Broken bone

It is obvious that a broken bone needs time to heal. How long depends on the techniques used to fix it, the state it was in when broken, the person the bone belongs to and what that person does to help it heal.

Mandibular fractures

Time-lines short term: in most cases a fractured mandible should be operated (reduced and fixed) within 24 hours. This is partly because it is a ‘compound’ fracture, being exposed to the contaminants of the mouth, and partly out of humanity. The breaks affecting the tooth bearing areas of the jaws are usually put together (reduced) and held in place (fixed) by titanium (or rarely by resorbable plastic) plates and screws buried beneath the gum. There may be wires, buttons or metal bars fixed to the teeth to ensure the bite of the teeth is returned exactly to the pre-injury position. These devices may remain after the fixation to help support the repair and ensure the teeth remain biting correctly, or be removed if the surgeon is confident everything is in the right place.

Breaks away from the tooth bearing area, especially the condylar neck of the mandible may be managed only by elastic bands guiding the teeth together, or this may be used for a week to see if the area around the jaw joint and the fracture adapt as the teeth come together. If not then an open operation to reduce and fix the condylar fracture may be needed.

Accepting this, short term after injury you can expect to be admitted for a day and night and leave with the fracture put back together. It will be uncomfortable and mouth opening and jaw movement will be limited for the first week to 10 days, even if the teeth are not held tightly together by wires or elastic bands (this is unusual nowadays).

Time-lines medium term: by 3 weeks after the repair, especially if internal fixation with plates and screws has been used, you should feel almost back to normal and be eating food of increasing consistency. Bruising and swelling should be largely resolved but don’t expect to eat apples, toffee or tough meats.

A soft diet is required for 2 to 4 weeks to ensure the plates are not overstressed during the healing period. The fracture is sufficiently healed after this period to allow normal mandibular function. The plates, now obsolete, remain in situ without causing problems. In the immediate postoperative period a strict oral hygiene regimen is implemented, in the form of 0.2% chlorhexidine gluconate mouth rinses, and tooth brushing.

You may be aware of a loss of feeling, especially in your lower lip. This may have happened at the time of the break as the nerve supplying feeling to the lower lip runs through the mandible. Alternatively it may have been damaged during the operation to repair the fracture.

Time-lines long term: most people will have a fully healed mandible at around 3 months after treatment with a normal (for them) bite and normal sensation. If the bite has not returned to its pre-treatment state, something is wrong and further treatment may be needed. If altered sensation was noticed in the medium term it can take up to 18 months for sensation to fully return. Usually it will, but if the nerve was completely divided this may never return to its pre-injury state.

Zygomatic complex (cheekbone) fractures

Time-lines short term: these fractures are very unlikely to be compound (connected to the skin and at greater risk of infection) fractures. They are connected to the air sinuses around the nose and nose blowing should be avoided as this can force air underneath the skin, creating a bizarre situation called subcutaneous emphysema. This increases the risk of infection. Generally these breaks are better treated in a delayed fashion to get best results when swelling has settled down. During this time the fractures may be uncomfortable but don’t tend to be painful unless they become infected. Double vision can be a problem and you should not drive if affected by double vision.

Time-lines medium term: 3 weeks after surgery the impressive black eye and red conjunctiva should have largely settled down and appearances returned to normal. During this time, if the fractures have been fixed with small plates, there is little in the way of special precautions to take. If no fixation has taken place it is important to avoid pressure on the area. Double vision should have largely settled down. You may notice altered sensation in the area below the affected eye, side of nose and even the upper front teeth and gums on that side. This is because the nerve supplying feeling to that area runs in a bony canal in the floor of the eye socket and emerges below the rim of the eye socket and can be squeezed, crushed or severed by these fractures. There may be a dull pain in the region of the fracture during winter months, slow recovery of the infraorbital nerve, fighting and contact sports need to be avoided for six to eight weeks after fracture repair.

Time-lines long term: in the long term most of these fractures have healed to full strength within 3 months and the plates can be forgotten about.

Persistent diplopia (double vision) requires a specialist ophthalmological opinion. Prescription of a prism lens, eye rehabilitation and potential use of corrective eye muscle surgery may be necessary. Again, nerve damage may take up to 18 months to fully resolve and if it hasn’t by that stage, it may be permanent.

Nasal fractures

Time-lines short term: these fractures are usually treated once swelling has settled down and the bones can be aligned properly. A stuffy blocked nose can be expected until at least 10 days after treatment, although treatment itself is usually done as a planned day case operation.

Time-lines medium term: nasal discomfort, difficulty in nasal breathing and stuffiness may continue for 3 weeks but usually rapidly settles down over this period.

Time-lines long term: as long as the nasal septum is in the correct position, airway problems should resolve within a couple of months. Persisting pain or difficulty with nasal breathing or discharge is unusual and you should ask your specialist about this if it persists.

Midface fractures

Time-lines short term: these are variable injuries. If combined with other facial injuries they may be treated simultaneously, accepting the limitations and problems caused by swelling. If the fractures are isolated it is perfectly reasonable to wait for swelling to settle, check how the bite relates to the pre-injury state and treat accordingly (if necessary – if the fragments (and there are often many) are not displaced, this may not be needed). If operated it is usual to fix 4 main ‘pillars’ of the maxilla (top jaw) to provide a buttress for biting forces and allow other areas to heal spontaneously. There can be a lot of swelling, black eyes, red conjunctivae and difficulty in eating during this phase. Once treated and the top jaw is stable, the bones heal quickly.

Time-lines medium term: after 3 weeks the bones are quite firm. If internal fixation has been used, you should be biting and eating reasonably normally. Again, hard foods and extensive chewing is not a good idea at this stage but gradual progression towards firmer consistencies is sensible. You may notice loss of sensation over the cheeks from the same nerve described in cheekbone fractures. Double vision is a sporadic problem in high level fractures involving the eye sockets.

Time-lines long term: most mid-face fractures will have fully healed within 3 months. Unless the bite has not been returned to normal or there has been nerve damage (about which the same rules as above apply), you should be back to normal unless extensive dental work is needed. That can take much longer than the bone healing.

Frontal bone & frontal sinus fractures

Time-lines short term: these are generally reduced and fixed after swelling has resolved, unless the brain is involved. In that case the surgery is combined with any neurosurgery needed. The approaches range from minimal and endoscopic approaches to raising a coronal flap which involves a hairline incision from ear to ear to peel back the forehead. This sounds dramatic but allows excellent visualisation of the fractures and heals within 10 days. Drains are usually used, especially in coronal flaps and at least one night in hospital is needed.

Time-lines medium term: there may be slight discomfort for a week or so and you will usually have to take decongestants for 10 days, unless the frontal sinus has been obliterated by bone graft. If this is done the donor site (usually the hip) is a bigger problem than the head. Medium term issues with post-concussion syndrome (headaches, mild personality changes, relative photophobia, avoidance of noise) is not unusual.

Time-lines long term: some people experience mucous cysts from residual lining of the frontal sinus. This is one reason some surgeons are in favour of removing all the mucosal lining and obliterating the sinus with grafted bone.