A pragmatic approach to the management of condylar fractures

Abstract

A pragmatic approach to the management of condylar fractures: pragmatic in this sense means dealing with a problem by practical methods adapted to the circumstances rather than methods based on theory or ideology. It is an unfortunate fact that despite nearly 100 publications on the subject of condylar fractures in the last 50 years this pragmatic approach remains the only option for the clinician. There is a concerted move by government health departments and corporate bodies who purchase health care towards evidencebased medicine and a consequent responsibility for providers to produce such evidence in support of treatment protocols. The more common the medical problem the more demand there is for evidence-based treatment as we have graphically witnessed in relation to third molar surgery. Regrettably, a review of the recent literature relating to fractures of the condyle suggests we are unlikely to produce evidence-based guidelines for treatment from this symposium, but I do believe we have a chance to develop a realistic protocol for prospective clinical examination of the problem and that would be a major step forward. In Britain our national specialist audit committee embarked on a prospective study of condylar fractures two years ago. The committee was only able to agree on a workable protocol on the basis of a study of isolated unilateral fractures. This was a mnlticentre audit of patients over the age of 12 years. The preliminary results are disturbing in that they reveal that in the UK adult fracture displacements and dislocations are not being optimally managed in 30% of cases. These results are even more disturbing because we already know from countless retrospective studies that unilateral fractures are not the main problem. It is the bilateral condylar fracture particularly in combination with other injuries which is our major clinical concern. In our own unit at East Grinstead one of my registrars, Mr Newman, has just looked at the resnlts of the last 58 bilateral condylar fractures we have treated in all single jaw injuries. Ten per cent of these required osteotomies for consequent malocclusion. Although the six cases treated by open reduction on one or both sides had acceptable function, these are bad results over all for a reputable department which treats over 300 facial bone fractures each year. In a short paper such as this it is impossible to review the whole of the literature. This has in any case been carried out recently in two excellent papers by HAYW~,V & SCOTT in 19939 and H ~ L s in 1994. I have decided to address five questions which I believe are relevant in order to provoke discussion: 1. Should all condylar fractures before puberty be treated conservatively? 2. Is capsular damage and rupture of the articular disk siL, nificanff and can it in practical terms be diagnosed? 3. Do we agree on a case for ORIF in selected condylar fractures? 4. How to address the technical pr0bIcms of ORIF when there are multiple facial injuries? 5. Have we the basis of a protocol for operative intervention?