Signs of fractures.

By Dr. Vishaal Bhat on Thursday 22 November 2007 with 0 comments



An injured patient’s examination should always begin with a careful anamnesis. A description of events during an injury can help to elucidate its extent and location, providing a patient can recall it.


Soft tissues swelling, changes of physiognomy.

An apparent sign of the middle skull skeleton injuries during the palpation are notably large swollen soft tissues. It appears very shortly after an injury, sometimes the whole face gets swollen (the face resembles a soccer ball). At another cases, such as flattening of a prominent cheek area during zygomatic-maxillar complex fractures, swelling of soft tissues masks a facial area deformation. If the whole middle third gets dislocated downwards and the face gets elongated which can be observed at the nose and the inner eye corners that are limp. During injuries at the nose base or orbital area with breakage of lig. canthus med., the distance between eyes widens (post - injury hypertelorism).


Bite and occlusion maladies.

Damaged occlusion or bite occur after dislocation of fragments. A patient can bite together at the distal molars only and an unclosing, frontally open bite is the result. In case of one-sided injury, a decrease occurs resulting in a traumatic bite on an affected side. If the lower jaw pushes up forcefully, the deformation disappears, but only until the mouth is opened again. In such cases, it is important to examine the hard palate inside the mouth, since an oro-nasal communication may be formed that is a sign of a sagittal fracture of palatal bones.


Bleeding and hemorrhages.

Soft tissue and bony structures damages are accompanied by bleeding. A direct bleeding from the nasal cavity is most frequent, although blood can partially accumulate at secondary nasal sinuses forming blood clots that show up as an obscured maxillar sinus at an X-ray image (at semi-axial projection). Hematomas form at soft tissues. Hematomas of lower or upper eye lids, conjunctiva or the face skin often help to locate affected parts. Hematomas of eye lids are very common, they can close the eye and hamper vision. An “eyeglasses-like” hematoma can develop as a sign of the skull’s base fracture ( it has to be confirmed on an X-ray exam).


Bony structures deformation.

Palpation with gentle and careful touching can revise bony structures shape and location, providing a developed tissue edema or hematoma allows it. At typical places where bone fractures often appear, a physician can sense irregularity, a step or a bone is missing completely as a result of breaking off and shifting away (a dislocated fragment). Places suitable for such examination by palpation are the following: lower and lateral edges of orbits, nose base, hard palate, lateral edge of maxillary sinus (zygomatic-alveolar crista). In cases of widened fractures, these are: the upper edges of orbits, frontal area. A typical sign of fractures in these areas is a subcutaneous emphysema, resulting from air being blown under pressure into the subcutis from secondary nasal sinuses through broken bone walls.


Pathological mobility of fragments or parts of the middle facial third.

During a palpation examination, a movability of bony parts can already be felt, initiated by a slight pressure onto a fragment. It can be used for determination of an injury type and presence or absence of a fracture.


Impairment of vision, mobility of eyeballs or eye-lids.

Vision impairment, hampered eyeballs and eye-lids movability may occur at injuries to bone structures of orbits. Position of both eyeballs can be readily observed by eyes (aspection). An eyeball can be dislocated at different types of injuries ventrally, dorsally, or caudally (dorsally and caudally in cases of breakage of the orbit’s base which happens during isolated hydraulic fractures of orbits). Traumatic enophthalmus occurs as well. On the contrary, an exophthalmus occurs at ventral dislocation. In cases of fractures of an orbital base, an eyeball moves downwards, the eye optical axes shift and double vision - diplopia - appears.

Double vision may occur in cases of trapping an eye moving muscle into a fracture line. For this reason, movability of eyeballs should be examined at all directions in order to identify, at what direction the movement is impaired. If a fracture line runs over the upper orbital fissure, impairment of functions at regions innervated by one of the head nerves (n. oculomotorius, trochlearis and abducens) that are located at these areas may happen.

Category: Oro-Maxillo Facial Surgery Notes

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