Unilateral condylar fractures

Inspection

Any movement of the lower jaw is likely to be restricted and painful. There is often swelling over the temporo-mandibular joint area and there may be haemorrhage from the ear on that side. Bleeding from the ear results from laceration of the anterior wall of the external auditory meatus, caused by violent movement of the condylar head against the skin in this region. In the normal subject the close relationship of the condyle to the skin of the external auditory meatus can be appreciated if the little finger is placed within the external ear and the jaw moved.

It is important to distinguish bleeding originating in the external auditory canal from the more serious middle ear haemorrhage. The latter signifies a fracture of the petrous temporal bone and may be accompanied by cerebrospinal otorrhoea. In all cases of suspected condylar fracture the ear should be examined carefully with an otoscope. The appearance may be extremely confusing even to an experienced maxillofacial surgeon, and there should be no hesitation in asking the opinion of an otologist in these circumstances.

The haematoma surrounding a fractured condyle may track downwards and backwards below the external auditory canal. This gives rise to ecchymosis of the skin just below the mastoid process on the same side. This particular physical sign also occurs with fractures of the base of the skull, when it is known as «Battle's sign». It is vital not to confuse the aetiology when an ecchymosis at this site is discovered

On the very rare occasion when the condylar head is impacted through the glenoid fossa, the mandible will be locked and middle ear bleeding may present externally.

If the condylar head is dislocated medially and all oedema has subsided due to passage of time, it may be possible to observe a characteristic hollow over the region of the condylar head, but in the immediate post-traumatic phase this physical sign is obscured by oedema.

Palpation

In the recently injured patient there is invariably tenderness over the condylar area. When post-traumatic oedema is present it is difficult to palpate the condylar head and what is believed to be the condylar head may, in fact, be that portion of the condylar neck continuous with the lower portion of the ramus. It may be possible to determine whether the condylar head is displaced from the glenoid fossa by palpation within the external auditory meatus. Standing in front of the patient both little fingers can be hooked into each external auditory meatus and the position and movement of each condylar head compared.

Intra-ora l.

Displacement of the condyle from the fossa or over-riding of the fractured condylar neck shortens the ramus on that side and produces gagging of the occlusion on the ipsilateral molar teeth. The mandible deviates on opening towards the side of the fracture and there is usually painful limitation of protrusion and lateral excursion to the opposite side.

Bilateral condylar fractures

The signs and symptoms already mentioned for the unilateral fracture may be present on both sides. Overall mandibular movement is usually more restricted than is the case with a unilateral fracture.

Intra-orally

It only requires one condyle to be displaced with shortening of the ramus to lead to premature contact of the posterior teeth on the side of injury. Accordingly derangement of the occlusion is more usual with bilateral than with unilateral condylar fractures. Intracapsular fractures produce little if any shortening and the occlusion is often found to be normal. If both fractures have resulted in displacement of the condyles from the glenoid fossa or overriding of the fractured bone ends, an anterior open bite is found to be present. In all cases of bilateral fracture there is pain and limitation of opening with restricted protrusion and lateral excursions.

Bilateral condylar fractures are frequently associated with fracture of the symphysis or parasymphysis and these areas should always be carefully examined.