Fractures of the Face & Upper Limbs-Dr M Schranz Page1

Fractures of the face and upper limbs

Facial Fractures

Radiography

• Water's view - the single most valuable radiograph , visualising maxilla,

maxillary sinus, orbital floor and rim, zygomatic bone, nasal bone, mandible
fractures · Submental vertex to visualize zygomatic arch
• Frontal (Caldwell) and lateral sometimes helpful frontal bone,
zygomaticofrontal suture, frontal sinus, medial orbital rim, ethmoid
• CT scan - coronal cuts helpful in identifying orbital floor fracture

Both the Waters and the Caldwell views are posteroanterior (PA) projections, a
technique allowing closer distance between the face and the film for better detail. The
need to extend the patient's neck is a large disadvantage to PA views, unless the
patient's cervical spine already has been cleared.

The Waters view or occipitomental projection is taken at an angle 37° caudal to the
canthomeatal line. This view optimally visualizes the superior and inferior orbital
rims, nasal bones, zygoma, and maxilla.

The Caldwell view, angled 15° caudal to the canthomeatal line, allows additional
views of the frontal sinus and superior orbital rim. The 6-ft Caldwell view is helpful
intraoperatively for frontal sinus obliteration surgeries. The lateral view is useful for
the anterior frontal sinus wall and anterior and posterior maxillary sinus walls. The
base or submentovertex view allows visualization of the zygomatic arches and any
impingement of these bones upon the coronoid process of the mandible.

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Lefort Fractures:

Fractures of mid portion of face have been classified as

- Lefort type I: - transverse fracture through maxillary sinus and pterygoid plates; -
Fracture detaching palate and maxillary alveolus

- Lefort type II: - separation through frontal process, lacrimal bones, floor of orbits,
zygomaticomaxillary suture line, lateral wall of maxillary sinus and pterygoid plates; -
Pyramidal fracture through sinus wall laterally and nasal bones medially

- Lefort type III: - separation of mid third of face at zygomaticotemporal, and naso-
frontal sutures, and across the orbital floors; - Fracture through frontozygomatic
sutures and orbits detaching facial skeleton from base of skull

Blowout fractures of the skull

Blowout fractures are caused by direct trauma to the globe which causes an increase
in intraorbital pressure and decompression via fracture of the orbital floor. Classical
blowout floor fractures generally are limited laterally by the infraorbital neurovascular
structures and medially by the maxillo-ethmoidal strut of stronger bone. Medial wall
blowout fractures are limited superiorly by the stronger bone of the fronto-ethmoidal
suture and inferiorly by the maxillo-ethmoidal strut

Radiographically, fragments may be seen in the maxillary sinus or there may be

opacification of the maxillary sinus with blood. Clinically, there may be diplopia on
upward gaze due to entrapment of the inferior
rectus muscle.

Waters' radiograph. This reveals herniation of

fat into the left maxillary sinus, due to an orbital
floor fracture.

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Mandible fractures

Mandible fractures are due to direct

trauma. Most are comminuted and
typically involve both sides of the
mandible.

The weakest areas of the mandible are the

angles as well as the mental and incisive
foramen.

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Upper Limb

Acromioclavicular separation

Acromioclavicular separation refers to abnormal widening of the acromioclavicular

joint. The injury is caused by direct trauma to the shoulder. The principal ligament to
consider is the coracoclavicular ligament with a lesser role played by the
acromioclavicular ligament. Ligamentous injury to the acromioclavicular joint is
classified by Grade I, II, and III
injuries. Grade I injury is termed
sprain.

Radiographs of both shoulders are

acquired with stress views to see if
there is abnormal widening of the
acromioclavicular space (normal < 4
mm). Grade II injuries are termed
subluxations and the
acromioclavicular ligament is either
severely torn or completely torn. The
coracoacromial ligament remains
intact meaning that only a small amount of superior migration of the clavicle is
present when imaged with stress. Grade III injuries indicate that both the
coracoclavicular and acromioclaviclar ligaments are torn with abnormal widening of
the coracoclavicular space and superior migration of the distal clavicle relative to the
acromion.

The Hill-Sachs fracture

The Hill-Sachs fracture results

from anterior dislocation of the
humeral head and is located on
the posterolateral aspect of the
humeral head. 97 % of shoulder
dislocations are anterior in
direction. This fracture is
produced when the humeral
head strikes the inferior margin
of the glenoid. The dislocation
may also cause a Bankart
fracture at the impact site on
the glenoid.

Anterior dislocations are

produced by complex forces
acting on the humerus,
including abduction and
external rotation. (1)

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Glenohumeral anterior dislocation (2) Hill-Sachs fracture, hypointense (T1),

hyperintense (DP and T2) (3) Probable associated partial tear of subscapularis tendon
(4) Associated dislocation tear of the anterior labrum

Anterior shoulder dislocations

Anterior shoulder dislocations account for 97 %

of shoulder dislocations. They are usually due to
indirect force, such as from abduction and
internal rotation. The humeral head lies inferior
and medial to the glenoid. As the dislocation
occurs, the Hill-Sachs lesion and the Bankart
fracture may occur as a result of the humerus
striking the inferior rim of the glenoid. Labral
(non-osseous) injuries may also result, leading to
recurrent
dislocations. AP
radiograph of the shoulder. This shows marked overlap
of the humeral head and the glenoid.

Axial view of the shoulder. This view demonstrates

the anterior dislocation of the humeral head (towards
the coracoid).

Posterior dislocations of the humerus Posterior dislocations of the humerus account

for less than 5 % of shoulder dislocations and are usually due to direct force.
Classically, the causes are seizure or electric shock. The axillary view is the best view
to demonstrate this type of dislocation

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AP radiograph of the right shoulder.

A cursory examination reveals no obvious

dislocation.

Axillary
radiograph.

Notice the
anterior
coracoid
with the posteriorly dislocated humeral head
relative to the glenoid.

Pathologic fractures Pathologic fractures result from an underlying abnormality of

the bone, usually either from a primary bone tumor or from metastatic disease.
However, pathologic fractures may result from metabolic conditions as well. A
pathologic fracture results when normal stress is placed onto
abnormal bone.

Lateral radiograph of the humerus.

There is a comminuted fracture of the shaft. Examining the image

closely shows a permeative destructive process as well. This
patient had lung cancer with other osseous metastases. This is a
pathologic fracture

Olecranon fractures

Olecranon fractures result from a

direct fall onto a flexed elbow. As
the triceps inserts upon the
olecranon, most olecranon fractures
tend to be displaced. These fractures
are not generally comminuted.

Lateral radiograph of the elbow

The typical appearance of an olecranon fracture. The triceps tendon has distracted the
fracture fragments.

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Fractures of the capitellum

Fractures of the capitellum are the

result of direct trauma to the extremity.
In pediatric patients, this site is the
second most common site of injury
about the elbow Lateral radiograph of
the elbow.

This demonstrates a fracture of the

capitellum.

Galeazzi's fracture

Also called a reverse Monteggia fracture, Galeazzi's fracture

consists of a fracture of the radius at the junction of the middle
and distal thirds with distal radioulnar joint dislocation. This
fracture pattern may be caused by a fall on an outstretched hand or
from a direct trauma to the dorsal aspect of the wrist.

Monteggia fracture

Monteggia fracture is an angulated fracture at

the junction of the proximal and middle third of
ulna accompained by ANTERIOR dislocation of
the radial head

Greenstick fractures The greenstick fracture results from

direct trauma. There is an incomplete fracture of a long
bone (radius or ulna) with cortical disruption on one side
and deformity on the other, resulting in bowing of the bone

AP radiograph of the forearm demonstrates the appearance

of a greenstick fracture

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Colles fracture This is a common fracture in elderly patients, consisting of a

transverse fracture of the distal radial metaphysis proximal to the joint with dorsal
displacement of the distal fragment and volar dislocation. It results from a fall on an
outstretched hand. The ulnar styloid is commonly fractured as well. Another name is
the Pouteau fracture.

Lateral radiograph of the wrist.

This shows the typical appearance of Colles fracture with

dorsal tilt of the distal radial fracture fragment

The Barton fracture

The Barton fracture consists of an

intraarticular fracture of the dorsal margin
of the distal radius.

The fracture line is oblique and extends to

the radiocarpal joint. The fracture results
from a fall on an outstretched hand

Lunate and peri-lunate dislocation Significant trauma to the wrist may completely
disrupt the two carpal rows, resulting in lunate dislocation (the lunate is seen lying
anterior to the wrist on the lateral x-ray) or in perilunate dislocation.

The result is wrist pain and numbness along the distribution of the median nerve.
Perilunate dislocation is often associated with fracture of the scaphoid. Lunate and
perilunate dislocations are reduced with open repair and stabilization, especially of the
fractured scaphoid.

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. Lateral radiograph of the wrist. This shows volar displacement of the lunate Oblique
radiograph of the wrist. This shows the abnormal carpal bone relationships

Scaphoid fractures

Scaphoid fractures are the most common carpal fractures, resulting from a fall on an
outstretched hand. 70 % of these occur at the waist, 20 % at the proximal pole, and 10
% at the distal pole. Blood supply for the proximal pole enters at the waist. If this
blood supply is interrupted due to fracture, the proximal pole is at risk for avascular
necrosis. Special scaphoid views with the hand in ulnar deviation may be needed to
detect these fractures.

PA radiograph of the wrist. This demonstrates a

scaphoid waist fracture

PA radiograph of the wrist. Another patient shows

the proximal pole to be dense and has undergone
avascular necrosis.
This is a known
complication of waist fractures.

Triquetral fractures

Triquetral fractures are usually

best seen on the lateral
radiograph of the wrist. Most of these fractures are dorsal
avulsion fractures at the attachment of the radiocarpal
ligament. The mechanism of injury is forced hyperflexion.

Lateral radiograph of the hand.

This shows a small bone fragment located dorsally. This a

fractured triquetrum.

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Torus fracture

Also known as a buckle fracture. This is a

compression fracture of a long bone, typically in
children. This type of fracture usually occurs near
the metaphysis. Both cortical margins are affected,
but a discreet fracture line or trabecular disruption
is not present. Minimal buckling of the cortex is
present.

AP radiograph of the forearm. The typical

appearance of a torus fracture with buckling of the
cortical surface.

The Bennett fracture

The Bennett fracture is an intraarticular fracture of the base of the

first metacarpal. The fracture must involve the first carpometacarpal
joint to be called a Bennett fracture. The action of the abductor
pollicis longus causes distraction of the fracture fragments. The volar
base of the first metacarpal stays with the trapezium.

PA radiograph of the first digit.

The Rolando fracture Rolando's fracture refers to a

comminuted intraarticular fracture of the thumb metacarpal
base. Unlike Bennett's fracture, the additional comminution
makes percutaneous fixation much less satisfactory.
Although technically difficult, open reduction and internal
fixation gives the best chance of restoring a working joint
surface. AP radiograph of the first digit. This demonstrates
the comminuted intraarticular fracture at the base of the first
metacarpal, a Rolando fracture.

Volar plate fractures

Volar plate fractures are the result of hyperextension. This injury typic ally involve the
proximal interphalangeal joint of the fingers. At this location, the volar plate (a dense
fibrous band) forms a portion of the capsule. Typically, there is a small fragment of
bone avulsed from the volar aspect of the base of the proximal phalanx. If not
repaired, this can lead to instability. A Wilson fracture refers to a volar plate injury to
the middle phalanx of a finger.

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Lateral radiograph of the hand. This shows an

avulsion fracture of the base of the middle
phalanx of the third digit.

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