Palpation will disclose the majority of facial fractures. The entire face should be palpated carefully for tenderness, bony crepitus, and subcutaneous air. The presence of subcutaneous air is pathognomonic for fracture of a sinus or nose.
During palpation, target vulnerable sutures such as those on the infraorbital rim and the zygomatic-frontal suture located on the upper lateral aspect of the orbit. Simultaneous palpation of the zygomatic arches will reveal any asymmetry. The best way to distinguish tenderness of the soft tissues of the cheek from bony tenderness is by intraoral palpation. Place a gloved finger inside the patient's mouth and on the buccal surface of the upper molars (outside the teeth). In this position, locate the examining finger under the zygomatic arch. This method will identify displacement or collapse of the arch.
To assess facial stability, open the patient's mouth and grasp the maxillary arch ( not the central incisors—which might pull out). LeFort fractures are best diagnosed by rocking the maxillary arch and simultaneously feeling the central face for movement with the opposite hand. This maneuver is more sensitive for maxillary fractures than are plain films.
Test sensation. Although anesthesia of the face may be secondary to nerve contusion, it often signifies a fracture. Damage to the infraorbital nerve (often due to blowout or rim fractures) results in anesthesia of the ipsilateral upper lip, nasal mucosa at the vestibule, lower eyelid, and maxillary teeth. Lower lip and lower dental anesthesia occurs with mandibular fractures.
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