Interactive Transcript
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This was a patient who got hit in the
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face with a bag of bricks, frankly.
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And this patient has quite a few fractures.
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And we're going to keep coming back to this case
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because it's a nice example of a patient who
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has multiple facial fractures of
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various types. But for now,
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we're going to concentrate on orbital fractures.
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So once again, for the fractures,
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we're going to go to the thinnest section images.
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In this case,
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we want the 0.5 millimeter thick sections
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and to scroll through them.
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You could do an initial evaluation with 3 mm,
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but for the medial orbital wall,
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lamina papyracea in particular,
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I find that looking at the thin sections is really
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worth the extra time. So, general overview,
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we see that there are multiple fractures.
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Now, let's go through them individually.
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For orbital fractures,
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you can sort of think in terms of, all right,
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is the orbital floor, medial wall, lateral wall,
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superior wall, are they all fractures?
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And you can think of it in those terms.
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Suffice it to say that the orbital floor and the
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medial orbital wall are the ones that are most
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commonly fractured with trauma.
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But the lateral orbital wall is involved in our
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tripod fractures or trimalleolar fractures that
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we'll talk about in just a moment.
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In any case, let's start with the axial scans.
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And for this purpose of looking
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for orbital fractures,
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we're just going to look at the
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bone windows for now.
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So as we scroll upward from below,
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we will come into some fractures which
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are involving the maxillary antrum,
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which for now we're going to ignore.
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On the axial scans,
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you have to recognize that the top of the maxillary
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antrum is going to be the floor of the orbit.
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So I'm always very conscious
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of looking for this structure.
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This structure right here is our infraorbital
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foramen. Right here. And on the other side,
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you can see it right here.
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Since the infraorbital foramen, which transmits
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the infraorbital nerve, marks the orbital floor.
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We use that as our marker for whether or not
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the orbital floor is fractured
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on an axial scan.
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So, here I can see that there is a fracture
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segment just lateral to the infraorbital
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foramen. And in point of fact,
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this infraorbital foramen has a line going
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through it, that shouldn't be there,
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recognizing that as a fracture,
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compared that to the contralateral side.
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Even on the contralateral side, which looks fine,
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we do see a small line coming to the
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infraorbital foramen, medially,
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which we'll check out and see whether
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that represents a fracture.
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So orbital floor fracture is sometimes tricky.
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On the axial scans,
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we will have the benefit of the
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coronal reconstructions.
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Here we can see another fracture more medially,
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and that is going towards the
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lacrimal apparatus.
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Here's our nasal lacrimal duct with
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fractures there. When we look at
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the lamina papyracea,
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we want to look at this.
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And we note that there is some depression
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of the lamina papyracea on the right side.
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And we can see, on the left side,
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there is outward disruption.
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We have a little fracture fragment
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protruding on the left side.
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We notice also on the lateral aspect of the
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orbital wall, that the lateral wall on the
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left side has a comminuted fracture.
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So, so far we've got the orbital floors,
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we've got the lamina papyracea bilaterally.
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Let's look at the orbital roof.
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Here we are coming up to
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the top in the orbital roof.
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So that seems as if there's sparing of the orbital roof.
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So we've made a pretty good sense of things we
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can ignore for right now, the nasal bones.
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But we'll come back to all those
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other additional fractures.
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We notice also that the maxillary antrum
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has an air-fluid level within it.
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And it's likely that that's going
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to be the blood products.
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I'm going to just quickly look on the soft tissue
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windows to demonstrate the globes.
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And as you can see,
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the patient has lens implant
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here and lens implant here.
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But the anterior chamber looks fine on both sides.
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No blood, no shallowness. The vitreous looks fine.
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So I've shown you cases where the globes are
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all traumatized and there's no fractures.
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Here's a case where there's all kinds of
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fractures and yet the globes themselves are perfectly fine.
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And if you look at the retrobulbar
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space and the intraconal space,
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there's really no strandedness or hematoma
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to really to speak of behind the globes.
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That's one of the curious things about orbital
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injury. Now, let's look on the coronal images.
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So anytime you see air in the orbit,
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we're going to use the term orbital emphysema.
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I use little droplets of air to focus my attention
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on adjacent bone, because you want
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to know where that air came from.
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It's likely that it came from a fracture very close by.
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So let's magnify this a little bit and get into
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it. All right, so we'll start with the left globe.
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We have orbital emphysema.
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We have the infraorbital foramen.
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We have the fracture that we worried
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about. It's very subtle here,
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but it is present going towards
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the infraorbital foramen, you see a tiny little
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drop of air. That's my little marker.
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Look very closely at this bone just above it, because
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it's offset a little bit and there's discontinuity.
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So the orbital floor here is fractured.
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And use the little droplets of air that you
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see to focus your attention and lower your
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threshold for calling it fractured.
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We see that the lateral orbital wall has that comminuted
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fracture. Here's a focus of air, right?
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What's it doing there?
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Here is a discontinuous area where there has
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been fracture of the lamina papyracea.
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So little droplets of air, always look adjacent and
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look for hemorrhage, and look for fractures.
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So here again,
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discontinuity of the lamina
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papyracea on the left side.
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And we'll deal with the other fractures when we
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come back to the nasal orbital ethmoid or NOE fractures
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I want to point out one structure which is
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often misunderstood as a fracture or site,
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and that is the entry of the ethmoidal artery.
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So the anterior ethmoidal artery canal is seen
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here, and here on the right and left side.
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Those are not fractures. That's not depression.
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That's where the artery,
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the anterior ethmoidal artery comes in.
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If you go further posteriorly,
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you will find a second area right here,
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which is the posterior ethmoidal artery entry.
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Okay, let's look on the right side.
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So on the right side, here's our infraorbital
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foramen. And again,
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some discontinuity here without displacement.
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You can see a tiny little drop of air here.
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Tiny little drop of air here.
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That's in the offset, that's the fracture.
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The anterior rim here has been fractured, as well.
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Let's look at the lamina papyracea.
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I'm looking for any little droplets of air.
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Lamina papyracea, we're going to pass.
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And the lateral orbital wall, we're going to pass.
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So just a nondisplaced fracture of
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the orbital floor on the right side.
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