Pediatric emergency medicine trisk 813

ideal, they are alternative mediums that are preferred over water or worse
allowing the root surface to air dry ( Fig. 105.5 ). The patient should proceed
directly to the dentist for radiographs, final alignment, splinting, and close followup.

JAW FRACTURES
CLINICAL PEARLS AND PITFALLS
Trauma to the chin may result in a condylar fracture.
Because the jaw is a ring structure, identification of a single fracture
warrants careful examination for an accompanying injury.
Mandibular fractures can lead to airway compromise, most commonly
secondary to tongue and soft tissue falling against the posterior
pharyngeal wall.

Current Evidence
Mandibular fractures are the third most common facial fractures in children
(behind frontal and nasal bones). Whenever a facial fracture is present, the
cervical spine, CNS, orbits, and teeth need to be carefully evaluated for
associated injuries. The majority of mandibular fractures occur at the level of the
condyle, which often results after trauma to the chin. Other areas of the jaw that
are predisposed to fracture include the angle of the mandible where deep
impacted teeth or unerupted 6-year molars make the mandible more vulnerable.
Symphyseal and parasymphyseal fractures can also accompany upper mandibular
fractures, as part of the closed ring of the jaw.

Goals of Treatment
History, physical examination, and appropriate radiographic evaluation should be
used to establish the diagnosis of mandibular fracture. Patients should be rapidly
evaluated for airway compromise and appropriate management initiated when
identified. Diagnosed jaw fractures are commonly referred for outpatient
treatment, although some injuries may require more urgent intervention.

Mandibular Fractures/Dislocations
Clinical recognition. The mandible can be compared with an archery bow, which
is strongest at its center and weakest at its ends. Thus, most fractures occur at the
neck of the condyles. Patients may present with pain or limitation when opening
the mouth, or swelling at the TMJ.


Mandibular dislocation occurs when the capsule and TMJ ligaments are
sufficiently stretched to allow the condyle to move to a point anterior to the
articular eminence during opening. Dislocation can be unilateral or bilateral and
often accompanies a history of extreme mouth opening (e.g., deep yawn) or
following a prolonged dental appointment. The muscles of mastication enter a
tonic contraction state, and the patient is unable to move the condyle back into the
glenoid fossa and close his or her mouth.
Clinical assessment. Local bleeding, gingival/mucosal tears, or sublingual
ecchymoses may be clues to underlying bony injury. Posterior tooth fractures, or
evidence of malocclusion may also alert the emergency physician to the
possibility of a jaw fracture. In some cases, depressed or mobile jaw fragments
may be identified. A unilateral condylar fracture should be suspected if the
mandible deviates toward the affected side on opening.
A panoramic radiograph or CT scan should be obtained when mandibular
fractures are suspected. A panoramic radiograph may not be possible in a young
or severely injured child, and may not be available in the emergency department
setting.
Management. The appropriate service (dentistry, oral and maxillofacial surgery,
or plastic surgery) should be consulted depending on availability. In cases where
the fracture is none/minimally displaced, there is no evidence of airway
obstruction, dehydration, or unremitting pain, a patient may be discharged on a
soft diet with close outpatient follow-up with specialty care. For unstable or
concerning fractures, specialty services are required to stabilize the fracture, using

either open or closed reduction.
For a dislocation, gentle downward and backward pressure should be applied
by the physician’s thumb (wrapped in gauze) on the occlusal surfaces of the
posterior teeth ( Fig. 105.6 ). The downward pressure moves the dislocated
condyle below the articular eminence; subsequent backward pressure on the
molars shifts the condyle posteriorly into the mandibular fossa. If this approach
fails, intravenous diazepam (0.2 mg/kg, maximum 10 mg) can be administered as
an adjunctive muscle relaxant before reattempting to relocate the condyles.
Figure 105.7 shows the anatomic landmarks and repositioning of the TMJ.


FIGURE 105.5 If a child loses or avulses a tooth, find the tooth and determine whether it is a
primary or permanent tooth by checking Table 105.1 . If it is a primary tooth, do not reimplant.
Gently rinse under running water or with saline, but do not scrub the tooth. Insert the tooth back
into the socket or place in milk or Hanks balanced salt solution and take immediately to the
dentist. Vitality of the tooth is time dependent, with compromise starting after only 15 to 30
minutes.


Maxillary Fractures
Premaxillary or anterior maxillary alveolar bone (commonly referred to as
alveolar ridge) fractures are a common finding associated with the displacement
or avulsion of maxillary anterior teeth. Acute management can be performed by
the emergency physician. Gentle digital manipulation of the labial plate of bone
can be guided back into position under local anesthesia. Infiltration with 2%
lidocaine with 1:100,000 epinephrine is commonly used. The bone fragment can
be held in place temporarily by aluminum foil (three thicknesses) molded over the
teeth and alveolar ridge. This emergency splint should be held in place by having
the child gently bite down. A dental consultant should be contacted as soon as
possible for fabrication of a more permanent dental splint. Splinting the loose

teeth and suturing the gingival tissue hold the bone fragments in place.
Commonly associated mandibular and other facial fractures are covered in greater
detail in Chapter 107 Facial Trauma .

FIGURE 105.6 Position for the reduction of a dislocated mandible.