# Examination Examination Primary survey The primary survey is aimed at protection of the airway , control of bleeding, restoration and maintenance of the circulation Coma Scale (GCS) score, with cervical spine control. The head and neck region should be inspected, with wounds assessed for skin or soft-tissue loss and subsequently dressed appropriately to control any bleeding. The wound siz e, location and depth should be carefully r ecorded. Large and obvious foreign bodies should be removed but care should be exercised with penetrating wounds involving large fragments or blades, which can potentially penetrate important deep structures. These should be removed in the operating theatre, under more controlled conditions, after appropriate imaging. Secondary survey The secondary survey examination should be conducted in a systematic way , preferably following a top-down approach carefully examining all structures, recording obvious as well as less conspicuous injuries. The surface inspection should include the scalp, posterior neck and ears and then move to the frontal - view . A brief cranial nerve examination should be undertaken as guided by the injury site. Particular attention must be paid to cervical spine examination as the patient with facial injury may have concurrent spinal injury , which may have been missed in the primary assessment. Examination of the eyes should include visualisation of the periorbital tissues and assessment of globe position, visual acuity , diplopia (double vision), intercanthal distance and eye motility . This e xamination may be di ffi cult if the eyelids are swollen and the eyes are shut. However, such an examination is crucial as inadequate examination may lead to a delay in the diagnosis of serious eye injury that may need urgent interven - tion to prevent blindness. Examination is possible even in the most swollen of eyes by gently pulling the eyelids apart with dry gauze, a cotton bud/roll or a microbiology swab stick. Gentle pressure on the eyelid for a brief period may reduce oedema, which may facilitate the opening of the eyelids. It may be help - ful to ask a colleague to perform the eye examination if one is holding the eyelids apart to facilitate examination. The facial bones should be palpated for signs of fractures, which may include step deformity , tenderness or bony asym - metry . A systematic approach would include palpa tion of the supraorbital ridge followed by the lateral orbital wall, inferior orbital rim, zygomatic bone, nasal bones, temporomandibular joint and the rest of the mandible on both sides. The examination of the oral cavity should include inspec - tion for any soft-tissue lacerations, bruising, haematoma, injury to dentition and assessment of occlusion (bite). Any blood and excessive secretions should be suctioned and a good light source used to facilitate thor ough examination. The teeth should be examined and their presence or absence noted. Teeth may be knocked out completely (avulsed), displaced but still attached to soft tissues and/or bone (luxated) or fractured. It is important to account for all missing teeth or tooth fragments as aspiration is a major risk for developing chest infection. If it is unclear about the location of missing teeth, a chest radiograph should be considered. A key feature of displaced mandibular or maxillary frac - tures is altered occlusion. The patient may be able to detect even a tiny alteration in their occlusion. If there is a fracture of the mandible, the o verlying mucosa is often torn and there may be an associated haematoma in the floor of the mouth ( Figure 31.4 ). If the mandibular fracture is grossly displaced, the patient may have altered sensation in the region of the lip and chin, due to damage to the inferior alveolar nerve running along the canal within the mandible and involvement of the mental nerve, a sensory branch, which emerges from the men - tal foramen. Figure 31.4 Left parasymphyseal fracture of the mandible demon strating a step deformity that could be confused with a missing tooth in inexperienced eyes. (a) (b) Figure 31.5 (a) Orthopantomogram (OPT) demonstrating a right man dibular body and left condylar fracture. (b) A posteroanterior mandible radiograph reveals the left low condylar fracture more clearly, which may not be as obvious as in the OPT to an inexperienced clinician. - Figure 31.6 Occipitomental radiograph demonstrating a right zygomatic fracture. Note the right maxillary sinus opaci /f_i cation, which is one of the radiological hallmarks of zygomatic fracture due to collection of /f_l uid in the sinus. Examination Primary survey The primary survey is aimed at protection of the airway , control of bleeding, restoration and maintenance of the circulation Coma Scale (GCS) score, with cervical spine control. The head and neck region should be inspected, with wounds assessed for skin or soft-tissue loss and subsequently dressed appropriately to control any bleeding. The wound siz e, location and depth should be carefully r ecorded. Large and obvious foreign bodies should be removed but care should be exercised with penetrating wounds involving large fragments or blades, which can potentially penetrate important deep structures. These should be removed in the operating theatre, under more controlled conditions, after appropriate imaging. Secondary survey The secondary survey examination should be conducted in a systematic way , preferably following a top-down approach carefully examining all structures, recording obvious as well as less conspicuous injuries. The surface inspection should include the scalp, posterior neck and ears and then move to the frontal - view . A brief cranial nerve examination should be undertaken as guided by the injury site. Particular attention must be paid to cervical spine examination as the patient with facial injury may have concurrent spinal injury , which may have been missed in the primary assessment. Examination of the eyes should include visualisation of the periorbital tissues and assessment of globe position, visual acuity , diplopia (double vision), intercanthal distance and eye motility . This e xamination may be di ffi cult if the eyelids are swollen and the eyes are shut. However, such an examination is crucial as inadequate examination may lead to a delay in the diagnosis of serious eye injury that may need urgent interven - tion to prevent blindness. Examination is possible even in the most swollen of eyes by gently pulling the eyelids apart with dry gauze, a cotton bud/roll or a microbiology swab stick. Gentle pressure on the eyelid for a brief period may reduce oedema, which may facilitate the opening of the eyelids. It may be help - ful to ask a colleague to perform the eye examination if one is holding the eyelids apart to facilitate examination. The facial bones should be palpated for signs of fractures, which may include step deformity , tenderness or bony asym - metry . A systematic approach would include palpa tion of the supraorbital ridge followed by the lateral orbital wall, inferior orbital rim, zygomatic bone, nasal bones, temporomandibular joint and the rest of the mandible on both sides. The examination of the oral cavity should include inspec - tion for any soft-tissue lacerations, bruising, haematoma, injury to dentition and assessment of occlusion (bite). Any blood and excessive secretions should be suctioned and a good light source used to facilitate thor ough examination. The teeth should be examined and their presence or absence noted. Teeth may be knocked out completely (avulsed), displaced but still attached to soft tissues and/or bone (luxated) or fractured. It is important to account for all missing teeth or tooth fragments as aspiration is a major risk for developing chest infection. If it is unclear about the location of missing teeth, a chest radiograph should be considered. A key feature of displaced mandibular or maxillary frac - tures is altered occlusion. The patient may be able to detect even a tiny alteration in their occlusion. If there is a fracture of the mandible, the o verlying mucosa is often torn and there may be an associated haematoma in the floor of the mouth ( Figure 31.4 ). If the mandibular fracture is grossly displaced, the patient may have altered sensation in the region of the lip and chin, due to damage to the inferior alveolar nerve running along the canal within the mandible and involvement of the mental nerve, a sensory branch, which emerges from the men - tal foramen. Figure 31.4 Left parasymphyseal fracture of the mandible demon strating a step deformity that could be confused with a missing tooth in inexperienced eyes. (a) (b) Figure 31.5 (a) Orthopantomogram (OPT) demonstrating a right man dibular body and left condylar fracture. (b) A posteroanterior mandible radiograph reveals the left low condylar fracture more clearly, which may not be as obvious as in the OPT to an inexperienced clinician. - Figure 31.6 Occipitomental radiograph demonstrating a right zygomatic fracture. Note the right maxillary sinus opaci /f_i cation, which is one of the radiological hallmarks of zygomatic fracture due to collection of /f_l uid in the sinus. Examination Primary survey The primary survey is aimed at protection of the airway , control of bleeding, restoration and maintenance of the circulation Coma Scale (GCS) score, with cervical spine control. The head and neck region should be inspected, with wounds assessed for skin or soft-tissue loss and subsequently dressed appropriately to control any bleeding. The wound siz e, location and depth should be carefully r ecorded. Large and obvious foreign bodies should be removed but care should be exercised with penetrating wounds involving large fragments or blades, which can potentially penetrate important deep structures. These should be removed in the operating theatre, under more controlled conditions, after appropriate imaging. Secondary survey The secondary survey examination should be conducted in a systematic way , preferably following a top-down approach carefully examining all structures, recording obvious as well as less conspicuous injuries. The surface inspection should include the scalp, posterior neck and ears and then move to the frontal - view . A brief cranial nerve examination should be undertaken as guided by the injury site. Particular attention must be paid to cervical spine examination as the patient with facial injury may have concurrent spinal injury , which may have been missed in the primary assessment. Examination of the eyes should include visualisation of the periorbital tissues and assessment of globe position, visual acuity , diplopia (double vision), intercanthal distance and eye motility . This e xamination may be di ffi cult if the eyelids are swollen and the eyes are shut. However, such an examination is crucial as inadequate examination may lead to a delay in the diagnosis of serious eye injury that may need urgent interven - tion to prevent blindness. Examination is possible even in the most swollen of eyes by gently pulling the eyelids apart with dry gauze, a cotton bud/roll or a microbiology swab stick. Gentle pressure on the eyelid for a brief period may reduce oedema, which may facilitate the opening of the eyelids. It may be help - ful to ask a colleague to perform the eye examination if one is holding the eyelids apart to facilitate examination. The facial bones should be palpated for signs of fractures, which may include step deformity , tenderness or bony asym - metry . A systematic approach would include palpa tion of the supraorbital ridge followed by the lateral orbital wall, inferior orbital rim, zygomatic bone, nasal bones, temporomandibular joint and the rest of the mandible on both sides. The examination of the oral cavity should include inspec - tion for any soft-tissue lacerations, bruising, haematoma, injury to dentition and assessment of occlusion (bite). Any blood and excessive secretions should be suctioned and a good light source used to facilitate thor ough examination. The teeth should be examined and their presence or absence noted. Teeth may be knocked out completely (avulsed), displaced but still attached to soft tissues and/or bone (luxated) or fractured. It is important to account for all missing teeth or tooth fragments as aspiration is a major risk for developing chest infection. If it is unclear about the location of missing teeth, a chest radiograph should be considered. A key feature of displaced mandibular or maxillary frac - tures is altered occlusion. The patient may be able to detect even a tiny alteration in their occlusion. If there is a fracture of the mandible, the o verlying mucosa is often torn and there may be an associated haematoma in the floor of the mouth ( Figure 31.4 ). If the mandibular fracture is grossly displaced, the patient may have altered sensation in the region of the lip and chin, due to damage to the inferior alveolar nerve running along the canal within the mandible and involvement of the mental nerve, a sensory branch, which emerges from the men - tal foramen. Figure 31.4 Left parasymphyseal fracture of the mandible demon strating a step deformity that could be confused with a missing tooth in inexperienced eyes. (a) (b) Figure 31.5 (a) Orthopantomogram (OPT) demonstrating a right man dibular body and left condylar fracture. (b) A posteroanterior mandible radiograph reveals the left low condylar fracture more clearly, which may not be as obvious as in the OPT to an inexperienced clinician. - Figure 31.6 Occipitomental radiograph demonstrating a right zygomatic fracture. Note the right maxillary sinus opaci /f_i cation, which is one of the radiological hallmarks of zygomatic fracture due to collection of /f_l uid in the sinus.