When is external fixation of the jaw reserved, specifically for pathological mandibular (lower jaw) fractures, infected fractures, or edentulous (toothless) patients?

From the Guidelines

External fixation of the jaw is typically reserved for complex cases including pathological mandibular fractures, infected fractures, or edentulous patients when other fixation methods are contraindicated or insufficient. This approach is recommended when there is significant bone loss, comminution (multiple bone fragments), or when internal fixation would compromise the patient's healing potential, as noted in the management of fracture-related infections 1. The procedure involves placing pins or screws through the skin into the bone fragments, which are then connected to an external frame. For pathological fractures caused by conditions like osteoradionecrosis or malignancy, external fixation provides stability while avoiding placement of hardware in compromised bone, a consideration also relevant in the treatment of bone sarcomas 1. In infected fractures, it allows for wound drainage and antibiotic delivery without introducing additional foreign material into the infected site, aligning with principles of managing fracture-related infections 1. For edentulous patients, especially those with atrophic mandibles, external fixation prevents further fragmentation of thin bone that might occur with plate fixation. The fixation typically remains in place for 6-8 weeks until adequate healing occurs, with regular follow-up every 1-2 weeks to assess stability and manage pin site care using chlorhexidine or povidone-iodine solutions to prevent infection. This method allows for earlier jaw function and nutrition while maintaining fracture reduction, though patients must be counseled about the temporary cosmetic impact and need for meticulous hygiene around pin sites.

Key considerations in the decision to use external fixation include:

• The presence of significant bone loss or comminution
• The risk of compromising the patient's healing potential with internal fixation
• The need to avoid introducing additional foreign material into an infected site
• The requirement for stability in pathological fractures without placing hardware in compromised bone
• The prevention of further fragmentation in edentulous patients with atrophic mandibles

In the context of fracture-related infections, the choice between implant retention, exchange, or external fixation depends on factors such as the ability to perform proper debridement and the type of implant used 1. For bone sarcomas, external splintage is recommended over internal fixation to avoid disseminating tumor cells into surrounding tissues and to reduce the risk of local recurrence 1. Overall, the decision to use external fixation of the jaw must be tailored to the individual patient's condition, taking into account the specific challenges posed by pathological, infected, or edentulous cases.

From the Research

Indications for External Fixation of the Jaw

External fixation of the jaw is reserved for specific cases, including:

• Pathological mandibular fractures: External fixation can be used to stabilize and treat fractures that occur in weakened or diseased bone 2, 3.
• Infected fractures: External fixation can be used to treat infected fractures, especially when there is significant tissue loss or contamination 4, 3, 5, 6.
• Edentulous patients: External fixation can be used to treat fractures in patients who are missing teeth, as it can provide stability and support without relying on dental structures 2, 6.

Advantages and Disadvantages of External Fixation

The use of external fixation in the treatment of mandibular fractures has several advantages, including:

• Ability to preserve tissue and maintain anatomic integrity 3
• Can be used in cases where internal fixation is contraindicated due to infection or tissue loss 6
• Can be used temporarily until definitive treatment is delivered 6 However, external fixation also has some disadvantages, including:
• May not provide the same level of stability as internal fixation 2
• Can be uncomfortable for patients and may require additional care and maintenance 3

Clinical Applications of External Fixation

External fixation can be used in a variety of clinical situations, including:

• Comminuted or compound fractures 3, 6
• Infected fractures with nonunion or subacute infection 3
• Acute comminuted and compound fractures 3
• Ballistic injuries 3
• Pathologic fractures 2, 3