%
with floor fracture
More common to cause orbital
emphysema
Rarely surgically repaired
Complications: Horizontal
gaze palsy, enopthalmous,
epistaxis
Medial Orbit Wall Blow-out
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Medial orbital wall fracture- emphysema
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Medial blow-out with muscle
herniation (entrapped?)
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Orbital Blow-in fracture
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Rare
Orbital roof fragments explode into
frontal lobe
Typical – dural tears and CSF leak
Frontal sinus involvement common
Blow-up
fracture
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Orbital Blow-up fracture
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Traumatic Optic Neuropathy
Secondary acute trauma (Assault, MVC):
demyelinating, inflammatory, ischemic causes
Direct or indirect axon damage
Impaired -- to loss of vision
Avulsion, hemorrhage, emphysema, transection
0.5 to 5% closed head injury (forehead, supraorbital)
Afferent pupillary defect
Optic nerve atrophy 4-6 weeks
Treatment – steroids (< 8 hrs. after injury)
FLAIR with fat & fluid suppression (CUBE): 3D
FSE sequence used to perform whole-brain
FLAIR T2-weighted imaging.
Increased signal on diffusion.
STIR with fat suppression
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Traumatic Optic Neuropathy
Case 1
Case 2
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Superior Orbital Fissure Syndrome
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Orbital Apex Syndrome
Optic neuropathy and ophthalmoplegia
Loss of cranial nerves II, III, IV, opthalmic
division of V, and VI
Blindness, fixed dilated pupils, proptosis,
ptosis
Causes: inflammatory, infectious neoplastic,
iatrogenic/traumatic, and vascular conditions
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LeFort Fracture Patterns Described as symmetric mid-face lines of weakness -
experimental
Often asymmetric clinically and combined with ZMC, NOE
Always involves pterygoid plate fractures
Higher energy usually leads to higher grade
Any pattern of Lefort 1,2,3 fractures can occur
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LeFort Fracture II
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Lefort II and Naso-
orbital- ethmoid
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Le Fort 2/3
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Combined LeFort Fracture Pattern - Smash
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Manson Classification:
medial support injury
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3-wall orbital fracture
and globe hemorrhage
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Knife to right orbit - blind
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Globe Extrusion
Traumatic exopthalmous – sudden reduced orbital volume,
reduced vision. Hemorrhage, emphysema, loss afferent and
efferent /direct pupillary responses
Severe orbital tension, firm globe, limited ocular movement
Globe tenting/stretching; acute proptosis; torn nerves,
muscles; CCF
Posterior globe angle < 120 degree with proptosis surgery
Globe angle<
130 degree
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Protective plastic on
table saw
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Figure 24 of 33
choroidal vitreous
retinal retinal CCF
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Stick in inferior orbit
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“That’s All Folks“