Rosen & Barkin's 5-Minute Emergency Medicine Consult (700 page)

TMJ syndrome can be managed on an outpatient basis unless a locked or dislocated joint cannot be reduced

Treat as outpatient with pain medication, muscle relaxants, and warm compresses

Patients with TMJ syndrome may need referral to ENT, oral surgeon, or dentist for further care

• TMJ locking must be addressed urgently
  
• If ear pain with no ear findings, evaluate for TMJ
  
• NSAIDs, rest, and heat are 1st-line therapy
  

• Buescher JJ. Temporomandibular joint disorders.
  Am Fam Physician
  . 2007;76:1477–1482.
  
• Gordon SM, Viswanath A, Dionne RA. Evidence for drug treatments for pain related to temporomandibular joint disorder.
  TMJ News Bites, Newsletter of the TMJ Association
  , 3:6, Sept 2011.
  
• Heitz CR. Face and jaw emergencies. In: Tintinalli JE, Stapczynski JS, Cline DM, et al., eds.
  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
  7th ed. New York, NY: McGraw-Hill; 2011.
  
• Lewis EL, Dolwick MF, Abramowicz S, et al. Contemporary imaging of the temporomandibular joint.
  Dent Clin North Am
  . 2008;52:875–890.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice.
  7th ed. St. Louis, MO: Mosby; 2009.
  
• Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders.
  N Engl J Med
  . 2008;359:2693–2705.
  

CODES

• 524.60 Temporomandibular joint disorders, unspecified
  
• 524.62 Temporomandibular joint disorders, arthralgia of temporomandibular joint
  
• 524.64 Temporomandibular joint sounds on opening and/or closing the jaw
  

BASICS

• Based on mechanism
  
• External trauma:
  
  • Penetrating trauma:
    
    • Gunshot wounds
      
    • Glass
      
    • Knives
      
    • Foreign bodies
      
  • Blunt trauma:
    
    • Crushing force or avulsion from hyperextension of a joint
      
• Internal trauma:
  
  • Entrapment/laceration from bony fracture (rare)
    

Tendon injuries grossly categorized into those affecting upper vs. lower extremities:

• Upper-extremity injuries frequently related to the workplace, home, an assault, or attempted suicide
  
• Lower-extremity injuries most often associated with work or motor vehicle accident
  

DIAGNOSIS

• Pain is the cardinal symptom.
  
• Functional deficit
  
• Soft tissue damage:
  
  • Swelling
    
  • Ecchymosis
    
  • Lacerations
    
  • Hemorrhage
    
• Abnormal resting position of the extremity or large joint instability increases suspicion for tendon injury.
  

• A careful history:
  
  • Mechanism, time of injury
    
  • Hand position during injury
    
  • Hand dominance
    
  • Drug allergies
    
  • Medications
    
  • Past medical history
    
  • Tetanus vaccination status
    
• Physical exam:
  
  • Examine resting position of hand. (At rest there is natural flexion of fingers increasing from radial to ulnar side.)
    
  • Examine the wound in position of initial injury.
    
  • Perform neurovascular exam before local anesthesia is instilled.
    
  • Examine each digit separately.
    
  • Test strength against resistance.
    
  • Examine tendon with direct visualization through full range of motion.
    
• Flexor digitorum profundus injuries:
  
  • Present with inability to flex the distal interphalangeal (IP) joint
    
  • Exam involves stabilizing the proximal IP joint in full extension while the patient attempts to flex distal IP joint.
    
• Flexor digitorum superficialis injuries:
  
  • Present with inability to flex the proximal IP joint of a digit
    
  • Usually established by means of standard superficialis tendon test:
    
    • While holding the uninjured digits in full extension, the patient attempts to flex the affected finger at the proximal IP joint.
      
    • False negative if profundus is functional.
      
  • The distal IP joint extension test:
    
    • May make this diagnosis more apparent
      
    • Patient is asked to make a precision pinch between thumb and the injured finger.
      
    • Then asked to flex the proximal IP joint so that the distal IP joint is hyperextended
      
    • Confirms the integrity of the flexor digitorum superficialis
      
• Forearm and wrist flexor injuries:
  
  • Present with inability to flex ulnar or radial side of wrist or to flex the wrist while opposing the thumb to the little finger
    
• Extensor tendon injuries:
  
  • Found by weakness or lack of extension of the distal phalanx against resistant
    
  • Indicates partial or complete disruption
    
  • Best determined with patient placing palm on flat surface and asking the patient to attempt to extend the fingers individually
    
  • Palpate each tendon.
    
  • Loss of normal tension indicates injury.
    
• Further explore tendons and wounds after local anesthesia (1% lidocaine or 0.5% bupivacaine) in a bloodless, well-lit surgical field:
  
  • Tendons near lacerations must be explored through complete range of motion.
    
  • Best elucidates tendon injuries distal or proximal to a skin wound
    

• More difficult to get an adequate exam
  
• The healing process is usually quicker and more often associated with complete return to preinjury function.
  

Wounds 1st examined >12 hr after injury or wounds with evident infection should be cultured.

• Radiographs are frequently needed to identify radiopaque foreign bodies or fractures.
  
• High-frequency US can be used to identify complete tendon lacerations:
  
  • Partial tendon lacerations difficult to image
    
  • A water bath may help when attempting to image a painful extremity.
    
• US guidance may help to guide removal of foreign bodies.
  
• MRI
  

• Always rule out an associated foreign body or fracture.
  
• Lacerations over the proximal IP joint may involve the lateral bands or the central slip of the extensor mechanism:
  
  • Boutonnière deformity from improper repair
    
• Disruption of the extensor tendon distal to the central slip results in a mallet finger deformity.
  
• “Jersey finger” is a closed traumatic injury with avulsion of the flexor digitorum profundus, seen when a football player grabs the jersey of another player and his finger gets stuck.
  
• Avulsion of the flexor digitorum superficialis distally may be present with or without an associated avulsion fracture:
  
  • Suspect when a grasping finger is hit by a fast-moving object (jammed finger).
    

TREATMENT

• Do not remove foreign matter from the patient in the field.
  
• Immobilize and transport patient.
  
• Apply direct pressure to control hemorrhage.
  
• Assess distal neurovascular status for signs of compromise.
  
• Contact medical control before any attempted reduction.
  

• Evaluate extremity and control hemorrhage with direct pressure.
  
• Remove all jewelry or constricting bands.
  

• Pain control as required
  
• Administer tetanus toxoid as needed.
  
• Copious irrigation with 1 L NS
  
• Broad-spectrum antibiotic, such as a 1st-generation cephalosporin (Cefazolin)
  
• Tendon lacerations associated with human bites:
  
  • Must be copiously irrigated
    
  • Place on IV antibiotics with coverage of oral anaerobes (ampicillin/sulbactam).
    
  • Immobilize and elevate the hand.
    
• Remove all foreign bodies and provide débridement of avascular tissue.
  
• Partial tendon lacerations that involve >20% of the cross-sectional area of the tendon must be repaired.
  
• Simple extensor tendon lacerations may be repaired in the ED:
  
  • Use a 4-0 or 5-0 nonabsorbable suture in a figure-of-8 or a modified Kessler stitch.
    
• All
  suspected flexor tendon, wrist, and distal forearm tendon lacerations require consultation by a hand surgeon, ideally within 12 hr.
  
• Tendon lacerations over the proximal IP joint may result in a boutonnière deformity:
  
  • Refer to a hand surgeon.
    
• The superficial nature of multiple tendons, nerves, and vessels on the volar aspect of the wrist renders them easily vulnerable to penetrating trauma:
  
• “Spaghetti wrist” or “full house”:
  
  • Volar wrist laceration with at least 10 structures involved
    
  • Requires prompt consultation with a hand surgeon
    
• Tendon lacerations associated with fractures require referral for operative repair.
  
• If a surgeon is not promptly available:
  
  • Irrigate copiously.
    
  • Close skin without repair of tendon.
    
  • Immobilize injured hand with a bulky volar dressing and splint.
    
  • Wrist in 20–30° of flexion
    
  • Metacarpal joint in 60–70° of flexion
    
  • IP joints in 10–15° of flexion