Ap in ae ppt Nes ee ope Nag Nk Neways hates eee Meo Meg dp ee (Crane Be Dyk Cope og ane er hm hoot UPPITY WILLIAMS & WILKS «Wn Kew tee © 197 Walls Wan gn ror Te ks mel gps Neh b e ep fe by moe ggg ng hy ye mg deca Crewe poem im epg oe etl nan eben alc Se Ftp Mota nasa oman ese sto com gon ic ened bay f Can CaloingePbion Da Tat pb my inne Cong ing Fed Hg nn “Mor Rng fwd} Son Goan toga le Hepa tory mine, ‘Sov ren arse Tamwlearrasiaoe [inden oman 2 Penman Ce 9 MeL (ONULEL frre EOL apy Moe ek wean Soe ca bem end de cy einen peed rie gl sol pnien Hom tenor nr ey mya pS en te ay enectene fom pinto ae emer sed keene momepepetor (Spelt es ce Semeny cen yo ome ep pon Fe Ec pe entree eoenesp poem ommendaen "Taran le nd aba ety et cme a ge gt ‘rh nt etn clin ah se seems sl pte ew cee oer treo apa ge @ geome npn oe oe nf ae sete ng cay eae lr naples ‘hegemony a orale engl pce Th pen enc Soom agenin a webu coed ‘Sond nk re done pred te bce Fl Dog Ab (ren aren ete dhe Be pyc pan Moen FOM mach ger pend eos pe "Te pthread ee me eye saris eink yl pened mae marae oegnee ee “Tern alten spc eb ck ane Gems war dpe # ON AAEM et fa enn 00220300 genet Wika Wake come ter epee ma {nn 810 et po ES. dy hn a i wpe es Var Unt Wi Nib oe beer bap ewe em woeresaazySauoyerey ere), PEDIATRIC EMERGENCY PROCEDURES mare Ge item aire bcc Males Sveti teic) oy DaaReduction of Temporomandibular Joint Dislocation > INTRODUCTION ita joint dislocation isthe displacement of ‘he mandibular condyle From the mandibular ors. rendering ‘the paient unable to achieve eduction withowt asitance. ie serencommon condition in children but may our in ado ‘ems Due tothe associated pain and anxict, paints in the ate penal ypecaly present to the emengeney department (ED) orto a dental or primary care office The procedure for racing a temporomandhular joint Ehevion dg ine ce Hipporaes he i «aly credited with the atest description ofthe Ths pal erseee bs tte tnioeron soe function, and allewate pai. The ear the reduction is at- tempted the grater the ikeihoodaf wacce (1.2) Reduction ‘© most fequenty performedin che fice oF ED sting by a ‘Plysicin, deat, or oral surge and is rdativey uncom «ated, assuming that proper technigu is fllowed. > ANATOMY AND PHYSIOLOGY The temporomandibule joint consists of the head of the ‘mandibular condyle sting within the mndibular fossa ofthe temporal bone (Fi, 681A). The aricular surfices ae lined by + synovial membrane and separated by a dk oF tenio- «is composed of fous eonsective sue. The sruter of the join allows for hinge, ling and side-to-side mocions “The capa igamenataches to both the manda fons and the neck of the condyle Ie laity allows for the leble movement of the joint. The oie is abo supported by two ligaments om the meal surface. the salar and soylomandibulargareres and one on the lateral surface, the temporomanchibular hgamene Recurent dislocation may be sociated with exesie les in these ligament, a occurs ‘in ENer-Danlos of Matan syndrome. ‘The lateral prerygoid muscle and several neck muscles ate responsible for opening the jaw Clore controlled by the rmasstet, medial eerypid. and temporal muscles, ‘Acute dislocation ofthe ermporomandibular joint occas most fern in ananteiordestion casing he mance Lnrcondsletobecome lockedin front of the articular eminence (Fig. 6818), Dislocation car occu bilteally o unilaterally Spasms the teal perygoid and temporal mses aie the ddocation and oftenmskerlectiondificuk. Condi hat predispose o dislocation ich pic setching of the joint capa alow articular eminence, increased tonicity of themusce of mastication and excessive lgamentouslaiy. ‘Arnumber of mechani ate aeocsted with aneroe die Ioeation inching extreme mouth opening, ax occurs daring pisos of | yawning oF vomiting. and prokanged Se wreath came oe act 2py(1.3) Dislocation abo can occurs result of comulsons, panic reactions trams ‘Akhough unasual posterior and superior dlocations may be sean. Pasteroedisiation sgenerally the rou of taut and often is asocated with damage tothe nearby auditory system. Disruption ofthe exemal aadeory canal or facture of the temporal pate common (4). Superior dislocation ‘eeu with sever trauma and associated with Fractures of the mandibuiar fess. Laer diocaions occur nly with «concomitant fractures of the mandibular body (5) > INDICATIONS Patents with an acute anterior dislocation of the temporo= smandibela join complain of severe pin inthe presurtcularUAL OF EMERGENCY MEDICINE Crs) Editor G. Richard Braen, mo, FACEP Proesso¢ and Chair, Department of Emexgency Medicine, Assitant Dean, Graduate Mesical Education, School of Medicine and Biomedical Sciences State University of New York ar Buffalo, Buffalo, New York Editor Emeritus Jon L. Jenkins, mo, FAGEP Former Chairman, Department of Emergency Medicine Wakefield Hospital, Melrose, Mascachusects Assistant Editors Jeanne Basior, MD, FACEP Associate Profesuor of Clinical Emergency Medicine, Assistant Residency Ditector, Department of Emergency Medicine, School of Medicine and Biomedical Seiences, University of Bulle, Buffalo, New Yorks Samuel Cloud, 00, FACEP Astrant Profisor of Clinical Emergency Medicine, Assstne Resideney Director, Depactment of Emergency Medicine, School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, New Yor Christian DeFazio, mo, saccP Assan: Profesor of Cliaal Emengency Medicine, Residency Director, Department of Emergency Medicine, School of Medictne and Biomedical Sclonces, Universiy of Buffalo, Buffalo, New Yorks Robert McCormack, Mb, FACEP rofessor of Clinical Emergency Medicine, Department of Emengeney Medisine School of Medicine and Biomedical Sciences, Univesity of Buffalo, Buffalo, New Yorks Dirsstos, Department of Emergency Medicine, Buffalo General Hospital, Buffalo, New York Asoc EI. Wolters Kluwer | Lippincott Williams & Wilkins Pied hime = New York tendon Buenos ies HongKong Syne Tokyoor bacterial parotitis may occur spontaneously 0 secondary to stone or stricture. Bacterial infection is typically produced by staphylo- cocci, and on palpation and “milking” of the gland and duct, punslent material may be noted to appear at the duct orifice. Treatment for patients with bacterial infection involves the culture of any expressed material, relief of obstruction by stone ext surgical extitpation ofa fibrotic stenotic lesion, and the administration of an antistaphy- lococeal antibiotic. Otolaryngologic consultation is appropriate in most patients. Temporomandibular Joint Syndrome Patients with che temporomandibular joint syndrome primarily complain of sharp or ach- ing pain related to chewing or opening the mouth typically radiating to the ear. A history of recent jaw injury, dental work, or long-standing malocclusion is often obtained, Emo- sional stress associated with clenching the tecth or nocturnal grinding of the cecth may Sho be reported. Examination ofthe temporomandibular joint bee performed withthe ‘examiner's index fingers placed within the external auditory canals. Anterior fullness and renderness may be noted with this maneuver, particularly with the mouth open; erepita- tion and limited motion may also be observed. Treatment involves the use of heat applied locally, che administration of aspirin or other ant-inflammatory agents, and limiting the dict to soft foods. The patient should be referred to an oral surgeon if symptoms persist Temporomandibular Joint Dislocation ‘Temporomandibular joint dislocation may follow trauma to the face or may occur asa result of simply opening the mouth widely with yawning, laughing, or chewing, Patients are unable to close the mouth and complain of severe discomfort and varying degrees of anxiety. Radiologic assessment of the entire mandible is indicated before atcempting reduction, because condylar fractures are occasionally present and should be documented before manipulation ral disloca Importantly, dystonic reactions to the phenothiazines or antipsychotic medica- tions may simulate this disorder as well as a variety of other conditions. This phe- nomenon should be considered in all patients with atraumatic facial pain and can usually be rapidly excluded on the basis of history. (See “Temporomanclibulae Joint Dislocation” in Chapter 4 for treatment of dystonic reactions and for treatment of dislocations.) SIT COPT FE TSRAY OF TOT po virus; suppuracne ion with ductal obstruction ns often occur. Sinusitis See “Acute Sinusitis in Chapter 42 for treatment of acute sinusitis.Sor Aeyuition Editor: Paces DeSean Prout Dirtor jis Seo Ver Menge: Bide Dovghery {enor Manning Manager Benin Rivers Sor Maring Mang Anges Peta Daign Cini Try Nall Dratiow Sncee SH Cla (© 201 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business “we Commerce Syare 2001 Mkt Sr, Priel, PA 19105 USA BWWcon, Allcights sro. This book pcb copyright No prt thi took my be reproduc ny form by any means, including photocopy ng or tld bya norman sg andra tysem without writen psmision fom the copyright owner. forbid quo embed ihertzalaricles andrews Matealsappesting i this bck repaed by nvidia» prtof ‘hil duce ar. povernent employer ot ont ye above menaced coyegh atl in Chine Library of Corgress Calg i- Publication Da Manual ofemegency mele! ite, Reka Bran. — Gil. bon Inch de [BBN S781-60831.2008 1. 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