Mandible fracture: Difference between revisions
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==Background== | ==Background== | ||
*Always make sure that a unilateral | *Always make sure that a unilateral fracture is not in fact bilateral | ||
*Presume an open | *Presume an open fracture until intraoral examination shows otherwise | ||
*Favorable vs unfavorable based on whether musculature reduces or opens the | *Favorable vs unfavorable based on whether musculature reduces or opens the fracture | ||
== | ==Clinical Features== | ||
*Malocclusion | *Malocclusion | ||
*Pain worsened by attempted movement | *Pain worsened by attempted movement | ||
=== | |||
==Differential Diagnosis== | |||
{{Maxillofacial trauma DDX}} | |||
==Evaluation== | |||
[[File:NoDisManFracMark.png|thumb|Non-displaced fracture of the mandible on CT.]] | |||
[[File:3D CT mandible fracture.jpg|thumb|3D CT reconstruction of mandible fracture, white arrow marks fracture, red arrow marks moderate displacement and open bite]] | |||
===Bite-Test=== | |||
*Have patient bite on tongue blade and twist it | |||
**If mandibular fracture present patient should reflexively open mouth (cannot break blade) | |||
***Sn 95%, Sp 65% | |||
===Exam for concomitant injuries=== | |||
*Test for inferior alveolar and mental nerve injury | *Test for inferior alveolar and mental nerve injury | ||
*Intraoral exam to rule-out: | *Intraoral exam to rule-out: | ||
**Sublingual hematoma (suggestive of occult mandible | **Sublingual hematoma (suggestive of occult mandible fracture) | ||
**Dental or alveolar ridge | **Dental or alveolar ridge fracture | ||
*Condyle injury test | *Condyle injury test | ||
**Place finger into external auditory canal and have | **Place finger into external auditory canal and have patient open and close mouth | ||
*Check Stenson's duct for bleeding | *Check Stenson's duct for bleeding | ||
===Workup=== | |||
''If high-risk (e.g. positive bite-test)'' | |||
*Panorex is initial imaging study of choice (if available) | |||
*CT face or mandible if: | |||
**Suspected condyle fracture | |||
**Complex fracture | |||
**Multiple facial fractures | |||
==Management== | ==Management== | ||
* | *Consider Barton's bandage | ||
**Ace wrap over top of head and underneath mandible | **Ace wrap over top of head and underneath mandible | ||
*Prophylactic antibiotics (treat all empirically as "open" fractures) | *Prophylactic antibiotics (treat all empirically as "open" fractures) | ||
**Penicillin G IV 2-4million units OR | **[[Penicillin G]] IV 2-4million units '''OR''' | ||
**[[Clindamycin]] 600 | **[[Clindamycin]] 600 QID (if penicillin-allergic) | ||
==Disposition<ref>Trauma: A Comprehensive Emergency Medicine Approach,, eds. Erick Legome and Lee W. Shockley. Cambridge University Press 2011.</ref> | ==Disposition== | ||
Admit (ENT, OMFS, Plastics) for:<ref>Trauma: A Comprehensive Emergency Medicine Approach,, eds. Erick Legome and Lee W. Shockley. Cambridge University Press 2011.</ref> | |||
#Airway compromise (e.g when lying flat) | #Airway compromise (e.g when lying flat) | ||
#Unable to tolerate POs or secretions | #Unable to tolerate POs or secretions | ||
#Inadequate pain control | #Inadequate pain control | ||
#Open and/or unstable fractures<ref>Widell T et al. Mandible Fracture Treatment & Management. Oct 2016. https://emedicine.medscape.com/article/825663-treatment#d2.</ref> | |||
*Otherwise may | *Otherwise may follow up as outpatient in 2-3 days | ||
==See Also== | ==See Also== | ||
[[Maxillofacial Trauma]] | *[[Maxillofacial Trauma]] | ||
==References== | ==References== | ||
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[[Category:ENT]] | [[Category:ENT]] | ||
[[Category: | [[Category:Orthopedics]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 05:48, 10 May 2019
Background
- Always make sure that a unilateral fracture is not in fact bilateral
- Presume an open fracture until intraoral examination shows otherwise
- Favorable vs unfavorable based on whether musculature reduces or opens the fracture
Clinical Features
- Malocclusion
- Pain worsened by attempted movement
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Evaluation
Bite-Test
- Have patient bite on tongue blade and twist it
- If mandibular fracture present patient should reflexively open mouth (cannot break blade)
- Sn 95%, Sp 65%
- If mandibular fracture present patient should reflexively open mouth (cannot break blade)
Exam for concomitant injuries
- Test for inferior alveolar and mental nerve injury
- Intraoral exam to rule-out:
- Sublingual hematoma (suggestive of occult mandible fracture)
- Dental or alveolar ridge fracture
- Condyle injury test
- Place finger into external auditory canal and have patient open and close mouth
- Check Stenson's duct for bleeding
Workup
If high-risk (e.g. positive bite-test)
- Panorex is initial imaging study of choice (if available)
- CT face or mandible if:
- Suspected condyle fracture
- Complex fracture
- Multiple facial fractures
Management
- Consider Barton's bandage
- Ace wrap over top of head and underneath mandible
- Prophylactic antibiotics (treat all empirically as "open" fractures)
- Penicillin G IV 2-4million units OR
- Clindamycin 600 QID (if penicillin-allergic)
Disposition
Admit (ENT, OMFS, Plastics) for:[1]
- Airway compromise (e.g when lying flat)
- Unable to tolerate POs or secretions
- Inadequate pain control
- Open and/or unstable fractures[2]
- Otherwise may follow up as outpatient in 2-3 days
See Also
References
- ↑ Trauma: A Comprehensive Emergency Medicine Approach,, eds. Erick Legome and Lee W. Shockley. Cambridge University Press 2011.
- ↑ Widell T et al. Mandible Fracture Treatment & Management. Oct 2016. https://emedicine.medscape.com/article/825663-treatment#d2.