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CASE REPORT
Year : 2008  |  Volume : 26  |  Issue : 1  |  Page : 32-35
 

Greenstick fracture of the mandible: A case report


1 Department of Oral and Maxillofacial Surgery, Desh Bhagat Dental College and Hospital, Kotkapura Road, Muktsar, Punjab, India
2 Department of Human Anatomy, Desh Bhagat Dental College and Hospital, Kotkapura Road, Muktsar, Punjab, India

Correspondence Address:
V Kalia
Desh Bhagat Dental College and Hospital, Kotkapura Road, Muktsar, Punjab
India
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DOI: 10.4103/0970-4388.40320

PMID: 18408270

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   Abstract 

This case report is an insight in to pediatric traumatology whereby bilateral greenstick fracture of condyle is used as a means to discuss the incidence and anatomic considerations for the management of the same, highlighting the fact that dental surgeons require a unique understanding of the anatomy, growth considerations, healing pattern and operative management involving minimal manipulation while managing pediatric facial fractures.


Keywords: Craniomaxillofacial trauma, dento-alveolar anatomy, greenstick fracture, pediatric mandible


How to cite this article:
Kalia V, Singh A P. Greenstick fracture of the mandible: A case report. J Indian Soc Pedod Prev Dent 2008;26:32-5

How to cite this URL:
Kalia V, Singh A P. Greenstick fracture of the mandible: A case report. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2014 Dec 20];26:32-5. Available from: http://www.jisppd.com/text.asp?2008/26/1/32/40320



   Introduction Top


The incidence and etiology of craniomaxillofacial trauma in the pediatric population is affected by the age-related activities besides the social, cultural and environmental factors.

Facial fractures in the children comprise less than 15% of all the facial fractures [1],[2] inspite of their increased supervised and non-supervised physical activity as compared to adults. Maxillofacial trauma is rare below the age of five years (0.6-1.4%) [1],[2],[3],[4] and their incidence increases as children begin school. [1] Another peak incidence is seen during puberty and adolescence. [3] Amongst the facial fractures, nasal fractures are the most common, followed by the mandibular fractures as reported in hospitalized pediatric trauma patients. [1] Mid-face fractures are rare in children because of the retrusive position of midface relative to prominent calvaria. [5],[6] The most common fractures in children requiring hospitalization and/or surgical intervention involves the mandible, in which the angle, condyle and the sub-condylar region account for approximately 80% of mandibular fractures. Symphysis and parasymphysis fractures account for 15-20% and body fractures are rare. [2] Pediatric maxillofacial trauma is a unique and highly specialized branch of traumatology as a child's face has protective anatomic features, growth considerations, higher cranial to facial skeleton size, softer and more elastic bones, protective thick soft tissues, etc. Immature bone has an increased proportion of cancellous bone, which leads to an increased incidence of Greenstick fractures in children. This article is an attempt to understand the same and review the treatment modalities with the help of a case report.


   Case Report Top


A 11-year-old girl reported to the department of Oral and Maxillofacial Surgery of Desh Bhagat Dental College and Hospital, Muktsar (Punjab) with a history of fall from the terrace of her house (10 feet height from the ground) while watching kite flying. After the fall, the patient did not loose consciousness, was well-oriented to time and space and had no history of convulsions or vomiting. The local physician had put a dressing on the open wound on the chin. The patient was anxious, but cooperative and allowed conversation [Figure - 1]. She complained of difficulty in wide opening of the mouth, pain in front of her ears particularly during mastication.

On examination

Extra-oral examination revealed a one inch lacerated wound on the chin with gaping borders but homeostasis had been achieved [Figure - 2]. There was a mild swelling in both pre-auricular regions, which were tender on palpation. Intra-oral examination revealed normal sized jaws with all permanent teeth erupted.

Radiographic examination

An OPG showed bilateral sub-condylar fractures, which were not displaced, but fractured segments seemed bent and caused a little shortening [Figure - 3]. They fell into the category of greenstick fractures whereby a single cortical plate is fractured and other cortex gets bent.

Management

Since the pediatric mandible has high osteogenic potential non-surgical conservative management was the treatment of choice. Eyelet wiring was done on all the four segments and Maxillomandibular fixation (MMF) was done [Figure - 4]. The extra-oral lacerated wound was sutured in layers and sub-cutaneous suturing was done to close the skin. The maxillomandibular fixation was maintained for three weeks, followed by active physiotherapy of the jaws by inter-maxillary elastics and active movement of the jaws. The healing was uneventful. The patient could open the mouth, occlude and was rehabilitated to normal mastication [Figure - 5].


   Discussion Top


The last three decades have witnessed considerable advances and understanding of prevention, diagnosis and management of craniomaxillofacial injuries in children. There has been a decrease in the incidence and severity of pediatric facial fractures particularly in children below the age of ten years. [7] Management of mandibular fracture in children differs from that of adults because of anatomic variation, rapidity of healing, degree of co-operation and the potential for interference with the mandibular growth. Management principles for soft tissue injuries are much the same, except that the treatment should be initiated as early as possible because healing occurs sooner. Immature collagen in the child's soft tissues provides cosmetic results though hypertrophic scars and keloids may form. [8] In this case also, the chin wound, caused due to direct impact of fall, healed as a linear scar in the sub-mental region.

Site and pattern

The site and pattern of a fracture depends on the inter-relationship between etiology and force of injury and the unique anatomic features of the child's stage of development. [9] Mandibular fractures are the most common facial fracture seen in hospitalized children [4],[13] and their incidence increases with age. [14] The condylar region is the most frequently fractured site [4],[13] being affected bilaterally in about 20% of pediatric patients. [15] Fractures of the condyle are more common in children than in adults i.e. 5:3 [16] as the highly vasularized pediatric condyle and thin neck are poorly resistant to impact forces during fall besides having a large amount of medullary bone surrounded by a thin rim of cortex. The three types of condylar fractures include intra-capsular crush fractures of the condylar head and high condylar fractures through the neck above the sigmoid notch. They are most common till six years of age. The third type, which is the most common is a lower sub-condylar fracture associated with a Greenstick fracture and is usually seen in children above six years of age. [17] It is important to note that the incidence of growth disturbance is most influenced by the type of condylar fracture.

Management

In children, the pre-injury skeletal and dento-alveolar anatomy and function are re-established by the anatomic reduction of fracture based on the occlusion. [18],[19] Children have a greater osteogenic potential and faster healing rate than adults [20],[21] and hence anatomic reduction in the children should be accomplished earlier [22],[23] and the immobilization times should be shorter i.e. 2-3 weeks as compared to 4-6 weeks in adults. [24],[25] The high osteogenic potential in children allows rapid union within three weeks and non-union or fibrous union is almost never seen in pediatric patients. These factors allow for a much greater potential to remodel even in imperfectly reduced fractures. Before initiating treatment, mandibular range of motion, open bite or occlusal deformity and associated injuries should be evaluated. Most of the condylar fractures are treated with observation and a soft diet. Those with open bites or limitation of mandibular motion may be treated with closed reduction and a short period of MMF i.e. no more than 7-10 days in children below six years of age and three weeks in higher age groups. [12] MMF should be essentially followed by a period of physiotherapy consisting of manibular exercises guided by elastics to promote remodeling of the condyle and prevent ankylosis and help in rehabilitation of the child to normal function. [13] In this particular case, due to bilateral sub-condylar Greenstick fracture a conservative approach was adopted. The full compliment of permanent teeth was an added advantage, but as they were still in a phase of development islet wiring was the method of choice of wiring and extremely tight MMF was avoided as it could have resulted in tooth movement. Conclusively we may add that the decision regarding MMF, physiotherapy, open reduction should be taken as per the merits of each pediatric trauma case, yet although open reduction of condylar fractures avoids MMF and may improve the functional outcome, [14] most authors recommended closed reductions. Frequent post-operative follow-up is recommended to detect and treat early complications such as infections, malocclusion, mal-union or non-union, which are rare in children. [1] Children should be monitored longitudinally for late complications such as damage to permanent teeth, temporomandibular joint (TMJ) dysfunction like recurrent sub-luxation, chicking pain, limited condylar translation, deviation on opening, ankylosis and growth disturbances like secondary mid face deformity, mandibular hypoplasia or asymmetry. [26] When developing after 12 years stage, ankylosis-related abnormality in facial growth rarely require surgical correction. [12]


   Conclusion Top


The following points should be kept in mind while managing condylar fractures in children:

a) Condylar fractures are usually Greenstick. b) Swelling on the T.M.J area may be a sign. c) Reconstitution of normal anatomy is the goal. d) Unilateral non-displaced fractures can be treated by soft diet alone. e) Non-displaced bilateral fractures of condylar or displaced fractures must be conservatively managed. f) MMF should be maintained for minimum period of time. g) Open reduction is reserved only for non-reducible condylar fractures, which mechanically prevent jaw movement.


   Acknowledgment Top


Our sincere thanks to Dr. Zora Singh, MBBS.DCH, Chairman Desh Bhagat Group of Institutes.

 
   References Top

1.Adekeye EO. Pediatric fractures of the facial skeleton: A survey of 85 cases from Kaduna, Nigeria. J Oral Surg 1980;38:355-8  Back to cited text no. 1    
2.Bataineh AB. Etiology and incidence of Maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:31-5  Back to cited text no. 2    
3.Bamjee Y. Paediatric maxillofacial trauma. J Dent Assoc S Afr 1996;51:750-3  Back to cited text no. 3    
4.Carrol MJ, Mason DA, Hill CM. 'Facial fractures in children'. Br Dent J 1987;163:289  Back to cited text no. 4    
5.Kaban LB. Diagnosis and treatment of fracture of the facial bones in children 1943-1993. J Oral Maxillofac Surg 1993;51:722-9  Back to cited text no. 5    
6.Posnick JC, Wells M, Pron GE. Pediatric facial fracture evolving patterns of treatment. J Oral Maxillofac Surg 1993;51:836-45  Back to cited text no. 6    
7.Agran PF, Dunkle DE, Winn DG. Effects of legislation on motor vehicle injuries to children. Am J Dis Child 1987;141:959-64  Back to cited text no. 7    
8.Sawhney CP, Ahuja RB. Faciolmaxillary fractures in North India: A statistical analysis and review of management. Br J Oral Maxillofac Surg 1988;26:430-4  Back to cited text no. 8    
9.Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fracture: Recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2006;35:2-13  Back to cited text no. 9    
10.Action CH, Nixon JW, Clark RC. Bicycle riding and oral/Maxillofacial trauma in young children. Med J Aust 1996;165:249-51  Back to cited text no. 10    
11.Baumann A, Troulis MJ, Kaban LB. Facial trauma II: Dentoalveolar injuries and mandibular fracture. In : Kaban LB, Troulis MJ, editors. Pediatric Oral Maxillofacial Surgery. Elsevier Sciences: USA 2004. p. 441-60  Back to cited text no. 11    
12.Demianczuk AN, Verchere C. Phillips JH. The effect on facial growth of pediatric mandibular fractures. J Craniofac Surg 1990;10:323-8  Back to cited text no. 12    
13.Berthouze E, Sagne D, Momege B, Achard R. Treatment of mandibular fractures in children. Our therapeutic approach (author's transl). Rev Stomatol Chir Maxillofacial 1980;81:285-8  Back to cited text no. 13    
14.Dahlstrom L, Kahanberg KE, Lindahl L. 15 year's follow- up on condylar fractures. Int J Oral Maxillofac Surg 1989;18:18-23  Back to cited text no. 14    
15.Lund K. Mandibular growth and remodelling processes after condylar fracture. A longitudinal roentgencephalometric study. Acta Odontol Scand Suppl 1974;32:3-117  Back to cited text no. 15    
16.Kaban LB. Mulleken JB, Murray JE. Facial fracture in children: An analysis of 122 fractures in 109 patients. Plast Reconstr Surg 1977;59:15-20  Back to cited text no. 16    
17.Thoren H, Lizuka T, Hallikainen D, Nurminen M, Lindqvist C. An epidemiological study of patterns of condylar fracture in children. Br J Oral Maxillofac Surg 1997;35:306-11  Back to cited text no. 17    
18.Cawood JI, Stoelinga PJ. Facial trauma. Int J Oral Maxillofac Surg 1990;19:193  Back to cited text no. 18    
19.Denny AD, Rosenberg MW, Larson DL. Immediate reconstruction of complex cranioorbital fractures in children. J Craniofac Surg 1993;4:8-20  Back to cited text no. 19    
20.Kaban LB. Facial trauma I: Midface fracture. In : Kaban LB, editors: Pediatric Oral and Maxillofacial Surgery. W.B Saunders: Philadelphia, PA; 1990. p. 209-32  Back to cited text no. 20    
21.Maniglia AJ, Kline SN. Maxillofacial trauma in the pediatric age group. Otolaryngol Clin North Am 1983;16:717-30  Back to cited text no. 21    
22.Heitsch M, Mohr C, Schettler D. Indications for the surgical treatment of midfacial fracture in children. Dtseh Zahanrztkl Z 1990;45:803-5  Back to cited text no. 22    
23.Messinger A, Radkoski MA, Greenwald MJ, Pensler JM. Orbital roof fracture in the pediatric population. Plast Reconstr Surg 1989;84:213-8  Back to cited text no. 23    
24.Gussack GS, Luterman A, Powell RW, Rodgers K, Ramenofsky ML. Pediatric maxillofacial trauma: Unique feature in diagnosis and treatment. Laryngoscope 1987;97:925-30  Back to cited text no. 24    
25.OJIC. Fractures of the facial skeleton in children: A survey of patients under the age of 11 years. J Craniomaxillofac Surg 1998;26:322-5  Back to cited text no. 25    
26.Selle A, Thieme V. Injuries to the facial portion of the skull and their late effects in children and juveniles - a 10-year analysis (author's transl). Zahn Mund Kieferheilkd Zentrabl 1979;67:377-85  Back to cited text no. 26    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]


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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    Acknowledgment
    References
    Article Figures

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