Mandible Fracture in Emergency Medicine Clinical Presentation

Because maxillofacial fractures are the result of trauma, primary survey and attention to airway, breathing, and circulation takes priority.^{[1, 3, 6]}

Focus primary evaluation on patency of airway, control of cervical spine, breathing and circulatory impairment, and loss of consciousness if patient is experiencing neurologic impairment.

Once life threats are addressed, obtain a thorough (AMPLE) history.

• Allergies
• Medications
• Past medical history
• Last meal
• Events leading to injury

Next, ask specific questions regarding the facial injury.

• Does patient have epistaxis or clear fluid running from nares or ears?
• Did patient lose consciousness? If so, for how long?
• Has patient had any visual problems, such as double or blurred vision?
• Has patient had any hearing problems, such as decreased hearing or tinnitus?
• Does patient have any malocclusion, and is patient able to bite down without pain?
• Does moving the jaw cause pain or spasm?
• When the jaw moves, is a grinding sound produced?
• Does the patient have areas of numbness or tingling on the face?
• In women, ask if the injury was from a partner or if they feel threatened by anyone.
• In children, ask questions to determine if child abuse is an issue.

Complete examination of the face is necessary because multiple injuries can easily occur.^[7] Portions of the examination specific to the mandible are marked with an asterisk (*).

• Inspect face for asymmetry, performed while looking down from head of bed.
• Inspect open wounds for foreign bodies and palpate for bony injury.
• Palpate bony structures of supraorbital ridge and frontal bone for step-off fracture.
• Thoroughly examine eyes for injury, abnormal ocular movements, and visual acuity.^[8]
• Inspect nares for telecanthus and widening of nasal bridge, then palpate for tenderness and crepitus.
• Inspect nasal septum for septal hematoma and clear rhinorrhea, which may suggest cerebrospinal fluid (CSF) leak.
• Palpate zygoma along its arch as well as along its articulations with the frontal bone, temporal bone, and maxillae.
• Check facial stability by grasping teeth and hard palate and gently pushing back and forth then up and down, feeling for movement or instability of midface.^[7]
• *Test teeth for stability and inspect for bleeding at gumline, a sign of fracture through the alveolar bone.
• *Check teeth for malocclusion and step-off.
• *Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and coronoid process anterior to the ear canal.
• *Check for localized edema or ecchymosis in the floor of the mouth.
• Evaluate distributions of the supraorbital, infraorbital, *inferior alveolar, and *mental nerves for anesthesia.
• *If teeth are missing, account for them to ensure they have not been aspirated.
• *Inspect area just anterior to the meatus of the ear for ecchymosis and palpate for tenderness. This is the condyle of the mandible and site of an often-missed fracture. Plain radiographs are not good at visualizing the condyle, thus maintain a high level of suspicion if physical exam is suggestive.
• *Mandibular fracture is suggested by inability to open mouth, trismus, malocclusion of teeth, or palpable step-offs of bone along symphysis, angles, or body. Gingival bleeding at the base of a tooth suggests fracture, especially if teeth are malaligned. Edema or ecchymosis may be present in the floor of the mouth. Neurologic findings may include hypesthesia in distribution of inferior alveolar or mental nerves.

• Motor vehicle accidents, as occupant or as pedestrian stuck by the vehicle
• Violence, by being struck with fists, feet, or objects including bullets in penetrating injuries
• In falls, either from a height or in cases of syncope