Best X-Ray View for Facial Trauma Below the Orbit
X-ray is insufficient for evaluating facial trauma below the orbit—CT maxillofacial without contrast is the imaging modality of choice. 1, 2
Why CT is Superior to Plain Radiography
Multidetector CT (MDCT) has replaced plain radiography as the first-line imaging for maxillofacial trauma because it provides:
- Superior detection of orbital floor fractures, which are the most common injury in trauma below the orbit 1, 2
- High-resolution thin-section acquisitions that detect subtle nondisplaced fractures missed on plain films 1
- Multiplanar and 3D reconstructions critical for surgical planning, particularly for complex zygomaticomaxillary and orbital fractures 1, 3
- 94.9% sensitivity for detecting intraorbital foreign bodies, especially metallic ones that may accompany facial trauma 4, 2
- Faster acquisition time and less reliance on patient positioning compared to radiography 1
If Plain Radiography Must Be Used
While plain radiographs are insufficient for detecting orbital pathology 2, if X-ray is the only available option:
- A single 30-degree occipitomental (Waters) view is the most useful plain film view for screening maxillofacial trauma 5
- This view demonstrates orbital floor fractures, maxillary fractures, and zygomaticomaxillary complex injuries better than other plain film projections 5
- However, all radiologic abnormalities visible on three-view plain film series are detectable on the single Waters view, making additional Caldwell or lateral views unnecessary 5
Critical Clinical Caveat
Any patient with facial trauma below the orbit requires assessment for vision-threatening injuries before focusing on fracture imaging 1:
- Check for oculocardiac reflex signs (bradycardia, nausea, vomiting) indicating muscle entrapment requiring urgent surgical intervention 1
- Perform forced duction testing to distinguish muscle restriction from paresis 1
- Evaluate for globe injury, hyphema, or penetrating trauma which take priority over fracture management 1, 6
Recommended Imaging Protocol
Non-contrast thin-section orbital CT with multiplanar reconstructions should be obtained for any patient with:
- Periorbital soft tissue swelling or ecchymosis 2
- Diplopia or restriction of ocular movement 2
- Vision loss or visual field defects 1
- Suspicion of orbital wall fractures or muscle entrapment 2, 3
Contrast is not needed in the trauma setting 1, 2, and MRI is contraindicated if metallic foreign bodies are suspected 4, 2.