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Pediatric emergency medicine trisk 813

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ideal, they are alternative mediums that are preferred over water or worse allowing the root surface to air dry ( Fig 105.5 ) The patient should proceed directly to the dentist for radiographs, final alignment, splinting, and close followup JAW FRACTURES CLINICAL PEARLS AND PITFALLS Trauma to the chin may result in a condylar fracture Because the jaw is a ring structure, identification of a single fracture warrants careful examination for an accompanying injury Mandibular fractures can lead to airway compromise, most commonly secondary to tongue and soft tissue falling against the posterior pharyngeal wall Current Evidence Mandibular fractures are the third most common facial fractures in children (behind frontal and nasal bones) Whenever a facial fracture is present, the cervical spine, CNS, orbits, and teeth need to be carefully evaluated for associated injuries The majority of mandibular fractures occur at the level of the condyle, which often results after trauma to the chin Other areas of the jaw that are predisposed to fracture include the angle of the mandible where deep impacted teeth or unerupted 6-year molars make the mandible more vulnerable Symphyseal and parasymphyseal fractures can also accompany upper mandibular fractures, as part of the closed ring of the jaw Goals of Treatment History, physical examination, and appropriate radiographic evaluation should be used to establish the diagnosis of mandibular fracture Patients should be rapidly evaluated for airway compromise and appropriate management initiated when identified Diagnosed jaw fractures are commonly referred for outpatient treatment, although some injuries may require more urgent intervention Mandibular Fractures/Dislocations Clinical recognition The mandible can be compared with an archery bow, which is strongest at its center and weakest at its ends Thus, most fractures occur at the neck of the condyles Patients may present with pain or limitation when opening the mouth, or swelling at the TMJ Mandibular dislocation occurs when the capsule and TMJ ligaments are sufficiently stretched to allow the condyle to move to a point anterior to the articular eminence during opening Dislocation can be unilateral or bilateral and often accompanies a history of extreme mouth opening (e.g., deep yawn) or following a prolonged dental appointment The muscles of mastication enter a tonic contraction state, and the patient is unable to move the condyle back into the glenoid fossa and close his or her mouth Clinical assessment Local bleeding, gingival/mucosal tears, or sublingual ecchymoses may be clues to underlying bony injury Posterior tooth fractures, or evidence of malocclusion may also alert the emergency physician to the possibility of a jaw fracture In some cases, depressed or mobile jaw fragments may be identified A unilateral condylar fracture should be suspected if the mandible deviates toward the affected side on opening A panoramic radiograph or CT scan should be obtained when mandibular fractures are suspected A panoramic radiograph may not be possible in a young or severely injured child, and may not be available in the emergency department setting Management The appropriate service (dentistry, oral and maxillofacial surgery, or plastic surgery) should be consulted depending on availability In cases where the fracture is none/minimally displaced, there is no evidence of airway obstruction, dehydration, or unremitting pain, a patient may be discharged on a soft diet with close outpatient follow-up with specialty care For unstable or concerning fractures, specialty services are required to stabilize the fracture, using either open or closed reduction For a dislocation, gentle downward and backward pressure should be applied by the physician’s thumb (wrapped in gauze) on the occlusal surfaces of the posterior teeth ( Fig 105.6 ) The downward pressure moves the dislocated condyle below the articular eminence; subsequent backward pressure on the molars shifts the condyle posteriorly into the mandibular fossa If this approach fails, intravenous diazepam (0.2 mg/kg, maximum 10 mg) can be administered as an adjunctive muscle relaxant before reattempting to relocate the condyles Figure 105.7 shows the anatomic landmarks and repositioning of the TMJ FIGURE 105.5 If a child loses or avulses a tooth, find the tooth and determine whether it is a primary or permanent tooth by checking Table 105.1 If it is a primary tooth, not reimplant Gently rinse under running water or with saline, but not scrub the tooth Insert the tooth back into the socket or place in milk or Hanks balanced salt solution and take immediately to the dentist Vitality of the tooth is time dependent, with compromise starting after only 15 to 30 minutes Maxillary Fractures Premaxillary or anterior maxillary alveolar bone (commonly referred to as alveolar ridge) fractures are a common finding associated with the displacement or avulsion of maxillary anterior teeth Acute management can be performed by the emergency physician Gentle digital manipulation of the labial plate of bone can be guided back into position under local anesthesia Infiltration with 2% lidocaine with 1:100,000 epinephrine is commonly used The bone fragment can be held in place temporarily by aluminum foil (three thicknesses) molded over the teeth and alveolar ridge This emergency splint should be held in place by having the child gently bite down A dental consultant should be contacted as soon as possible for fabrication of a more permanent dental splint Splinting the loose teeth and suturing the gingival tissue hold the bone fragments in place Commonly associated mandibular and other facial fractures are covered in greater detail in Chapter 107 Facial Trauma FIGURE 105.6 Position for the reduction of a dislocated mandible ... underlying bony injury Posterior tooth fractures, or evidence of malocclusion may also alert the emergency physician to the possibility of a jaw fracture In some cases, depressed or mobile jaw... radiograph may not be possible in a young or severely injured child, and may not be available in the emergency department setting Management The appropriate service (dentistry, oral and maxillofacial... the displacement or avulsion of maxillary anterior teeth Acute management can be performed by the emergency physician Gentle digital manipulation of the labial plate of bone can be guided back into

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