The greater number of the injuries of the face are too obvious in their nature to require notice here; but it may be pointed out that wounds must always be carefully examined for foreign bodies, that bruises must be examined for signs of fracture of the subjacent bone, and that the swelling following laceration of tissue is often more marked in the face, particularly the lips and eyelids, than in other regions. When from a wound of the cheek there is a great flow of a watery fluid during mastication, the fluid being alkaline in reaction, and amyloid, it indicates a wound of the parotid gland or of Stenson's duct (ductus paroticus). And if, when the rest of the wound heals up, a sinus remains which continues to discharge saliva, it is called a salivary fistula. The alkaline reaction of the fluid, and its intermittent flow, which is always excited by mastication, are usually alone relied upon to decide the nature of the fluid; but if, on adding some of the fluid to a small quantity of a watery decoction of starch, and maintaining it at a temperature of about 100° F for an hour, it is found that the addition of a drop of tincture of iodine fails to give the characteristic deep-blue reaction, and that a brown colour is produced, or no effect at all, the diagnosis is rendered certain. If the wound or the fistula is behind the middle of the masseter muscle, the saliva is escaping from the parotid gland; but if in front of that line, it must be the duct which is wounded.<Callout type="tip" title="Tip">Always check for foreign bodies before treating any facial wounds.</Callout> If, in addition to an ordinary bruise of the face, such as a 'black eye,' there is a distinct swelling, circumscribed, prominent, fluctuating, and dull on percussion, it is a haematoma. Such a swelling may become solid from coagulation of the blood, or may suppurate.<Callout type="important" title="Important">Haematomas can turn into abscesses if not treated properly.</Callout> If immediately after a blow upon the nose a smooth, tense, rounded, glossy, purple swelling is found blocking up one nasal fossa and fixed to the septum of the nose, it is a haematoma of the nasal septum.<Callout type="risk" title="Risk">Nasal fractures can lead to airway obstruction if not addressed promptly.</Callout> If after a blow upon the face there is a puff swelling, soft, crackling under the fingers, and resonant on gentle percussion, it is due to emphysema, and indicates a fracture extending into one of the air-containing cavities of the face. The position of the earliest swelling will indicate whether the fracture is into the frontal sinus, the nose, or the antrum.<Callout type="gear" title="Gear">Sterile gloves are essential for handling facial wounds to prevent infection.</Callout> For the detection of fractures of the facial bones, each bone should be carefully examined to determine whether there is any marked deformity, abnormal mobility, or crepitus. This examination is easily carried out unless there is much swelling of the soft parts. In cases of difficulty a good skiagram will be of great service.<Callout type="warning" title="Warning">Avoid applying pressure directly to suspected fractures; it can worsen the injury.</Callout> Run the forefinger along the bridge of the nose to see if there is any sharp break in it; then, in the same manner, with the two forefingers examine the sides of the nasal bones and the nasal processes of the superior maxillae. To deformity may be added mobility and crepitus, and in that case, there can be no doubt in the diagnosis; the point or line of deformity and mobility will determine the position of the fracture.<Callout type="tip" title="Tip">Always compare both sides when examining facial bones for symmetry.</Callout> Then examine the upper row of teeth and the alveolar process, see if its line is broken, and if any part of it can be moved; with the eye and finger examine the hard palate to determine if it is regular and symmetrical, and that the two halves are not separated. Then throw back the patient's head and, gently everting the nostril, examine the septum nasi on each side; it may be found fractured and displaced vertically or laterally, with depression of the tip of the nose. But care must be taken not to mistake a natural deflection of the septum for a fracture in it; when the mucous membrane over the septum is unaltered in colour and not swollen, the curvature not tender, and there is no unwonted obstruction to the passage of air along the nose, it may be considered a natural deflection of the septum; but when, on the other hand, the curvature is abrupt, the part swollen, discoloured, and tender, and there is unwonted obstruction to nasal respiration, along with flattening or deflection of the nose, it must be regarded as a fracture.<Callout type="important" title="Important">Always check for signs of natural anatomical variations before diagnosing fractures.</Callout> Then compare the two malar bones and note any irregularity, flattening, or mobility of the one struck; and from these pass the fingers back along the zygomatic arches to determine whether either is broken across, which will be indicated by irregularity of the bone and mobility of the fragment. In some cases of fracture of the bones of the face the fragments move with the utmost ease, in others they are impacted; in other cases again there is so much swelling and bruising of the soft parts that the characteristic bony deformity is only detected when this has cleared up, and early diagnosis such cases can only be made with certainty by good stereoscopic skiagrams.<Callout type="tip" title="Tip">Use a combination of visual inspection and palpation to diagnose facial fractures accurately.</Callout> The lower jaw must be examined in a similar manner. The surgeon should first run his fingers along the outer and under surfaces of the body of the bone to detect any irregularity or want of symmetry of the two sides. Then let him look at the line of the teeth, and if any irregularity in it is seen, let him grasp the bone, with one hand on each side of the deformity, and try whether there are mobility and crepitus, and note whether the fracture extends through the alveolar process alone or through the body of the bone as well. If the fracture is opposite to or behind the canine tooth, the sensibility of the lower lip on the same side should be tested, to ascertain whether there is also injury of the inferior dental nerve.<Callout type="important" title="Important">Always test for sensory changes when suspecting facial fractures.</Callout> The surgeon should carefully note whether all the teeth are in place, and if not he should make sure that one has not slipped down between the fragments. The ramus of the bone must then be carefully examined: by seizing the angle mobility can be tried for; the contour of the posterior border as well as of the surface should be felt through the masseter muscle. Should these parts be sound and yet the patient complains of great pain in opening and closing the mouth, while he can himself feel and hear crepitus, the coronoid and articular processes should be carefully examined. Place the forefingers, one immediately in front of each pinna, to feel the condyles in their normal position, carefully compare them to make certain whether they are or are not symmetrical, and look closely at the position of the chin, noting whether the space between the lower central incisor teeth is vertically below that between the upper; should there be deformity of one condyle, while the chin is displaced to the same side, a fracture of the neck of the jaw on that side is to be diagnosed. The coronoid process is to be explored by the finger in the mouth, which may detect that it is movable on the rest of the bone, and sometimes a sharp projecting edge or point of the fracture can be felt.<Callout type="warning" title="Warning">Be cautious when moving the jaw; improper handling can worsen the injury.</Callout> If, however, on placing the finger immediately in front of the tragus, the firm, slightly projecting condyle of the lower jaw is not to be detected, but, on the contrary, a hollow (the glenoid fossa) is felt, while there is a fullness of the temporal fossa just above the zygoma, there is a dislocation of the jaw. This may be unilateral, in which case the chin is displaced to the opposite side, or bilateral, when the mouth will be open and the chin protruded.<Callout type="important" title="Important">Dislocated jaws require immediate attention to prevent airway obstruction.</Callout>
Key Takeaways
- Carefully examine wounds for foreign bodies and signs of underlying fractures.
- Recognize the specific symptoms of salivary fistulas, haematomas, and emphysema.
- Use a combination of visual inspection, palpation, and mobility tests to diagnose facial fractures accurately.
Practical Tips
- Always wear sterile gloves when handling facial wounds to prevent infection.
- Keep an eye out for natural anatomical variations that can mimic fractures.
- Use a skiagram if you are unsure about the diagnosis of a facial fracture.
Warnings & Risks
- Avoid applying direct pressure to suspected fractures; it can worsen the injury.
- Be cautious when moving the jaw; improper handling can cause further damage.
- Dislocated jaws require immediate attention to prevent airway obstruction and other complications.
Modern Application
While many of the techniques described in this chapter are rooted in historical practices, the principles of careful examination and accurate diagnosis remain crucial for modern survival preparedness. Understanding how to identify and manage facial injuries can be vital during emergencies where medical facilities may not be readily available.
Frequently Asked Questions
Q: How can I tell if a facial wound is infected?
Look for signs of infection such as increased swelling, redness, warmth, or pus. If present, the wound should be cleaned and treated with antibiotics to prevent further complications.
Q: What are some common signs of a fractured jaw?
Common signs include pain when opening and closing the mouth, difficulty swallowing, and changes in bite alignment. A dislocated jaw may also cause an open mouth position or protrusion of the chin.
Q: How can I test for sensory changes after a facial injury?
Gently touch different areas of the face with a pinprick to check if sensation is normal on both sides. Any loss of sensation could indicate damage to nerves and should be evaluated by a medical professional.