Because the radiographic anatomy of the facial skeleton is complex,
attempting to identify a fracture simply by looking for discontinuity
or deformity of the facial bones is inefficient and may fail to
identify the pertinent findings. Facial fractures are best detected
by looking for specific injury patterns (tripod fracture, blow-out
fracture, isolated zygomatic arch fracture, or LeFort fracture).
Fracture patterns are best understood by considering the main
structural elements of the facial skeleton (Figure 1).
Supportive struts of the facial skeleton.
- Three vertical struts: (A)
nasal strut, (B) lateral orbital rim and lateral wall of the maxillary
sinus, and (C) pterygoid plate (posterior).
Three horizontal struts: frontal
bone (roof of the orbit), zygomatic arch and inferior orbital rim,
and hard palate (maxilla).
The walls of the maxillary sinus and orbital floor are cut away
in this illustration.
[From: Harris, et al: An approach to mid-face fractures. Crit Rev Diagn Imaging 1984;21:105–132.
Copyright CRC Press, Boca Raton, FL.]
When to Order
Does every patient with a “black eye” need
an imaging study? There are no clinical decision rules to guide
the ordering of facial radiographs.
Many facial fractures can be diagnosed clinically, and signs
of specific injuries serve as a guide to ordering facial imaging.
Such clinical findings include: palpable deformity of the orbital
rim or zygomatic arch (can be masked by soft tissue swelling), malar
flattening, periorbital subcutaneous emphysema, infraorbital anesthesia,
restriction of ocular motion (especially upward gaze), dental malocclusion,
mobility of the maxilla (LeFort fractures), enopthalmus, proptosis,
sagging of the lateral canthus, and telecanthus (widening of the
intercanthal distance). However, patients with nondisplaced fractures
may only have nonspecific clinical findings such as swelling or
ecchymosis. Radiography is therefore indicated even without definite
signs of a fracture. On the other hand, in patients with massive
facial injuries that have a dramatic clinical appearance, the serious associated
injuries must be given priority over radiography—namely,
airway, intracranial, ocular, and cervical injuries.
In institutions where it is available on an emergency basis, Multidetector CT (MDCT) has supplanted facial radiography.
Nonetheless, the anatomical landmarks and patterns of facial injury
remain the same.
The facial skeleton consists of three horizontal and three vertical
supportive struts (Figure 1). Most facial fractures are oriented
perpendicular to these supportive struts.
There are several standard radiographic views of the facial skeleton.
These views are usually grouped into two radiographic series—a facial series and an orbital
The facial series includes a Waters
view, a Caldwell view, a lateral view, and a submental-vertical
view (bucket-handle view). The orbital
series includes a Waters view, a Caldwell view, and two oblique