History and Examination for Maxillofacial Injuries
It is important to elicit careful medical, dental and accident histories: Your initial record of the history may be used to give evidence to the police, particularly in cases of alleged assault. It is therefore important to be as comprehensive as possible, even at 4am with the intoxicated patient. It may not seem vital at the time but it can be very difficult to recall events accurately at a later stage.
History:
- When, where and how did the injury occur? What hit with - fist/weapon/sports equipment?
- Who was involved? Anybody else present? Alcohol involved?
- Be alert to the possibility of other injuries
- Unconsciousness? Amnesia? Vomiting? Visual disturbances? - neurological problem, be very wary of accepting. Discuss with 2nd on call/neurology
- Any allergies or serious illnesses?
- Any previous injuries to the teeth?
- Always record any assault as an alleged assault, you weren't at the incident so you only have the patients' account of what happened
Examination:
- Full examination of hard and soft tissues in a systematic fashion. Do not just focus on the obvious.
- Extra-oral examination
- stand behind the patient, palpate the supraorbital rims, ZF suture and infraorbital rims - note any tenderness or step defects
- palpate the zygomas and zygomatic arches, note any dishing/flattening of the face, infra-orbital nerve parasthesia
- palpate the TMJs and assess mouth opening
- palpate the mandible from the mental region to the angle, again note any parasthesia, step defects or tenderness
- get the patient to open against gentle pressure from your hand, no pain on opening against resistance almost certainly signifies no mandibular fracture
- hold the anterior hard palate with thumb and forefinger with one hand, place your thumb and forefinger of the other hand at the top of the nasal bridge and apply gentle pressure to the hard palate to assess for a Le Fort fracture
- note any lacerations, abrasions or contusions - it is often helpful to draw a diagram of the areas of injury
- clean any lacerations with saline and a gauze swab and assess the extent (superficial/deep to muscle/through and through)
- ensure visual acuity, preferably with a Snellen Chart but a simple question asking of any visual changes can be very useful
- assess eye movement in all fields, assess for diplopia, enopthalmus, exopthalmus and subconjunctival haemhorrage
- a quick check to ensure there is no septal haematoma is very important to ensure there is no necrosis of the nasal septum
- Intra-oral examination
- Check for missing teeth
- Check for step defects/mobility of the mandible at a suspected fracture site - this can be performed by holding the two edges of the mandible and applying pressure to assess any movement
- check for sublingual haematoma - almost certainly a mandibular fracture
- mobility of teeth, displacement of teeth, percussion testing +/- vitality testing
- check for occlusal disturbances
- A Lost tooth needs locating - risk of aspiration especially if LOC. If unable to locate tooth, you need to order a chest x-ray
- Radiographic (+photographic) examination. The most common radiographic projection will be the OPG, a PA mandible is required if there is a suspected mandible fracture. Occipitomental views (2 at different angles e.g. 15 and 30 degrees) are used to assess for fractures of the zygomatic complex. Soft tissue x-rays can be ordered if there is a risk of a radio-opaque foreign body in the soft tissues, e.g. tooth/glass. CT scans are invaluable in assessing complex craniofacial trauma and 3D reconstructions show fine detail to such an extent that often no other views are required.
See also
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