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Imaging in head, face and cervical spine trauma

In head trauma, non-contrast CT is done according to decision rules, an epidural haematoma (lens-shaped, not crossing sutures) is distinguished from a subdural one (crescent, crossing sutures), CTA is added by the Denver criteria, and facial fractures are recognised by the Le Fort patterns.

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Why it matters in the exam

By the Canadian CT Head Rule, high risk: GCS below 15 two hours after injury, suspected open or depressed fracture, signs of skull base fracture, vomiting twice or more, and age 65 or above. Epidural haematoma: lens-shaped, does not cross sutures (but may cross the midline), usually arterial from the middle meningeal artery with a temporal fracture, and sometimes a "lucid interval". Subdural haematoma: crescent-shaped, crosses sutures but not the falx, from bridging veins — common in the elderly, in alcohol misuse and in abused infants. Contusions at the frontal and temporal poles "blossom" in the first 24–48 hours. Diffuse axonal injury (DAI): CT is usually normal or nearly so; MRI with SWI shows microbleeds at the grey–white junction, corpus callosum and brainstem.

CTA of the neck and head vessels is added by the expanded Denver criteria: a fracture through the carotid canal, a cervical spine fracture (especially C1–C3 or through the transverse foramen), a Le Fort II or III fracture, a seat-belt sign on the neck, and a neurological deficit not explained by CT. All Le Fort fractures pass through the pterygoid plates: I — horizontal above the upper teeth ("floating palate"); II — pyramidal, through the nasal bones, the medial orbital wall, the orbital floor and the infraorbital rim; III — craniofacial dissociation, through the zygomatic arch and the lateral orbital wall. The zygomatic complex fracture involves the arch, the frontozygomatic suture, the orbital floor and rim, and the maxillary sinus walls.

A "blowout" fracture of the orbital floor may trap the inferior rectus muscle — restricted upward gaze; in children entrapment may occur with a small fracture ("trapdoor") and needs urgent treatment. Cervical spine: in an adult with an indication by decision rules, CT is the first test. A Jefferson fracture is a "burst" fracture of C1 from axial load; if the combined overhang of the lateral masses beyond C2 exceeds 7 mm — suspect transverse ligament rupture and instability. A burst fracture of a lumbar or thoracic vertebra: the posterior part of the body is pushed into the canal — middle column involvement. In an infant with suspected abuse: head CT even without neurological signs when there are fractures, facial or head bruises, or age below one year with unexplained injury.

Key points

• Epidural — lens; subdural — crescent.
• DAI — MRI with SWI.
• Denver: carotid canal, C1–C3, Le Fort II–III, seat-belt sign.
• Le Fort I horizontal, II pyramid, III dissociation.
• Jefferson — overhang above 7 mm = torn transverse ligament.

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Sources

• Canadian CT Head Rule (Stiell et al.), 2001, validated 2005 — High- and medium-risk criteria
• ACR Appropriateness Criteria: Head Trauma, 2021 — Initial imaging and vascular imaging
• Western Trauma Association: Blunt Cerebrovascular Injury (expanded Denver criteria), 2020 — Screening indications

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.

See also: Facial fractures: Le Fort, zygoma, orbital floor, mandible and frontal sinus