How to manage a mandibular fracture at the emergency room level?

Emergency Room Management of Mandibular Fractures

Obtain CT maxillofacial with multiplanar reformations immediately as the primary diagnostic imaging, actively search for a second fracture site since 67% of cases have paired fractures, assess for associated intracranial injury (present in 39% of cases), and arrange urgent oral and maxillofacial surgery consultation for definitive management. 1, 2

Initial Assessment and Imaging

Primary Diagnostic Imaging

• CT maxillofacial with multiplanar reformations is the gold standard imaging modality, with nearly 100% sensitivity for detecting mandibular fractures, including subtle nondisplaced fractures that radiography misses 1, 3
• CT is superior to conventional radiography (which has only 86-92% sensitivity) and is especially critical for detecting posterior mandibular fractures, ramus fractures, and condyle fractures where displacement can be subtle 1, 3
• 3-D reconstructions provided by CT are essential for surgical planning, particularly for characterizing comminution and displacement 1

Critical Rule: Always Search for a Second Fracture

• After identifying the first fracture, you must actively search for and exclude a second fracture site, as the U-shaped ring configuration of the mandible results in two separate fractures in approximately 67% of cases 1, 2
• Common paired fracture patterns include:
  • Mandibular angle or subcondylar fracture with contralateral parasymphyseal fracture 1, 2
  • "Flail mandible": bilateral subcondylar fractures with symphyseal fracture 1, 2

Assess for Associated Injuries

Screen for Intracranial Injury

• Obtain CT head in addition to maxillofacial CT, as coexisting intracranial injuries occur in approximately 39% of patients with mandibular fractures 1, 2, 3
• 68% of patients with facial fractures have associated head injury, and there is an appreciable association between mandibular fractures and concussion 1

Evaluate for Cervical Spine Injury

• Assess for cervical spine injury, which occurs in approximately 11% of patients with mandibular fractures 2, 3
• This is a commonly overlooked associated injury that can have devastating consequences if missed 2

Check for Additional Injuries

• 20-40% of patients with mandibular fractures have further injuries beyond the mandible 1, 2, 3

Clinical Examination Priorities

Key Symptoms to Document

• Pain during masticatory movements, malocclusion, facial asymmetry, and limited mouth opening are the primary symptoms 2
• Swelling and bruising at the fracture site 2
• Deviation of the jaw to the affected side when opening the mouth (particularly with condylar fractures) 2

Assess for Nerve Injury

• Evaluate for anesthesia or paresthesia of the lower lip, chin, anterior tongue, and mandibular teeth, which indicates inferior alveolar nerve damage when fractures extend through the mandibular canal 1, 2
• These sensory disturbances significantly impact quality of life and may persist if nerve damage is severe 2

Immediate Management

Airway and Stabilization

• Ensure airway patency, particularly with bilateral subcondylar fractures or flail mandible
• Control bleeding and provide analgesia

Infection Prevention

• Administer antibiotic prophylaxis for compound fractures (fractures communicating with the oral cavity or external environment) 4
• Most mandibular fractures are compound due to periodontal ligament communication

Occlusion Assessment

• Document the patient's baseline occlusion, as the goal of any surgical intervention is to restore the preinjury occlusion, even if the preinjury occlusion is abnormal 5
• Malocclusion occurs as fracture displacement disrupts normal dental alignment 2

Disposition and Consultation

Urgent Specialty Consultation

• Arrange immediate oral and maxillofacial surgery consultation for definitive management planning
• Timing of surgical intervention depends on fracture pattern, displacement, and associated injuries

Treatment Planning Considerations

• CT findings regarding comminution and displacement are critical, as these result in changes in surgical management 1
• Preservation of teeth and tooth buds in the line of fracture should be attempted when possible 4

Common Pitfalls to Avoid

• Failing to search for a second fracture after identifying the first one - this is the most critical error given the 67% incidence of paired fractures 1, 2
• Relying on conventional radiography alone, which will miss subtle fractures and has significantly lower sensitivity than CT 1, 3
• Overlooking associated cervical spine injuries, which are present in 6-19% of cases with significant maxillofacial trauma 2
• Missing intracranial injuries, which occur in 39% of mandibular fracture patients 1, 2
• Failing to document baseline occlusion before treatment 5