Introduction - Confex



Title: Closed Reduction and Fluoroscopically Assisted Percutaneous Stabilization of Displaced Subcondylar Mandible Fractures

Author: Sean Boutros, MD

Introduction and purpose: Subcondylar fractures of the mandible represent between 20% and 62% 1,2 of all mandible fractures, and despite their frequency, the management is controversial. Closed treatment adds no iatrogenic injury. It however, leaves a displace fracture and relies on joint remolding. It requires frequent postoperative visits for elastic therapy. With significantly displaced fractures, there is an increased risk of long term TMJ problems3-6,8,9. Open treatment for unilateral subcondylar fractures can be a difficult procedure with risk of facial nerve injury, facial scarring, and long term joint stiffness3-7,10.

Percutaneous manipulation and fluoroscopic reduction of fractures is commonplace in plastic surgery. It is used to accurately align fractures without added dissection and tissue injury11-14. The purpose of this study was to explore the application of these techniques to subcondylar fracture to demonstrate the feasibility of percutaneous reduction of subcondylar fractures of the mandible.

Methods: Four cadaver manipulations and dissections were performed. In each of the cadavers, fractures were created by simulating a fall with impact to the chin. Fluoroscopy was used to visualize the fractures. K-wires were placed in the condylar segments and used to manipulate the fractures. In all cases, control of the condylar segment was obtained and the fragment was easily manipulated.

Six patients with unilateral subcondylar fractures were treated. MMF was established with arch bars. Associated fractures were treated with rigid internal fixation and MMF released. Using fluoroscopy, the condylar segment was visualized and K-wires placed perpendicular, high on the condylar segment to act as a joystick. K-wires were placed obliquely from superior to inferior in the condylar segment so that the K-wire entered the fracture line after passing through only the outer cortex. Under fluoroscopy, the fractures were reduced in two views and the oblique K-wire used to engage the inner cortex of the ramal segment. MMF was established and “joysticks” removed. The patients remained in MMF for 14 to 20 days.

Results: Postoperative studies showed reduced fractures in all cases. (Figure 1-4) Upon release of MMF, all patients opened in the midline with no deviation of the mandible. MMO was greater than 38 in all patients at eight weeks postoperative. Patients all did well at up to one year, with no popping, clicking, or locking of the TMJ.

Figures:

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Figure 1 - Posterior view showing loss of mandibular height.

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Figure 2 - Later view showing displacement

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Figure 3 - Posterior view showing reestablishment of mandibular height

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Figure 4 - Later view post reduction

References:

1. Mitchell DA.A multicentre audit of unilateral fractures of the mandibular condyle. Br J Oral Maxillofac Surg. 1997 Aug;35(4):230-6.

2. Silvennoinen U, Iizuka T, Lindqvist C, Oikarinen K.Different patterns of condylar fractures: an analysis of 382 patients in a 3-year period. J Oral Maxillofac Surg. 1992 Oct;50(10):1032-7.

3. Villarreal PM, Monje F, Junquera LM, Mateo J, Morillo AJ, Gonzalez C. Mandibular condyle fractures: determinants of treatment and outcome. J Oral Maxillofac Surg. 2004 Feb;62(2):155-63.

4. Yang WG, Chen CT, Tsay PK, Chen YR. Functional results of unilateral mandibular condylar process fractures after open and closed treatment. J Trauma. 2002 Mar;52(3):498-503.

5. Haug RH, Assael LA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. J Oral Maxillofac Surg. 2001 Apr;59(4):370-5; discussion 375-6.

6. Ellis E 3rd, Simon P, Throckmorton GS.Occlusal results after open or closed treatment of fractures of the mandibular condylar process. J Oral Maxillofac Surg. 2000 Mar;58(3):260-8.

7. De Riu G, Gamba U, Anghinoni M, Sesenna E. A comparison of open and closed treatment of condylar fractures: a change in philosophy. Int J Oral Maxillofac Surg. 2001 Oct;30(5):384-9.

8. Palmieri C, Ellis E 3rd, Throckmorton G.Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures. J Oral Maxillofac Surg. 1999 Jul;57(7):764-75; discussion 775-6.

9. Smets LM, Van Damme PA, Stoelinga PJ.Non-surgical treatment of condylar fractures in adults: a retrospective analysis. J Craniomaxillofac Surg. 2003 Jun;31(3):162-7.

10. Rodriguez ED, Adamo AK, Anastassov GE. Open reduction of subcondylar fractures via an anterior parotid approach. J Craniomaxillofac Trauma. 1997 Fall;3(2):285-34.

11. Hornbach EE, Cohen MS.Closed reduction and percutaneous pinning of fractures of the proximal phalanx. J Hand Surg [Br]. 2001 Feb;26(1):45-9.

12. Belsky MR, Eaton RG, Lane LB.Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg [Am]. 1984 Sep;9(5):725-9.

13. Yung PS, Lam CY, Ng BK, Lam TP, Cheng JC.Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children. J Pediatr Orthop. 2004 Jan-Feb;24(1):7-12.

14. Green DP, Anderson JR.Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am. 1973 Dec;55(8):1651-4.

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