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Identification of Specific Bony Injuries and Facial Neurologic
Deficits
Following airway stabilization and cervical spine protection, examination for
specific bony injuries should be performed. After careful observation for
deformity and asymmetry, the clinician should palpate the facial bones in a
systematic fashion ( Fig. 107.1 ). Tenderness, crepitus, and “step off” are signs of
underlying fracture. Particular attention should be paid to the malar eminences,
zygomatic arches, and superior and inferior orbital rims.
Assessment for a fracture of the maxilla can be performed by grasping and
attempting to move the upper central teeth. Any laxity of the maxilla or crepitus
is suggestive of fracture. External and intraoral palpation of the mandibular
symphysis, body, angle, and ramus can help diagnose fractures in these areas.
Inspection of the mouth and oral cavity should also be performed to assess for
injury to the maxilla and mandible. Occlusal disharmony is an indication of
mandibular and/or maxillary displacement. Older children will be able to report if
their bite “feels normal.” Opposing teeth that do not come together, but that
exhibit wear facets (smoothing of mammillations along the incisal surfaces of the
teeth) suggest a traumatic malocclusion. An inability to hold a tongue blade
between occluded teeth on each side of the mouth is suggestive of a mandibular
fracture.
Examination of the eyes should include the assessment of pupillary reactivity
and size, examination of extraocular movements, visual acuity, and a thorough
inspection for surrounding orbital injuries. Orbital dystopia and/or enophthalmos
are suggestive of a fracture of the orbit. Examination of the nose should include
documentation of focal tenderness, swelling and asymmetry, bleeding, or other
nasal discharge, as well as the presence or absence of a septal hematoma.