Mandible fracture

Background

• Always make sure that a unilateral fracture is not in fact b/l
• Presume an open fracture until intraoral examination shows otherwise
• Favorable vs unfavorable based on whether musculature reduces or opens the fracture

Evaluation

History

• Malocclusion
• Pain worsened by attempted movement

Exam

• 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%
• 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

• Imaging
  • Panorex is initial imaging study of choice
  • CT face or mandible if:
    • Suspected condyle fracture
    • Complex fracture
    • Multiple facial fractures

Management

• 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 600-900mg (if penicillin-allergic)

Differential Diagnosis

Maxillofacial Trauma

• Le Fort fractures
• Skull fracture (peds)
• Auricular hematoma
• Nasal fracture
  • Nasal septal hematoma
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Dental trauma
• Mandible fracture

Orbital trauma

Acute

• Ruptured Globe^
• Corneal Abrasion
• Ocular foreign body
• Conjunctival laceration
• Caustic Keratoconjunctivitis^^
• Subconjunctival hemorrhage
• Traumatic iritis
• Traumatic hyphema
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
• Traumatic mydriasis
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture

Subacute/Delayed

• Endophthalmitis^
• Corneal Ulcer^

Disposition

Admit (ENT, OMFS, Plastics) for:

1. Airway compromise (e.g when lying flat)
2. Unable to tolerate POs or secretions
3. Inadequate pain control

• Otherwise may follow up as outpatient in 2-3 days

See Also

• Maxillofacial Trauma

References

Authors

Jordan Swartz, Ross Donaldson, Neil Young, Daniel Ostermayer