Hackenberg Berit, Lee Cameron, Caterson E J
From the *Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; †University of Heidelberg Medical School, Heidelberg, Germany; ‡Harvard School of Dental Medicine, Boston, Massachusetts; and §Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
J Craniofac Surg. 2014 Jan;25(1):166-71. doi: 10.1097/SCS.0000000000000498.
The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. Historically, the treatment algorithm was between open reduction and closed treatment. Now, recent technical advances regarding the use of the endoscope in the field of craniofacial surgery provide additional treatment options. This article aimed to evaluate 3 current management strategies: closed reduction with maxillomandibular fixation, open reduction with internal fixation, and endoscopic-assisted reduction with internal fixation. We present our rationale for surgical decision making and attempt to develop an algorithmic approach to subcondylar fractures. Ankylosis of the temporomandibular joint is a feared complication in these fractures that can lead to the decision to apply maxillomandibular fixation for potentially too short of a period. It is the condylar head fractures within the joint's capsule that contain the hemarthrosis that are often responsible for ankylosis. Subcondylar fractures are, by definition, below the attachment of the joint capsule and in general are devoid of ankylosis. Therefore, maxillomandibular fixation is recommended to be applied for a period of 4 to 6 weeks in most cases. Open reduction with internal fixation can increase the risk for facial nerve damage during the operative approach. However, open reduction is often necessary in fracture patterns with a high degree of displacement. In these cases, facial nerve monitoring can successfully mitigate risks to allow safe exposure for open reduction with internal fixation of subcondylar fractures. Endoscopic-assisted reduction with internal fixation combines the benefits of both techniques while minimizing their associated risks. Nevertheless, reduction can be difficult especially when there is significant medial displacement of the proximal fracture fragment. In our experience, the endoscopic option is optimal for mildly displaced fractures and for the patient with multiple injuries who cannot tolerate closed reduction.
下颌骨髁突骨折的治疗是一个存在争议的话题，尽管这些骨折很常见，但治疗方法可能因人而异。从历史上看，治疗方案在切开复位和闭合治疗之间。如今，颅面外科领域内窥镜使用方面的最新技术进展提供了更多治疗选择。本文旨在评估三种当前的治疗策略：颌间固定闭合复位、切开复位内固定以及内窥镜辅助复位内固定。我们阐述了手术决策的依据，并试图开发一种针对髁突骨折的算法式治疗方法。颞下颌关节强直是这些骨折中令人担忧的并发症，这可能导致颌间固定的应用时间可能过短。正是关节囊内包含血肿的髁头骨折常导致关节强直。根据定义，髁突骨折位于关节囊附着点以下，一般不会发生关节强直。因此，在大多数情况下，建议颌间固定应用4至6周。切开复位内固定在手术过程中会增加面神经损伤的风险。然而，对于移位程度较高的骨折类型，切开复位往往是必要的。在这些情况下，面神经监测可以成功降低风险，以便安全暴露以进行髁突骨折的切开复位内固定。内窥镜辅助复位内固定结合了两种技术的优点，同时将其相关风险降至最低。然而，复位可能很困难，尤其是当近端骨折块有明显的内侧移位时。根据我们的经验，内窥镜治疗方案对于轻度移位骨折以及无法耐受闭合复位的多发伤患者是最佳选择。
