ORIGINAL ARTICLE
Management of Pediatric Condyle Fractures
David M. McGoldrick, MBBCh, MRCSI, Paras Parmar, BDS, MFDS RCSEd,y
Rhodri Williams, FRCS (OMFS),y Andrew Monaghan, FDSRCS (Eng), FRCS (Eng),y
and Kevin McMillan, MFD, FRCSy
Introduction: Mandibular condyle fractures are a common type of
facial fracture in children. The authors aimed to examine the
demographics, etiology, treatment, and outcomes of these fractures
managed in a single pediatric trauma unit.
Materials and Methods: A retrospective review was performed of
patients presenting to a pediatric hospital between 2003 and 2016
with mandibular condyle fractures. Initial data was extracted from a
dedicated trauma database. Included patient’s medical records and
imaging were then reviewed. Data on demographics, etiology,
fracture type, and treatment were recorded. Univariate statistical
analysis was performed.
Results: Forty-four patients with 49 condyle fractures were included.
The average age of patients was 11.4 years (range 3–15 years). A fall
from a bicycle/scooter was the most common mechanism. Twenty-
six fractures were isolated and 23 involved a further fracture of the
mandibular arch. The condylar neck was the most common site of
fracture (55%). There was no statistical significance between age (0–
10 years, 10–16 years) and site of fracture or the presence of an
associated arch fracture. The majority of isolated fractures (73%)
were treated conservatively without inter-maxillary fixation. Thirty-
nine patients attended the follow-up and the median follow-up period
was 196 days (interquartile range 21–165 days). Two patients had a
malocclusion at follow-up that required intervention.
Conclusion: There was a broad range of presentations in our cohort.
Conservative management in isolated fractures resulted in stable
outcomes and this large case series supports the consensus that
management of pediatric condyle fractures should be as
conservative as possible.
Key Words: Condyle, pediatric, trauma
(J Craniofac Surg 2019;30: 2045–2047)
From the Queen Elizabeth Hospital, University Hospitals Birmingham
NHS Foundation Trust; and yBirmingham Children’s Hospital, Birming-
ham Women and Children’s Hospital NHS Foundation Trust, Birming-
ham, United Kingdom.
Received November 22, 2018.
Accepted for publication May 24, 2019.
Address correspondence and reprint requests to David M. McGoldrick,
MBBCh, MRCSI, Department of Oral and Maxillofacial Surgery,
University Hospitals Birmingham NHS Foundation Trust, Queen
Elizabeth Hospital, Mindelsohn Way, Birmingham, B15 2TH, United
Kingdom; E-mail: david.mcgoldrick@nhs.net
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005787
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A lthough facial fractures are less common in children than
adults, mandibular condyle fractures represent a common type
of fracture within this cohort.1,2 Condylar fractures may be the
result of a direct force to the area or, as is commonly the case, a
transmitted force from an impact site distant to the condyle.
Pediatric condylar fractures are important to recognize and appro-
priately manage given concerns about possible effects on growth or
the development of complications, in particular ankylosis.3,4 Treat-
ment options for condylar fractures include conservative, closed,
and open approaches. The decision as to which option is most
suitable often varies by age and has created controversy in the past.
This reflects the need to balance the degree of intervention against
possible consequences on growth. This paper examines the demo-
graphics, etiology, treatment and outcomes of these fractures
managed in a single pediatric trauma unit over a 13-year period.
METHODS
A retrospective review was performed of patients presenting with
mandibular condyle fractures to a level 1 pediatric trauma center
between January 2003 and December 2016. All patients were under
16 years old. Initial data was extracted from a dedicated maxillofa-
cial trauma database. The medical records and imaging of included
patients were then reviewed. Data on demographics, etiology
mechanisms, fracture type, treatment, follow-up, and outcomes
were recorded.
Condyle fractures were classified as either isolated or in combi-
nation with another mandibular arch fracture. The pattern of
condyle fractures were classified using the Strasbourg Osteosynth-
esis Research Group (SORG) classification.5 This classifies frac-
tures into 3 types. Condylar head or diacapitular fractures are where
the fracture line starts in the articular surface of the temporoman-
dibular joint and may extend outside the capsule. Fractures of the
condylar neck are those in which more than half of the fracture
line is superior to a line drawn perpendicular to the ramus and which
lies at the most inferior aspect of the sigmoid notch. Fractures of the
condylar base are those in which more than half of the fracture line
is inferior to this line.
Treatment was classified as conservative if no intervention was
undertaken and patients were managed with simple measures such
as soft diet. Closed treatment involved placing the patient in
intermaxillary fixation (IMF). This decision would be made by a
senior clinician and was undertaken if the patient presented with a
deranged occlusion or significant displacement and/or shortening of
the condylar fracture. The method of IMF varied depending on
patient age and dental status. In the permanent dentition, archbars
would be employed while circumandibular and piriform rim wires
would be used in patients with a mixed dentition. Closed reduction
was maintained for 7 to 10 days and reviewed in a subsequent
trauma clinic. Open treatment involved open reduction and internal
fixation (ORIF) of fractures using standard non-resorbable mini-
plates.
Statistical analysis was performed using GraphPad QuickCalc
(Graphpad Inc, CA) and Microsoft Excel (Microsoft Inc, Redmond,
WA) software. Univariate analysis was performed using the Fisher
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McGoldrick et al The Journal of Craniofacial Surgery
exact test to test associations in categorical data with a P value of
0.05 or less considered to be statistically significant.
RESULTS
Forty-four patients with 49 condyle fractures were included in the
analysis. The average age of patients was 11.4 years (range 3–15
years) and the majority of patients (89%) were male. A fall from a
bicycle/scooter was the most common mechanism of injury fol-
lowed by alleged assaults and road traffic accidents. The majority of
patients (89%) presented within one day of injury. Four patients
presented with other concomitant facial fractures and 24 had an
associated soft tissue injury. Four patients presented with poly-
trauma (Table S1, Supplemental Digital Content, http://links.
lww.com/SCS/A715).
Twenty-six condyle fractures were isolated and 23 were related
to a further fracture of the mandibular arch. Five patients had
bilateral condyle fractures. The condylar neck was the most com-
mon site of fracture (55.1%) followed by the condylar base (32.7%)
and condylar head (12.2%). There was no statistical significance
between age (0–10 years, 10–16 years) and site of fracture or the
presence of an associated arch fracture (see Table S2, S3, Supple-
mental Digital Content, http://links.lww.com/SCS/A715).
The majority of isolated fractures (73%) were treated conserva-
tively without inter-maxillary fixation. Six patients were placed in
intermaxillary fixation. There were a range of treatments for
condylar fractures involving another arch fracture (see Table S4,
Supplemental Digital Content, http://links.lww.com/SCS/A715).
No condyle fracture was treated using an open approach.
Five patients sustained bilateral condylar fractures. In 1 case,
there was no associated arch fracture and the patient was treated
satisfactorily with IMF. In the remaining 4 patients, 2 were man-
aged entirely conservatively and the other 2 had ORIF of the arch
fracture only. Two of these patients were referred to other units for
follow-up but no complications were noted in the remaining 3
patients at follow-up.
Thirteen patients (30%) presented with fracture dislocations.
Only 1 fracture displaced laterally with the majority positioned
medially or anteromedially. Four patients were placed in IMF and
the remaining patients were treated conservatively. Ten patients in
this group attended follow-up, 1 patient was placed in IMF at initial
review after an unsatisfactory occlusion was noted. No complica-
tions were noted at later reviews.
Thirty-nine patients (89%) attended follow-up appointments.
Two patients were referred for follow-up at other institutions and 3
patients did not attend. The median follow-up period was 196 days
(interquartile range 21–165 days). Two patients had an obvious
malocclusion at initial follow-up. One patient had undergone ORIF
of an associated arch fracture and IMF using arch bars for the
condylar fracture. At review, inadequate reduction of the arch
fracture was felt to be the source of the malocclusion rather than
the condylar component. The patient returned to theatre for a repeat
ORIF of the arch fracture and a satisfactory occlusion was obtained.
The second patient was initially managed conservatively for an
isolated condylar neck fracture. The occlusion was felt to be sub-
optimal at the initial follow-up and the patient was subsequently
treated satisfactorily with IMF. No complications in relation to
malocclusion or mouth opening were noted in other patients.
DISCUSSION
Pediatric facial fractures represent a small but important aspect of
Oral and Maxillofacial Surgery practice, accounting for up to 15%
of fractures treated.6 A number of subtleties exist in relation to their
aetiology and management. The developing paediatric skull and
face is believed to account for the variation in fracture patterns seen
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Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 7, October 2019
in children as compared to adults. Younger children have a high
skull to facial bone ratio as well as relatively elastic bone stock,
factors protective of facial fractures. As the face grows however, to
occupy a larger ratio, so too does the risk of facial injuries.1
Condylar fractures represent a large cohort within pediatric
facial fractures. The mandible is the most common facial bone
affected and the condyle the most common fracture site.1,7,8 Man-
agement of these injuries are important given the importance of the
condylar head to mandibular growth. Ankylosis of the temporo-
mandibular joint or growth disturbances as a result of these fractures
are also well-documented.3,10,11 Given these concerns it is unsur-
prising to note the variety of treatment approaches that have been
adopted in the past. In current practice, treatment is guided by
patient age, function and an overarching aim to maintain as
conservative approach as possible.
Although some controversy exists in open versus closed man-
agement in adults, in younger patients with an acceptable occlusion,
no intervention other than conservative measures is commonly
required.12 As age increases, short periods of intermaxillary fixation
may be considered. Open fixation of pediatric condylar fractures is
not commonly performed but some small case series have been
reported. Deleyiannis et al published a small case series involving
pediatric patients with dislocated condylar fractures treated with
ORIF.13 Although the cohort was small (6 patients), all still
developed shortening of the ramus and 4 developed signs of
temporomandibular joint dysfunction. Based on their findings, they
concluded that ORIF did not provide a consistent functional advan-
tage over conservative treatment. A more recent series by Zhang et
al reported results using bioabsorbable plates.14 Their similar sized
cohort all had satisfactory occlusion with no developmental
changes at 3- to 10-year follow-up.
Closed treatment remains a far more commonly favored treat-
ment option and a number of authors have published case series of
their experience with this approach. Ghasemzadeh et al reported on
their cohort of 62 patients over 20 years. All condylar fractures were
treated conservatively or with IMF and only five patients had a
persistent malocclusion.9 Lekven et al showed favourable long term
outcomes after a mean of 4 years in 74% of patients treated
conservatively.2 A further similar case series by Thorén et al
reported a high frequency of abnormal remodeling or asymmetry
on radiological follow-up but this did not appear to affect clinical
outcomes.16
Our cohort represents a large sample and demonstrated a number
of similarities to these previously reported studies. The majority of
patients were male, with a mean age (11.4 years) similar to
previously reported studies.2,8,9 Mechanisms of injury, such as falls
from bicycle/scooters or road traffic collisions, were also similar
although interpersonal violence was more common in our cohort.
Fractures of the condylar neck was the most common site of fracture
in our study, a finding in keeping with some studies2,8 but not others
where the head/diacaptiulum was more commonly affected.9,15
This may represent variations in the mean age amongst cohorts
as higher, intracapsular fractures are thought to occur more com-
monly in younger patients.7 Our statistical analysis did not support
this theory however, with no statistical significance seen between
fracture type and age.
The treatment adopted in this cohort was predominately conser-
vative where possible. In isolated condylar fractures simple con-
servative measures were adopted in 19/25 cases. Intermaxillary
fixation was required in the remainder. In the 19 cases with an
associated mandibular arch fracture, closed treatment of the condyle
component was only adopted in 6 cases. The vast majority of our
patients were compliant with follow-up with a median surveillance
period of 6 months employed. The results at follow-up support this
predominantly conservative approach a finding that once again
# 2019 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
mirrors previous studies.2,8,9 To allow for a longer-term assessment
of possible growth disturbances, our unit now also offers these
patients ongoing follow-up until adolescence.
There are a number of limitations to this study. The data is
retrospective in nature and relies heavily on data entry into the
trauma database. This creates the potential for error or missed data
during the study period. Data on factors such as range of motion,
deviation and opening measurements were not uniformly recorded
in patient notes. This data would have significantly added to the
interpretation of our findings but is not reported as it was not
complete. The relatively small sample, while similar to previous
studies, also limits the applicability of statistical analysis and
comparisons between groups. Although the majority of patients
attended follow-up our data does not allow for an assessment of any
potential long term complications. Despite these limitations, we feel
our cohort and the findings outlined is relatively representative of
this population.
CONCLUSION
There was a broad range of presentations in our cohort. Conserva-
tive management in isolated fractures resulted in stable outcomes
and this large case series supports the consensus that management
of pediatric condyle fractures should be as conservative as possible.
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