What is the appropriate management for a patient with bilateral jaw pain after being hit in the face with a volleyball?

Management of Bilateral Jaw Pain After Volleyball Facial Trauma

Immediately assess for jaw fracture by evaluating occlusion (bite), palpating the facial skeleton for tenderness or step-offs, and checking for malocclusion, limited jaw opening (trismus), or deviation of the mandible during opening—if any of these are present, obtain CT maxillofacial without IV contrast and refer urgently to oral and maxillofacial surgery. 1

Initial Clinical Assessment

The systematic evaluation must prioritize life-threatening injuries before addressing the jaw pain itself:

• Rule out cervical spine injury and intracranial trauma first, as facial trauma can transmit force to these structures 1
• Assess airway patency, as maxillofacial trauma can compromise the airway through hemorrhage, soft-tissue edema, or loss of facial architecture 1
• Perform neurologic screening including questions about loss of consciousness, dizziness, headache, nausea, or vomiting to identify possible concussion 1

Specific Jaw Examination Findings

After stabilization, focus on findings that distinguish fracture from soft tissue injury:

• Check occlusion (bite) by asking the patient to say "cheese" or the letter "e" to visualize whether posterior teeth (molars) fully interdigitate—disturbances indicate displaced tooth, alveolar fracture, or jaw fracture 1
• Palpate the facial skeleton systematically for tenderness, step-offs, or crepitus along the mandible and maxilla 1
• Observe for mandibular deviation during mouth opening, which suggests condylar or ramus fracture 1, 2
• Assess for trismus (limited mouth opening), gingival hemorrhage, mucosal tears, loose or fractured teeth, and facial asymmetry 1
• Test for infraorbital nerve paresthesia if midface involvement is suspected 1

Imaging Decision Algorithm

CT maxillofacial without IV contrast is the first-line imaging modality for suspected mandibular or maxillary fracture, with sensitivity approaching 100% and superior ability to detect nondisplaced, comminuted, and posterior fractures compared to radiography 1. The ACR Appropriateness Criteria (2022) designates this as "usually appropriate" for patients with trismus, malocclusion, gingival hemorrhage, or loose/fractured teeth 1.

• Obtain CT if any of the following are present: malocclusion, trismus, mandibular deviation, facial asymmetry, palpable step-off, gingival bleeding, or multiple loose teeth 1
• Panoramic radiograph (OPG) may be considered only in low-suspicion cases with isolated tenderness and normal occlusion, though it misses 8-14% of fractures and is increasingly disfavored in emergency settings 1
• CT provides multiplanar and 3-D reconstructions critical for surgical planning, particularly for condylar, subcondylar, and comminuted fractures 1

Management Based on Findings

If Fracture is Identified:

• Urgent referral to oral and maxillofacial surgery for definitive management, which focuses on restoring normal dental occlusion through reduction and stabilization 3, 2
• Treatment modalities may include intermaxillary fixation, interosseous wiring, or open reduction with internal fixation depending on fracture location and displacement 3

If No Fracture (Soft Tissue Injury/Contusion):

• Temporomandibular disorder (TMD) or muscular injury is the likely diagnosis when bilateral jaw pain occurs without fracture 1, 2
• Initial conservative management includes patient education, soft diet, ice application in first 24-48 hours, NSAIDs for pain control, and avoidance of extreme jaw movements 1, 2
• Physical therapy techniques such as gentle jaw stretching exercises and heat application after 48 hours can be beneficial 2
• Muscle relaxants may be added for persistent muscle spasm 2
• Referral to dentist or oral surgeon if symptoms persist beyond 1-2 weeks or worsen despite conservative measures 2

Critical Pitfalls to Avoid

• Do not dismiss bilateral pain as "just a bruise" without proper examination—bilateral condylar fractures can present with bilateral pain and may be missed on clinical exam alone 1
• Do not rely on panoramic radiography alone in moderate-to-high suspicion cases, as it misses anterior nondisplaced fractures and condylar fractures with anterior displacement 1
• Assess for dental trauma separately, including avulsed, luxated, or fractured teeth, as these require specific dental management 1, 4
• Consider child abuse in any patient under 5 years with facial trauma, documenting mechanism and assessing consistency with developmental stage 4

Associated Injuries to Screen For

Given the mechanism (direct facial impact), maintain vigilance for:

• Dental injuries: Check for loose, fractured, displaced, or avulsed teeth requiring immediate dental referral 1, 4
• Nasal fracture: Visible or palpable deformity, epistaxis 1
• Zygoma fracture: Infraorbital paresthesia, facial flattening 1
• Intracranial injury: Occurs in 43.7% of patients with facial fractures in trauma settings 5