Lotions Creams Other Moisturizers

The Body Shop: Vanilla Body Lotion, body lotion, moisturizer, vanilla, lotion | | My Account | Login | Favorites | View Cart Body Butter Lotions Creams Other Moisturizers Hand Care Foot Care Massage Spa Scrubs Sun Care Accessories Gift Ideas Strawberry Bath Shower Soap Scrubs Accessories Gift Ideas Cleansers Toners Moisturizers Scrubs and Masks Treatments Lips Eye Care Make-up Removers Sun Care Accessories Palettes Lips Eyes Face Make-Up Tools Oils Aroma Jars Candles & Accessories Gift Ideas Eau de Toilette Perfume Oils Body Sprays Lotions Shower Bath Lifestyle Fragrances Invent Your Scent Gift Ideas Scent-Me Collection Shampoo Conditioner Treatment Styling Products Brushes Essential Oils Massage Lotions Bath & Shower Home Fragrance Bergamot Lavender Ylang-Ylang Mandarin Gift Ideas Shaving & Face Hair & Body Fragrance Accessories Massage Gift Ideas Bath Hair Brushes Hand & Foot Massage Skin Accessories Make-Up Tools Bags & Cases Support a Cause Books Gift Ideas Sign up to receive discounts and special offers. Vanilla Body Lotion Moisturising body lotion that leaves the skin smooth, supple and subtly scented with a sweet, warm and velvety vanilla fragrance. Easily absorbed with grape seed oil and Community Trade babassu oil. View Larger See More Details 6.75 fl. oz. Vanilla Body Lotion 71144 Add to My Favorites List $12.00 Quantity 16.8 fl. oz. Vanilla Body Lotion 71138 Add to My Favorites List $22.00 Quantity We also recommend... Vanilla Bath & Shower Gel Vanilla Eau de Toilette More Details Key Ingredients All Ingredients Instructions Tip Zone Bergamot, peach, strawberry, orange flower, jasmine, plum, ylang ylang, vanilla, sandalwood, amber and musk Have been blended together to create the sweet, warm and velvety vanilla fragrance. Babassu oil Moisturizes the skin. Grapeseed Oil Is very rich in essential fatty acids that help to repair the skin's moisture barrier, thus helping to restore smoothness and suppleness. Glycerin Is an effective moisturizer which helps improve softness and maximize hydration. Community Trade Information The babassu oil in many of our fragrance body lotions is a real success story. Produced by a co-operative of 12 different communities in north eastern Brazil, the oil produced by pressing the babassu kernels is harvested by women known as "babassu breakers" who use axes to crack open the nuts. Indeed, the women had to campaign for the right to collect the nuts in the first place, a success story in itself. Buoyed on by their success, and with the increased respect they gained as earners within thier communities, the women then campaigned to stop the big landowners chopping down babassu palms to graze cattle. They won. And so by helping preserve the forest, they've preserved their livelihood. Another reason why you'll feel good moisturizing with a product made from Community Trade babassu oil. View More Corporate Site | News | Employment Opportunities | The Body Shop Canada | The Body Shop UK | Terms & Conditions | Privacy Policy | About Us Affiliate Program | Store Locator | Site Map | Help | Contact Us Lotions | Lifestyle Fragrances | Lotions © 2005 The Body Shop International plc. All Rights Reserved.

Retinal Cream

Pediatric Rheumatology Online Journal rcarter PEDIATRICS 2 17 2003-04-23T20:30:00Z 2003-04-23T20:30:00Z 3 1353 7715 University of Chicago 64 15 9474 9.2720 MicrosoftInternetExplorer4 Clean Clean In the current issue: Calinosis in Juvenile Dermatomyositis B isphosphonates in the Pediatric Rheumatic Diseases Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection Review for the Primary Care Physician: Kawasaki Syndrome CD154 and Lupus CASE DISCUSSION-JUVENILE DERMATOMYOSITIS CASE HISTORY A6 year old female child is brought to your clinic with a 3 month history of ared rash on her knuckles. It had beenseen 2 months before by a family doctor who diagnosed a contact allergy andprescribed a corticosteroid cream. Therash has persisted and recently worsened. She has stopped riding her bike and now is having trouble climbing thestairs at home. Her father has had tohelp her walk in the afternoon due to leg pains and has even carried her in hisarms. Her parents have noted a fever of38.5-39 degrees Centigrade on three occasions in the past month. She has developed a rash on her cheeks. She has choked on a piece of hamburgerrecently. Initialphysical examination reveals a child with a red macular rash on her cheeks andeyelids. She has red papules on all ofher MCP's and PIP's and abnormal nailfold capillaroscopy. Her right knee is swollen. She cannot do a situp or hold her head upagainst gravity. She has a nasal speechpattern and a positive Gower's sign. She is admitted immediately to yourhospital. She is noted to have troublewith her secretions and has a decreased tidal volume. Issues: 1) What workup would you perform? 2) What treatment would you initiate? 3) What prognosis would you discuss with the parents? 4) What tests and/or outcome parameters would you followto measure disease activity? 5) What would be your 2 year plan of treatment? DISCUSSANT #1 Onadmission, we would like to get an insight in the severity of thedermatomyositis of this six-year-old. Clinically, the skin manifestations are present, with the typical facialrash and the Gottron's papules, together with other signs of cutaneousvasculopathy. Muscle involvement is alsoprominent with progressive proximal and distal muscle weakness, difficultiesswallowing and an altered speech. In ourdepartment, the degree of muscle involvement is assessed by isometric handhelddynamometry (HHD), the Childhood Mysositis Assessment Scale (CMAS) andendurance, which is tested by a maximal exercise test using a motor-driventreadmill. Diseaseactivity is assessed biochemically by a full blood count, erythrocytesedimentation rate and especially by the elevation of muscle enzymes as CK,LDH, AST and APT. An immunologicalworkup includes determination of ANA, extractable nuclear antigens andmyositis-specific autoantibodies. There is an ongoing discussion about the needfor a muscle biopsy, performed under general anesthesia, to confirm thediagnosis, especially in patients with an impaired lung function. A STIR MRI with fat suppression can bescheduled in order to determine the degree of muscle involvement. To assess the involvement of other organsystems, a cardiac ultrasound is planned, together with an esophageal manometry,especially in the case of difficulties swallowing. Examination of stool, todetect occult bleeding, and a urine sedimentation has to be done. An abdominal ultrasound is performed todetermine the size of the liver and spleen and the state of the abdominalvessels. To exclude retinal vasculitis, a fundoscopy is scheduled. As soonas possible, treatment should be initiated. The symptoms of this girl are indicative for a more severe disease, withevidence of vasculopathy and decreased muscle strength. At present, the initial therapy is prednisone2 mg/kg/day orally in combination with calcium and vitamin Dsupplementation. For more severedisease, as in this patient, we should advise to give steroids intravenously inmultiple daily doses, because of the possibility of impaired abdominalabsorption due to vasculitis. In severe,life-threatening disease, intravenous methylprednisolone pulse therapy (15-30mg/kg/dose for 3 days) is thought to induce a rapid improvement of severedysphagia, myocarditis and in individuals who have rapidly worsening muscleweakness. As a cut-off value, weconsider a CMAS score below 24, being 45% of optimal performance, as a risk fortrauma such as tripping over, falling without protection of arms, aspiration,etc. When the initial treatment withsteroids appears to be ineffective after 4 weeks or if we are not able to taperoff the prednisone, a second line immunosuppressive agent should be added. Use of methotrexate (MTX) early in thedisease is currently first choice, with a dosage of 1mg/kg intravenously, onceweekly. We avoid subcutaneous orintramuscular administration because we consider this administration a risk forinducing ulceration or calcifications. When using MTX, potential adverse effects such as photosensitization,oral ulcers or opportunistic infections should be monitored. The initial response usually occurs between 4to 8 weeks after starting this therapy. Intravenous immunoglobulin has been reported to have benefit incombination with the ongoing treatment in resistant disease, however iv immunoglobulin therapy is very expensive and not evidence based . As important as the pharmacologicaltherapy, is the physical therapy program to preserve, and if possible, improveexisting muscle function, to prevent disuse atrophy, to avoid jointcontractures and to restore the aerobic capacity of the chronically illchild. In the early phase of thedisease, it is sufficient to encourage children and parents to maintain ADL,because of serious risk of inflicting trauma to an inflamed muscle whenstretching in an active phase. In ourPhysical Therapy Department, special programs, including aquatic training, areimplemented after the initial phase of muscle edema and general malaise with emphasis on muscle flexibility. Inthe discussion with the parents, the severity of the disease has to be stressed.We would explain that JDM is a rare, mostly chronic disease, with an unknownetiology. The prognosis has improvedsince the start of corticosteroids and other immunosuppressive agents. The course of the disease is difficult topredict, but is known to have a long course with remissions and exacerbationsor, in some cases, a chronic course with a severe debilitating morbidity. The presence of dysphagia, dysphonia,cutaneous vasculitis and severe decreased muscle strength are indicators ofserious disease. We would discuss thatthe use of immunosuppressive therapy is warranted and that this can haveconcomitant side-effects, which would be followed-up and treated ifnecessary. Finally, the possibility ofcalcifications should be discussed, with a decreased frequency due to earlyaggressive treatment. In thebeginning of the treatment, the girl will be admitted in order to assess theresponse to the treatment and to start physical therapy. The global assessments of the patient andphysician, which each integrate a number of facets of disease activity fromdifferent perspectives play a major role in assessing the therapeutic responsein combination with the more objective parameters as discussed before. In case of unsatisfactory response to thesteroids, second line agents will be added to the therapy. Prednisone dosage is tapered after 4 to 6 weeks, to avoidsteroid myopathy. In the course of thedisease, disease activity will be followed clinically on regular outpatientclinic visits, as well as by laboratory measures and assessment of the muscleparameters. It is well known that muscleenzymes and BSE can be normal even in active disease, so these are no perfectparameters during follow-up. It has beensuggested earlier to measure von Willebrand factor antigen to assess the degreeof endothelial inflammation, but we think it is not helpful in evaluating thedisease activity in an individual patient. Muscle strength, muscle function and endurance can be assessed in timein a quantitative manner. Whenindicated, the tests to exclude other organ involvement, discussed earlier, arerepeated. The aim is to taper the steroidsfurther, to a minimal dose. Then, in thecase of stable disease, the MTX treatment can also be diminished. Part 2 Two years later the rash is stillactive but the muscle strength and muscle enzymes are normal. The child has developed sheets of calciumdeposits in her forearms and arms. Issues: 1) In general, would you treat aggressively with immunosuppressives if the rash is active but the muscle strength isnormal? 2) How would you address the calcification problem? Answer First it is important that all themuscle modalities [muscle strength as well as (an-) aerobic performance] andmuscle enzymes are normal. Then, we would not treat the skin manifestationsaggressively if there is no indication of severe cutaneous vasculitis. Usually,we start with hydroxychloroquine at an oral dose of 5 mg/kg/day. Monitoring is needed for potential retinal toxicity. Regularlywe treat the skin locally with a cream based on corticosteroids but there are new interesting developments for local treatment like a cream based on FK-506(tacrolimus). Until now, there is not enough evidence for thislocal treatment. For the treatment of calcifications there are no controlledtherapeutic trials, and there can even be a spontaneous, unpredictable regression. We suggest to start treatment with the oral calcium antagonist Diltiazem, at a dose of 2 mg/kg/day,increased to 5 mg/kg/day after 3 to 4 weeks. The therapeutic effect is expected after several months. In case of severe calcinosis, a combinationtreatment with bisphosphonates is started. Oral alendronate (< 1 m 2 BSA: 10 mg/day; > 1 m 2 BSA: 20 mg/day) can be added to the therapy with control of serum levels ofcalcium, phosphorus, alkaline phosphatase and theurinary calcium/creatinine ratio. Elisabeth Elst 1 , Annet vanRoyen 1 , Janjaap van der Net 2 , Wietse Kuis 1 Departments of Pediatric Immunology 1 and Pediatric Physical Therapy 2 , Wilhelmina Children's Hospital University Medical Centre Utrecht , the Netherlands . References 1.Pachman LM. Juvenile dermatomyositis. Pathophysiology and disease expression. Pediatr Clin North Am 1995 ;42:1071 -98. 2.Ramanan AV, Feldman BM. Clinical features and outcomes of juveniledermatomyositis and other childhood onset myositis syndromes. Rheum Dis Clin North Am 2002 ;28 (4):833-57. 3.Takken T, et al. The physiological and physical determinants of functional abilitymeasures in children with juvenile dermatomyositis. Rheumatology 2003 ;42:158 -62. 4.Reed AM, Lopez M. Juveniledermatomyositis. Recognition and treatment. Pediatr Drugs 2002 ;4 (5):315-21. 5.Oliveri MB et al. Case Report : Regression of calcinosis during diltiazem treatment in juvenile dermatomyositis. J Rheumatol 1996 ;23:2152 -55. DISCUSSANT #2 INITIAL INVESTIGATIONS: To assess thedegree of muscle involvement, a formal muscle assessment is important. This centre uses the childhood myositisassessment scale (CMAS), as well as the MMT8 (eight muscle manual testing)pending validation of these scores. An MRI of thigh muscles will provideevidence of inflammatory changes in the fat, fascia and muscles. An open biopsyis performed in this hospital, though it may not be necessary for diagnosticpurposes if the MRI is abnormal. A needle biopsy is not advisable because ofthe small sample and, as the disease is often patchy, it may be normal. Musclebiopsies stained by conventional histopathology techniques may be normal inearly disease with very few/no inflammatory cellular infiltrates present. Sheshould also have a Child Health Assessment Questionnaire (CHAQ) to assess herfunction and quality of life(to be filled in by her parents). The blood work up should include full bloodcount, ESR, CRP, muscle enzyme such as creatinine kinase and LDH, U&E's,LFT's, ANA, ENA, and if possible specific auto antibodies (such as Jo 1 andRMP), to exclude overlaps and other rare muscle diseases. Her nasal speech may be associated withswallowing difficulties and a video fluoroscopy is advisable. Assessment of other organ involvementincludes pulmonary function and chest radiograph. If abnormal, a highresolution fine-cut CT scan is needed to delineate any inflammatory lungdisease (ILD). TREATMENT: IV m ethylprednisolone, at 30mg per kiloper dose on day one, two and three is our current practice to achieve animmediate and sizable anti-inflammatory response. This may be repeated thefollowing week. In between the IV m ethylprednisolone, she should have0.5-1mg per kilo orally of Prednisolone. If the child did not responddramatically to the IV MP, or there is evidence of malabsorption or GIvasculitis (symptoms such as abdominal pain), the equivalent dosage ofprednisolone should be given as MPIV. A switch to oral administration will belater, once the symptoms improve (usually after 1-2 weeks). For medium tolong-term control of disease activity, methotrexate is given sc afterdiscussion with the parents, the child, and the primary care physicians. Thestarting dose given here is 15mg per m 2 . If the CT scan showed any signs of lungabnormalities (alveolitis or fibrosis), IV Cyclophosphamide at 500-750/m2 andat monthly intervals for the first six months is advisable as well asmethotrexate. PROGNOSIS: With this child one should discuss thespectrum and the disease course for dermatomyositis (unicyclic, polycyclic orcontinuous). In this case, the possible ILD suggests a poorer prognosis, andshe is likely to be in the continuous or polycyclic group. The types of therapywill be discussed and in view of her poorer prognosis, the emphasis will bebiased towards more aggressive treatment. Controlling the disease is of paramountimportance, in order for the child to have no long-term sequelae once thedisease has gone into remission. MEASURES OF DISEASE ACTIVITY AND OUTCOME: To assess muscle disease activity, the CMASand MMT8, and CHAQ are used in this unit, MRI scans are done at 6 monthlyintervals or with a disease flare. Clinical observation of the presence ofarthritis, rash, or oedema is an indicator of disease activity. Calcinosis isan indicator of severe disease activity. CK and LDH are useful indicators ofinitial response to therapy, and of flares of disease. However CK may not be asgood a marker of muscle inflammation as LDH, especially later on in the diseasewith significant loss of muscle bulk. MRI is often useful in these cases.Video fluoroscopy and lung functiontest should be also used to monitorprogress of the lung disease, with a CT scan at appropiate intervals. PLAN OF TREATMENT at 2 years: The critical issue is whether there issubacute inflammation that has contributed to the sheets of calcinosis, despitethe normal CK. Disease activity is also suggested by the prominent rash. An MRIof the proximal muscle groups would be essential. If there is active muscleinflammation, as well as lung involvement, cyclophosphamide should be started.In this unit, IV is preferred as there are no concerns with compliance,absorption, or hydration, and there appear to be fewer long-term side-effects.A change to cyclosporin A orally is unlikely to be effective at this stage, butcombination therapy may be worth a try for a limited period. If the child's disease has progresseddespite 6 months' of cyclophosphamide, thenmore experimental treatments such as anti TNF should be considered. Pamidronate for the calcinosis isworth considering, and our unit has had 3 patients who have responded well tothis combination between 6 months and 1 year. ACTIVE RASH WITH NORMAL STRENGTH AND NOEVIDENCE OF MUSCLE INFLAMMATION: These children can pose a difficultproblem. The rash is indicative ofactive disease but does not always respond as well to the same medication asthe muscle inflammation. Ongoing disease is often seen in these children asthey are also often underweight and growth retarded. Different medications such as pulses ofIVIG, h ydroxychloroquine/mepacrine or Tacrolimus may be helpful. Clarissa Pilkington and Patricia Woo Great Ormond Street Hospital for Sick Children, London Table of Contents

exfoliate skin, leaving it

How to make your own face mask Search iVillage for: Home Join free Horoscopes Quizzes Related Channels: Health | Entertainment | Diet and Fitness | more ... You are here iVillage.co.uk beauty skin care facial care Virtual makeovers Hair care Skin care Make-up & fragrance Body basics Hints, tips and tricks Kickstart 2006 Valentine's beauty D.I.Y. detox Lovely lingerie Win a San Fran trip Fashion forecast Win a weekend in London Blistex Lip Splash Get beautiful nails Win a spa day Spa finder Morning routine quiz Make up matcher Ageing attitude quiz All tools & quizzes Beauty Entertainment Diet and Fitness more newsletters Beauty home Make your own facial mask by Josephine Fairley With all the wonderful cosmetic masks available these days, you'll never want for an exotic concoction to 'feed your face'. But why not give yourself one of the simplest, quickest DIY beauty treats and create your own? You may not think your kitchen is particularly well stocked, but chances are you have enough ingredients on hand to make a fabulous face mask. The only equipment you'll need is a mixing bowl, a fork, a wooden spoon and a few fresh ingredients. A blender or food processor will also be helpful if you want to save preparation time, but it isn't essential. Below are some basic masks for different skin types, but feel free to use your imagination when making your own. The advantage of homemade masks, of course, is that because they use fresh ingredients, they're free of additives and preservatives. You can even make yours 100 per cent organic if you choose. Enjoy these facial indulgences, which will help moisturise and exfoliate skin, leaving it with a healthy glow: Nourishing face mask for dry skin You will need: 2 oz/60g ripe avocado flesh 1 oz/25g orange juice 1 tsp/5g pure acacia honey 1 tsp/5g molasses 5 drops chamomile essential oil Put all the ingredients in a blender, or mash by hand in a bowl. Add extra orange juice if the mixture is too thick. Use your fingers to spread the mask over your face and neck and leave it on for at least 30 minutes, preferably longer, before removing. Use a warm flannel to rinse off the mask - this will help gently exfoliate skin as well as clean your face. This mask will keep for a day or two in the fridge if you don't use it all. Honey face mask for sensitive skin Warm a small pot of honey in a double boiler, then test a small amount on your hand to make sure it's not too hot. When warm, apply the honey generously over your entire face. Leave the mask on for 15 minutes. Rinse thoroughly with warm, then cool water. PAGE 1 OF 2 NEXT related links ARTICLE: Better skin diet ARTICLE: Five fab facial washes ARTICLE: DIY treatments: At-home facial peel ARTICLE: Banish the blemish ARTICLE: Protection on the piste Get the latest iVillage news on your desktop Sign up for more iVillage RSS feeds iVillage Channels Community Services About iVillage Beauty Diet & Fitness Food & Drink Health Horoscopes Money Motoring News & Showbiz Parenting Pregnancy & Baby Relationships Travel Work & Career Join free Member Centre Competitions eCards Help Instant Games Newsletters Online Dating RSS About Us Privacy Policy Site Map Terms of Service © iVillage Limited 2000-2005. All rights reserved. © iVillage inc. 1995-2005. All rights reserved. 1 -- Fabulous face! Facial washes put to the test Discover the right way to moisturise Try the better skin diet Banish the blemish The five most commonly asked skin care questions answered read this later send to a friend printer friendly

Bath Salts Whether for

How to Make Bath Salts - eHow.com Clear Instructions on How To Do (just about) Everything Web eHow.com Home Hobbies & Games Center Crafts How to Make Bath Salts Whether for yourself or as a gift, bath salts are easy to make and feel oh-so-relaxing. Steps: 1. Use a plastic bowl with a tight-fitting lid. It needs to have a capacity of at least 30 ounces. 2. Mix 1� c. of Epsom salts with 1 c. baking soda and 1/2 c. borax or table salt. 3. Combine a few drops of food coloring and 3 to 6 drops of your favorite essential oils in a tablespoon and stir well with a toothpick. 4. Add the color/oil mixture to the salt. 5. Put the lid on the bowl and shake it for a couple of minutes to make sure the color and scent are evenly distributed. 6. Package the salts in a paper envelope or pretty glass container. Be sure to include a measuring scoop. Use about � c. per tub. Tips from eHow Users: Bath Salts by Annette P. Combine 1/2 cup of sea salt, 1 cup of Epsom salts, essential oil fragrance, and food coloring. Mix them together in a jar or a plastic container with a tight lid. Add the essential oil fragrance of your choice drop by drop to your desired smell. Add food coloring to color the salts. Food coloring adds a lot of color fast, so start with a tiny drop and go from there. You can also add a little bit of liquid glycerin to give it more shine. Rate this tip: View 1 More Tip(s) from Users Please Share Your Tips with Us More Resources: Contribute to eHow: Write an eHow Article Suggest a Topic Give Us Feedback on This Article Related eHows: Find Free Time Clean a Bathtub Take a Bubble Bath Make an Herbal Bath Use Essential Oils Things You'll Need: baking soda covered, glass containers scoops medicine droppers food coloring toothpicks Epsom salts plastic bowls with lid essential oils tablespoons measuring scoops Project Details: Skill Advisory: Easy New! -- Related eHows: Find Free Time Clean a Bathtub Take a Bubble Bath Make an Herbal Bath Use Essential Oils Check out Thousands of How-To Solutions in eHow's Centers Automotive Careers & Education Computers & Home Electronics Family & Relationships Finance & Business Food & Entertaining Health Hobbies & Games Holidays & Traditions Home & Garden Personal Care & Style Pets Sports & Fitness Travel How to: --? Web eHow.com Home | Site Map | About Us | How To Books | Link to eHow Subscribe to the eHow of the Day Mailing List : Have the eHow of the Day appear on your My Yahoo! Page: Add the eHow of the Day to your RSS reader: © 1999-2005 eHow, Inc. How things get done. Use of this web site constitutes acceptance of the eHow Terms of Use and Privacy .

Facial Fractures The Painful

Facial and Mandibular Fractures UW Radiology Home Approaches To DDx In Musculoskeletal Imaging Contents Preface General Principles Arthritis Appendicular Axial Lucent Lesions of Bone Sclerotic Lesions of Bone Periosteal Reaction Soft Tissue Calcifications Fractures Without Significant Trauma Facial Fractures The Painful Joint Prosthesis Orthopedic Hardware Scoliosis Osteopenia Osteonecrosis Skeletal Dysplasias Search this site Approaches To Differential Diagnosis In Musculoskeletal Imaging Michael L. Richardson, M.D. Facial and Mandibular Fractures Facial Fractures The bones of the skull and face collectively make up the most complex area of skeletal real estate in the body. Analysis of the fractured face requires a knowledge of not only normal anatomy, but also of common fracture patterns in the face. Although they represent serious injuries, the workup and treatment of facial fractures is often properly delayed until more pressing problems have been addressed, such as the establishment of an adequate airway, hemodynamic stabilization, and the evaluation and treatment of other more serious injuries of the head, chest and skeleton. Once these problems have been managed, it is time to work up facial fractures. At our institution, high resolution CT is currently the imaging procedure of choice for most facial fractures. The complex anatomy and fractures of the facial bones are shown extremely well by CT, and soft tissue complications can be evaluated to a far greater degree with CT. Therefore, the plain film facial series has taken a back seat to CT in the past few years, and is now used only in certain situations, such as when the facial trauma is very focal (nasal fracture), or when CT is unavailable. However I find it easier to initially teach the anatomy and fracture patterns of the face with plain films. Once these concepts have been grasped by the resident, one can then move on to the axial and coronal anatomy shown by CT. A basic facial series consists of three or four films: a Waters view (PA view with cephalad angulation), a Caldwell view (PA view), a lateral view, and occasionally a submentovertex view. If a nasal fracture is suspected, then a lateral view of the nasal bone with special nasal technique may be done. Of these views, the most consistently helpful view in facial trauma is the Waters view. It tends to show all of the major facial structures at least as well and often better than other radiographic views of the face. It can initially be a bit daunting to think about ruling out fractures of the complex collection of bones that make up the face. However, here are several simplifying rules that can make life a lot easier: Look at the orbits carefully, since 60 - 70 % of all facial fractures involve the orbit in some way. The exceptions: a local nasal bone fracture, a zygomatic arch fracture, and the LeFort I fracture. It is especially important to examine the orbital borders and apex, as well as the optic canal. Know the most common patterns of facial fractures and look for them. Bilateral symmetry can be very helpful. Normal radiopacities are usually bilateral, while abnormal ones are usually unilateral. Carefully trace along the lines of Dolan when examining the Waters view in a facial series. the lines of Dolan and the elephants of Rogers What are the lines of Dolan? They are three anatomic contours best seen on the Waters view of the face, and they were first popularized by Dolan et al . As you can see, the 3 lines of Dolan lead the eye along some facially important structures. Lee Rogers pointed out that the 2nd and 3rd lines together form the profile of an elephant. When you search for a fracture, you are really searching for one or more of the following radiographic signs. Radiographic signs of facial fractures Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a "double-density" asymmetry of face Indirect Signs soft tissue swelling periorbital or intracranial air fluid in a paranasal sinus The most common mechanism producing facial fractures is auto accidents. About 70 % of auto accidents produce some type of facial injury, although most are limited to soft tissue. The face seems to be a favorite target in fights or assaults, which are the next most common mechanism. The remainder of facial fractures are produced by falls, sports, industrial accidents and gunshot wounds. Less than 10 % of all facial fractures occur in children, perhaps because of the increased resiliency of a child's facial skeleton. The most common patterns of midfacial fractures are summarized in the table below. Fracture Type Prevalence Zygomaticomaxillary complex (tripod fracture) 40 % LeFort I 15 % II 10 % III 10 % Zygomatic arch 10 % Alveolar process of maxilla 5 % Smash fractures 5 % Other 5 % Probably the most common facial fracture is the tripod or zygomaticomaxillary complex fracture, so called because it involves separation of all three major attachments of the zygoma to the rest of the face. frontal view of a zygomaticomaxillary complex fracture submentovertex view of a zygomaticomaxillary complex fracture Although it may be fractured, the separation of the frontal process of the zygoma from the frontal bone usually occurs in the form of a diastasis of the zygomaticofrontal suture. This fracture is usually due to a direct blow to the body of the zygoma. This fracture will generally cause contour abnormalities of all three of the lines of Dolan. Occasionally, extraocular muscles may become entrapped in the zygomaticomaxillary component of the fracture complex. The displaced tripod fragment may physically restrict motion of the mandible. In some cases, force may propagate along the long axis of the lateral orbital wall and involve the orbital apex or optic canal, resulting in diminished vision. CT is extremely helpful in evaluating these fractures. Fractures may be isolated to the zygomatic arch. Clinically, these injuries are usually due to a blow from the side of the face. Patients with this injury often present with flatness of the lateral cheek area and inability to open their mouth, due to impingement of the zygomatic arch fragment upon the coronoid process of the mandible or the temporalis muscle. Adequate visualization of this fracture may require a submentovertex view or CT. Another focal fracture type is a fracture of the alveolar process of the maxilla, which involves a small piece of the maxilla, associated with several fractured teeth. The main treatment goal here is to maintain viability of the teeth. If all of the fractured teeth cannot be accounted for, a chest film should be carefully examined to look for evidence of aspirated tooth fragments. Another common fracture is the orbital floor fracture, or "blowout" fracture. The usual mechanism is a blow to the eye, with the forces being transmitted by the soft tissues of the orbit downward to the thin floor of the orbit. The floor is usually the path of least resistance, and fractures downward into the maxillary sinus. Common clinical signs are enophthalmos and diplopia (especially on upward gaze), and one should remember that about 24 % of these fractures are associated with ocular injury as well. On a Waters view, one may see a soft tissue mass on the superior margin of the maxillary sinus, representing the herniated periorbital tissues into the sinus. One may also see a "trapdoor" fragment of bone protruding down into the sinus, often hinged on the ethmoidal side. CT will, of course, show these fractures and soft tissue mass much better. "blowout fracture" -- the arrows point to the fracture fragments and periorbital tissue which have herniated into the maxillary sinus The nose is the most frequently injured facial structure, undoubtedly because of its prominent position on the face. Likewise, the most commonly missed facial fracture of the face is a fracture of the nasal bone. Although one can occasionally see a nasal bone fracture well on a standard lateral skull film, these fractures are much better seen when the film is shot with special low kVp nasal bone technique (essentially soft tissue technique). One should always look at the inferior nasal spine (part of the maxilla) as well for subtle fractures. Common pitfalls in viewing the nasal bone are the normal sutures lining the nasal bone, as well as the linear channel for the nasociliary nerve, which may all be mistaken for a fracture. A helpful rule is that this channel runs parallel to the bridge of the nose, while most nasal bone fractures will run perpendicular to the bridge. It is well to remember that the humble nasal bone fracture may be associated with more extensive injuries, such as the orbital rim or floor and the ethmoid or frontal sinuses. normal nasal bone anatomy The next set of fractures in this rogue's gallery of common facial fractures are the LeFort complexes. These are complex bilateral fractures associated with a large unstable fragment ("floating face") and invariably involve the pterygoid plates. Legend has it that LeFort dropped skulls off of a French tavern roof and analyzed the resulting fracture patterns. This certainly sounds like the kind of study that we would all like to do, even without NIH funding. In reality, LeFort studied fracture patterns produced in cadavers. He found three main planes of "weakness" in the face, which correspond to where fractures often occur: the transmaxillary plane, the subzygomatic or pyramidal plane (this is really two planes with an apex up at the bridge of the nose), and a craniofacial plane. frontal views of LeFort complex fractures I - III lateral views of LeFort complex fractures I - III The LeFort I, or transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the lower maxilla with the maxillary teeth. The LeFort II occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape. A common mechanism is a downward blow to the nasal area. The most severe of the classic LeFort fracture complexes is the LeFort III. I suppose that this is pretty obvious, given a three-part grading system. In this case, the large unstable (floating) fragment is virtually the entire face! Thus, this fracture is also referred to as craniofacial disassociation. This is a very severe injury, and is often associated with significant injury to many of the soft tissue structures along the fracture lines. Generally, considerable force is necessary to produce this injury, and it is uncommon as an isolated injury. It may also occur in association with severe skull and brain injuries. With the exception of the LeFort I injury, "pure" LeFort injuries are not commonly seen. More commonly seen are variants of the LeFort classification. One of the most common of these is the LeFort II - tripod fracture complex. This complex is usually due to the large forces encountered in a motor vehicle accident. LeFort was probably unable to apply this much force to the cadaver faces in his study, and it is therefore not too mysterious why he didn't describe these more complex injuries. When describing these injuries, one should probably give a separate diagnosis to each half of the face. Even more complex patterns may be encountered, such as a mixed LeFort II/LeFort III complex or a LeFort III/LeFort II/tripod complex. Besides the classic LeFort patterns and the mixed LeFort variants, there is another common pattern which is called, for obvious reasons, a "smash" fracture. In these injuries, severe comminution of the face is present, and underlying skull injury is likely. These patients are often in unstable condition with associated axial and appendicular skeletal injuries as well. This category includes several varieties of otherwise unclassifiable fractures, which are named for the portion of the face primarily involved. Subclassifications of smash fractures include the frontal, naso-frontal (naso-ethmoid) or central facial smash syndromes. CT is mandatory for adequately displaying all of the bony and soft tissue components of these injuries. Wise sayings about facial fractures Look at the orbits carefully, since 60 - 70 % of all facial fractures involve the orbit in some way. Bilateral symmetry can be very helpful. Carefully trace along the lines of Dolan. Use CT liberally in working up facial fractures. Mandibular Fractures The mandible is another commonly fractured bone in the head, and most of these fractures are obvious on clinical exam. Clinical findings include facial distortion, malocclusion of the teeth, or abnormal mobility of portions of the mandible or teeth. The mandible is one of those bones covered by the "ring bone rule", which may be stated thusly: if you see a fracture or dislocation in a ring bone or ring bone equivalent, look for another fracture or dislocation. You can experiment with this tendency of ring bones to break in more than one place by going through a bag of pretzels and trying to break one of them in just one place. Then try it with a bag of bagels. You should now have a good appreciation for Lee Rogers' corollary to the ring bone rule, which he calls the "pretzel-bagel spectrum". To wit, the stiffer a ring bone is, the more likely it is to break in more than one place. The more flexible it is, the more likely it is to break in just one place. The mandible has some flexibility, due not only to the mobility around the temporomandibular joints (TMJ's) but also to the tendency of the TMJ's to absorb some forces during trauma. What this boils down to is that one sees an average of 1.5 to 1.8 mandibular fractures per customer, depending on whether the mechanism is blue collar (fist or other anonymous blunt object) or white collar (automobile crash) respectively. Like the nose, the mandible also has a prominent position on the face, making it a favorite target for either of these mechanisms. Mandibular fractures have traditionally occurred at twice the prevalence of facial fractures, but this ratio has been decreasing with the increasing prevalence of high-speed auto accidents. Only 5 % of all mandibular fractures occur in children, and most of these are also caused by auto accidents, with about 1/3 due to bicycle accidents. Mandibular fractures can occur at any of the following sites. common sites of mandibular fractures Fracture Type Prevalence Body 30 - 40 % Angle 25 - 31 % Condyle 15 - 17 % Symphysis 7 - 15 % Ramus 3 - 9 % Alveolar 2 - 4 % Coronoid process 1 - 2 % When double fractures occur, they are usually on contralateral sides of the symphysis. Common combinations include the angle plus the contralateral body or condyle. Triple fractures occasionally occur, and the most common type is fracture of both condyles plus the symphysis. The mandible may also be dislocated without fracture, sometimes spontaneously during a large yawn. The patient usually presents with considerable pain. Spasm in the masseter and pterygoid muscles tend to force the condyles up the anterior slope of the articular eminence and prevent normal mouth closure. mandibular dislocation -- the condyle (c) is anterior to the articular eminence (e) Wise sayings about mandibular fractures Remember the ring bone rule. Symphyseal fractures can be diabolically hard to see, even on a well-exposed AP film Remember the Panorex view -- this can usually only be taken by a special machine in the oral surgery department, but it provides the best single view of the mandible and will show you fractures that cannot be seen by any other method short of CT. Look carefully along the cortical margin of the whole mandible for discontinuities. This may be the only sign of a fracture that you will see. Also carefully examine the mandibular canal for discontinuities. A fracture line entering the root of a tooth is considered an open fracture by definition. Pathologic fractures can occur in the mandible. Look carefully for evidence of a periapical abscess or a mandibular tumor, especially if there doesn't seem to be enough trauma to match the injury. References Dolan KD, Jacoby CG. Facial fractures. Semin Roentgenol 1978;13:37-51 . Dolan KD, Jacoby CG, Smoker WR. The radiology of facial fractures. Radiographics 1984;4:575-663. For further information, contact Michael L. Richardson, M.D. , webmaster © 2000 University of Washington Department of Radiology All rights reserved. Do not use without written permission. Last update: Wednesday, January 24, 2001 at 10:59:41 AM.