The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2017 Published by Elsevier Inc. 0736-4679/$ - see front matter
Clinical Communications: Adult MANDIBULAR DEGLOVING: A CASE REPORT AND LITERATURE REVIEW Joshua M. Jabaut, MD, MS,* Joseph Kotora, DO, MPH, FACEP, FAAEM,† and Art Ambrosio, MD‡§ *Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, †Department of Emergency Medicine, Naval Hospital Camp Lejeune, Jacksonville, North Carolina, ‡Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, and §Department of Otolaryngology–Head and Neck Surgery, Naval Hospital Camp Pendleton, Oceanside, California Reprint Address: Joshua M. Jabaut, MD, MS, Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin, Avenue, Bethesda, MD 20889
, Keywords—mandible; degloving; facial trauma; occult injury
, Abstract—Background: Degloving injuries of the extremities are well documented; however, there are few reports of degloving injuries to the mandible. A literature review demonstrates several cases of mandibular degloving in pediatric patients. However, no isolated mandibular degloving injuries have been reported in adults. Case Report: We report a case of a 21-year-old male who presented to the emergency department with facial trauma after a motorcycle accident. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. Following completion of maxillofacial computed tomography after primary and secondary survey, the intraoral lesion was found to be a degloving injury of the mandible. This injury was irrigated with bacitracin and betadine before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially. Why Should an Emergency Physician Be Aware of This?: Facial trauma is a common presentation in the emergency department. It is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. Without a high level of suspicion, such lesions may be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity. Published by Elsevier Inc.
INTRODUCTION Injuries to the head and neck account for 4.1% of all emergency department trauma-related visits in the United States (1). Clinically, injuries to the face are usually recognized during the initial assessment and physical examination of the patient, however, occult injuries may be missed (2). Open wounds of the jaw and mandible represent a relatively infrequent injury, accounting for only 3.3% of all facial trauma (1). The oral mucosa—in particular the gingivobuccal sulcus—is capable of obscuring injury due to its existence as a natural crease (3). This vulnerability highlights the importance of a thorough head and neck examination in facial trauma, including examination of the oral mucosa along the gingivobuccal sulcus. Although more commonly seen in the extremities, degloving injuries may occur in the face as well. Several case reports exist in the literature demonstrating degloving injury to the face, including the mandible (3–6). Here we present a case of mandibular degloving that was not detected on initial examination, but was found with more extensive manipulation of the lip during repair of a lateral commissure laceration.
RECEIVED: 1 July 2016; FINAL SUBMISSION RECEIVED: 10 February 2017; ACCEPTED: 14 March 2017 1
J. M. Jabaut et al.
CASE REPORT A 21-year old male presented to the emergency department via ground ambulance after a low-speed motorcycle accident. The patient stated that he was wearing a helmet at the time of impact. Examination of the helmet demonstrated a plastic ‘‘skull cap’’-style helmet without chin protection. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. There were no overt signs of intracranial or skull base injury. Given the mechanism of soft tissue injury and a suspicion for open mandibular fracture, the patient was given a bolus of intravenous clindamycin. The patient’s tetanus status was verified as current in his military electronic health record. Subsequent head and maxillofacial computed tomography demonstrated no evidence of intracranial injury or facial fractures. After cleaning, debridement, and closure of the synchronous lacerations, it was discovered that the intraoral laceration was a degloving injury of the anterior symphysis and bilateral parasymphyseal segments of the mandible from the overlying muscle (mentalis and orbicularis oris), subcutaneous tissue, and skin en bloc. Mental nerves bilaterally were visible, but not avulsed. Occlusion was class I bilaterally. Although there was no mandibular fracture identified, the on-duty head and neck surgeon was consulted for evaluation and disposition of complex repair of the mandibular degloving injury. This injury was irrigated with bacitracin-infused saline irrigation to clean the injury before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially (Figure 1). The patient was seen for follow-up 8 weeks later and found to have a well-healed gingivobuccal sulcus without evidence of pocketing or gross deformity (Figure 2).
Figure 1. Shaded region identifying the area of degloving injury. Please note that the injury was deep to the shaded region.
the mandible are less developed, making it more vulnerable to degloving injury (3). The patient presented in this case was 21 years old, perhaps making him more vulnerable to a degloving injury. Facial trauma is becoming more common with increased participation in athletic activities, and indeed sport-related trauma is a common cause of mandibular degloving (5). As seen in this case, in order to detect a mandibular degloving injury, the provider must have a high level of suspicion, as these injuries are often occult. Patients who have a delayed presentation after a traumatic facial injury
DISCUSSION Degloving injuries are defined as the stripping of soft tissue, including the neurovascular bundle, from bone. They are produced when a shearing force causes traumatic separation of soft tissue and periosteum, down to the capillary and lymphatic level, from bone (3). They occur most commonly in the upper and lower extremities, but several cases have been reported in facial trauma (3–9). Although more commonly seen in pediatric and adolescent populations, mandibular degloving also occurs in the adult population. It is theorized that in the younger population, the periosteum and musculature of
Figure 2. A well-healed gingivobuccal sulcus seen at 8-week follow-up.
may complain only of a chin that is more sore than the patient might otherwise expect. Another factor in these delayed presentations can be the presence of infection, with the pain being more due to the consequences of the infection than to the consequences of the original injury (5). In order to detect a degloving injury, a thorough head and neck evaluation must be performed. During the examination, the clinician should pay particular attention to the oral examination and cranial nerve function. A thorough oral examination should include interrogation of the gingivobuccal sulcus with a headlamp, gloved fingers, and tongue depressors. When evaluating cranial nerve function, the provider should pay close attention to sensation in the V3 distribution, as chin sensation may be diminished due to mental nerve disruption in such injuries. Should a sensory deficit secondary to nerve disruption be detected, anastamosis should be attempted, as surgical repair increases the rate of reinnervation and can decrease the morbidity of drooling associated with loss of sensation (4). Management of the wound should include thorough irrigation with saline and chlorhexidine to minimize risk of mucosal tattooing or infection. Discharge with a course of oral antibiotics will further minimize risk of infection (3–5). When the injury is managed acutely, primary closure should be attempted, however, a delayed presentation increases risk of infection and warrants healing by secondary intention. Advantages of primary closure are the elimination of dead space (which can entrap food particles), minimizing hematoma/seroma formation, maintaining the vestibular anatomy and preventing aberrant scarring, and increasing patient comfort and hastening recovery (4). Primary closure should be done in layers for reapproximation of the mucosa, muscle, and periosteum. A compressive dressing may be used at discharge to minimize risk of hematoma/ seroma formation and may remain in place for a period of 24–72 (6). Discharge management should include strict oral hygiene with toothbrushing, salt water rinse, and weekly follow-up to ensure rigorous oral hygiene (3,4).
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Oromaxillofacial trauma is a common presentation in the emergency department. In such cases, it is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. As was seen in this case, it was not until further manipulation of the lower lip that the mandibular degloving was detected. Several other cases reported in the literature showed delayed diagnosis and treatment because the injuries were not even detected by the patient. Without a high level of suspicion, such lesions can be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity. REFERENCES 1. Sethi RK, Kozin ED, Lee DJ, Shrime MG, Gray ST. Epidemiological survey of head and neck injuries and trauma in the United States. Otolaryngol Head Neck Surg 2014;151:776–84. 2. Berbaum KS, El-Khoury GY, Franken EA, et al. Missed fractures resulting from satisfaction of search effect. Emerg Radiol 1994;1: 242–9. 3. Pollock RA, Huber KM, Sickels JE. Degloving injuries of the oral cavity change the operative approach to fractures of the anterior segment of the mandible. Craniomaxillofac Trauma Reconstr 2011; 4:137–44. 4. Dula DJ, Leicht MJ, Moothart WE. Degloving injury of the mandible. Ann Emerg Med 1984;13:630–2. 5. Mclaughlin PP. Degloving injury to the mental protuberance: a case report. Int J Paediatr Dent 2000;10:234–6. 6. Rahpeyma A, Khajeahmadi S. Bone suture in management of mandibular degloving injury. J Surg Tech Case Rep 2013;5: 35–7. 7. Olateju OS, Oginni FO, Fatusi OA, Faponle F, Akinpelu O. Multiple midface degloving injury in an elderly man: challenges and management outcome. J Natl Med Assoc 2007;99: 810–3. 8. Panse N, Sahasrabudhe P, Joshi N. Face avulsion and degloving. World J Plast Surg 2014;3:64–7. 9. Perumal C, Bouckaert M, Robson M. Degloving facial injury treated with hydroconductive dressing. Ann Maxillofac Surg 2013;3:87–8.