Friday, September 3, 2010

Open vs. closed reduction of condylar fractures

There's quite a bit of scientific literature out there on whether condylar fractures should be treated closed (wiring/arch bars) or open (surgery where plates/screws are inserted).  Surgery involves more immediate risk (nerve damage etc., unsightly facial scars, infection), but outcomes are slightly better (less chance of limited mouth opening (<4 cm), misaligned bite, chronic pain) and there is quicker return of function to the jaw.  There is some debate/disagreement in the literature that I've read, but overall, most recommend closed reduction since its essentially a toss up unless the patient has mitigating factors like an eating disorder, severe displacement, no teeth, other facial fractures, etc. as surgery is thought to be more tramatic to the patient.

So while I totally think my doctor did the right thing in my case (closed reduction) according to the science that is available now, I do sometimes think that I would have preferred to have my face cut open instead.  This is no doubt colored by the fact that I'm extremely frustrated right now, and that the open reduction I had on my parasymphasis fracture was a very easy recovery (the incision there is invisible, down through the chin, at least in comparison to the primarily mental crap I'm dealing with now. Now its also likely/possible that incisions by the condyle are more risky/more difficult recovery than what I had done on my chin. I think my doctor may have even mentioned this.

However, I do wonder if the people who are conducting these studies may be underestimating how difficult it is to have your mouth wired shut, or have very limited mouth opening.  One study I read did evaluate depression, and only a few patients met diagnostic criteria for depression.  Having some experience with the psychological scales from my previous jobs, I know that I would not qualify as depressed either, but that doesn't mean that my mental state is ideal right now :)  I.e. someone should look at subcliinical and more linear measures of mental status as well, perhaps using the POMS scale that we've used in some of the studies I worked on previously (http://en.wikipedia.org/wiki/Profile_of_mood_states).  Perhaps this has even been done, I have not done an exhaustive search of the literature as 1) I don't have easy access to all journal articles anymore and 2) obsessing over this probably isn't healthy for me right now.

Anyway, overall outcomes at one year follow up are quite good with either method. In one study, only 15% of patients with bilateral condylar fractures had maximal mouth openings less than 4cm,  and this was the most common complication.  Numbers were even better for those with only one fractured condyle. Misaligned bite was the next most common though I don't recall the percent.

I have no doubt that my perspective on all of this will change a year from now and will likely be dependent on my functioning at that time, regardless of what the literature says, 'cause even I (science is my religion lol) am not that objective.

ETA: I've noticed from my blog stats that a lot of people are referred to my blog from this post, so I feel compelled to mention that I am certainly not an expert on this.  I also have questions as to how much the recovery period is shortened with open as opposed to closed reduction.  To me this is a key question as jaw wiring/rubberbands, limited mouth opening is pretty freaking terrible, both physically and mentally from my perspective. I'd have taken several days of being in severe pain if it enabled me to eat more normally a few weeks earlier.

 The choice also depends a lot upon how comfortable/experienced  your doctor is with surgically fixating condylar fractures. Still, I do think that it's something worth discussing with your doctor, particularly if you have multiple fractures, or some other characteristics that make the choice not so clear cut.  Of course in most cases this discussion is unlikely to occur (at least not by the patient's initiative) as the decision is made quickly after the fracture when the patient is unlikely to have looked into the matter at all.

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