General Examination

Following a rapid ABCD assessment, a general examination is important to identify any further potential threat to the airway and the systemic effects of bleeding. Some specific points to consider in maxillofacial trauma are outlined below.

Look

Look for the following, remembering to use a head light, nasal speculum and suction when examining the nose:

• Areas of swelling, bruising and bleeding – persisting bleeding and/or discharge from the nose may indicate a nasoethmoidal fracture
• Deformity of the nose and zygomatic arch – depression of the zygomatic arch (flattened face) is best identified by looking from above or below
• Septal haematoma of the nose – a haematoma on the side of the nasal septum which needs draining urgently to prevent a ‘saddle nose’ deformity from ischaemic necrosis
• Evidence of injury to the eye(s): the position of the eye and visual acuity must be checked. Enophthalmos and proptosis both indicate a significant orbital injury. Features suggesting progressive retrobulbar haemorrhage require an emergency decompression (lateral canthotomy). Any contact lenses must be removed to prevent keratitis.For a more comprehensive account of eye assessment see the Assessment of the eye module.
• Subconjunctival haemorrhage – if the posterior limit of the haemorrhage cannot be seen, it is likely that blood has tracked round the eye from a fracture of the orbital wall. A clear posterior border suggests a direct blunt injury to the globe. The image shows a subconjunctival haemorrhage from an orbital wall fracture with no posterior border visible

Learning bite

Subconjunctival haemorrhage with no visible posterior margin is a useful sign usually indicating orbital wall fracture.

It may be impossible to accurately identify deformity or evidence of eye injury due to marked swelling. If this is the case, arrangements must be made either to re-examine the patient once the swelling has subsided or, if available, to image the eye using ultrasound, CT or MRI scan.

Feel

Learning Bite

Beware children with maxillofacial trauma. An orbital floor (“trapdoor”) fracture can entrap the inferior rectus muscle much more easily than in adults, leading to ischaemia and permanent diplopia. It is a surgical emergency.

A systematic palpation of facial bony landmarks and an assessment of neurological function should be undertaken, specifically:

• Identifying the zygomatic arch – check for a step or flattening caused by a depressed fracture
• Identifying the periorbital region for the crepitus of surgical emphysema – this indicates a fracture involving a sinus, usually the maxillary
• Intraorally – to assess the maxilla in the upper buccal sulcus for tenderness or a step
• Assessing sensation to the skin supplied by the infraorbital nerve. The image shows cutaneous distribution of the right infraorbital nerve.

Move

Movement of the eye and jaw must be assessed:

• Eye movement, particularly upward gaze, may be restricted in orbital blow-out fractures due to trapping of the herniated inferior rectus muscle
• Limited jaw movement, caused by restricted movement of the coronoid process of the mandible under the zygomatic arch, may be found in depressed fractures of the zygomatic arch. Mandibular fracture may also be a cause – see the LZ session Mandibular and Temperomandibular Injury