What is the treatment for a right subcondylar fracture?

Treatment of Right Subcondylar Fracture

Open reduction and internal fixation (ORIF) is the recommended treatment for displaced subcondylar fractures in adults to achieve superior functional outcomes compared to closed treatment. 1

Treatment Decision Algorithm

Initial Assessment

1. Determine fracture displacement and pattern using radiographic evaluation including CT scan 2
2. Assess for:
   • Degree of displacement
   • Presence of malocclusion
   • Mouth opening limitation
   • Associated mandibular fractures

Treatment Options

1. Non-Displaced or Minimally Displaced Fractures

• Immobilization with removable splint or sling 2
• Early controlled mobilization as pain allows
• Regular follow-up at 1,3, and 6 weeks to ensure fracture stability

2. Displaced Subcondylar Fractures

• Open reduction with internal fixation is recommended for displaced subcondylar fractures in adults 1
• Benefits of ORIF over closed treatment include:
  • Fewer persistent symptoms (9% vs 67%)
  • Less chin deviation (0% vs 40%)
  • Less restricted mouth opening (3mm vs 5mm)
  • Better functional scores (1.92 vs 0.861) 1

Surgical Approaches for ORIF

1. Retromandibular Approach

• Short retromandibular approach provides good visualization and access 3
• Allows for symmetric laterotrusive movements and good mouth opening (average 43mm) 3
• Lower risk of permanent facial nerve injury compared to other extraoral approaches

2. Transoral Approach

• Can be performed using an angulated screwdriver system 4
• Benefits include avoiding external scarring and lower risk of facial nerve injury
• May be more technically challenging with longer operative times
• Best suited for mildly displaced fractures 5

3. Endoscopic-Assisted Reduction

• Combines benefits of open and closed techniques while minimizing risks 5
• Particularly useful for:
  • Mildly displaced fractures
  • Patients with multiple injuries who cannot tolerate closed reduction
  • Challenging when significant medial displacement of proximal fragment exists

Postoperative Management

1. Early mobilization to prevent elbow stiffness 2
2. Three-phase rehabilitation protocol:
   • Initial phase (0-2 weeks): Sling immobilization and pendulum exercises
   • Early mobilization phase (2-6 weeks): Progressive active-assisted range of motion
   • Strengthening phase (6-12 weeks): Progressive resistive exercises 2

Potential Complications

• Transient facial nerve weakness (reported in 6% of open cases) 1
• Triceps weakness if posterior approach used
• Elbow stiffness (preventable with early mobilization)
• Hardware prominence
• Infection 2

Important Considerations

• Open treatment typically requires longer operating room time (76.39 minutes vs 56.15 minutes for closed treatment) 1
• Facial nerve monitoring during surgery can mitigate risk of nerve injury 5
• Anatomical reduction with rigid fixation allowing immediate postoperative movement gives the least morbidity and best results in adult patients 2

While both open and closed treatment options exist, the most recent high-quality evidence demonstrates superior long-term functional outcomes with open treatment for displaced subcondylar fractures in adults 1.