History and Physical Examination
After the patient has been initially stabilized, as complete a history as possible should be obtained. This history should be obtained from the patient; however, because of loss of consciousness or impaired neurologic status, information must often be obtained from witnesses or accompanying
family members. Five important questions should be considered: (1) How did the accident occur? (2) When did the accident occur? (3) What are the specifics of the injury, including the type of object contacted, the direction from which contact was made, and similar logistic considerations? (4) Was there a loss of consciousness? (5) What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and malocclusion? A complete review- of systems, including information about allergies, medications, and previous tetanus immunization, medical conditlons, and prior surgesies should be obtained.
FIG. 24-2 Tracheostomy, and cricothyrotomy sites with landmarks for emergency surgical airway access.
A neurologic examination of the face should include careful evaluation of all cranial nerves. Vision, extraocular movements, and pupillary reaction to light should be carefully evaluated. Visual acuity or pupillary changes
may suggest intracranial (cranial nerve II-or III dysfunction) or direct orbital trauma. Uneven pupils (anisocoria) in a lethargic patient suggest an i~tracranial bleed (sub-
FiG. 24-3 Periorbital ecchyrnosrs and lateral sUUCUIlJUlKtl>JIIH:1lion IIU;)l’ J~;u(iatt!d witfl
zygomatic complex fracture
dural or epidural hematoma or intraparenchvmal bleed I or injury .. ·\n avyrnmetric or .irregular (not round) pupil is most likelv 4,,’I~ed by a globe (ereball) perforation . .Abnormalltlcs of ocular movements 111ayalso indicate either central neurologic problems (cranial ncrv es III, 1\’,
or \’1) or mechanical restriction of the movements of the eye muscles, resulting from’ fractures of the orbital complex (Fig. 24-4). Motor function of the facial muscles (cranial nerve VII) and muscles of mastication (cranial
nerve V) and sensation over the facial area (cranial nerve V) should be evaluated. Any lacerations should be carefully cleaned and’ evaluated for possible transection of major nerves or dllcts,such as the facial nerve or’
The evaluation Of the midface begins with an assessment of the mobility of the maxilla either as an isolated structure or in combination with the zygoma or nasal bones. To assess maxillary mobility, the patient’s head
should be stabilized by using pressure over the forehead with one hand, With the thumb and forefinger of the other hand, the maxilla is grasped; firm pressure should be used to elicit maxillary mobility (Fig. 24-6).
F!G. 24-4 A, 14-year-old patient with a left orbital floor fracture in upward gaze. B, Entrapment of inferior rectus muscle is the result of impingement in area of linear orbital floor racture. In down gaze, patient is unable to rotate the left eye nferiorly
Intraoral inspection should include an evaluation of areas of mucosal laceration or ecchymosis in the buccal vestibule or along the palate and an examination of the occlusion and areas of loose or missing teeth. These areas .should be assessed before, during, and. after manual manipulation of the mandible and midface. Unilaterai occlusal prematurities with contralateral open bites. arc. highly suspicious for some type of jaw fracture.
FIG 24-5 AND 24-6
FIG. 24-7 Injury to nasoorbital-ethmoid (NOE) complex, which resulted in the displacement of medial canthal Ugaments and a widening of the intercanthal distance (i.e., traumatic telecanthus),