Britkh Journal of Oral Surgery (1983) 21, 208-213 @ 1983 The British Association of Oral and Maxillo-Facial Surgeons

THE TRANS-NASAL KIRSCHNER WIRE AS A METHOD OF FIXATION OF

THE UNSTABLE FRACTURE OF THE ZYGOMATIC COMPLEX

JAMESBROWNB.D.S.(E~~~.)~~~DAVIDBARNARDF.D.S.R.C.S.(E~~.),F.D.S.R.C.P.S.(GI~~.) Department of Oral Surgery, Queen Alexandra Hospital, Cosham, Portsmouth

PO6 3LY

Summary. A technique for the fixation of the unstable zygomatic complex is described and compared with other methods currently available.

Introduction

Fractures of the zygomatic complex comprise about 60 per cent of all facial bone fractures requiring treatment (Matsunagaetaf., 1977). Some form of fixation may be required following reduction although the incidence of fractures needing stabilisa- tion has been variably reported as 100 per cent (Matsunagaet al., 1977), 40 per cent (Knight & North, 1961), and 25 per cent (Jay Hoyt, 1979). The following methods for fixation of the unstable fracture of the zygomatic complex have been described:

1 Antral support

(a) Packs i) Whitehead’s varnish (Rowe & Killey, 1968)

ii) Plastic tubing (Altonen et al., 1976) (b) Balloon catheter (Anthony, 1952) (c) Silicone wedge (Gorman, 1979)

2 Transosseous wires (Rowe & Killey, 1968)

3 Suspensory wires (Duckert & Boies, 1977)

4 External pin .fixation

(a) Front0 zygomatic (Rowe & Killey, 1968) (b) Maxi110 zygomatic (c) Cranio zygomatic

5 Internal pin fixation

(a) Trans-Maxillary (zygomatico-zygomatic) Kirschner Wire (Fryer, 1950; Brown et al., 1952; Crewe, 1963; Fryer et al., 1969; Silverton et al., 1978)

(b) Zygomatico-Palatal Steinman pin (Matsunaga et al., 1977)

The Trans-Nasal Kirschner Wire is extensively used in the United States (Barnard, 1978), but does not appear to have been described in the literature. This paper describes the technique and suggests advantages over alternative methods of fixation of the unstable zygomatic complex fracture.

(Received 28 April 1982; accepted 24 August 1982)

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THE TRANS-NASAL KIRSCHNER WIRE AS A METHOD OF FIXATION 209

Method

Under oral endotracheal anaesthesia the zygomatic complex is reduced by an elevator introduced via a temporal approach (Gillies et al., 1927), or by a hook inserted through a stab incision in the cheek (Poswillo, 1976).

The position of the bone is maintained by the assistant standing at the head of the patient whilst the operator stands on the opposite side to the fracture. A .062” Kirschner wire (K-wire) is inserted and secured in a hand drill so that sufficient length projects from the chuck to traverse the face from the contra-lateral side of the nose to the inner aspect of the fractured zygomatic complex. The K-wire is inserted through the skin of the side of the nose opposite the fracture as far posteriorly as possible and sufficiently inferior to the eye to ensure that the chuck of the drill does not traumatise the globe in the final stages of drilling. The point of entry is usually above the mid-point between the medial canthus and the alar base. It is wise for the

Fig. 1

Figure l-(A) Occipitomental radiographs showing severely displaced fracture of the right zygomatic complex with comminution of the infra-orbital margin. (B) Occipitomental radiographs showing position of zygomatic complex after reduction and fixation with a transosseous zygomatico-frontal wire and

trans-nasal Kirschner wire. Note the angulation of the K-wire.

210 BRITISH JOURNAL OF ORAL SURGERY

assistant to protect the closed eye with gauze during the early part of the drilling phase until the wire is stabilised in bone. The wire is aimed at the inner aspect of the fractured zygomatic bone being angled slightly inferiorly and posteriorly. As it is advanced the angulation is carefully monitored in the supero-inferior plane by the operator, and the antero-posterior plane by the assistant from the head of the patient. The drill is slowly rotated and advanced when resistance will be felt as the wire passes through the frontal process of the maxilla (unaffected side), the nasal septum, the lateral nasal wall and finally as it impacts against the inner aspect of the fractured zygomatic bone (Fig. lA, B). The assistant then relaxes the elevator or hook to check that the fractured complex has been stabilised in the correct position. Slight adjustments to achieve the optimum position of the fractured zygomatic complex can be carried out at this stage by altering the final placement ‘of the K-wire. Taking care to protect the eye, the wire is trimmed to leave 2 millimetres projecting through the skin on the side of the nose to facilitate later removal (Fig. 2). The projecting end is covered with a small piece of elastoplast. The K-wire is removed 2 to 3 weeks later. The projecting tip is secured in the chuck of a Watson Jones Guide Wire Introducer (Howmedica), and, with slight oscillating movements, the K-wire is slowly withdrawn. Again, care must be taken to protect the eye, particularly during the final stages of removal. There is minimal discomfort to the patient and local or general anaesthesia is not required.

Discussion

The Trans-nasal Kirschner wire offers stable and effective fixation of the fractured zygomatic complex with minimal morbidity. With the technique described the risk of damage to important anatomical structures is minimal (Fig. 3). The most vulnerable structure is the naso-lacrimal duct which should lie posterior to the K-wire but no functional problems have been encountered by the authors, or reported in the literature. The wire passes inferior to the infra-orbital nerve. The K-wire is well

Fig. 2

Figure 2-End of the trans-nasal Kirschner wire projecting through skin after trimming.

THE TRANS-NASAL KIRSCHNER WIRE AS A METHOD OF FIXATION 211

Fig. 3

Figure 3-Dried skull showing the tram-nasal Kirschner wire in position (the end has not been trimmed). (A) Frontal view with the wire passing inferior to contra-lateral infra-orbital nerve. (B) Inferior view with

the wire passing anterior to nasolacrimal canal. Note the position and angulation of the wire.

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tolerated by the patient and the technique is simple and rapid to perform without prolonging the stay in hospital. Residual scarring is minimal. The trans-nasal Kirschner wire may be used as the only method of stabilisation, or in combination with other techniques, particularly the zygomatico-frontal transosseous wire. It is of limited value where the zygomatic body is grossly comminuted, or with isolated fractures of the zygomatic arch.

The antral pack is widely used to support the unstable zygomatic complex. How- ever, in a recent survey comparing antral packs (Whitehead’s varnish) and external pin fixation, it was found that prolonged infra-orbital nerve paraesthesia and poor cosmetic results occurred most often in the pack group (Findlay & Ward-Booth, 1981). Altonen et al. (1976) reviewed 55 cases and showed similar morbidity when the antrum was packed with plastic tubing. The use of a balloon catheter to support the unstable zygomatic complex has been suggested (Anthony, 1952), but good control of the fragments is uncertain. Additionally, when the antrum is opened there is a risk of persistent oro-antral fistula (Killey & Kay, 1975).

Direct transosseous wiring at the zygomatico-frontal suture prevents inferior displacement, but even in conjunction with an infra-orbital transosseous wire, medial displacement may not be prevented due to the pull of the masseter muscle (Mat- sunaga et al., 1977). This is particularly noticeable where there is comminution or bone loss in the infra-orbital region.

Fronto-zygomatic external pins provide effective fixation in the long term (Findlay & Ward-Booth, 1981), but the pins are cumbersome to the patient and there is a risk of secondary damage where the patient is allowed home during the period of fixation. Insertion of.these pins may leave more noticeable scars than the smaller K-wire. The zygomatico-zygomatic Kirschner Wire (Silverton et al., 1978, Fryer, 1950) is an alternative method of internal pin fixation but the wire is longer and therefore errors of angulation are more easily made. The zygomatico-palatal Steinman pin fixation technique (Matsunaga et al., 1977) is complicated by the need to begin the drilling through the unstable zygomatic bone, and incorrect angulation may place vital structures at risk.

Conclusion

The trans-nasal Kirschner wire appears to have advantages over other techniques for fixation of unstable fractures of the zygomatic complex. It provides antero-lateral stability more effectively than the antral pack, though the latter is still indicated where the bones are severely comminuted, or where support is required for the orbital floor. It is more convenient than external pin fixation, and while not replacing the need for transosseous wires, may be a useful adjunct. It appears to have technical advantages over previously described methods of internal pin fixation. However, the technique needs to be further evaluated in the long term.

References

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Brown, J. B., Fryer, M. P. & McDowell, F. (1952). Internal Wire-pin Fixation of Fractures of the upper jaw, orbit, zygoma and severe facial crushes. Plastic and Reconstructive Surgery, 9, 276.

Crewe, T. C. (1963). Facial transfiiation in Maxilla-Facial Injuries.NewZealandDentalJournal, 59,201.

TRANS-NASAL KIRSCHNER WIRE FIXATION 213

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