Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications

[Trauma of the midface : Symptoms, diagnostics and treatment]

Midface fractures present a clinical challenge in otorhinolaryngology due to their often complex injury pattern and nonspecific symptoms. Precise diagnostics, including differentiated imaging procedures, are required. Interdisciplinary consultation between otorhinolaryngology, maxillofacial surgery, neurosurgery, and ophthalmology is often necessary. When selecting radiographic modalities, radiation hygiene should be taken into account. Sonography provides a radiation-free imaging alternative for fractures of the nasal framework and anterior wall of the frontal sinus. The goal of treatment is to achieve stable and symmetrical reconstruction. Depending on the injury pattern, different osteosynthesis materials, individual access routes, and various surgical procedures can be used. In clinical practice, the management of midface fractures requires a multidisciplinary, flexible, and pragmatic approach based on the fracture pattern and clinical experience.

A review on artificial intelligence for the diagnosis of fractures in facial trauma imaging

Patients with facial trauma may suffer from injuries such as broken bones, bleeding, swelling, bruising, lacerations, burns, and deformity in the face. Common causes of facial-bone fractures are the results of road accidents, violence, and sports injuries. Surgery is needed if the trauma patient would be deprived of normal functioning or subject to facial deformity based on findings from radiology. Although the image reading by radiologists is useful for evaluating suspected facial fractures, there are certain challenges in human-based diagnostics. Artificial intelligence (AI) is making a quantum leap in radiology, producing significant improvements of reports and workflows. Here, an updated literature review is presented on the impact of AI in facial trauma with a special reference to fracture detection in radiology. The purpose is to gain insights into the current development and demand for future research in facial trauma. This review also discusses limitations to be overcome and current important issues for investigation in order to make AI applications to the trauma more effective and realistic in practical settings. The publications selected for review were based on their clinical significance, journal metrics, and journal indexing.

Factors Influencing Outcome of Orbital Floor Reconstruction

Introduction  Orbital floor fractures are routinely encountered in facial trauma. Many factors influence the final outcome of the orbital floor surgery, time interval and the extent of other facial bone fractures are the two factors which can significantly influence the postoperative outcome following orbital floor reconstruction. Our study aims to find the ideal time for intervention and the association of other factors in the final outcome of orbital floor reconstruction. Methods  A retrospective and prospective cohort study of patients who were operated at Pondicherry Institute of Medical Sciences for orbital floor fractures, between 2011 January and 2017 July. All the data were entered on an Excel work sheet and statistically analyzed. Results  In our study 8 patients (8/29, 27.58%) had diplopia prior to surgery, 5 patients (5/29, 17.24%) had complete recovery following surgery and 3 patients (3/29, 10.34%) had persistence of diplopia postoperatively. Patients with diplopia operated prior to 7 days were found to have significant improvement in postoperative diplopia. Patients with 5 or more facial fractures were found to have persistence of diplopia, infraorbital numbness, and enophthalmos postoperatively. Conclusion  Our study suggests that early intervention, before 7 days improves the outcome in patients with diplopia and provides a better result postoperatively. In our study preoperative diplopia and infraorbital numbness and postoperative persistence of enophthalmos, diplopia, and paresthesia were found more in patients with 5 or more facial bone fractures. Our study suggests a poor postoperative outcome when 5 or more facial bones are fractured.

Facial fractures: The "bottom-up" approach

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

Imaging of Maxillofacial Trauma

Maxillofacial trauma is common. Computed tomography is the primary imaging tool for diagnosis. Study interpretation is aided by understanding regional anatomy and clinically relevant features of each subunit. Common injury patterns and the most important factors related to surgical management are discussed.

Association of Absent or Trace Fluid in the Maxillary Sinus and Inferior Rectus Muscle Entrapment in Patients With Orbital Floor Fracture

Inferior rectus (IR) entrapment requires urgent surgical intervention in patients with traumatic orbital floor fracture (OFF). We evaluated 47 patients who underwent CT showing acute OFF, 10 of whom had surgically confirmed entrapment. Absent or trace dependent fluid in the ipsilateral maxillary sinus had sensitivity of 40% and specificity of 95% for entrapment. In comparison, sensitivity and specificity were 80% and 78% for IR thickening and 70% and 59% for sinus herniation of orbital contents.

Application of optimized three-dimensional digital surgical guide plates for complex midfacial fractures

INTRODUCTION

The treatment of midfacial fractures is always difficult. The purpose of this study was to verify whether optimized three-dimensional (3D) digital surgical guide plates combined with preformed titanium plates improved the treatment effect in complex midfacial fractures.

PATIENTS AND METHODS

Twenty-six patients with complex midfacial fractures were recruited and randomized into three groups: ten for Group A, eight for Group B, and eight for Group C. Group A was treated with a combination of preformed titanium plates and optimized 3D digital surgical guide plates. Group B was treated with preformed titanium plates only. Group C was treated conventionally. Clinical effects, patient-reported outcome measures (PROMs), midfacial contour, facial symmetry, surgical accuracy, △orbital volume (the absolute value of the bilateral orbital volume difference), and maximum deviation were evaluated in each of the three groups.

RESULTS

Group A had the best postoperative clinical effects and patient-reported outcomes. Significant improvements in midfacial contour (L1[0.72±0.29 mm, P = 0.001], L2[1.04±0.46 mm, P < 0.001]), facial symmetry (S1[0.71±0.30 mm, P < 0.001], S2[0.96±0.58 mm, P < 0.001], S3[0.86±0.40 mm, P < 0.001], S5[0.81±0.16 mm, P = 0.003], S8[0.95±0.30 mm, P < 0.001], S9[1.03±0.38 mm, P < 0.001], S11[0.64±0.46 mm, P < 0.001]) and surgical accuracy (M1[R, 0.82±0.31 mm, P < 0.001], M2[R, 0.87±0.44 mm, P < 0.001], M3[L, 0.88±0.22 mm, P = 0.004], M3[R, 1.06±0.31 mm, P = 0.003], M4[L, 0.96±0.45 mm, P = 0.008], M4[R, 1.11±0.57 mm, P = 0.003], M5[R, 0.76±0.26 mm, P < 0.001], M6[L, 1.00±0.46 mm, P = 0.003], M6[R, 1.00±0.58 mm, P = 0.001], M7[0.87±0.53 mm, P = 0.001], M8[R, 0.91±0.53 mm, P < 0.001], M9[R, 0.81±0.32 mm, P = 0.010], M10[R, 1.19±0.42 mm, P = 0.009], M11[L, 0.85±0.51 mm, P = 0.021], M11[R, 0.96±0.49 mm, P = 0.003]) were found in Group A compared with the other two groups. The results of △orbital volume and maximum deviation analysis showed an ideal surgical treatment effect in Group A.

CONCLUSION

Optimized 3D digital guide plates can accurately locate preformed titanium plates and effectively improve the treatment effect in complex midfacial fractures.

Incidence, Aetiology, and Associated Fracture Patterns of Infraorbital Nerve Injuries Following Zygomaticomaxillary Complex Fractures: A Retrospective Analysis of 272 Patients

STUDY DESIGN

Retrospective study.

OBJECTIVE

Zygomaticomaxillary complex (ZMC) fractures are common facial injuries with heterogeneity regarding aetiologies, fracture types, infraorbital nerve (ION) involvement, and treatment methods. The aim of this study was to identify associations between aetiologies, fracture types, and neurological complications. Additionally, treatment methods and recovery time were investigated.

METHODS

Medical files of 272 patients with unilateral and bilateral ZMC fractures were reviewed, whose cases were managed from January 2014 to January 2019 at the Department of Oral and Maxillofacial Surgery, University hospitals Leuven, Belgium. History of ION sensory dysfunction and facial nerve motoric dysfunction were noted during follow-up.

RESULTS

ION hypoaesthesia incidence was 37.3%, with the main causes being fall accidents, road traffic accidents, and interpersonal violence. Significant predictors of ION hypoaesthesia were Zingg type B fractures (P = 0.003), fracture line course through the infraorbital canal (P < .001), orbital floor fracture (P < 0.001), and ZMC dislocation or mobility (P = 0.001).

CONCLUSION

Of all ZMC fractures, 37.3% exhibited ION hypoaesthesia. Only ZMC Zingg type B fractures (74.0%) were significantly more associated with ION hypoaesthesia. ION hypoesthesia was more likely (OR = 2.707) when the fracture line course ran through the infraorbital canal, and was less dependent on the degree of displacement. Neuropathic pain symptoms developed after ZMC fractures in 2.2% patients, posing a treatment challenge. Neuropathic pain symptoms were slightly more common among women, and were associated only with type B or C fractures. No other parameters were found to predict the outcome of this post-traumatic neuropathic pain condition.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Postoperative Computed Tomography for Facial Fractures

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

CT of Skull Base Fractures: Classification Systems, Complications, and Management

As advances in prehospital and early hospital care improve survival of the head-injured patient, radiologists are increasingly charged with understanding the myriad skull base fracture management implications conferred by CT. Successfully parlaying knowledge of skull base anatomy and fracture patterns into precise actionable clinical recommendations is a challenging task. The authors aim to provide a pragmatic overview of CT for skull base fractures within the broader context of diagnostic and treatment planning algorithms. Laterobasal, frontobasal, and posterior basal fracture patterns are emphasized. CT often plays a complementary, supportive, or confirmatory role in management of skull base fractures in conjunction with results of physical examination, laboratory testing, and neurosensory evaluation. CT provides prognostic information about short- and long-term risk of cerebrospinal fluid (CSF) leak, encephalocele, meningitis, facial nerve paralysis, hearing and vision loss, cholesteatoma, vascular injuries, and various cranial nerve palsies and syndromes. The radiologist should leverage understanding of specific strengths and limitations of CT to anticipate next steps in the skull base fracture management plan. Additional imaging is warranted to clarify ambiguity (particularly for potential sources of CSF leak); in other cases, clinical and CT criteria alone are sufficient to determine the need for intervention and the choice of surgical approach. The radiologist should be able to envision stepping into a multidisciplinary planning discussion and engaging neurotologists, neuro-ophthalmologists, neurosurgeons, neurointerventionalists, and facial reconstructive surgeons to help synthesize an optimal management plan after reviewing the skull base CT findings at hand. Online supplemental material is available for this article. ^©RSNA, 2021.

Scoping Zygomaticomaxillary Complex Fractures With the Eyes of Virtual Reality: Operative Protocol and Proposal of a Modernized Classification

INTRODUCTION

Fractures of the zygomaticomaxillary complex (ZMC) represent an extremely heterogeneous group of injuries to the midfacial skeleton. Traditionally, the diagnosis of such fractures was based on 2-dimensional radiograms and, more recently, on volumetric computed tomography (CT) scans, while the treatment was exclusively based on the surgeon's experience. Many classification attempts have been made in the past, but no paper has taken into account the importance of virtual surgical planning (VSP) in proving a modernized classification. The authors propose a classification based on the use of VSP which can guide the surgeon to identify the optimal reduction method and reproduce it in the operating room through the use of navigation.

METHODS

Patients with ZMC fractures were collected to create a study model. The VSP was used to generate 3-dimensional models of fractures. Fractured segments were duplicated and digitally put in the optimal reduction position. Repositioned fragments were overlapped to their original preoperative counterparts and exported to the surgical navigator to be navigated. Planned virtual reduction was overlaid to postoperative CT scan to assess the accuracy of reduction, explored using color maps and the calculation of root mean square error.

RESULTS

For all patients, the application of VSP was successfully accomplished. High accuracy was confirmed between the planned virtual reduction and the postoperative CT scan. A 5-item classification based on VSP is proposed. All patients were included in the presented subclasses.

CONCLUSIONS

The adoption of virtual planning in ZMC fractures allows for an improved study of the displacement of the fracture and might indicate to the surgeons the required maneuvers to achieve optimal reduction. The presented proposal of classification might be an aid to simplify the choice of the most appropriate reduction method and might provide a deeper insight into the morphologic characteristics of fractures.

Adaptive statistical iterative reconstruction for computed tomography of the spine

INTRODUCTION

The utility of evaluating a sagittal view of CT of the spine is well-known. In many clinical cases, the sagittal view includes noise generated from surrounding objects and may degrade the image quality. Iterative reconstruction (IR) techniques are useful for noise reduction; however, they can reduce spatial resolution. The aim of this study was to evaluate the effectiveness of the adaptive statistical iterative reconstruction (ASiR) for generating sagittal CT images of the spine when compared to filtered back projection (FBP).

METHODS

The image quality of clinical images from 25 patients were subjectively assessed. Three radiologists rated spatial resolution, image noise, and overall image quality using a five-point scale. For objective assessment, z-direction modulation transfer function (z-MTF) was measured using a custom-made phantom. Additionally, z-axis noise power spectrum (z-NPS) was measured using a water phantom. An improved adaptive statistical iterative reconstruction algorithm called ASiR-V was used in this study. Blending levels were 50%, and 100% (ASiR-V50, ASiR-V100, respectively).

RESULTS

For subjective assessments, images using ASiR-V100 were determined to have the best overall image quality, despite having received the worst score in the assessment of spatial resolution. For objective assessments, the image using ASiR-V50 and ASiR-V100 curves were slightly degraded in terms of low contrast z-MTF when compared to FBP.

CONCLUSION

ASiR-V was effective to improve the image quality when compared with FBP when reviewing sagittal reformats of the spine.

IMPLICATIONS FOR PRACTICE

This study suggests that high resolution is not the only thing that is key when reviewing sagittal CT spinal reformats. Such images should be provided as part of routine CT spine protocols, where available.

Intimate Partner Violence: A Primer for Radiologists to Make the "Invisible" Visible

Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient's currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging-based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims' lives. ^©RSNA, 2020.

Validity of computed tomography in diagnosing midfacial fractures

The aim of this study was to evaluate the sensitivity, accuracy, and reliability of two-dimensional computed tomography (2D-CT) scans (axial, coronal, sagittal planes) and three-dimensional computed tomography (3D-CT) reconstructions in diagnosing midfacial fractures in relation to actual fractures identified clinically and during surgery (gold standard). The imaging diagnosis was performed by a radiologist and an oral and maxillofacial surgeon. Sixty-two patients with a total of 429 midfacial fractures were included. Frontal sinus and nose fractures were easily diagnosed. For the three CT planes, there was a statistically significant difference between the CT examination and the gold standard for five to seven of the nine bones evaluated, while for 3D-CT, a difference was observed only for fractures of the orbital floor. The inter-observer agreement between the oral and maxillofacial surgeon and the radiologist was 75.5%. In conclusion, in this study 3D-CT reconstructions showed significantly the best sensitivity, accuracy, and reliability for the diagnosis of midfacial fractures. The sagittal reconstructions were the least diagnostic of the 2D-CT images. For areas where the parameters studied showed less agreement and hence a more difficult diagnosis, we recommend a combination of 3D and 2D-CT images to improve diagnostic accuracy.

An Exploration of Multidisciplinary Team Care With Digital Technology for Complicated Cranio-Maxillofacial Bone Defects and Fractures

OBJECTIVE

Early treatment of fractures of the cranio-maxillofacial complex (CMFC) is challenging and likely to result in craniofacial deformity. Multidisciplinary team (MDT) care has developed very rapidly and has recently been accepted in cancer treatment. Therefore, the authors explored the application of MDT care with digital technology in CMFC fractures.

STUDY DESIGN

A 29-year-old man presented for treatment of CMFC fractures and bone defects. An MDT of oral surgeons, ophthalmic surgeons, neurological surgeons, and other experts was convened. After CT scan and three-dimensional reconstruction, the authors performed personalized surgery that included 9 specialists over an 8-hour period.

RESULTS

The operation was successful and all fractures achieved clinical stability. At 1-month follow-up, appropriate appearance and functional recovery had been achieved.

CONCLUSION

In this study, MDT care with digital technology was very effective and had low associated costs. The involvement of more disciplines in MDT care may result in fewer complications.

Imaging in trauma of the facial skeleton and soft tissues of the neck

Trauma to the face and neck is a frequent reason for emergency department attendance. Imaging is invaluable in the characterisation of such injuries, enabling delineation of fracture patterns as well as identification of vascular and other soft tissue injuries. It may also be used to prevent long-term mortality and morbidity and provide a roadmap for surgical intervention so that form and function may be restored. This article gives a pictorial review of the imaging of craniofacial trauma, stratified according to the thirds of the face, followed by a review of blunt and penetrating trauma of the neck. It discusses appropriate imaging modalities for each trauma category, describes major patterns of craniofacial trauma on cross-sectional imaging and identifies clinically relevant imaging features that should trigger subspecialist review or be of relevance to pre-surgical planning. It starts with the upper third comprising frontal sinus fractures before describing the component fractures of the middle third (including nasal, zygomaticomaxillary and orbital fractures) and then focusing on the lower third (specifically mandibular and dentoalveolar fractures). The article concludes with a review of soft tissue injuries of the neck, particularly penetrating, blunt and laryngeal trauma.

Facial fractures: classification and highlights for a useful report

In patients with facial trauma, multidetector computed tomography is the first-choice imaging test because it can detect and characterize even small fractures and their associated complications quickly and accurately. It has helped clinical management and surgical planning, so radiologists must communicate their findings to surgeons effectively. In Le Fort fractures, there is a breach between the pterygoid plates and the posterior maxilla. These fractures are classified in three basic patterns that can be combined and associated with various complications. Conceptualized when low-speed trauma was predominant, the Le Fort classification system has become less relevant giving more importance on maxillary occlusion-bearing segments. The classification of naso-orbito-ethmoid depends on the extent of injury to the attachment of the medial canthal tendon, with possible complications like nasofrontal duct disruption. Displaced fractures of the zygomaticomaxillary complex often widen the angle of the lateral orbital wall, resulting in increased orbital volume and sometimes in enophthalmos. Severe comminution or angulation can lead to wide surgical exposure. In orbital fractures, entrapment of the inferior rectus muscles can lead to diplopia, so it is important to assess its positioning and morphology. Orbital fractures can also result in injuries to the globe or infraorbital nerve. Frontal sinus fractures that extend through the posterior sinus wall can create a communication with the anterior cranial fossa resulting in leakage of cerebrospinal fluid, intracranial bleeding. It is essential to categorize fracture patterns and highlight features that may affect fracture management in radiology reports of facial trauma.

A Comprehensive Review of Cross-Sectional Imaging of the Nasolacrimal Drainage Apparatus: What Radiologists Need to Know

OBJECTIVE. The purpose of this study is to provide a comprehensive review of the radiographic anatomy and cross-sectional imaging findings of the full gamut of nasolacrimal drainage apparatus diseases, highlighting imaging findings from the different nasolacrimal drainage apparatus surgeries, posttreatment complications, and potential imaging pitfalls. CONCLUSION. Radiologists play a critical role in guiding the management of nasolacrimal drainage apparatus diseases and should be familiar with the anatomy and characteristic imaging findings of commonly encountered nasolacrimal drainage apparatus abnormalities and surgeries.

Multidetector computed tomography for facial trauma: structured reports and key observations for a systematic approach

Facial fractures, often related to traffic accidents, assault, work-related accidents, or falls, account for a considerable number of emergencies in our hospitals and are associated with high morbidity and mortality. Multidetector computed tomography (MDCT) is the imaging technique of choice in this scenario because it is widely available, fast, and useful for characterizing facial fractures and associated complications, including those located in the head. For all these reasons, MDCT is fundamental in the clinical management of these patients and in planning surgery. This paper describes the radiological anatomy of the facial region, underlining the importance of the facial buttresses, and it indicates the key points necessary for carrying out a structured approach and elaborating the corresponding radiologic report.

Dog bite injuries of the eye and ocular adnexa

Dog bites result in a diverse range of injuries and complications in the periocular region, particularly in school aged children. It is therefore incumbent on the oculoplastic surgeon to be well versed in both acute and long-term management. The intent of this review is to provide a systematic evaluation of the epidemiology, principles of dog bite wound care, and specific considerations related to common patterns of ophthalmic injury. Review of clinical literature from 1976 to 2014. The majority of periocular injuries result from seemingly benign interactions between young children and familiar dogs. Aggressive saline lavage combined with selective debridement of devitalized tissue is essential. High-risk wounds and vulnerable patient groups may benefit from preventive antibiotic coverage as well as appropriate rabies and tetanus prophylaxis. While the nuances of surgical repair are variable given the heterogeneity of presentation, systematic examination and an algorithm-driven approach underlie the optimal management of these complex injuries.

New and emerging patient-centered CT imaging and image-guided treatment paradigms for maxillofacial trauma

This article reviews the conceptual framework, available evidence, and practical considerations pertaining to nascent and emerging advances in patient-centered CT-imaging and CT-guided surgery for maxillofacial trauma. These include cinematic rendering-a novel method for advanced 3D visualization, incorporation of quantitative CT imaging into the assessment of orbital fractures, low-dose CT imaging protocols made possible with contemporary scanners and reconstruction techniques, the rapidly growing use of cone-beam CT, virtual fracture reduction with design software for surgical pre-planning, the use of 3D printing for fabricating models and implants, and new avenues in CT-guided computer-aided surgery.