eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Mandible

Thomas Widell, MD, Vice Chairman, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin School of Medicine/The Chicago Medical School, North Chicago, Illinois; Associate Residency Director, University of Chicago Emergency Medicine Program, Chicago, Illinois; Program Director Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center, Chicago, Illinois

Updated: Mar 6, 2008

Introduction

Background

Hippocrates described an array of facial injuries as long ago as 400 BCE. In 1823, von Graeffe described the use of an elastic tube placed in the nares to maintain an open airway. During the early 20th century, Sir Harold Gilles, father of plastic surgery, taught army personnel about breathing problems in patients with facial injuries. He recommended positioning them supine to maintain an airway. Frenchman René Le Fort studied cadavers in 1901 and described 3 basic types of facial fractures. Endotracheal anesthesia and radiography, developed during the First World War, led to a better understanding and treatment of facial fractures. During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve outcomes of severely injured soldiers. Advent of CT-guided reconstruction, along with new surgical techniques, has improved the final appearance of patients with bony injuries immensely.

Pathophysiology

Maxillofacial fractures are the result of blunt or penetrating trauma. Most are blunt injuries caused by vehicular crashes, altercations, sporting-related trauma, occupational injuries, and falls. Penetrating injuries are mainly the result of gunshot wounds, stabbings, and explosions.

Determinants of type of injury (ie, soft tissue alone vs bony) are shape and velocity of the striking object.

The amount of force needed to fracture different bones of the face has been studied, and these bones have been divided into those that require high impact to fracture (greater than 50 times the force of gravity [g]) and those that require only low impact to fracture (less than 50 g).

High impact
- Supraorbital rim - 200 g
- Symphysis of the mandible - 100 g
- Frontal-glabella - 100 g
- Angle of mandible - 70 g
Low impact
- Zygoma - 50 g
- Nasal bone - 30 g

Mandibular fractures usually occur in 2 or more locations because of the bone's U shape and articulations at the temporomandibular joints. Fractures also may occur at a site apart from the site of direct trauma. A large percentage of mandibular fractures are open, as they often fracture between teeth and communicate with the oral cavity.

Different mechanisms are associated with varying locations. Fractures from automobile crashes most frequently occur at the condyle and symphysis, those from motorcycle accidents at the symphysis and alveolus, and those from altercations mostly at the condyles, angles, and body.

For more information, see Medscape's Trauma Resource Center.

Frequency

United States

The mandible is the third most fractured bone of the face. Of these fractures, approximately 20-35% are at the condyle and ramus, 20-30% at the angle, 15-30% at the body, 8-20% at the symphysis, and 1-5% at the alveolar ridge.

One study placed the incidence of severe maxillofacial injury (fractures, lacerations) at 0.04-0.09% for motor vehicle crashes. Incidence of fractures due to motor vehicle injuries is higher in rural areas; altercation-related injuries are more frequent in inner cities.

Mortality/Morbidity

Incidence of other major injuries is as high as 50% in high-impact mandibular fractures, whereas it is 21% in low-impact fractures. Mortality rate in high-impact fractures is as high as 12%, yet death rarely results directly from maxillofacial injury.
Patients who are involved in motor vehicle crashes are more likely to have additional injuries than patients with violence-related injuries.
Incidence of associated cervical spine injuries ranges from 0.2-6%.

Sex

Adult male-to-female ratio is 3:1. Suspect domestic violence or sexual assault in women as this may coexist in 30% of cases.

Age

Male predominance is reduced to 3:2 in children. In nonmotor vehicle injury, the possibility of child abuse should be a concern.

Clinical

History

Since maxillofacial fractures are the result of trauma, primary survey and attention to airway, breathing, and circulation takes priority.
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 history.
- Allergies
- Medications
- 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.

Physical

Complete exam of the face is necessary, since multiple injuries can occur easily. Portions of the exam 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.
- 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.
- *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.

Causes

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

Differential Diagnoses

Dislocations, Mandible
Foreign Bodies, Trachea
Fractures, Face
Neck Trauma
Pediatrics, Child Abuse

Workup

Laboratory Studies

Direct laboratory studies toward workup of a trauma patient. If this is an isolated injury, laboratory studies may not be required.
If fracture is an isolated injury, obtain preoperative labs if surgery is planned.

Imaging Studies

Radiographs
- Best plain film to assess the mandible is a panorama view (ie, Panorex), which shows the mandible in its entirety in a single view. Panoramic view is not always available, as it requires a special radiographic machine. If panorama view is not available or patient is unable to sit for film, obtain routine mandible films.
- Routine views include bilateral lateral oblique projections to look at the angle, body, and to a lesser extent, symphysis, and Townes view to look at the condyles.
- Submental view can be helpful in evaluating the symphysis.
- Obtain chest films of patients with unaccounted missing teeth to rule out aspiration.
- Cervical spine radiographs may be indicated with severe facial injuries or in patients with a consistent mechanism and neck pain.
Computed tomography
- In selected patients with nondiagnostic radiographs in whom mandibular fracture is suspected strongly, CT scan may be necessary to diagnose condylar fracture.
- CT scans often are used to better evaluate fracture prior to surgical repair.
- Consider CT scan of the brain to rule out intracranial injury.

Treatment

Prehospital Care

Airway, breathing, and circulation are the first priority. Hold airway open by jaw thrust or airway adjuncts, including endotracheal intubation.
Treat hypoventilation with intubation and bag ventilation. Nasotracheal intubation is considered a relative contraindication with severe maxillofacial trauma because of concern for intracranial placement of endotracheal tubes.
Suction usually is needed to keep airway free of blood and debris.
Place patient on a backboard with a collar if cervical spine injury is a possibility.
Control actively bleeding wounds by applying direct pressure with a bandage.

Emergency Department Care

Airway, breathing, and circulation
- Frequently assess airway. Isolated mandible fracture from a blunt mechanism usually does not require intubation, but frequent suctioning is mandatory.
- Early intubation before swelling occurs makes airway control much easier, rather than waiting until a problem arises from obstruction. This is usually a clinical decision based on projected course.
- Before using paralytics in an intubation, carefully evaluate the ability to manage the airway with a bag and mask or laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiber optic guides or bronchoscopic-guided intubation may be an option. If in doubt, prepare for a cricothyrotomy before attempting the airway with either sedation or paralytics.
- Do not focus on obvious deformity, thereby forgetting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.
Secondary survey
- Diagnosis of mandibular fracture is part of the secondary survey of ED care, though it should be kept in mind when evaluating the airway in the primary survey.
- A Barton bandage can be placed if the patient has no airway compromise by wrapping a gauze roll over the crown of head and around the jaw to provide support. Wrap a second gauze roll around forehead and back of head to hold first bandage in place.
- Open fractures require antibiotics. Penicillin or one of the cephalosporins are current DOC. Penicillin-allergic patients can be given clindamycin.
- The following procedure takes a fair amount of time and usually is performed by an ear, nose, and throat (ENT) or dental consultant.
  - Erich arch bar can be used to hold fractures that are stable by placing arch bar around the base of the teeth and bending ends around the posterior molar.
  - Next, wire each tooth to the bar by wrapping a 26-gauge steel wire around base of tooth and then around arch wire and twisting it tight.
  - If maxillary teeth are to be used as a splint, they are wired in the same manner. Then, use elastic bands to tie the 2 arch wires together.
  - Remember, patient's mouth is now banded shut. Do not perform this procedure if the patient has a risk of vomiting or has problems with the airway.

Consultations

Provide care for the multiple-injured patient in conjunction with a surgeon who has experience in trauma care.
Definitive treatment of mandibular fractures is performed by an oral-maxillofacial surgeon or an ENT specialist.
The incidence of posttraumatic stress disorder is high in patients with facial injuries, and consultation with a psychiatrist should be considered.

Medication

When airway control is needed, rapid sequence induction often is the preferred method. Rapid sequence induction utilizes medications to induce unconsciousness and muscle paralysis to facilitate intubation. Cricothyroidotomy kit should be at the bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, and local anesthetics.

Patients with open fractures, which are the majority, should be given IV antibiotics. Current choices are penicillin or a cephalosporin. In penicillin-allergic patients, clindamycin is a good alternative. If the patient has an open wound, administer tetanus toxoid if the patient is not current.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

<6 years: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

For relief of mild to moderately severe pain and inflammation.
Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease.
Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, decreasing prostaglandin biosynthesis.

Dosing

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or in those with upper GI disease or taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses q24h

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Dosing

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tabs q4h; not to exceed 12 tab/d

Pediatric

0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg
IV/IM/SC and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC prn
Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Antibiotics

Prophylaxis is given to patients with open fractures. Therapy must cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active replication, resulting in bactericidal activity against susceptible microorganisms.

Dosing

Adult

2.4 million U IM as single dose in 2 injection sites

Pediatric

50,000 U/kg IM

Interactions

Probenecid can increase effects; tetracyclines can decrease effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function

Ceftriaxone (Rocephin)

Third-generation cephalosporin that has broad-spectrum activity against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Dosing

Adult

1-2 g IV qd/bid for 5-7 d; not to exceed 4 g/d

Pediatric

>7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV q12h; not to exceed 2 g/d

Interactions

Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Clindamycin (Cleocin)

Lincosamide useful as a treatment against serious skin and soft-tissue infections caused by most staphylococci strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome, where it preferentially binds to 50S ribosomal subunit, inhibiting bacterial replication.

Dosing

Adult

600-1200 mg/d IV/IM q6-8h depending on degree of infection

Pediatric

20-40 mg/kg/d IV/IM tid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Tetanus toxoid

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing DOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

Dosing

Adult

Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Administer as in adults

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons recommended

Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (Hyper-Tet)

Used for passive immunization of any patient with a wound that may be contaminated with tetanus spores.

Dosing

Adult

Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM

Pediatric

Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3,000-10,000 U IM

Interactions

None reported

Contraindications

Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible

Follow-up

Further Inpatient Care

Fractures of the mandible can be stable (favorable) or unstable (unfavorable) depending on how the fracture line courses in the bone. Muscles attached to the mandible continue to exert their forces. Elevators of the mandible are the masseter, temporalis, and medial pterygoid, while depressors and retractors are the mylohyoid, geniohyoid, and anterior belly of the digastric. Lateral pterygoid is the protrusor of the mandible.
Direction of fracture determines whether it is stable or unstable. Fractures running from posterior downward to anterior (favorable) generally are stable, because muscles pull the fragments together and can be treated with soft diet and arch wires if fragments are not aligned.
Fractures of the body of the mandible running from anterior to posterior in a downward direction (unfavorable) usually are displaced and can be stabilized with wire bar fixation of upper and lower teeth. Unstable fractures may require open reduction and internal fixation if they are not reduced by wire fixation or if they are markedly unstable.
An edentulous mandible usually is unfavorable, because the patient has no teeth to stabilize the fracture. A stable nondisplaced fracture in an edentulous patient may be splinted with his or her denture and the patient restricted to a diet of soft food. An unstable fracture usually requires internal fixation to maintain reduction.
All open fractures and unstable fractures require admission. Depending on institution, some patients with stable fractures that require arch band fixation are treated and released from ED, while others are treated on an inpatient basis.

Further Outpatient Care

Place patient on a diet of soft or pureed food.
Instruct patient to return if any signs of infection are noted.
If arch wires are in place, instruct patient on release of interwire bands and give proper tools. Inability to release bands can be fatal if the patient vomits or has an airway problem.

Inpatient & Outpatient Medications

Medications such as NSAIDs, acetaminophen, and a short course of narcotics can be used for pain control.
Liquid preparations of medications are preferable.

Transfer

If appropriate specialists are not available in the receiving institution, arrange transfer to a higher-level hospital.

Deterrence/Prevention

Use of seat belts and airbags can reduce incidence of facial injuries in motor vehicle crashes.
Use of helmet with facial guards can reduce injury in motorcycle accidents and accidents in such sports as skiing, snowboarding, hockey, and football.

Complications

Loss of airway
Aspiration of avulsed teeth
Infection
Nonunion
Malnutrition and weight loss if teeth are banded together
Injury to inferior alveolar or, more distally, mental nerve
Posttraumatic stress disorder

Prognosis

Prognosis is generally favorable with proper treatment.

Patient Education

Instruct patient on how to release Erich arch wire if he or she has problems with airway.
Place patient on a diet of soft or pureed food.
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken Jaw.
Patients should be informed of the high risk of posttraumatic stress disorder and be referred to a psychiatrist should symptoms occur.

Miscellaneous

Medicolegal Pitfalls

Failure to diagnose associated intracranial or cervical spine injuries because focus was on obvious injury
Failure to account for missing teeth, which may have been aspirated

Special Concerns

Always consider potential for loss of airway and intrathoracic, intraabdominal, and intracranial injuries.

References

Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. Jul 2003;61(7):785-92. [Medline].
Hendler B. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.
McGill J, Ling L, Taylor S. Facial trauma. In: Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.
Smith R. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams & Wilkins Publishers; 1991:337-43.
Snell R, Smith M. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-41.
Spoor T, Ramocki J, Kwito J. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2^nd ed. Lippincott, Williams & Wilkins; 1996:225-41.
Sullivan W. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2^nd ed. Lippincott, Williams & Wilkins; 1996:242-69.
McKay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 6^th ed. Philadelphia, PA: Mosby Elsevier; 2006:382-98/chap 39.
Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-1590.

Keywords

mandible fracture, facial fracture, maxillofacial fractures, mandibular fractures, fractures of the mandible, high-impact mandibular fractures, low-impact mandibular fractures, maxillofacial injury, facial injury, jaw fracture

Contributor Information and Disclosures

Author

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Further Reading

eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Mandible

Introduction

Background

Pathophysiology

Frequency

United States

Mortality/Morbidity

Sex

Age

Clinical

History

Physical

Causes

Differential Diagnoses

Other Problems to Be Considered

Workup

Laboratory Studies

Imaging Studies

Treatment

Prehospital Care

Emergency Department Care

Consultations

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Ibuprofen (Ibuprin, Advil, Motrin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Ketoprofen (Oruvail, Orudis, Actron)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Naproxen (Anaprox, Naprelan, Naprosyn)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Flurbiprofen (Ansaid)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Analgesics

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Acetaminophen and codeine (Tylenol #3)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions