Facial fractures: The "bottom-up" approach

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.