Episode 62 – Dental Emergencies

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We review a trick of the trade from Academic Life in Emergency medicine for temporomandibular joint (TMJ) dislocation, the extra-oral reduction.

TMJ dislocation reduction

Traditional Approach to TMJ dislocation and Syringe Technique from Core EM

Core Content

We delve into core content on dental injuries using Rosen’s Emergency Medicine (8th edition) Chapter 70 “Oral Emergencies” and Tintinalli’s Emergency Medicine (8th edition) Chapter 245 “Oral and Dental Emergencies” as a guide.

dental infections

dental trauma

mandible fracture

 Rosh Review Emergency Board Review Questions

A 19-year-old man presents to the Emergency Department with an avulsed tooth. He struck his mouth on the back of another player’s head while playing basketball. He arrives thirty minutes after the injury with his right maxillary central incisor in a bag of cold milk. Which of the following is the most appropriate management?

A. Discharge home with next day dental follow up

B. Fill the alveolar socket with eugenol oil

C. Reimplant the avulsed tooth

D. Scrub the tooth with normal saline

Answer

C. Reimplant the avulsed tooth (B) is the most appropriate next step. Avulsed permanent teeth should be reimplanted as soon as possible, ideally within 30 minutes of the injury. For every minute that the tooth is out of its socket, there is a 1% chance of reimplantation failure. If the tooth is not able to be reimplanted immediately, it should be stored in an appropriate medium. Cold milk is preferable to sterile water or saliva as it has magnesium and calcium. Hank’s solution, a neutral cell culture medium, is ideal. Once the tooth is reimplanted, the tooth should be stabilized until dental follow up is arranged. Avulsed primary teeth should not be reimplanted.

A 25 year-old man presents after falling face forward off his bike.  He sustained an abrasion inside his upper lip and complains of a broken front tooth. He brought the fractured fragment with him. On examination, the bony structures of the jaw are non-tender. There is no malocclusion. Tooth #8 has a fracture and in the center of the exposed area is a small pink dot. What is the most appropriate plan for this patient?

A. Dental follow-up within the next 24 hours

B. Irrigation of the tooth

C. Placement of the tooth fragment in Hank’s solution

D. Viscous lidocaine for pain control

Answer

A. This patient has a dental fracture with exposed pulp. This is a dental emergency requiring dental follow-up within the next 24 hours. The most superficial dental fractures involve only the enamel on the surface and treatment is mostly cosmetic and aimed at dulling any sharp edges. Fractures that expose dentin will have an ivory-yellow appearance. In younger patients, there is less dentin relative to the pulp and treatment is aimed at protecting any pulp contamination with placement of a calcium-hydroxide dressing. Younger patients need more urgent follow-up with a dentist. The most significant dental fractures involve the pulp as in this clinical scenario. The tooth should be gently wiped clean with gauze and inspected for a drop of blood or pink blush which represents pulp exposures. The area is usually exquisitely painful. Timely follow-up (within 24 hours) is required for evaluation and possible root canal and extraction of the pulp. If dental follow-up will be delayed, the tooth should be covered with moist cotton and sealed with dry foil or a temporary commercial sealant. In order to clean the tooth, a clean gauze should be used to wipe off the surface, not irrigation of the tooth (B) as the patient will be extremely sensitive to that and all efforts should be maintained to avoid pulp contamination. Hank’s solution (C) is a physiologic solution in which an avulsed tooth may be placed while waiting for reimplantation into the socket. There is no role in a partial tooth fracture. Viscous lidocaine (D) is not an appropriate analgesic for a dental fracture. Oral analgesics or dental block should be provided for pain control.

References

  1. Gorchynski J, Karabidian E, Sanchez M. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. The Journal of emergency medicine. 47(6):676-81. 2014. [pubmed]
  2. Caputo ND, Raja A, Shields C, Menke N. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? The Journal of emergency medicine. 45(1):8-12. 2013. [pubmed]
  3. Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofacial trauma & reconstruction. 9(2):121-4. 2016. [pubmed]

Episode 61 – The Elbow

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We review a podcast from Dr. Tim Horeczko’s Pediatric Emergency Playbook on elbow injuries.

critoe

Core Content

We delve into core content on other elbow adjacent injuries using Rosen’s Emergency Medicine (8th edition) Chapter  and Tintinalli’s Emergency Medicine (8th edition) Chapter  as a guide.

Elbow Trauma

olecranon bursitis

 Rosh Review Emergency Board Review Questions

A 63-year-old man presents with left arm pain after a fall. His X-ray is shown below. What structure is commonly injured with this fracture?

A. Axillary nerve

B. Median nerve

C. Radial nerve

D. Ulnar nerve

Answer

C. Radial nerve injury is the most common nerve injury seen after humeral shaft fractures. These fractures usually occur from a direct blow to the arm and can be seen in falls and motor vehicle collisions. Patients present with severe pain, arm swelling and decreased range of motion. The arm can be shortened or rotated in a complete fracture depending on the location of the fracture. A complete neurovascular exam should be performed as with all fractures and dislocations. The radial nerve may be injured during humeral fracture in up to 20% of patients. The injury is usually a neuropraxia and resolves spontaneously in most patients. However, this recovery can take months. Humeral fractures rarely need specific reduction maneuvers for treatment. They should be placed in a sugar tong splint and placed in a sling. Gravity alone is typically successful in fracture reduction. The axillary nerve (A) may be injured during glenohumeral dislocations. The median nerve (B) may be injured during posterior elbow dislocations. Anterior elbow dislocations can be associated with ulnar nerve injury (D).

 

A 3-year-old girl was walking on the sidewalk with her mom when she fell onto the street. In a panicked state, her mom picked up the little girl by her arm. Immediately after, the little girl refused to move her right arm complaining that it hurt. In the emergency room, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling or point tenderness along the entire right arm or clavicle. Which of the following is the next step in management of this patient?

A. Actively supinate and flex the elbow while applying pressure over the radial head

B. Consult orthopedics for casting

C. Obtain an ultrasound

D. Perform a skeletal survey

Answer

A. This child has “nursemaid’s elbow” that is due to subluxation of the annular ligament rather than dislocation of the radial head. The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. It occurs in toddlers due to traction via pulling on a pronated and extended arm. The child immediately refuses to the move the arm and often cradles the affected arm. Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm. The diagnosis is clinical and imaging studies are generally not needed. If reduction is unsuccessful after 2–3 attempts then imaging studies may be warranted. Treatment is manual reduction via supination and flexion or hyperpronation. A palpable click may be felt and the child usually regains immediate movement of the arm and relief of discomfort. A skeletal survey (D) should be obtained in all cases of suspected child abuse to assess for fractures in multiple stages of healing. Child abuse should be on the differential in all pediatric orthopedic cases. Consulting orthopedics for casting (B) is not necessary as this is a dislocation injury. Ultrasonography (C) has been used as a noninvasive modality to assess for annular ligamentous injury and displacement of the radial head from the capitellum. It has also been used to assess progress of treatment for patients with recurrent subluxations, however it is not the first-line diagnostic nor treatment option.