Bored? Don't Yawn - Review

Crocodile Dundee walks through your ED door saying: “A ant eose ai aouh”.

You look at him, bewildered, thinking: That isn’t an australian accent.

You gather from Dundee that while attempting the mating stance of a Burmese Python, his jaw “just popped out”.

You palpate his face and feel a depression just anterior to the anterior tragus (almost like an empty socket…).

(1) What type of dislocation does Dundee likely have (anterior, posterior or lateral / unilateral or bilateral?)

Old Crock most likely experienced a spontaneous atraumatic bilateral anterior temporomandibular joint (TMJ) dislocation.

Anterior dislocation:

– Non traumatic TMJ dislocations are almost exclusively anterior and very often bilateral.

– They occur due to extreme opening of the mouth (seizure, yawning, laughing, fellatio).

– The mandibular condyle slips in front of the articular eminence.

– Preauricular depressions.

– Cannot close mouth.

Posterior or lateral:

– Traumatic.

(2) How do you reduce such an injury?

Traumatic: Obtain films and consider calling whoever covers facial trauma (oromaxillofacial or otolaryngology).

Atraumatic, anterior: almost exclusively anterior → proceed to external reduction.

Pharmacology: Benzodiazepines as muscle relaxants and opiates are commonly used for analgesia. You can inject 2cc of 2% Lidocaine into the joint space (right at the preauricular depression). If necessary, conscious sedation can be used.

Technique (Here is a good video if words are too slow for you):

(1) Wrap your thumbs with a thick layer of gauze to protect yourself from a closing jaw (you can use tongue depressors broken in half under to gauze too).

(2) Place the patient against the back of the chair or the stretcher.

(3) Stand over the patient and place your thumbs in the mouth over the molars and press down and back.

(4) If this does not work, you can place a stack of tongue depressors in the mouth to force it open, adding an additional one every few minutes. This will fatigue the spasmed temporalis and pterigoyd muscles that are preventing you from pulling to condyle above the articular eminence.

(5) Mouth should completely close after reduced.

** No post reduction films necessary if no complications.

Disposition:

The patient should eat a soft diet and avoid opening mouth more than 2cm for 2 weeks.

(3) Who was the original Crocodile Dundee?

Rod Ansell was the man on which the character of Crocodile Dundee was based. He was a cattle grazer from northern Australia who was stranded somewhere in the Northern Territories for 54 days surviving on cattle blood and crazy. He later died in a police shootout tripping on methamphetamine.

Did you know, in the US we don’t just have alligators, we also have The American Crocodile, an evil looking lizard monster.

References

Tintinalli, Judith E., and J. Stephan. Stapczynski. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, 2011. Print.