Imaging for Zygomatic Injury After Head Trauma
CT maxillofacial without contrast is the recommended initial imaging modality for evaluating zygomatic injury after head trauma, as it provides superior detection of fractures compared to plain radiographs and is essential for surgical planning. 1
Why CT Over Plain Radiographs
CT has largely replaced plain radiographs for midface injuries because radiologists miss 12% of maxillofacial fractures on plain films compared to CT, primarily due to superimposition of adjacent anatomic structures and lack of technical expertise with plain radiography. 1
MDCT offers high-resolution thin-section acquisitions that detect subtle nondisplaced fractures of the facial skeleton and provides multiplanar and 3-D reconstructions critical for surgical planning. 1
CT is faster and less reliant on patient positioning than radiography, making it more practical in the acute trauma setting. 1
If Plain Radiographs Must Be Used
If CT is unavailable and plain radiographs must be obtained:
The Waters view (30-degree occipitomental view) is the single most important radiographic projection for screening zygomatic fractures, as it demonstrates the zygomaticomaxillary buttress and temporozygomatic bone in all cases. 1, 2
When combined with physical examination, Waters, Caldwell, and submentovertex views can provide sufficient information to verify zygomaticomaxillary complex fractures, though both patient positioning and technical experience are essential. 1
A single 30-degree occipitomental (Waters) view captures all radiologic abnormalities seen on three-view screening, making additional Caldwell and lateral views unnecessary. 2
The modified posteroanterior projection (10-20 degrees) clearly demonstrates frontozygomatic, infraorbital rim, and temporozygomatic fracture lines in all cases. 3
Critical Associated Injuries to Evaluate
Given the mechanism of head trauma, assess for concomitant injuries:
Intracranial injury occurs in 68% of patients with facial fractures, warranting consideration of head CT if loss of consciousness or altered mental status occurred. 1
Cervical spine injuries are present in 6-19% of cases with significant maxillofacial trauma, with higher likelihood as injury severity increases. 1
Orbital floor fractures occur in up to 24% of zygomatic fractures and may cause diplopia, enophthalmos, or oculocardiac reflex requiring urgent intervention. 4, 5
Common Pitfall
Do not rely on plain radiographs alone for surgical planning even if fractures are detected—proceed to CT for complete characterization of fracture patterns, as 3-D reconstructions are critical for preoperative planning in zygomaticomaxillary complex fractures. 1