When would a spiral facial CT scan be appropriate?
Although it is widely recognised [10] that a spiral facial CT scan is far more accurate at identifying ZMC and zygomatic arch fractures, its use in the ED is restricted to either a second line investigation, usually initiated by the maxillofacial team, or when other injuries (e.g. cervical spine injury) prevent routine facial x-rays being performed.
The facial CT shows an opacified right maxillary sinus.
What methods of investigation could be used to diagnose an orbital blow-out fracture?
The diagnosis of an orbital blow-out fracture may be made on routine facial x-rays (e.g. a teardrop sign) but CT scan remains the gold standard if this injury is suspected or identified. Relatively recently, focused ocular ultrasound (FOUS) has been evaluated in the ED [11,12] and found to be highly accurate in both diagnosing and excluding both orbital and ocular trauma.
The x-ray shows a teardrop sign on the left (arrow) indicating an orbital blow-out fracture.
Are x-rays of the nasal bones necessary?
It is now universally recognised that x-rays of the nasal bones are unnecessary as they do not alter management of the injury. EM doctors attempt to justify them [13] and they are still being performed [14], but they are not warranted for either clinical or medico-legal reasons due to a poor sensitivity and specificity.
Learning bite
There can be no justification for ordering x-rays of the nasal bones for a patient with a suspected nasal fracture.