This presentation was created for educational purposes. It was initially presented at the Accident & Emergency Residents Meeting In January 2015.

1. How to read Facial Bone Xrays
(45 mins)
Dr Peter Andre Soltau
3rd year A&E Resident
UWI Mona
P.A.SOLTAU@GMAIL.com

2. Epidemiology
Incidence :
20 -50% of cases admitted to traumatic emergency
room
Etiology:
1) M.V.A (up to 80%)
2) Direct Force e.g Fights (up to 60%)
3) Falls (up to 25%)
4) Sports (up to 10%)
5) Industrial accidents

3. Facial Fractures
Soft tissue injury is more common
Co-existence of other injuries:
3 - 14% have skull fractures
1 - 4% have c-spine fractures
20% of patients with c-spince
fractures have facial injury

4. Facial Fractures
Most common is nasal bone fracture
Site vary based on mechanism on injury
In admitted patients, most common fracture is
of the ZMC (40%) followed by complex fractures
Less common in children <10% (mid-face less
prominent, sinuses less pneumatized, elasticy of
bones)

5. Imaging
Why:
Identify fractures, fracture displacement and rotation,
stable bone
Identify soft tissue injury
CT is the modality of choice !!!
high accuracy (soft tissue and bone detail)
cost saving versus multiple view plain radiography
easier
quicker
pre-op planning

6. Imaging
Plain Film Radiography
can be obtained if CT not available
must have proper patient positioning of the head
alignment of x-ray beam is critical
multiple projections obtained relative to "canthomeateal line"
(outer canthus to EA meatus
overlapping obscures anatomic detail
if a fracture is identified other than a simple nasal bone fracture - CT
is required

7. Familiarity with facial bone anatomy is required for accurate interpretation
Face is defined as that area which
is bounded by
superiorly - supra-orbital rims
inferiorly - maxillary alveolar process

11. Plain X-rays Views
Water's View (P.A view with cephalad angulation)
Caldwell View (P.A view)
Towne View
Lateral View
Submentovertex / Basal
Additional view:
lateral nasal bone view

12. Adult Facial Bones - PA Caldwell

13. Adult Facial Bones - Occipito Mental (OM)
(Waters) View

14. Adult Facial Bones - PA 30° (Modified Parietocanthial)

15. Adult Facial Bones - Occipito Mental 30° (OM30) View

16. Adult Facial Bones - Lateral View

17. Adult Facial Bones - Submentovertex (SMV) / Slit
Basal / Jughandles View

18. Adult Facial Bones - Slit Townes

19. Pearls
Rule of symmetry : symmetry is usual, asymmetry
is suspect
Facial fractures usu occur in multiples

20. Radiographic signs of facial fractures
Direct Signs
nonanatomic linear lucencies
cortical defect or diastatic suture
bone fragments overlapping causing a "double-density"
asymmetry of face
Indirect Signs
soft tissue swelling
periorbital or intracranial air
fluid in a paranasal sinus

21. Dolan Lines
Three anatomic contours best seen on the Waters view of the face, and they were first
popularized by Dolan et al.
As you can see, the 3 lines of Dolan lead the eye along some facially important
structures.
Lee Rogers pointed out that the 2nd and 3rd lines together form the profile of an
elephant.

22. Line 1:
Look for widening of the zygomatico-frontal
sutures
Fractures of the superior rim of the orbits
“Black-Eyebrow” sign due to orbital emphysema
Opacification / air-fluid level in the frontal sinuses
Line 2:
Look for fractures of the superior aspect of the
zygomatic arch
Fractures of the inferior rim of the orbits
Soft tissue shadow in the superior maxillary
antrum
Fractures of the nasoethmoid bones and medial
orbits
Line 3:
Look for fractures of the inferior aspect of the
zygomatic arch
Fractures of the lateral maxillary antrum
Opacification / air-fluid level in the maxillary
sinuses
Fractures of the alveolar ridge
Compare the injured side with the uninjured side.

23. McGrigor-Campbell interpretation lines
Facial bone fractures result from direct trauma and usually follow one of only a small
number of patterns. 'McGrigor-Campbell' lines can be used as a simple aid to
interpretation. The eye follows these lines to check for these common fracture
patterns.

24. Facial fractures
Most common facial fractures:
Nasal bone fracture
Isolated zygomatic arch fracture
Tripod or zygomaticomaxillary complex fracture( involves
separation of all three major attachments of the zygoma to the rest
of the face)
Orbital "blowout" fractures

25. Fracture Type
Prevalence:
Zygomaticomaxillary complex (tripod fracture) - 40 %
LeFort
I - 15 %
II - 10 %
III - 10 %
Zygomatic arch - 10 %
Alveolar process of maxilla - 5 %
Smash fractures - 5 %
Other - 5 %

26. Isolated zygomatic arch fracture

27. 'Tripod' fractures

29. Maxillary antrum fluid level

30. Orbital 'blowout' fractures
Trauma to the orbit may lead to increased pressure in the orbit such
that the thin bone of the orbital floor bursts. This manifests as the
'teardrop' sign which is due to herniation of orbital contents into the
maxillary antrum.

31. Orbital 'blowout' fracture- Teardrop sign

32. Orbital emphysema
Occasionally a 'tripod' or 'blowout' fracture will cause a leak of air from the
maxillary antrum into the orbit. This can have the appearance of a dark
'eyebrow'.

33. Fractures of the Maxilla
The classification of maxilla fractures again follows the concept of areas of relative
strength within the facial skeleton
There are three principal fracture lines which correspond to relative areas of
weakness, and these are referred to as LeFort fractures
By definition, these fractures must transect the pterygoid process of the sphenoid
bone.

34. LeFort I
This is a transverse fracture through the inferior maxillary antra, which separates
off the alveolar process of the maxilla. The LeFort I is demonstrated on the OM view
with fractures through the medial and lateral walls of the maxillary antra, and the
nasal septum

35. LeFort II
This is a pyramidal fracture, which separates off the central portion of the face. The
OM film identifies the LeFort II with fractures through the lacrimal bones, medial
orbital walls, infra-orbital rim and lateral walls of the maxillary antra.

36. LeFort III
This fracture is characterised by separation of the entire facial skeleton from the
skull. The posterior aspect of the fracture extends down the posterior maxillary sinus
walls. Fracture lines will be visible on the OM view extending from the medial orbits
and nasoethmoid region across the ethmoids posteriorly. The orbits appear elongated
with wide diastasis of the zygomatico-frontal sutures, or fractures of the orbital
process of the zygoma.

37. Pathology Spotters

38. Pathology Spotters

39. Pathology Spotters

40. Pathology Spotters

46. Summary
Analysis of the fractured face requires a knowledge of not
only normal anatomy, but also of common fracture patterns
in the face
The workup and treatment of facial fractures is often
properly delayed until more pressing problems have been
addressed, such as the establishment of an adequate airway,
hemodynamic stabilization, and the evaluation and
treatment of other more serious injuries
Know the most common patterns of facial fractures and
look for them
Symmetry is frequent, asymmetry is suspect

47. Summary
Plain film is a 2D representation of a 3D object
Always utilise a systematic approach
Correlate radiological findings with clinical features

48. References
1.http://www.wikiradiography.net/page/Facial+Bones+Radiographic+Anatomy
2.http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-
ray_face_fracture.html#top_first_img
3.http://www.rad.washington.edu/academics/academic-sections/msk/teaching-
materials/online-musculoskeletal-radiology-book/facial-and-mandibular-fracture
4.http://www.imageinterpretation.co.uk/face.html
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