Mandible Fracture in Emergency Medicine Treatment & Management
- Author: Thomas Widell, MD; Chief Editor: Rick Kulkarni, MD more...
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.[4, 9]
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