Rosen & Barkin's 5-Minute Emergency Medicine Consult (435 page)

Diagnostic evaluation often requires tertiary care pediatric hospital with pediatric surgical and pediatric radiologic expertise.

As dictated by pediatric surgical service

• Early recognition of child with acute abdomen
  
• Prompt treatment of acidosis and shock
  
• Prompt referral to appropriate facility
  

• Applegate KE. Evidence-based diagnosis of malrotation and volvulus.
  Pediatr Radiol.
  2009;39:S161–S163.
  
• Fleisher GR, Ludwig S, eds.
  Textbook of Pediatric Emergency Medicine
  . 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  
• Lampl B, Levin TL, Berdon WE, et al. Malrotation and midgut volvulus: A historical review and current controversies in diagnosis and management.
  Pediatr Radiol.
  2009;39:359–366.
  
• Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood.
  Surgery.
  2011;149:386–393.
  
• Shew SB. Surgical concerns in malrotation and midgut volvulus.
  Pediatr Radiol.
  2009;39:S167–S171.
  

CODES

751.4 Anomalies of intestinal fixation

BASICS

• Typically due to a direct force
  
• The most common area fractured is the angle, followed by the condyle, molar, and mental regions.
  
• Because of its thickness, the mandibular symphysis is rarely fractured.
  
• Multiple fractures are seen in >50% of cases owing to the ring-like structure of the mandible.
  
• Bilateral mandibular fractures most commonly result from motor vehicle accidents (MVAs).
  
• Open fractures are common, including lacerations of the gum overlying a fracture.
  

• The mandible is the 3rd most common facial fracture following nasal and zygomatic fractures.
  
• MVAs, personal violence, contact sports, or industrial accidents
  
• Patients are often intoxicated and unable to give a clear history of events.
  
• Facial and head lacerations and facial fractures are the most commonly associated injuries.
  

• Mandibular fractures are uncommon in children <6 yr of age; when they do occur, they are often greenstick fractures and can be managed with soft diet alone.
  
• Inform parents that because any fracture of the mandible may damage permanent teeth, follow-up with a specialty consultant is advisable.
  
• Refer pediatric patients to a specialist with experience in children due to issues with growth plates and permanent teeth.
  

DIAGNOSIS

• Mandibular pain
  
• Facial asymmetry, deformity, and dysphagia
  
• Malocclusion, decreased range of motion of the temporomandibular joint (TMJ), trismus, or a grating sound conducted to the ear
  
• Gum laceration, subungual or gum hematoma
  

• Mechanism of injury
  
• Malocclusion, dental pain, associated injuries
  

• Inspect maxillofacial area for deformity, including ecchymosis or swelling.
  
• Malocclusion, trismus, or facial asymmetry
  
• Loose, fractured, or missing teeth; gross malalignment of teeth; separation of tooth interspaces, bleeding at the base of teeth; gum lacerations between teeth; and ecchymosis or hematoma of the floor of the mouth
  
• Step-off, bony disruption, or point tenderness with palpation along the entire length of the mandible
  
• Protrusion or lateral excursion of the jaw
  
• Interference with normal mandibular function, including decreased range of motion or deviation of the mandible with opening:
  
  • The examiner should be able to insert three fingers between the mandible and the maxilla.
    
  • Inability of the patient to hold a tongue depressor laterally between the teeth when pulled by the examiner, or attempted to be broken by twisting (positive tongue blade test)
    
• Paresthesia of the lower lip or gums indicates secondary damage to the inferior alveolar nerve.
  
• Inability to note motion of the mandibular condyles when palpated through the external ear canals suggests mandible fracture.
  
• Tenderness of the condyle at the TMJ
  

• Diagnosis of mandibular fractures requires radiographs – mandibular series or panorex.
  
• Panorex superior for evaluation of all of the mandible except condyles
  
• Low index for obtaining facial bone CT if associated injuries are suspected
  

Only indicated if immediate operative intervention is indicated, or for evaluation of other injuries

• Plain films or dental panoramic views should be obtained.
  
• Plain films including an anteroposterior (AP), bilateral obliques, and Towne view should be obtained:
  
  • Mandibular views are best for evaluating the condyles and neck of mandible (most common site of fracture).
    
• Dental panoramic view may be obtained:
  
  • Panorex best evaluates the symphysis and body (less common fracture site).
    
• If condylar fracture is still suspected and not noted on initial radiographs, obtain CT of the condyles in the coronal plane.
  
• Missing teeth that cannot be found mandate a chest radiograph to rule out aspiration.
  
• Obtain cervical spine films if the neck cannot be cleared clinically
  
• Obtain facial bone CT if other injuries of the face suspected.
  

• Contusions
  
• Dislocation of the mandible:
  
  • If a single condyle is dislocated, the jaw will deviate away from the side of the dislocation.
    
  • If fractured, the jaw will deviate toward the fractured side.
    
• Isolated dental trauma
  

TREATMENT

• Cautions:
  
  • Protect the airway.
    
  • Protect the cervical spine.
    
  • Preserve any avulsed teeth.
    

• 20–40% of patients with mandibular fractures have associated injuries:
  
  • Treatment is directed toward immediate, potentially lethal injuries such as airway obstruction, aspiration, major hemorrhage, cervical spine injury, and intracranial injury.
    
• Airway must be protected.
  
• Cervical spine precautions
  
• If oral intubation cannot be performed, nasotracheal intubation should be performed unless associated facial injuries are present, in which case cricothyrotomy may be indicated.
  

• With the exception of condylar fractures, many mandibular fractures are associated with mucosal, gingival, or tooth socket disruption and should be considered open fractures:
  
  • Antibiotics such as penicillin, clindamycin, amoxicillin, amoxicillin/clavulanate or azithromycin to cover intraoral anaerobic pathogens
    
• Tetanus prophylaxis for open fractures
  
• Analgesia such as acetaminophen, ibuprofen, or narcotic medications
  
• Definitive care usually consists of reduction and fixation by wiring upper and lower teeth in occlusion for 4–6 wk or by ORIF:
  
  • Linear, nondisplaced, or greenstick fractures may be treated with soft diet without wiring.
    
• If mandible dislocation is present, while the jaw is open apply bilateral downward pressure on the occlusal surface of the posterior lower teeth while grasping the mandible:
  
  • The goal is to free the condyle from its anterior position to the eminence.
    
  • Reduction is facilitated by muscle relaxants (diazepam or midazolam) or anesthetic injection of mastication muscles.
    
  • A bite block should be used, or the examiner’s fingers should be wrapped in gauze to prevent injury.
    

• Acetaminophen: 500 mg (peds: 10–15 mg/kg, do not exceed 5 doses/24h) PO q4–6h, do not exceed 4 g/24h
  
• Amoxicillin/clavulanate: 500/125–875/125 mg PO BID (peds: 40 mg/kg/d of amoxicillin PO BID
  
• Amoxicillin: 500 mg PO TID (peds: 40 mg/kg PO div. TID)
  
• Azithromycin: 500 mg PO day 1 followed by 250 mg day 2–4 (peds: 10 mg/kg day 1 followed by 5 mg/kg day 2–4)
  
• Clindamycin: 150–450 mg PO QID (peds: 10–20 mg/kg/24h)
  
• Diazepam: 5–10 mg (peds: 0.1–0.2 mg/kg) IV
  
• Ibuprofen: 600–800 mg (peds: 20–40 mg/kg/24h) PO TID–QID
  
• Midazolam: 2–5 mg (peds: 0.02–0.05 mg/kg/dose, max. dose 0.4 mg/kg total and not >10 mg) IV over 2–3 min
  
• Penicillin VK: 250–500 mg (peds: 25–50 mg/kg/24h) PO QID
  

FOLLOW-UP