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Internal kirschner wire fixation of fractures of the facial bones
INTERNAL KIRSCHNER WIRE FIXATION OF FRACTURES OF T H E FACIAL BONES
By Z. NEUMAN,M.D., and A. SCHWARTZ,M.D. From the Plastic Surgery Service and the Department of Radiology, Hadassah University Hospital, 37erusalem, Israel ROWE and Killey (1955) mention only very briefly the internal Kirschner wire fixation for fractures of the facial bones. Gibson and Allan (I956) mention this method and state that they have no personal experience, and Burch (I95I) considered it likely to result in poor apposition, delayed healing, and other complications. These remarks led us to report our experience with this method. Ipsen (I933) presented a case of a fractured mandible treated successfully by internal fixation. Brown et al. (I942, I95I, I952) perfected the method and widened its applicability to most fractures of the bones, thus presenting an invaluable tool in the management of severe trauma involving the facial bony structures. Internal Kirschner wire fixation has been used successfully in our department for most fractures, during a period of over three years. When enough teeth are present and are in adequate position for immobilisation, interdental wiring is an excellent method in the management of fractures of the mandible, but is uncomfortable for the patients. In the edentulous patient, however, or in fractures of the symphysis when the strong closing muscles pull the rami outward, for fractures of the angle with the posterior fragment displaced into the upper buccal fornix or if extra stability is required after interdental wiring, this method is of great help. In the more complicated, comminuted fracture-dislocation of the zygoma and orbit we found it to be a simple method of fixation. The internal Kirschner wire ensures adequate immobilisation, but if rotation is still present a second wire can be introduced in a different plane. It is always advisable to avoid the nerve canal even though the nerve may have been severed by the displacement of the fractured fragments. OPERATIVE TECHNIQUE
The operation is performed under adequate premedication, local infiltration of the skin and periosteum with xylocaine hydrochloride, 2 per cent., and with an injection of thiopental sodium (Pentothal) for a few minutes during the penetration of the wire into the bone. An electric or hand drill can be used. The wire penetrates longitudinally into the reduced bone fragments, while the assistant holds them together. The immediate post-traumatic swelling of the face and eyelids is markedly diminished by one injection of 500 units of hyaluronidase (Hyalase), dissolved in 3 to 4 ml. of normal saline. A small stab incision facilitates the passage of the wire through the soft parts of the face. The patients are capable of taking soft food the day following the operation. Antibiotics are administered during their hospital stay only, and they leave the hospital three to four days after the insertion of the wire. The wires are usually removed between five and six weeks after the operation and good clinical union is noted. 33z
INTERNAL KIRSCHNER WIRE FIXATION OF FRACTURES OF THE FACIAL BONEs
333
FIGS. I to 4 Fig. i.--Demonstrates two wires fixing the fractured fragments. Note the sharp displacement of the proximal fragment of the left condyle. Fig. 2 . ~ S h o w s good position of the symphysis, and wired condyle after open reduction. Fig. 3 . ~ K i r s c h n e r wire fixing the fragments of a fracture through the anterior part of the lower ramus of the right mandible. Fig. 4.--Admission film shows a comminuted fracture of the maxilla, with depression of its lateral half, and a fracture near the fronto-zygomatic suture with dislocation into the orbita, In addition, fracture of the zygomatic arch is seen,
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FIG. 5
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FIG. 6
Fig. 5.--After reduction of fracture through incision of buccal fornix, almost anatomical reduction and fixation of fragments with Kirschner wire. Fig. &--Six weeks after Fig. 5, following removal of wire.
A
B FIG. 7 A, Immediately after reduction of fracture. ~, Six weeks later.
INTERNAL kiRSCHNER WIRE I~IXATION OF FRACTURES Oi~ THE FACIAL BONES 335 REFERENCES BROWN, J. B., FRYER, M. P., and McDOWELL, F. (1951). Surg. Gynec. Obstet., 93, 676. BROWN, J. B., and McDowELL, F. (1942). Surg. Gynec. Obstet., 74, 227. BtlRCH, R. J. (1951). Oral Surg., 4, IIOI. GIBSON, T., and ALLAN, I. McD. (1956). Brit. J. plast. Surg., 9, 117. II'SEN, J. (1933). Zbl. Chit., 60, 2840. McDOWELL, F., and BROWN, J. B. (1952). Arch. Surg. Chicago, 64, 655. ROWE, N. L., and KILLEY, H. C. (1955). " Fractures of the Facial Skeleton." Edinburgh and London : E. & S. Livingstone Ltd.
By Z. NEUMAN,M.D., and A. SCHWARTZ,M.D. From the Plastic Surgery Service and the Department of Radiology, Hadassah University Hospital, 37erusalem, Israel ROWE and Killey (1955) mention only very briefly the internal Kirschner wire fixation for fractures of the facial bones. Gibson and Allan (I956) mention this method and state that they have no personal experience, and Burch (I95I) considered it likely to result in poor apposition, delayed healing, and other complications. These remarks led us to report our experience with this method. Ipsen (I933) presented a case of a fractured mandible treated successfully by internal fixation. Brown et al. (I942, I95I, I952) perfected the method and widened its applicability to most fractures of the bones, thus presenting an invaluable tool in the management of severe trauma involving the facial bony structures. Internal Kirschner wire fixation has been used successfully in our department for most fractures, during a period of over three years. When enough teeth are present and are in adequate position for immobilisation, interdental wiring is an excellent method in the management of fractures of the mandible, but is uncomfortable for the patients. In the edentulous patient, however, or in fractures of the symphysis when the strong closing muscles pull the rami outward, for fractures of the angle with the posterior fragment displaced into the upper buccal fornix or if extra stability is required after interdental wiring, this method is of great help. In the more complicated, comminuted fracture-dislocation of the zygoma and orbit we found it to be a simple method of fixation. The internal Kirschner wire ensures adequate immobilisation, but if rotation is still present a second wire can be introduced in a different plane. It is always advisable to avoid the nerve canal even though the nerve may have been severed by the displacement of the fractured fragments. OPERATIVE TECHNIQUE
The operation is performed under adequate premedication, local infiltration of the skin and periosteum with xylocaine hydrochloride, 2 per cent., and with an injection of thiopental sodium (Pentothal) for a few minutes during the penetration of the wire into the bone. An electric or hand drill can be used. The wire penetrates longitudinally into the reduced bone fragments, while the assistant holds them together. The immediate post-traumatic swelling of the face and eyelids is markedly diminished by one injection of 500 units of hyaluronidase (Hyalase), dissolved in 3 to 4 ml. of normal saline. A small stab incision facilitates the passage of the wire through the soft parts of the face. The patients are capable of taking soft food the day following the operation. Antibiotics are administered during their hospital stay only, and they leave the hospital three to four days after the insertion of the wire. The wires are usually removed between five and six weeks after the operation and good clinical union is noted. 33z
INTERNAL KIRSCHNER WIRE FIXATION OF FRACTURES OF THE FACIAL BONEs
333
FIGS. I to 4 Fig. i.--Demonstrates two wires fixing the fractured fragments. Note the sharp displacement of the proximal fragment of the left condyle. Fig. 2 . ~ S h o w s good position of the symphysis, and wired condyle after open reduction. Fig. 3 . ~ K i r s c h n e r wire fixing the fragments of a fracture through the anterior part of the lower ramus of the right mandible. Fig. 4.--Admission film shows a comminuted fracture of the maxilla, with depression of its lateral half, and a fracture near the fronto-zygomatic suture with dislocation into the orbita, In addition, fracture of the zygomatic arch is seen,
334
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FIG. 5
jOURNAL
OF PLASTIC
SURGERY
FIG. 6
Fig. 5.--After reduction of fracture through incision of buccal fornix, almost anatomical reduction and fixation of fragments with Kirschner wire. Fig. &--Six weeks after Fig. 5, following removal of wire.
A
B FIG. 7 A, Immediately after reduction of fracture. ~, Six weeks later.
INTERNAL kiRSCHNER WIRE I~IXATION OF FRACTURES Oi~ THE FACIAL BONES 335 REFERENCES BROWN, J. B., FRYER, M. P., and McDOWELL, F. (1951). Surg. Gynec. Obstet., 93, 676. BROWN, J. B., and McDowELL, F. (1942). Surg. Gynec. Obstet., 74, 227. BtlRCH, R. J. (1951). Oral Surg., 4, IIOI. GIBSON, T., and ALLAN, I. McD. (1956). Brit. J. plast. Surg., 9, 117. II'SEN, J. (1933). Zbl. Chit., 60, 2840. McDOWELL, F., and BROWN, J. B. (1952). Arch. Surg. Chicago, 64, 655. ROWE, N. L., and KILLEY, H. C. (1955). " Fractures of the Facial Skeleton." Edinburgh and London : E. & S. Livingstone Ltd.