Mandible fracture: Difference between revisions
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==Background==
==Background==
*Always make sure that a unilateral fx is not in fact b/l
[[File:Mandbular fractures.png|thumb|Mandibular fracture frequency by location<ref> Marius Pricop, Horațiu Urechescu, Adrian Sîrbu (Mar 2012). "Fracture of the mandibular coronoid process – case report and review of the literature". Revista de Chirurgie Oro-maxilo-facială și Implantologie (in Romanian). 3 (1): 1–4. ISSN 2069-3850. 58. Retrieved 2012-08-19.[permanent dead link]</ref>]]
*Presume an open fx until intraoral examination shows otherwise
[[File:Gray176.png|thumb|Mandibular anatomy, lateral view.]]
*Favorable vs unfavorable based on whether musculature reduces or opens the fx
[[File:Gray177.png|thumb|Mandibular anatomy, medial view.]]
*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


==Diagnosis==
==Clinical Features==
===History===
*Malocclusion
*Malocclusion
*Pain worsened by attempted movement
*Pain worsened by attempted movement
===Exam===
 
*Bite test
==Differential Diagnosis==
**Have pt bite on tongue blade and twist it
{{Maxillofacial trauma DDX}}
***If mandibular Fx present pt should reflexively open mouth (can't break blade)
 
****Sn 95%, Sp 65%
==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:
**Open fx
**Sublingual hematoma (suggestive of occult mandible fracture)
**Sublingual hematoma (suggestive of occult mandible fx)
**Dental or alveolar ridge fracture
**Dental or alveolar ridge fx
*Condyle injury test
*Condyle injury test
**Place finger into external auditory canal and have pt open and close mouth
**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
===Management===
 
*Imaging
===Workup===
**Panorex is initial imaging study of choice
''If high-risk (e.g. positive bite-test)''
**CT face or mandible if:
*Panorex is initial imaging study of choice (if available)
***Suspected condyle fx
*CT face or mandible if:
***Complex fx
**Suspected condyle fracture
***Multiple facial fx
**Complex fracture
*Barton's bandage  
**Multiple facial fractures
 
==Management==
*Consider Barton's bandage  
**Ace wrap over top of head and underneath mandible
**Ace wrap over top of head and underneath mandible
*Abx
*Prophylactic antibiotics (treat all empirically as "open" fractures)
**Penicillin G IV 2-4million units OR
**[[Penicillin G]] IV 2-4million units '''OR'''
**Clindamycin 600-900mg (if penicillin-allergic)
**[[Clindamycin]] 600 QID (if penicillin-allergic)
===Disposition===
 
*Closed fx > urgent oupt f/u
==Disposition==
*Open fx > admission for operative repair
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)
#Unable to tolerate POs or secretions
#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 follow up as outpatient in 2-3 days


==See Also==
==See Also==
[[Maxillofacial Trauma]]
*[[Maxillofacial Trauma]]


==Source==
==References==
*Tintinalli's
<references/>


[[Category:ENT]]
[[Category:ENT]]
[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 20:16, 2 December 2021

Background

Mandibular fracture frequency by location[1]
Mandibular anatomy, lateral view.
Mandibular anatomy, medial view.
  • 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

Evaluation

Non-displaced fracture of the mandible on CT.
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
  • 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)

Disposition

Admit (ENT, OMFS, Plastics) for:[2]

  1. Airway compromise (e.g when lying flat)
  2. Unable to tolerate POs or secretions
  3. Inadequate pain control
  4. Open and/or unstable fractures[3]
  • Otherwise may follow up as outpatient in 2-3 days

See Also

References

  1. ↑ Marius Pricop, Horațiu Urechescu, Adrian Sîrbu (Mar 2012). "Fracture of the mandibular coronoid process – case report and review of the literature". Revista de Chirurgie Oro-maxilo-facială și Implantologie (in Romanian). 3 (1): 1–4. ISSN 2069-3850. 58. Retrieved 2012-08-19.[permanent dead link]
  2. ↑ Trauma: A Comprehensive Emergency Medicine Approach,, eds. Erick Legome and Lee W. Shockley. Cambridge University Press 2011.
  3. ↑ Widell T et al. Mandible Fracture Treatment & Management. Oct 2016. https://emedicine.medscape.com/article/825663-treatment#d2.
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