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Should’ve worn eye protection…

February 8, 2014

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This patient was working on cutting copper wire without eye protection:

Ocular FB

 

On exam the patient had a small laceration just medial to the limbus in the scleral portion of the eye, no anterior chamber or corneal involvement.  He had a positive Seidel test (fluorcein stains vitreous green under blue light.  As the vitreous leaks out you can see green tinged fluid leaking from the area of concern). 

On CT there is a metallic fragment found in the posterior chamber indicative of a penetrating copper foreign body.  This is an ocular emergency and should prompt immediate evaluation by an ophthalmologist!

Author:  Russell Jones, MD

 

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I think I got stabbed in the eye…

January 18, 2014

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Patient presented after an altercation.  He thinks he got stabbed in the eye with a “razor blade or a pencil.”  Eye was swollen shut and unable to be opened due to significant edema:

Pencil orbit 1 Pencil Orbit 2

This patient has a radioopaque foreign body just lateral to the globe.  It is penetrating into the posterior orbital fossa but doesn’t appear to be causing proptosis or retrobulbar hematoma.  It does indeed look like a pencil!

Author:  Russell Jones, MD

Image Contributor:  Ken Kelley, MD

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LeFort would cringe…

December 14, 2013

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Motorcycle accident:

CT face 2 CT face 3 CT face...

CT face 3D

This patient has severe facial trauma, comminuted fractures of most (if not all) of his facial bones, a ruptured right globe. 

A review of facial fractures including the LeForte classification, courtesy of the University of Washington:

Facial Fractures

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Ruptured globe…

May 4, 2013

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Fight broke out at the local prison and this man was shot in the face with a rubber bullet…

Ruptured globe 5Ruptured globe 4Ruptured globe 3Ruptured globe 2Ruptured globe 1

The “brain” weighting CT (first figure) shows a ruptured globe with hemorrhage into the orbit.  The remainder of the figures are in “bone” weighting and show various fractures:

  1. Sagittal view of a comminuted fracture of the ethmoid sinus (medial orbital wall)
  2. Sagittal view of a comminuted fracture of the maxillary sinus (inferior orbital wall)
  3. Sagittal view of a posterior orbital fracture
  4. Coronal view re-demonstrating the ethmoid and maxillary sinus fractures

This poor fellow ended up losing his eye and going back to prison.

Author:  Russell Jones, MD

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Mandible fracture

February 8, 2013

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We’ve all seen it…the dude that had two beers after church and got jumped by a couple guys while he was minding his own business.

Mandible fx 1Mandible fx 2Mandible fx 3Mandible fx 4

This Facial CT demonstrates several comminuted fracture lines through the mandible.  CT imaging is highly sensitive and specific for mandible fractures and is the imaging-of-choice in most emergency departments.  Plain films can also be obtained but subtle fractures can be missed; the extent and characterization of the fractures is much better identified on CT.

Its always difficult in the minor facial trauma to know when to pull the trigger and order a CT of the face…especially in the current environment of questioning CT utilization.  Some clinical exam findings that would increase your suspicion of mandibular fracture include (1):

1.  The patient having subjective feeling that their “teeth don’t fit.”

2.  Malocclusion.

3.  Anesthesia of the upper lip or chin (mental nerve distribution).

4.  Pain or tenderness near the anterior ear, especially with mandibular range-of-motion.  This is concerning for mandibular condyle fracture but also could represent TMJ strain, sprain, or dislocation.

An obvious deformity, laceration of the gingival area (indicating an open fracture), or severe mechanism are high concerns for mandibular fracture and CT imaging should be considered.  The “tongue blade test” (have the patient bite down on a tongue blade with their molars on both sides.  Negative test if the patient is able to break the tongue blade) has a 95% sensitivity in excluding injury in a patient with mild jaw pain and no obvious injury or instability (1).

Author:  Russell Jones, MD

References

1.  Bailitz J.  Trauma to the Face.  In:  Tintinalli JE, Stapczynski JS, et al.  Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide.  7ed.

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Orbital Cellulitis

November 21, 2012

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This is a facial CT from a patient seen the other day in pediatrics with orbital cellulitis:

This is an interesting CT for several reasons:

Image #1 shows all ethmoid sinuses are opacified with destruction of the anterolateral wall of the ethmoid sinus, the cause of the orbital cellulitis

Image #2 shows a large abscess formation in the superior portion of the orbit causing…

Image #3  a significant proptosis of the left eye

Image #4 shows a frontal view further identifying the abscess.

Clinically this patient had a very proptotic eye, angry red and swollen periorbital area to the point that it was difficult to get an ocular view. 

Author:  Russell Jones, MD

Image contributor:  Ali Naqvi, MD

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