Dental Trauma: Ellis Classification

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Ellis Classification of Dental Fractures
Ellis I
Includes crown fractures that extend only through the enamel.
Teeth are usually nontender, and without visible color change, but have rough edges.
Ellis II
Fractures that involve the enamel and dentin layers.
Teeth are typically sensitive to cold, hot, touch and/or air exposure. A yellow layer of dentin may be visible on examination
Ellis III
Involve the enamel, dentin, and pulp layers.
Teeth are extremely sensitive, and have a visible area of pink, red, or even blood at the center of the tooth. 
The pulp of the tooth is very prone to infection. Infection of the pulp is termed pulpitis and can lead to potential tooth loss. The dentin of the tooth is very porous and is an ineffective seal over the pulp. In Ellis II and III fractures in which the dentin or pulp is exposed, the clinician caring for the tooth fracture in the acute setting must create a seal over these injured teeth to protect the pulp from intraoral flora and potential infection.
Other dental injuries that may or may not be associated with a dental fracture include the following:
  • Dental avulsion - Complete extraction of the tooth (crown and root)
  • Dental subluxation - The loosening of a tooth following trauma
  • Dental intrusion - The forcing of an erupted tooth below the gingiva
In these situations, the goal is to return the tooth to its correct anatomical position as quickly and securely as possible, without causing further trauma to the tooth, gingiva, or alveolar bone. 
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Did you get your Tetanus Shot?

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Name that Sign!  Hint: It’s not a Glasgow Smile
Answer:  Risus Sardonicus.  Caused by spasms of the facial muscles.  Also seen in Wilson’s Diseases and Strychnine poisoning.
TETANUS
  • Caused by Clostridium Tetani, which is present in soil, animal feces
  • Typical presentation of “Stepped on a rusty name” and didn’t get their tdap.
    • Also in IVDU, abdominal surgeries
  • Per CDC, leads to death in 1 in 10 cases, usually in the elderly.
SIGNS AND SYMPTOMS
  • Initial signs are trismus or “lock jaw”- spasms of muscles of mastication
  • If not treated, progresses to sustained muscles of the back:  Opisthotonus
  • By second week, tachycardia, labile HTN, sweating, hyperpyrexia, increased urinary excretion of catecholamines
PATHOPHYSOLOGY
  • Ubiquitous spores in soil and animal feces
  • Introduced into skin as spore-forming, non-invasive state
  • Germinates into toni-producing, vegetative form if oxygen tension is reduced
    • e.g. crushed, devitalized tissue
  • Toxins=Tetanolysin and Tetanospasmin
  • Tetanospasmin does not cross BBB but CAN enter via retrograde intraneuronal transport
  • Acts on motor endplates of skeletal muscle, spinal cord, CNS, and sympathetics
  • Inhibits glycine and GABA
    • In short get sympathetic overactivity and high circulating catecholamines
TREATMENT
  • Admit to ICU
  • Needs intubation if respiratory compromised
    • Succinylcholine for intubation, Vecuronium for longer blockade
  • Minimize environmental stimuli to avoid convulsive spasms
  • Tetanus Immunoglobulin 3K-6K units IM helps locally but not if it is in the CNS
    • Nevertheless, reduces mortality
  • Can give parenteral metronidazole
  • Do NOT give PCN because central acting GABA antagonist which may potentiate tetanospasmin
  • Mag sulfate to help inhibit release of catecholamines/reduce autonomic instability/spasms
  • Midazolam for muscle spasm
SUMMARY
  • Clinical dx- look for autonomic instability, muscle spasms
  • Tx w/ ICU, intubation, Midazolam, Mag sulfate, Flagyl but NO PCN
REFERENCES
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Compartment Syndrome

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Cue Scene:

  • 20yoM w/ no pmh who hurt his leg while playing basketball.  He tried to walk it off but the pain keeps getting worse.  He arrives via EMS, screaming in pain and clutching his leg.  You get an x-ray which shows a fibula fracture.
Remember your Ps:
1.  Pain out of proportion
2.  Pallor
3.  Paresthesias
4.  Paralysis- late finding!
5.  Pulseless- late finding!
 
Compartment syndrome is most commonly seen in legs and forearms.  Often seen in crush injuries, circumferential burns, constrictive dressings (e.g. casts that aren't bivalved), or ischemia-reperfusion injuries.  In Tibial Fractures the most common is the deep posterior compartment followed by the anterior compartment.
 
 
Here's a cool video for you to watch:  https://www.youtube.com/watch?v=ewMD0OUlpqg
 
Treatment:  Fasciotomy is indicated if the difference between patient's diastolic pressure and the compartment pressure is less than 30mmHg or if the compartment pressure itself alone is over 30mmHg.  Get ortho involved ASAP if available.  Otherwise you have to perform the fasciotomy.
 
Now let's review with a little Board question:
  • 24M presents as a trauma code shortly after a motorcycle accident. Pt was thrown from his motorcycle when a car suddenly braked in front of him, and his leg was caught under the wheel of the vehicle. Airway is intact, he is complaining of severe leg pain, and his blood pressure is stable. He was helmeted, and his injuries appear to be isolated to the left lower extremity. When you move to the secondary survey, you note severe left lower extremity edema, and the patient screams and writhes in pain upon palpation of the distal pulses. You observe diffuse road rash but no open lacerations. His peripheral pulses are palpable and strong. Radiograph of his left lower extremity is shown in Figure A. What is the next best step in management?
  • Next best step?
    • A.  Admission for observation and pain control
    • B.  Closed reduction and splinting
    • C.  Percutaneous pinning and casting
    • D.  Multi-compartment fasciotomy
    • E.  Physical and occupational therapy
 
 
 
 
 
 
 
 
 
 
 
 
Answer:  D
 
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