Examination of Facial Trauma

Facial trauma will constitute a large number of patients you see in the emergency department. This section will discuss how to conduct a thorough examination of the facial skeleton and the necessary investigations. Please note the examination tips provided below are not an exhaustive list.

Taking a history

As always it is crucial to obtain an accurate medical history. In addition to this you need to record a trauma history, the following things should be noted but this is not exhaustive:
1) Time and place of injury?
2) Mechanism of injury. If the injury was sustained due to an alleged assault, are the police involved?
3) Visual disturbances
4) Does the patient feel his/her teeth are meeting as they normally would?
5) Is there any numbness over the face?
6) Loss of consciousness and/or nausea/vomiting?
7) Are there are any safeguarding issues?

Lastly three important questions to ask before accepting a referral are:
1) Has the patient been cleared of a head injury?
2) Is there an injury to the cervical spine? If so, is it stable?
3) Are other specialties involved?

If the C-spine has not been stabilized/cleared and the patient has not been cleared of a head injury then these two things must be addressed before any maxillofacial input or surgery is to be planned or performed. It is worth asking, when the patient last had anything to eat or drink to plan for theatre should they need it.

Moving onto your physical examination try to develop a systematic assessment to ensure your findings are comprehensive.

Figure 1. Skull anatomy [1]


General signs to look out for:
1) General inspection
2) Elongation of face
3) Increased intercanthal distance
4) Dish face

Figure 2. Dish face [2]

Frontal region

Check for the following:
1) Lacerations
2) Loss of sensation over forehead
3) Lacerations within the hairline, scalp, eyebrows
4) Step deformities


Check for the following:
1) Lacerations
2) Inspection of tympanic membrane
3) Bleeding/CSF leak may indicate skull base/temporal bone fracture
4) Battle’s sign (mastoid ecchymosis) may also indicate skull base/temporal bone fracture

Figure 3. Battle's sign [3]

Eyes and Orbit

Things to check:
1) Position and alignment of eyes, inspect globes for proptosis, enophthalmos
2) Lacerations
3) Subconjunctival hemorrhage
4) Pupillary reflex – equal and reactive? Should be tested directly and indirectly
5) Range of eye movements/presence of restriction in a H pattern
6) Diplopia
7) Palpate orbital rim for step deformities
8) Palpate peri-orbital tissues for surgical emphysema
9) Visual acuity – Snellen chart
10) Retrobulbar haemorrhage – decreased vision, orbital pain, proptosis, inability to discern colour red, increased intra-ocular pressure, tense hard globe. Note this is an emergency and the on-call ophthalmologist should be contacted immediately to perform a lateral canthotomy. A delay in surgery can result in permanent vision loss. For more information on retrobulblar haemorrhages, please click here.

If you are ever in doubt regarding your eye assessment, obtain an ophthalmology assessment

Figure 4. Retrobulbar haemorrhage [4]

Nasal Skeleton

Thing to look for:
1) Deformities, lacerations – is the cartilage involved?
2) Intranasal examination – lacerations, septal fractures, septal haematoma
3) Presence of rhinorrhea – indicates skull base fracture
4) Palpate nasal bones for mobility, crepitus and obvious deviation
Note a septal haematoma should be treated immediately as it can lead to septal necrosis which can result in a nasal deformity long term. This is often managed by ENT. Incision and drainage can resolve a septal haematoma but should only be done if confident.

Zygomatico-maxillary complex

Thing to look for:
1) Facial asymmetry
2) Lacerations
3) Loose/missing teeth
4) Malar depression - Inspection from birds eyes view
5) Difficulty in opening mouth/lateral excursions
6) Palpate bony tenderness and crepitus
7) Infra-orbital nerve numbness
8) Mobility of maxilla - place thumb above upper central incisors and index finger on the palate and determine if there is any mobility of the maxilla in an AP/lateral direction
9) Intra-oral examination - bruising over buccal mucosa/buttresses, step deformities, tenderness over buttresses

Figure 5. OM view. Left zygomatic arch fracture [5]

Mandibular examination

Thing to look out for:
1) Lacerations
2) Loose/missing teeth
3) Mouth opening in mm
4) Step deformity along length of mandible and border
5) Numbness of lower lip
6) Sublingual haematoma – pathongnomic of a fractured mandible
7) Assess the occlusion – anterior open bite, premature contact, are the teeth not meeting on both sides?

Figure 6. PA mandible. Left parasymphysis
fracture [6]


Radiographic imaging is the mainstay of confirming facial fractures and there are a number of views obtainable. For CT scans, you must gain permission from a senior to request these as there is a set criterion.
Mid-face fractures - occipitomental (OM) views at 10 and 30 degrees
Fractured mandible - OPG (required) & Posteroanterior (PA) mandible (required)
Orbital fractures - CT orbits (ensure coronal, sagittal and axial views available)
Complex fractures of facial skeleton (ZMC fractures, frontal bone fractures, orbital fractures) - CT head (ensure coronal, axial and sagittal views are available)


[1] skull | Definition, Anatomy, & Function [Internet]. Encyclopedia Britannica. 2020. Available from: https://www.britannica.com/science/skull
[2] Knoop K. Atlas of emergency medicine. New York: McGraw-Hill Professional; 2010. [3] Becker A, Metheny H, Trotter B. Battle Sign [Internet]. Ncbi.nlm.nih.gov. 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537104/
[4] Essentials for Top 10 Eye Emergencies [Internet]. American Academy of Ophthalmology.Available from: https://www.aao.org/young-ophthalmologists/yo-info/article/essentials-for-top-10-eye-emergencies
[5] Murphy A. Zygomatic arch fracture | Radiology Case | Radiopaedia.org [Internet]. Radiopaedia.org. 2020. Available from: https://radiopaedia.org/cases/zygomatic-arch-fracture-1
[6] Imaging Mandibular Fractures - wikiRadiography [Internet]. Wikiradiography.net. 2020. Available from: http://www.wikiradiography.net/page/Imaging+Mandibular+Fractures