External Fixation for Ballistic Mandibular Trauma: An Old Method for a Modern Problem

Ballistic injuries to the mandible produce comminuted fractures with compromised vascularity and contaminated wound beds that challenge the assumptions of rigid internal fixation. External fixation, the earliest form of mandibular stabilization, preserves periosteal blood supply by avoiding open dissection, yet direct comparisons between the 2 approaches in the ballistic setting are scarce.

A retrospective review was conducted of consecutive patients with gunshot-related mandibular fractures treated at a single level 1 trauma center from January 2020 to August 2024. Patients were grouped by initial fixation method: external fixation (n=10) or internal fixation (n=30). Short-term and long-term complications were assessed through 6 months. Multivariable logistic regression compared long-term complication rates.

The cohort was 85% male with a median age of 35. Median operative time was shorter for external fixation (118.5 vs. 194.5 min, P =0.01). Short-term complications were higher with external fixation (80% vs. 33.3%, P =0.001), reflecting greater injury severity. After final fixation, the complication rate dropped to 10% for external fixation versus 33.3% for internal fixation. On multivariable analysis, long-term complications trended toward being less likely with initial external fixation, though without reaching statistical significance [OR=0.113, 95% CI (0.004, 1.11)].

Initial external fixation was associated with shorter operative time and lower long-term complication rates compared with primary internal fixation. These findings support external fixation as a staged approach to severe ballistic mandibular injuries, preserving periosteal vascularity and allowing soft tissue recovery before definitive reconstruction.