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By far, the two most common symptoms described are pain and the feeling that teeth no longer correctly meet (traumatic malocclusion, or disocclusion). The teeth are very sensitive to pressure (proprioception), so even a small change in the location of the teeth will generate this sensation. People will also be very sensitive to touching the area of the jaw that is broken, or in the case of condylar fracture the area just in front of the tragus of the ear.
Other symptoms may include loose teeth (teeth on either side of the fracture will feel loose because the fracture is mobile), numbness (because the inferior alveolar nerve runs along the jaw and can be compressed by a fracture) and trismus (difficulty opening the mouth).
Outside the mouth, signs of swelling, bruising and deformity can all be seen. Condylar fractures are deep, so it is rare to see significant swelling although, the trauma can cause fracture of the bone on the anterior aspect of the external auditory meatus so bruising or bleeding can sometimes be seen in the ear canal. Mouth opening can be diminished (less than 3 cm). There can be numbness or altered sensation (anesthesia/paraesthesia in the chin and lower lip (the distribution of the mental nerve).
Intraorally, if the fracture occurs in the tooth bearing area, a step may seen between the teeth on either side of the fracture or a space can be seen (often mistaken for a lost tooth) and bleeding from the gingiva in the area. There can be an open bite where the lower teeth, no longer meet the upper teeth. In the case of a unilateral condylar fracture the back teeth on the side of the fracture will meet and the open bite will get progressively greater towards the other side of the mouth.
Sometimes bruising will develop in the floor of the mouth (sublingual eccymosis) and the fracture can be moved by moving either side of the fracture segment up and down. For fractures that occur in the non-tooth bearing area (condyle, ramus, and sometimes the angle) an open bite is an important clinical feature since little else, other than swelling, may be apparent.
This type of fractured mandible can involve one condyle (unilateral) or both (bilateral). Unilateral condylar fracture may cause restricted and painful jaw movement. There may be swelling over the temporomandibular joint region and bleeding from the ear because of lacerations to the external auditory meatus. The hematoma may spread downwards and backwards behind the ear, which may be confused with Battle's sign (a sign of a base of skull fracture), although this is an uncommon finding so if present, intra-cranial injury must be ruled out. If the bones fracture and overlie each other there may be shortening of the height of the ramus. This results in gagging of the teeth on the fractured side (the teeth meet too soon on the fractured side, and not on the non fractured side, i.e. "open bite" that becomes progressively worse to the unaffected side). When the mouth is opened, there may be deviation of the mandible towards the fractured side. Bilateral condylar fractures may cause the above signs and symptoms, but on both sides. Malocclusion and restricted jaw movement are usually more severe. Bilateral body or parasymphysis fractures are sometimes termed "flail mandible", and can cause involuntary posterior movement of the tongue with subsequent obstruction of the upper airway. Displacement of the condyle through the roof of glenoid fossa and into the middle cranial fossa is rare. Bilateral condylar fractures combined with a symphyseal fracture is sometimes termed a guardsman's fracture. The name comes from this injury occurring in soldiers who faint on parade grounds and strike the floor with their chin.
Fractures of facial bones, like other fractures, may be associated with pain, bruising, and swelling of the surrounding tissues (such symptoms can occur in the absence of fractures as well). Fractures of the nose, base of the skull, or maxilla may be associated with profuse nosebleeds. Nasal fractures may be associated with deformity of the nose, as well as swelling and bruising. Deformity in the face, for example a sunken cheekbone or teeth which do not align properly, suggests the presence of fractures. Asymmetry can suggest facial fractures or damage to nerves. People with mandibular fractures often have pain and difficulty opening their mouths and may have numbness in the lip and chin. With Le Fort fractures, the midface may move relative to the rest of the face or skull.
Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.
Facial injuries have the potential to cause disfigurement and loss of function; for example, blindness or difficulty moving the jaw can result. Although it is seldom life-threatening, facial trauma can also be deadly, because it can cause severe bleeding or interference with the airway; thus a primary concern in treatment is ensuring that the airway is open and not threatened so that the patient can breathe. Depending on the type of facial injury, treatment may include bandaging and suturing of open wounds, administration of ice, antibiotics and pain killers, moving bones back into place, and surgery. When fractures are suspected, radiography is used for diagnosis. Treatment may also be necessary for other injuries such as traumatic brain injury, which commonly accompany severe facial trauma.
In developed countries, the leading cause of facial trauma used to be motor vehicle accidents, but this mechanism has been replaced by interpersonal violence; however auto accidents still predominate as the cause in developing countries and are still a major cause elsewhere. Thus prevention efforts include awareness campaigns to educate the public about safety measures such as seat belts and motorcycle helmets, and laws to prevent drunk and unsafe driving. Other causes of facial trauma include falls, industrial accidents, and sports injuries.
Symptoms that may be associated with condylar resorption include:
- Occlusion
- Anterior open bite
- Receding chin
- Clicking or popping when opening or closing the jaw
- Pain when opening or closing the jaw
- Limited jaw mobility
The symptoms can be numerous depending on the severity of the dislocation injury and how long the person is inflicted with the injury. Symptoms of a dislocated jaw include a bite that feels “off” or abnormal, hard time talking or moving jaw, not able to close mouth completely, drooling due to not being able to shut mouth completely, teeth feel they are out of alignment, and a pain that becomes unbearable
The immediate symptom can be a loud crunch noise occurring right up against the ear drum. This is instantly followed by excruciating pain, particularly in the side where the dislocation occurred.
Short-term symptoms can range from mild to chronic headaches, muscle tension or pain in the face, jaw and neck.
Long-term symptoms can result in sleep deprivation, tiredness/lethargy, frustration, bursts of anger or short fuse, difficulty performing everyday tasks, depression, social issues relating to difficulty talking, hearing sensitivity (particularly to high pitched sounds), tinnitus and pain when seated associated with posture while at a computer and reading books from general pressure on the jaw and facial muscles when tilting head down or up. And possible causing subsequent facial asymmetry.
In contrast, symptoms of a fractured jaw include bleeding coming from the mouth, unable to open the mouth wide without pain, bruising and swelling of the face, difficulty eating due to the constant pain, loss of feeling in the face (more specifically the lower lip) and lacks full range of motion of the jaw.
Basilar skull fractures are linear fractures that occur in the floor of the cranial vault (skull base), which require more force to cause than other areas of the neurocranium. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.
Basilar fractures have characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose (rhinorrhea) or ears (otorrhea); periorbital ecchymosis often called 'raccoon eyes' (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and retroauricular ecchymosis known as "Battle's sign" (bruising over the mastoid process).
Diastatic fractures occur when the fracture line transverses
one or more sutures of the skull causing a widening of the suture. While this type of fracture is usually seen in infants and young children as the sutures are not yet fused it can also occur in adults. When a diastatic fracture occurs in adults it usually affects the lambdoidal suture as this suture does not fully fuse in adults until about the age of 60.
Diastatic fractures can occur with different types of fractures and it is also possible for diastasis of the cranial sutures to occur without a concomitant fracture. Sutural diastasis may also occur in various congenital disorders such as cleidocranial dysplasia and osteogenesis imperfecta.
As with other types of fractures, scapular fracture may be associated with pain localized to the area of the fracture, tenderness, swelling, and crepitus (the crunching sound of bone ends grinding together). Since scapular fractures impair the motion of the shoulder, a person with a scapular fracture has a reduced ability to move the shoulder joint. Signs and symptoms may be masked by other injuries that accompany the scapular fracture.
Dislocations occur when two bones that originally met at the joint detach. Dislocations should not be confused with Subluxation. Subluxation is when the joint is still partially attached to the bone.
When a person has a dislocated jaw it is difficult to open and close the mouth. Dislocation can occur following a series of events if the jaw locks while open or unable to close. If the jaw is dislocated, it may cause an extreme headache or inability to concentrate. When the muscle's alignment is out of sync, a pain will occur due to unwanted rotation of the jaw.
If the pain remains constant, it may require surgery to realign the jaw. Depending on the severity of the jaw's dislocation, pain relief such as paracetamol may assist to alleviate the initial chronic pain. If the pain relief is taken for an extended period of time, it may negatively affect the person while talking, eating, drinking, etc.
Signs and symptoms include crepitus (a crunching sound made when broken bone ends rub together), pain, tenderness, bruising, and swelling over the fracture site. The fracture may visibly move when the person breathes, and it may be bent or deformed, potentially forming a "step" at the junction of the broken bone ends that is detectable by palpation. Associated injuries such as those to the heart may cause symptoms such as abnormalities seen on electrocardiograms.
The upper and middle parts of the sternum are those most likely to fracture, but most sternal fractures occur below the sternal angle.
The main symptoms of a hyoid bone fracture include pain when the affected person rotates their neck, trouble swallowing (dysphagia), and painful swallowing (odynophagia). Other symptoms can be crepitus or tenderness over the bone, suffocation when sticking out the tongue, dyspnea, dysphonia, and subcutaneous emphysema. On laryngoscope examination, lacerations on the pharynx, bruises, swelling, and/or hyoid bone fragments can be seen. If the hyoid bone is fractured, there is a high likelihood that the larynx, pharynx, mandible, and/or cervical spine may be injured as well. Common co-occurring injuries include Le Fort III fractures, mandibular or cervical vertebra fractures, and mandibular dislocation.
Condylar resorption, also called idiopathic condylar resorption, ICR, and condylysis, is a temporomandibular joint disorder in which one or both of the mandibular condyles are broken down in a bone resorption process. This disorder is nine times more likely to be present in females than males, and is more common among teenagers.
Hyoid bone fractures are classified into three different types:
- Inward compression fractures with outside periosteal tears
- Antero-posterior compression fractures with inside periosteal tears
- Avulsion fractures
A scapular fracture is a fracture of the scapula, the shoulder blade. The scapula is sturdy and located in a protected place, so it rarely breaks. When it does, it is an indication that the individual was subjected to a considerable amount of force and that severe chest trauma may be present. High-speed vehicle accidents are the most common cause. This could be anywhere from a car accident, motorcycle crash, or high speed bicycle crash but falls and blows to the area can also be responsible for the injury. Signs and symptoms are similar to those of other fractures: they include pain, tenderness, and reduced motion of the affected area although symptoms can take a couple of days to appear. Imaging techniques such as X-ray are used to diagnose scapular fracture, but the injury may not be noticed in part because it is so frequently accompanied by other, severe injuries that demand attention. The injuries that usually accompany scapular fracture generally have the greatest impact on the patient's outcome. However, the injury can also occur by itself; when it does, it does not present a significant threat to life. Treatment involves pain control and immobilizing the affected area, and, later, physical therapy.
A sternal fracture is a fracture of the sternum (the breastbone), located in the center of the chest. The injury, which occurs in 5–8% of people who experience significant blunt chest trauma, may occur in vehicle accidents, when the still-moving chest strikes a steering wheel or dashboard or is injured by a seatbelt. Cardiopulmonary resuscitation, commonly known as CPR, has also been known to cause thoracic injury, including sternum and rib fractures. Sternal fractures may also occur as a pathological fracture, in people who have weakened bone in their sternum, due to another disease process. Sternal fracture can interfere with breathing by making it more painful; however, its primary significance is that it can indicate the presence of serious associated internal injuries, especially to the heart and lungs.
Patients often complain of pain and instability at the joint. With concurrent nerve injuries, patients may experience numbness, tingling and weakness of the ankle dorsiflexors and great toe extensors, or a footdrop.
Shoulder related injuries include rotator cuff tear, strain or tendinitis, biceps tendinitis and SLAP lesion.
The temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral synovial articulation between the temporal bone of the skull above and the mandible below; it is from these bones that its name is derived.
Tennis elbow (Lateral Epicondylitis) is a common elbow injury among climbers, as is Golfer's elbow (Medial Epicondylitis, which is similar, but occurs on the inside of the elbow).
Posterolateral corner injuries (PLC injuries) of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.
While ligamentous laxity may be genetic and affect an individual from a very early age, it can also be the result of an injury. Injuries, especially those involving the joints, invariably damage ligaments either by stretching them abnormally or even tearing them.
Loose or lax ligaments in turn are not capable of supporting joints as effectively as healthy ones, making the affected individual prone to further injury as well as compensation for the weakness using other parts of the body. Afflicted individuals may improve over time and lose some of their juvenile hyperlaxity as they age. Individuals over age 40 often have recurrent joint problems and almost always suffer from chronic pain. Back patients with ligamentous laxity in the area of the spine may also experience osteoarthritis and disc degeneration.
In the case of extreme laxity, or hypermobility, affected individuals often have a decreased ability to sense joint position, which can contribute to joint damage. The resulting poor limb positions can lead to the acceleration of degenerative joint conditions. Many hypermobility patients suffer from osteoarthritis, disorders involving nerve compression, chondromalacia patellae, excessive anterior mandibular movement, mitral valve prolapse, uterine prolapse and varicose veins.
Prognathism in humans can be due to normal variation among phenotypes. In human populations where prognathism is not the norm, it may be a malformation, the result of injury, a disease state or a hereditary condition. Prognathism is considered a disorder only if it affects mastication, speech or social function as a byproduct of severely affected aesthetics of the face.
Clinical determinants include soft tissue analysis where the clinician assesses nasolabial angle, the relationship of the soft tissue portion of the chin to the nose, and the relationship between the upper and lower lips; also used is dental arch relationship assessment such as Angle's classification.
Cephalometric analysis is the most accurate way of determining all types of prognathism, as it includes assessments of skeletal base, occlusal plane angulation, facial height, soft tissue assessment and anterior dental angulation. Various calculations and assessments of the information in a cephalometric radiograph allow the clinician to objectively determine dental and skeletal relationships and determine a treatment plan.
Prognathism is less prevalent in East Asians and Caucasians. It is not to be confused with micrognathism, although combinations of both may be found. It affects the middle third of the face, causing it to jut out, thereby increasing the facial area, similar in phenotype of archaic hominids and apes. Mandibular prognathism is a protrusion of the mandible, affecting the lower third of the face. Alveolar prognathism is a protrusion of that portion of the maxilla where the teeth are located, in the dental lining of the upper jaw. Prognathism can also be used to describe ways that the maxillary and mandibular dental arches relate to one another, including malocclusion (where the upper and lower teeth do not align). When there is maxillary and/or alveolar prognathism which causes an alignment of the maxillary incisors significantly anterior to the lower teeth, the condition is called an overjet. When the reverse is the case, and the lower jaw extends forward beyond the upper, the condition is referred to as retrognathia (reverse overjet).
The reported symptoms are very variable, and frequently have been present for many months before the condition is diagnosed. Reported symptoms may include some of the following:
- Sharp pain when biting on a certain tooth, which may get worse if the applied biting force is increased. Sometimes the pain on biting occurs when the food being chewed is soft with harder elements, e.g. seeded bread.
- "Rebound pain" i.e. sharp, fleeting pain occurring when the biting force is released from the tooth, which may occur when eating fibrous foods.
- Pain when grinding the teeth backward and forward and side to side.
- Sharp pain when drinking cold beverages or eating cold foods, lack of pain with heat stimuli.
- Pain when eating or drinking sugary substances.
- Sometimes the pain is well localized, and the individual is able to determine the exact tooth from which the symptoms are originating, but not always.
If the crack propagates into the pulp, irreversible pulpitis, pulpal necrosis and periapical periodontitis may develop, with the respective associated symptoms.
Temporomandibular joint pain is generally due to one of four reasons.
- Myofascial pain dysfunction syndrome, primarily involving the muscles of mastication. This is the most common cause.
- Internal derangements, an abnormal relationship of the disc to any of the other components of the joint. Disc displacement is an example of internal derangement.
- Osteoarthritis of the temporomandibular joint, a degenerative joint disease of the articular surfaces.
- Temporal arteritis, for which it is considered a reliable diagnostic criteria.
Pain or dysfunction of the temporomandibular joint is sometimes referred to as "TMJ", and temporomandibular joint disorder (or "dysfunction") may be abbreviated TMD. This term is used to refer to a group of problems involving the temporomandibular joints and the muscles, tendons, ligaments, blood vessels, and other tissues associated with them.
Although rare, other pathologic conditions may also affect the function of temporomandibular joints, causing pain and swelling. These conditions include chondrosarcoma, osteosarcoma, giant cell tumor and aneurysmal bone cyst.