The Waters or occipital-mental view is the single most valuable study of the midface. It evaluates continuity of orbital rims, provides an initial diagnosis of blowout fractures, and will demonstrate air/fluid levels in maxillary sinus.
The posterior-anterior (PA or Caldwell) view, which best details the bones of the upper face, confirms ethmoidal and frontal sinus fractures, as well as lateral orbital injuries.
The cross-table or upright laterals are difficult to read and are not very helpful. On occasion, they suggest elongation of the face in LeFort injuries or disruption of the posterior sinus wall. Look for air/fluid levels in sphenoid or ethmoidal sinuses.
The submental-vertex view, known colloquially as the "jug handle" or zygomatic arch view, shows the base of the skull and the zygomatic arches. It may be the only film necessary for suspected arch fractures.
The Towne view is useful for evaluating the mandibular ramus and condyles, as well as the base of the skull. Computed Tomography
CT provides a conclusive diagnosis of complex maxillofacial fractures. Opinions regarding the role of CT vary widely. Some authorities recommend routine CT scanning for every case of significant facial trauma, whereas others feel it is superfluous. Its greatest utility lies in evaluating patients with known or suspected periorbital and midface fractures. Scans are especially useful to evaluate the globe and orbital fissures. Specialized views—such coronal, sagittal, or parasagittal cuts, thin-slice scans, and three-dimensional reconstruction—are useful in particular circumstances. In general, the slices should be in a plane 90° to that of the suspected fracture—and not parallel to the fracture line. Three-dimensional CT is superior to two-dimensional CT for serious midface fractures, such as tripod and complex maxillary fractures.12
Multiply injured patients, who are intubated, unconscious, or sedated, frequently have significant and unsuspected facial fractures. If they require a CT of the head, consider adding a scan of the face for clinically stable patients. Slightly more than 10 percent of such patients may have unsuspected facial fractures needing surgical repair.13 However, an unstable patient with severe concomitant injuries should not receive a facial scan if it delays emergency surgery.
CT with various manipulations, such as coronal and axial views, is essential for management of particular complex fractures. However, plain films still have an important role in screening for maxillofacial injury. In the case of clinically obvious, complex facial injuries (in particular, periorbital and midface fractures), plain films may be eliminated and CT performed directly. Coronal films should be ordered for periorbital fractures, and thin-slice scans may be appropriate in this area.
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