CC
A 21-year-old male comes to the local emergency department (ED), stating, “I fell and cut my chin.” You are consulted to evaluate this patient.
Subcondylar fractures are more commonly seen with falls as than other fracture patterns. The role of the dentition and the influence of open versus closed mouth position are likely of minor importance. The force from direct blunt trauma to the symphysis in a fall is transmitted to the condylar region, and given the reduced cross-sectional area, a fracture is most likely to occur at this site.
HPI
The patient reports that while riding a skateboard to class, he fell and landed on his chin and right hand. He presents to the local ED for the deep laceration on his chin. He also complains of an inability to fully open his mouth and pain in front of his right ear. The patient denies loss of consciousness, dizziness, nausea or vomiting, or visual changes. There is no dyspnea, stridor, or inability to manage secretions. The patient states that his bite is not reproducible, and he feels intense pain when attempting excursive movements. There are no neurosensory changes in the lip, chin, tongue, or midface.
Advanced Trauma Life Support should be standard protocol when evaluating trauma patients. A thorough review of systems is essential to identify further injuries. Traumatic force to the mandible may be transmitted to the skull base. A review of symptoms related to intracranial injury and closed head injury allows the surgeon to determine additional studies, evaluations, or referrals. The association between mandibular fractures and cervical spine injuries is well established (although these two types of injuries infrequently occur together). Any neck pain warrants further evaluation and is routinely completed during the primary survey. In addition, the surgeon must evaluate for signs of concomitant mandibular fractures because more than half of fractures are associated with contralateral parasymphysis or body or angle fracture. A significant impact to the chin, as occurred in the current patient, raises concern for bilateral subcondylar fracture with the potential for airway compromise; therefore, a review of symptoms related to airway obstruction must be performed.
PMHX/PDHX/medications/allergies/SH/FH
Noncontributory.
Examination
General. The patient is a well-developed and well-nourished male in no apparent distress.
Maxillofacial. There is a 3-cm hemostatic laceration at the submental region with no foreign body or signs of underlying fracture. The mandible deviates to the right upon opening, which is commonly caused by the unopposed contralateral lateral pterygoid muscle and impaired rotation and translation on the affected side. The maximal incisal opening (MIO) is limited to 20 mm, with associated pain. There are edema of the right preauricular region, no deformity of the ear, no blood at the external auditory canal (EAC), no hemotympanum, and normal auditory acuity. (Hemotympanum and blood at the EAC may indicate perforation of the anterior tympanic plate.) There is no otorrhea or Battle’s sign (which may indicate basilar skull fracture and cerebrospinal fluid leakage). Palpation of the right preauricular region also elicits pain. (Pain in the preauricular area with a history of trauma to the symphysis is highly suggestive of a subcondylar fracture.)
Intraoral. Left lateral excursive movement is limited to 2 mm. (Excursive movement of the mandible to the left requires the function of the right lateral pterygoid against an intact condylar neck.) There are no associated intraoral lacerations and no dental trauma. (Fractures of the teeth are not uncommon with forceful closure of the mandible at the time of trauma.) Occlusal examination shows premature contacts on the right side, with a left posterior open bite (secondary to collapse of the vertical height of the mandible on the right). The airway is patent with no obstruction or reduction in airflow.
Extremities. There is pain during passive range of motion (ROM) of the right wrist. A palpable radial pulse and normal capillary refill in the nail beds are present. (Vascular compromises from a distal radial fracture, a carpal bone fracture, or in the compartment system are surgical emergencies.)
Imaging
Depending on the facility, initial imaging for evaluation of the mandible may include a computed tomography (CT) scan, cone-beam CT scan, panoramic radiograph, or plain view mandibular series that includes lateral and posteroanterior cephalometric films, a reverse Towne’s view, and oblique views of the mandible. Many rural hospitals still use a plain view series of the mandible. Most hospitals use a CT scan, which has become the gold standard imaging modality. A CT scan allows the entire face to be evaluated in one study. The mandible can also be evaluated in several different anatomic planes. The axial and coronal planes are the two most used views, although the sagittal view should not be missed. The coronal plane can be very helpful for condylar process fractures and for determining the degree of medial displacement and orientation; the axial planes are useful for intracapsular fractures and the remainder of the mandible. Direct coronal imaging requires hyperextension of the neck and should not be obtained in patients with a suspicion of cervical spine injury. Three-dimensional reconstructions are extremely valuable and allow preoperative planning in a more sophisticated manner for complex cases such as gunshot wounds or severely comminuted fractures. A panoramic film is the single best plain film for evaluating the entire mandible at once. In combination with a reverse Towne’s view, the sensitivity for detecting a condylar process fracture increases. All modalities have limitations, and surgeons should use imaging studies based on individual cases and available resources.
For the current patient, a CT scan was obtained as the initial study. It demonstrated a right subcondylar fracture on coronal and axial views ( Fig. 49.1 ). A plain wrist film was also obtained, which revealed a right-sided fracture of the distal radius (Colles’ fracture).
Labs
No routine laboratory testing is indicated unless dictated by the medical history.
Assessment
A 21-year-old male with a right medially displaced subcondylar fracture of the mandible and associated chin laceration after a fall; Colles’ fracture of the right wrist; Facial Injury Severity Scale score of 1.
Treatment
The treatment of fractures of the mandibular condyle is one of the most widely debated topics in the maxillofacial literature. Several variables should be considered when determining treatment and predicting the prognosis, including the level of fracture, degree and direction of displacement, age and medical status of the patient, concomitant injuries, and status of the dentition. Assael has developed a comprehensive list of patient specific variables affecting treatment selection and outcome, all of which should be included in the evaluation of the patient before the surgery. Age, gender, medical status, compliance, associated injuries, and fracture type are a few examples of these variables.
The primary goal in the treatment of any fracture is adequate stabilization that allows for fracture healing and primary osseous union. In the treatment of mandibular condyle and subcondylar fractures, the goals of treatment are:
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Pain-free mouth opening with return to an acceptable MIO
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Pain-free functional movement
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Restoration of occlusion
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Facial and jaw symmetry and establishment of facial height
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Minimal visible scarring
Preinjury alignment of the mandibular condyle within the glenoid fossa is not essential for adequate rehabilitation. The pull of the lateral pterygoid muscle characteristically displaces the condyle anteriorly and medially. Closed reduction (more correctly termed “closed treatment”) typically does not reduce the condyle into its original position.
The treatment options are categorized into surgical and nonsurgical modalities. Surgical treatment includes open reduction with or without internal fixation. Many agree that if an open approach is taken, fixation should be applied. Endoscopic reduction and fixation of condylar fractures has gained popularity during the past decade. The use of this technique requires familiarity with an endoscope and the ability to convert the procedure to an open method if endoscopic reduction fails to successfully complete the procedure. The options for nonsurgical treatment include closed reduction (closed treatment) with maxillomandibular fixation (MMF) and dietary modification with ROM exercises. In the treatment of facial fractures, patients older than 10 years are treated in a manner similar to that for adults; however, it is rarely advocated that children and teenagers undergo open reduction of condylar fractures. A soft diet with mobilization is the initial treatment of choice in patients 15 years or younger. If the occlusion is unstable and not reproducible, a short period of intermaxillary fixation (2 weeks) can be advocated. This can be followed with guiding elastics if needed.
For the current patient, the occlusion was reestablished easily with minimal manipulation, and after extensive discussion of procedures, alternatives, risks, and benefits, the patient was placed in MMF for 4 weeks. After the 4 weeks, an aggressive posttreatment physiotherapy program was instituted, with active and passive ROM exercises. Return to full function occurred within 4 weeks of release from MMF. There were no postoperative complications because the patient returned to full function with stable and repeatable occlusion.
Complications
The complications of treating fractures of the mandibular condyle are well described in the literature and are often used as the basis of comparison for surgical and nonsurgical treatment. One of the most severe late complications can be temporomandibular joint (TMJ) ankylosis (fusion between the mandibular condyle and the glenoid fossa). Patients with TMJ ankylosis often have a history of facial trauma. Prevention of ankylosis was discussed by Zide and Kent in 1983. They advocated appropriate physiotherapy early in the phase of nonsurgical treatment. Other types of late mandibular dysfunction have been cited as complications of closed reduction. These include chronic pain, malocclusion, internal derangement, asymmetry, limited mobility, and gross radiographic abnormalities. (However, radiographic abnormalities in the absence of pain or functional impairment have no clinical significance.) Long-term complications of open reduction and internal fixation (ORIF) are scar perception, facial nerve palsy or paralysis, loss or failure of fixation, Frey’s syndrome, avascular necrosis, TMJ dysfunction, and facial asymmetry. The early complications are few and can include early failure of fixation, malocclusion, pain, and infection. Complications are a high yield portion of board review.
Discussion
As is common with most traumatic injuries, fractures of the mandibular condyle mainly occur in males (78%) between the ages of 20 and 39 years (60%). Most of the fractures are unilateral (84%); fewer are bilateral (16%); 14% of fractures are intracapsular, 24% are in the condylar neck, and 62% are subcondylar fractures. Whereas adults have a relatively narrow condylar neck and thick articular surface, children have a relatively broad condylar neck and thin articular surface in an active osteogenic phase. (Fractures in children are discussed later in the chapter.)
Many studies have compared various outcomes of surgical and nonsurgical therapy, with most of the debate centering on ORIF and closed treatment. The outcomes studied included perception of pain, occlusal function, asymmetry, MIO and ROM, muscle activity, malocclusion, midline deviation, radiographic changes, and nerve dysfunction. Brandt and Haug in 2003 conducted a review of the literature ( Table 49.1 ) regarding open versus closed treatment and suggested indications for closed and open reduction. If a patient has an acceptable ROM, good occlusion, and minimal pain, observation or closed treatment is preferred regardless of the level of the fracture. They also suggested that condylar displacement and ramus height instability are the only orthopedic indications for ORIF of condylar fractures. Based on their review, they concluded that under similar indications and conditions, ORIF is the preferred approach. In 2022, Bera et al. conducted a systematic review considering closed versus open treatment; their findings were consistent with those of Brandt and Haug. They also concluded that the efficacy of endoscopic over open approach has not been validated. In 2021, when reviewing pediatric mandible fractures, Bansal et al. determined the mainstay of treatment to be closed reduction unless faced with a displaced mandible fracture, particularly with a coexisting condylar fracture, to be ORIF. In 2009, Ellis developed a method for determining which patients would benefit from ORIF using preoperative imaging and intraoperative clinical evaluation. This method demonstrated that patients with fractures that maintained a reasonable occlusion with digital pressure would not require open reduction. Instead, they can be treated with elastics to attain an acceptable occlusion.
