Emergency Medicine News:
Wiler, Jennifer L. MD, MBA
Dr. Wiler is an assistant professor of emergency medicine and the vice chair of clinical quality, patient safety, and process improvement at the University of Colorado Denver School of Medicine and an adjunct assistant professor of emergency medicine at the Washington University School of Medicine in St. Louis.
A 27-year-old man was involved in an altercation at a bar. He complains of jaw pain and malocclusion. There are no obvious intraoral lacerations that you can appreciate.
What is your diagnosis, and how would you treat this condition? See p. 18.
Diagnosis: Mandible Fracture
Mandibular fractures are the second most common type of fractures in pediatric patients after nasal fractures. (Emerg Med Clin North Am 2013;31:553.) The mandible is the only mobile facial bone, which articulates at the temporomandibular junction, and is prone to injury-related fractures.
Fractures are often the result of direct trauma, and can occur on the same side or adjacent side to the direct blow. Given its U-shape fixed to the skull, the mandible acts like a ring when exposed to a direct blow, resulting in two fractures in approximately 60 percent of cases. (AJNR Am J Neuroradiol 2008;29:890.) Mandibular fractures are often displaced because of the strong tension from the muscular masseter attachments.
The initial evaluation of patients with suspected mandibular fractures should focus on signs of current or impending airway compromise. Anterior mandibular fractures are prone to posterior prolapse of soft tissues and ungula or subungual vascular injury with rapidly expanding hematoma and associated airway obstruction. A patient with limited ability to open his mouth because of fractured elements can significantly impede airway visualization and stabilization. (AJNR Am J Neuroradiol 2008;29:890.) Subjective malocclusion may be a helpful sign to note fracture. (Am J Emerg Med 1998;16:304.) It is concerning for mandibular fracture and necessitates radiologic imaging if the patient fails the “tongue blade test” (unable to keep tongue blade in teeth with active retraction by examiner, or inability to tolerate tongue blade rotational manipulation [must be performed bilaterally]). (Am J Emerg Med 1998;16:304; J Emerg Med 1995;13:297.)
Open fractures and associated dental trauma are common. Intraoral lacerations may be difficult to appreciate because of the inability of the patient to open his mouth; he may present only with blood in his mouth. Avulsed permanent teeth should be held by crown, avoiding the root, and placed in Hanks balanced salt solution (HBSS) or milk until reimplantation and stabilization are possible. (Dent Traumatol 2007;23:297.) Saline (0.9%) is an acceptable short-term alternative for up to two hours. Water can damage the periodontal ligament cells, and should not be used if at all possible. (Dent Traumatol 2002;18:1.) The secondary exam should identify any missing teeth and seek to find them; they could be embedded in adjacent soft tissue, aspirated in the tracheobronchial tree, or swallowed.
Imaging of the suspected isolated mandibular fractures can be performed by plain film series, Panorex, and CT scan. (Plast Reconstr Surg 2001;107:1369.) CT scans may be most helpful in planning operative interventions, however. (Semin Ultrasound CT MR 2009;30:174.)
The treatment of mandibular fractures depends on the age of the patient, dentition status, and the location and degree of fracture displacement. Decisions about management should be made in conjunction with an otolaryngologist or oral maxillofacial surgeon. Options range from operative repair (open reduction and internal fixation [ORIF]) to liquid diet and expectant management. Pediatric patients are at high risk for bone growth disturbance, so surgery is reserved for severe cases. (Oral Maxillofac Surg 2012;16:245.) Emergent treatment does not appear to improve outcomes (Laryngoscope 2011;121:906), and therefore typically occurs within 24-48 hours 0f diagnosis.
Most experts agree that open fractures require prophylactic antibiotic treatment, although the practice is not supported by prospective randomized data. (J Oral Maxillofac Surg 2011;69:1129.) Tetanus immunization should be updated as appropriate, and analgesia should be given for pain.
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