Demographics:
75 years old, Male
Indication:
Fall
Findings
- Bilateral acute Le Fort type I fractures with fractures of the pterygoid plates, nasal septum, and anterior, posterior, and medial walls of both maxillary sinuses.
- Additional right Le Fort type II fracture with a nasal arch fracture extending into the nasofrontal suture and medial and inferior orbital wall fractures. The medial orbital wall fracture involves the nasolacrimal canal and the orbital floor fracture extends into the infraorbital foramen. No evidence of extraocular muscle entrapment
- Acute bilateral nasal bone fractures with overriding fracture fragments
- Mild anteromedial and anteroinferior right retrobulbar, extraconal stranding without proptosis
- Right greater than left maxillary and right ethmoid hemosinus
- Extensive right greater than left facial swelling with subcutaneous emphysema. Partially imaged frontal scalp hematoma/laceration
Diagnosis
Bilateral Le Fort I, right Le Fort II fractures
Sample Report
Bilateral acute Le Fort type I and right Le Fort type II fractures. On the right, the medial orbital wall fracture involves the nasolacrimal canal and the orbital floor fracture extends into the infraorbital foramen. No evidence of extraocular muscle entrapment.
Acute bilateral nasal bone fractures with overriding fracture fragments.
Mild anteromedial and anteroinferior right retrobulbar, extraconal stranding without proptosis. Globes are intact.
Right greater than left maxillary and right ethmoid hemosinus.
Extensive right greater than left facial swelling with subcutaneous emphysema. Partially imaged frontal scalp hematoma/laceration.
Discussion