Hrev_master [Healthcare in Low-resource Settings 2023; 11:11304] [page 75] Fracture of the mandible treatment in a child: a simplified technique Christoph H. Houben, Lundy Campbell, Chuol Chiok S. Khuol MSF Hospital IDP Camp, Bentiu (Unity State), South Sudan Abstract After being hit by a motorcycle, a seven-year-old boy presented with a dis- placed fracture of the body of the right mandible [type III]. In the absence of orthodontic internal fixation or ligature wire equipment, suture material was used to pro- vide approximation and stabilization of the fracture. The non-absorbable suture was fed through a cannula which was pierced through the bone on either side of the frac- ture. We present this simplified technique as a suitable alternative for the fixation of mandible fractures in settings with very limited resources. Introduction Mandibular fractures were first reported in ancient Egypt in 1650 BC, albeit the author did not recommend a therapy because of the advanced soft tissue infec- tion surrounding the fracture site.1 Currently, in African countries mandibular fractures are mostly the result of motor vehicle accidents and interpersonal vio- lence.2,3 Assault dominates the cause of mandibular fractures in urban centers of the USA.4 Falls and sports accidents are also major contributors to mandibular fractures in children.5 Pediatric maxillofacial frac- tures are seen in less than 15% of facial fractures as a result of anatomical and developmental factors.6 Its incidence is rare below the age of ten years.7,8 Boys are more often affected by this type of fracture; one representative study quotes a male-to- female ratio of 2.5 to 1.9 We present the case of a patient who received a simplified treatment for his mandible fracture due to a lack of resources. Case Report A seven-year-old alert and orientated boy was admitted via the emergency room after being hit by a motorcycle on the right side of his body. He sustained multiple abrasions mainly on the right buttock and occipital area together with a forehead and back of the head wound. In the absence of a work- ing X-ray machine, the fractures were diag- nosed clinically. A closed right upper humerus fracture, a right-sided non-dis- placed mid-shaft tibia fracture, and a right displaced body of the mandible fracture [type III] were identified.10 He underwent general anesthesia for wound suturing, debridement of his abra- sions, placement of an above-the-knee plas- ter cast for his right tibia fracture, manipu- lation of the humerus fracture and an initial assessment of his displaced mandibular bone fracture at the level of the premolars. The following day we proceeded with general endotracheal anesthesia and through a one-inch submandibular incision on the right side we gained access to the fracture ends. The fracture was aligned manually with the help of a small retractor. At the lower border of the mandible, we placed a Sterican hypodermic needle (1.10´30 mm; B Braun Melsungen, Germany) through the buccal and lingual cortex on either side of the fracture (Figure 1). A 1 Nylon suture (Ethicon, New Jersey, United States) was passed through the needle lumen followed by a second suture which was placed bi-cor- tically just below the dental growth area again approximately 3-4 mm from the frac- ture side as illustrated by the artist impres- sion (Figure 2). The sutures allowed for a good approximation of the fractured mandible (Figure 3). The wound was closed in two layers with a Penrose drain left in for 48 hours. Postoperatively, granulation tis- sue formed at the wound site most likely as a result of a foreign body reaction to the drain. The tissue was excised without fur- ther disturbance of the wound healing; the sutures were removed at 10 days. In the early post-operative phase, the patient was only allowed a liquid diet. At around 3 weeks post fixation of his jaw fracture his mother confirmed he had regained his ability to chew. At four weeks post-surgery he received his third anesthesia to remove his plaster cast from his right leg and assess the stabil- ity of his healed fractures. The right jaw bone was found to be sound as were the two other previous fracture sites. The suture material was not obviously palpable and was left in situ as it caused him no prob- lems. At a review seven months after his trau- ma, the patient was in good spirits with no sign of any disability related to his former fractures. In particular, the lower jaw align- ment felt normal on palpation. Discussion Maxillofacial fractures are less frequent in small children as a result of the elasticity of young bone and flexible suture lines; fur- Healthcare in Low-resource Settings 2023; volume 11:11304 Correspondence: Christoph H. Houben, MSF Hospital IDP Camp, Bentiu (Unity State), South Sudan; available at Duffenterstr 89 A, 52222 Stolberg, Germany. Tel.: +49.24026322. E-mail: chhouben@web.de Key words: pediatric mandibular fracture; simplified technique. Contributions: CHH, operated on the patient, conceived the report, and drafted the article; LC, anesthetized the patient; CCSK, (nursing officer) conceived the novel idea to treat the fracture, and assisted in the operations; LC, CCSK, contributed to the pre- and post-opera- tive management. All the authors approved the final version to be published. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: no ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human participants or animals. Informed con- sent was obtained from the patient included in this study. Patient consent for publication: the patient’s guardian gave their written consent to use the patient’s personal data for the publication of this case report and any accompanying images. Availability of data and materials: all data underlying the findings are fully available. Acknowledgment: Dr. Deubner kindly con- tributed to the drawing. Received for publication: 11 March 2023. Accepted for publication: 30 August 2023. Early access: 11 September 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11304 doi:10.4081/hls.2023.11304 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guar- anteed or endorsed by the publisher. Non -co mmerc ial us e o nly [page 76] [Healthcare in Low-resource Settings 2023; 11:11304] thermore, children have a higher cancellous to cortical bone proportion and thicker over- lying soft tissue/fat in comparison to adults.11,12 Finally, the large head of a child protects the face, e.g., the cranium-to-face ratio is 4 to 1 in a five-year-old decreasing to 2.5 to 1 in an adult.6 Whilst concerns for the developing mandible and the odontogenesis favor a conservative approach to the management of mandibular fractures, we had to resort to an open reduction because of the displaced nature of the fracture of the mandibular body [type III].11 In the absence of intermaxillary fixation devices and equipment (plates) for an open reduction internal fixation lacking, we chose to fix the fracture with sutures in these limited resources setting. The non-absorbable sutures were placed at the inferior border of the mandibular body and below the developing tooth germs in the hope of avoiding dentition problems in the future (Figure 2). This suture tech- nique has been used before in a premature neonate with a symphysis fracture [type III] after a forceps-assisted delivery for breech presentation.13 Another investigator fixed the angle of mandible fracture [type II] in two cases with an absorbable polyglycolic acid suture and secured the arrangement with intraoral arch bars.14 We were satisfied having achieved bony union and normal occlusion for this young boy and hope to have avoided impediments to the growth of the mandible and the bud- ding teeth. Conclusions While undisplaced fractures of the mandible may well be treated with conser- vative means; the above outlined technique may serve as a valuable strategy in dealing with displaced bodies of the mandible frac- tures in a setting deprived of basic resources (Figure 3). There is justified hope in achiev- ing restoration of normal form and function with this minimalist approach. References 1. Breasted JH. A fracture of the mandible – Case 24. The Edwin Smith surgical papyrus. University of Chicago Press, Chicago; 1930;301-3. Available from: https://isac.uchicago.edu/sites/default/fi les/uploads/shared/docs/oip3.pdf 2. El-Rouby MA, El-Salam AA, El-Sherif AF. Metaanalysis of outcomes of treat- ment of mandibular fractures. J Plast Reconstr Surg 2019;43:361-4. 3. Adeyemo WL, Iwegbu IO, Bello SA, et al. Management of mandibular fractures in a developing country: a review of 314 cases from two urban centers. Nigeria World J Surg 2008;32:2631-5. 4. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:1251-5. 5. Dodson TB. Mandibular fractures in children. OMS knowledge update 1995;1:95-107. 6. Sharma A, Patidar DC, Gandhi G, et al. 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Elsevier Churchill Livingstone, Edinburgh, 2005:455-91. 13. Bhatt N, Khachi G, Yu J. Resorbable suture fixation of neonatal mandibular fractures: A novel technique. Plastic and reconstructive Surgery 2010;126:258e- 260e. 14. Roed-Petersen B. Absorbable synthetic suture material for internal fixation of fracture of the mandible. Int J Oral Surg 1974;3:133-6. Short Report Figure 1. Sterican hypodermic needle, B Braun Melsungen, Germany. Figure 2. Drawing of the technique. Figure 3. Fracture site after fixation. Non -co mmerc ial us e o nly