Closed reduction and fluoroscopically assisted percutaneous stabilization of displaced subcondylar mandible fractures

Background: Displaced subcondylar fractures of the mandible are difficult to treat. Open reduction with internal fixation carries significant risks including devascularization of the condylar segment, facial nerve injury, and scarring. Closed treatment with mandibular-maxillary fixation alone accepts a misaligned fracture and relies on joint remodeling. Both techniques carry risk for long-term temporomandibular joint arthritis and pain. In no other area of fracture treatment in adults is nonanatomic fracture reduction accepted as the standard of care when there is a misaligned joint. The purpose of this study was to evaluate closed reduction and fluoroscopically assisted percutaneous stabilization of subcondylar fractures. Methods: Fresh cadaver dissections were performed after fractures were created. Kirschner wires were placed in the condylar segment as "joysticks" to manipulate the condylar segment. Fluoroscopy confirmed that the condylar segment was easily manipulated. Seven patients with subcondylar factures were treated. Two Kirschner wires were placed in the condylar segment and, along with jaw manipulations, were used to reduce the fractures in six of the seven patients. Results: Manipulation of the condylar segment with the "joystick" was possible. Reductions were obtained in six of seven cases and additional Kirschner wires were used to stabilize the condyle with the fracture aligned, joint reduced, and mandibular height restored. All patients were placed in mandibular-maxillary fixation for 2 to 3 weeks. After release of mandibular-maxillary fixation, the mandible was midline through the arch of rotation in the patients who were treated. There were no complications from the procedure. Conclusions: Closed reduction of subcondylar fractures with a Kirschner wire "joystick" is possible in most cases. This method achieves anatomic reduction and restores mandibular height utilizing minimally invasive techniques with no need for novel equipment or expensive plating systems. There is minimal risk associated with the procedure and minimal additional operative time is required. The advantages of a reduced fracture are substantial and easily obtained with this minimally invasive technique.