Evaluation of the patient is the critical first step to assure complete and accurate fracture repair and optimal aesthetic results. There may be a temptation to truncate the physical exam, in deference to the almost universal use of admission pan computerized tomography (CT) for trauma patients. Although high-resolution CT has been a great advance in the diagnosis, treatment, and postoperative critical evaluation of facial trauma, imaging is not a substitute to the laying on of hands in a focused head and neck trauma evaluation. Poor aesthetic results should not be accepted in facial fracture repair, as the primary motivation for their repair in many cases is cosmesis.
Regardless of the existence of scans, or the putative diagnosis offered by the consulting physician, each new facial trauma patient should be evaluated in a systematic fashion, beginning with the history and physical exam.
All facial trauma patients are trauma patients, and are best served by the standardized Advanced Trauma Life Support (ATLS)
approach taught by the American College of Surgeons
. This evaluation process ensures the orderly evaluation and prioritization of treatment of the most lethal injuries first
. All residents and those practicing surgeons who manage facial trauma must be familiar with the trauma
evaluation process, and should consider certification in ATLS. We shall highlight portions of the trauma evaluation process that are particularly germane to the care of the maxillofacial trauma patient.
Airway issues can potentially be seen with any head and neck trauma sufficient to result in midface fractures. While isolated midfacial trauma is unlikely to compromise the airway, accompanying mandible fractures are particularly significant in this regard. A loss of continuity of the mandible arch results in retrusion of the tongue and larynx, which may create an obstructed upper airway. When evaluating such a patient, consideration should be given both to immediate need for airway management and its implications for fracture repair. If elective intubation (as opposed to an emergent airway) is possible, alternatives to oral intubation should be entertained if maxillomandibular fixation (MMF) will be required for fracture repair.
Concomitant C-spine injuries
are also common in patients with facial fractures, with an incidence approaching 10% (22
). All facial trauma patients should thus be managed with C-spine precautions as proscribed by ATLS, even though this can significantly complicate the evaluation and management of the facial injuries.
Neurologic deficits should be sought and well documented if they exist. Of particular pertinence in the facial trauma patient are cranial neuropathies. A regimented exam of cranial nerves II-XII should be performed. Findings of significance that may impact the timing and approach to repair include neuropathies affecting the eye (cranial nerves II, III, IV, and VI), the trigeminal nerve, and the facial nerve.
Eye-related cranial neuropathies might make surgery an emergency, especially if associated with an open globe. Conversely, the presence of a compromised optic nerve (optic neuropathy) may delay facial fracture management. More details of the ophthalmologic evaluation of facial trauma patients are presented below.
Trigeminal nerve injury is not an emergency per se but must be documented preoperatively. If not, the assumption is made that it was a surgical complication and this has been a point of litigation specifically related to facial fracture repair. Facial nerve dysfunction is usually related to a temporal bone fracture or extensive facial soft tissue injury. It is important to know if the nerve was functioning upon presentation or not. This will help with the decision to explore and perhaps repair the nerve immediately or to treat expectantly.
The Facial Assessment
There are key elements of the exam that must be appreciated and documented preoperatively. These elements will help the surgeon appreciate the full extent of the facial trauma as well as avoid problems with litigation that is a potential element in trauma cases.
The appearance of the face is examined. Is it wide or long? Is it asymmetrical? It is helpful but often difficult to obtain current pretrauma photos to assist with this assessment. Appreciation of any lacerations is important for planning surgical access as well as to focus exam for cranial nerve deficits. A full facial movement and sensory examination is also advised regardless of hard or soft tissue injury.
Overlying edema and patient discomfort may limit the utility of palpation. Still, palpation of the facial skeleton is mandatory, and can provide a more thorough understanding of the location of fractures and the extent of their displacement and mobility. A bimanual exam of the face should be performed. Placing gloved fingers in the mouth while stabilizing the head and face at various levels is used to examine for dentoalveolar and palatal stability, as well for the Le Fort fractures. Both visual and subjective (patient’s report) occlusal changes are vital to obtaining a successful reduction of facial fractures. Finally, are there exposed fracture elements and what is the status of the soft tissue? Will there be adequate soft tissue for reduction and closure of the fracture?
The Ophthalmologic Evaluation
The ophthalmologic exam of facial trauma patients deserves special emphasis and should never be deleted. Ocular injury is common in the facial trauma patient, at the time of initial injury, during the course of surgical repair, and even postoperatively. These injuries may be particularly devastating for patient and surgeon alike.
Early and complete ophthalmologic evaluation of every patient who has sustained a ZMC fracture (or any fracture involving the orbit) is an ideal yet often unrealized goal. The incidence of major (potentially blinding) ocular injury in ZMC fractures that require repair has been reported as 10% (23
). Reconstructive surgeons must be sensitive to the possibility of direct ocular trauma and obtain consultation as indicated. A minimal preoperative examination includes testing of visual acuity (subjective and objective in both eyes), pupillary function, and ocular motility; inspection of the anterior chamber for hyphema; and visualization of the fundus for gross disruption. The presence of an afferent pupillary defect
should be specifically sought, as this is a sensitive indicator of the presence of optic neuropathy
. A decrease in visual acuity, alteration in color perception, or any abnormality observed on the other portions of this screening examination warrants detailed examination by an ophthalmologist before reconstruction of the bony injuries is undertaken.