--------------------------------------------------------------------------- TITLE: MAXILLOFACIAL TRAUMA IN CHILDREN SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: Oct 2 1991 RESIDENT PHYSICIAN: Mark C. Littlejohn, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. --------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Introduction A. Incidence 1. Much less common in children than in adults, particularly during the first five years of life. 2. Depending on the series, 5-10% of facial fractures occur in children, approximately 1% in children less than 5 years of age. 3. Fractures of the nasal bones and mandible account for the great majority of facial fractures. 4. Etiologies include falls, motor vehicle accidents, playground accidents, sports activities, animal attacks, and child abuse. (One must always consider child abuse if the mandible alone is fractured in a child less than six years old. 5. Trauma secondary to motor vehicle accidents has decreased since the introduction of mandatory front-seat occupant and child restraint laws. 6. Fracture sites tend to shift from the upper to the lower aspect of the face with increasing age of the patient. B. Differences From The Adult 1. Pediatric patient exhibits much more lability in emergency management. 2. Greater difficulty in clinical and radiological examination. 3. Lack of facial development. 4. State of mixed dentition. 5. Faster rate of healing. 6. Concomitant intracranial and cervical spine injury more common. 7. Operative intervention may result in greater deformity, some of which may not manifest for several years. C. Anatomy 1. Relatively large cranium and forehead compared to proportionately smaller facial bones, which shields the lower facial skeleton from injury. 2. Relatively large interpupillary distance and flat nasal dorsum. 3. Larger amount of insulating fibroadipose tissue. 4. Bones are more resilient. 5. Lack of development of paranasal sinuses with smaller surrounding bony buttresses. 6. Large tooth-bone ratio which adds stability. 7. Pediatric facial bones have a thin cortex with a large cancellous component. II. Patient Evaluation A. ABC's 1. Pediatric airway is more prone to obstruction with very little mucosal edema or hematoma. 2. Consideration of posteriorly displaced tongue, grossly displaced tissue, or blood causing airway obstruction. 3. Smaller circulating blood volume can result in shock with as little as 100-200 cc's of blood loss. 4. Conservation of body heat is an important deterrent to shock, owing to the child's relatively greater ratio of body surface area to body volume. 5. Emergency management directed at maintenance of airway, restoring circulating volume, careful monitoring of hematocrit, and control of heat loss and pain. 6. Most series report the safe usage of orotracheal followed by naso- tracheal intubation for airway obstruction. B. Physical Examination 1. First talk to the child and make initial physical contact by touching the uninjured upper extremity to calm the child and initiate trust. 2. High correlation of maxillofacial trauma in children with intracranial and cervical spine injury, especially children less than six years of age. 3. Associated thoracic, abdominal, and extremity injuries must be searched for. 4. Systematic assessment of facial injuries. a. Physical signs of ecchymoses, facial asymmetry, bony depression, tenderness, crepitus, ocular proptosis, malocclusion. b. Comprehensive palpation of all facial areas. c. Associated ocular, otic injury. d. Gauge intercanthal distance by palpebral fissure width or alar-alar width. e. May have to consider general anesthesia for complete exam. f. Avoid extensive manipulation of midfacial fractures until ophthalmologic clearance obtained. C. Radiographs play a much more limited role in diagnosis. 1. Conventional views: Waters, PA, Townes, lateral, obliques. 2. Polytomography 3. CT scan will also assess intracranial injury. Axial and coronal CT essential for nasoethmoid complex fracture. 4. Possible 3D CT in the near future: detects subtle calcifications such as the early formation of a callus. D. Consultation 1. Neurosurgery: especially for children less than six years of age. Any infant with a mandible fracture must have additional head trauma ruled out. 2. Ophthalmology: for any complex midfacial fracture. 3. Pediatrics: team coordinator. III. General Principles of Repair A. Meticulous atraumatic repair of supporting soft tissues. B. Faster rate of healing necessitates reduction within an earlier time period, usually three to eight days from injury. C. Shorter time in fixation necessary for healing (two to three weeks for IMF). D. Treatment directed at the simplest means of fixation. Think conservative. Exception: nasoethmoid complex fractures. E. For ORIF, periosteal elevation only as needed for fracture reduction. F. If ORIF used, plating preferable to interosseous wiring for added stability. (Note: No long-term studies addressing the effect of rigid plating across actively growing suture lines exists.) Plates 2.0 mm or thinner utilized to avoid visibility. 0.8 mm plates of the Luhr microfixation system ideal. G. Once a fracture has healed, it is not as amenable to reconstruction. H. Complications are more likely to occur in children. I. Importance of parental counseling as to the nature of the injury and effects on future development cannot be overemphasized. IV. Anatomical Sites A. Nose 1. Probably the hardest diagnosis to make clinically, particularly in very young patients. a. Proportionately smaller bony pyramid with larger cartilagenous component. b. Less likelihood of mobility, crepitus on exam. c. Edema may mask deviation. d. Radiographs useful only for medicolegal considerations. e. Anesthesia may be necessary for adequate exam. 2. Resiliency of bones and immature suture lines tend to result in "open book" type of fracture. 3. Dislocation and fracture of the nasal cartilages are more common than in adults. 4. Buckling of the nasal septum with trauma predisposes to formation of septal hematoma. 5. Key signs of nasal fracture. a. Bleeding most important. b. Swelling of dorsum, ecchymosis, tenderness, x-ray evidence of fracture also significant. 6. Operative intervention indicated for fractures that result in significant cosmetic deformity or airway obstruction. 7. Reduction should be carried out within two to four days of injury due to rapid rate of healing. Closed reduction preferable. 8. Tendency to heal with hypertrophic callus at the site of fracture with resultant widening of the bony dorsum. 9. Importance of the nasal septum in the development of the facial skeleton. B. Nasoethmoid Complex 1. Nasoethmoid fractures constitute a more serious injury which requires open reduction and internal fixation. a. Flattened, widened nasal dorsum with traumatic telecanthus, rounding of the medial canthus, and positive bowstring test. b. Often associated with skull fractures, orbital roof fractures, and maxilla fractures. c. Neurological, ophthalmologic consultation. d. Open reduction with rigid plating, and transnasal wiring for medial canthal ligament(s). Transnasal wire may be fixated to plate. e. Overcorrection of intercanthal distance preferable to under- correction. Obviously, exact reduction ideal. f. Craniofacial approach. 1) Bicoronal incision. 2) Above the temporal line: subperiosteal plane Below the temporal line: deep to superficial temporalis fascia 3) Dissection carried to superior orbital rim and lateral orbital rim. 4) Subperiosteal and subfascial planes connected. 5) Temporalis fascia incised at the attachments to the lateral orbital rim and zygomatic arch. 6) Supraorbital vessels and nerves freed from their bony canals with osteotomies or diamond burr drill. 7) Subperiosteal dissection completed to the superior orbital fissure and lateral orbital fissure, over the nasal bones, medial orbital wall, and superior portion of the lacrimal fossa. C. Mandible 1. Treatment Considerations a. Fractures tend to be "greenstick" in nature in a longitudinal, oblique direction. b. Fractures more likely to be favorable if through both cortices. c. Growth centers are usually preserved and continue to function, but if damage occurs, results are profound. The condyle is the major growth center for the mandible. d. Healing is rapid necessitating early fixation (within three to four days). e. A significant amount of remodeling occurs under the influence of the forces of mastication, with much greater potential to remodel imperfectly reduced fractures. f. Mixed dentition creates a special problem. g. Uninterrupted teeth frequently involved in the fracture line. An impacted third molar will create an anatomic weak point. h. Avoid low-lying tooth buds with placement of interosseous wires or plates. If considering ORIF, plates are preferable to wires for greater stability. Consider miniplates. Screws must be placed at the inferior-most aspect of the mandible to avoid uninterrupted permanent teeth. i. For 0-12 y/o: leave IMF in place three weeks. For 12-18 y/o: leave IMF in place four to six weeks. j. 26 gauge stainless steel wire used for IMF. 2. Rowe's classification of mandibular fracture management. a. 0-2 years old: treat as edentulous patient with gunning splints, circum-mandibular wires. b. 2-4 years old: deciduous dentition well developed allowing use of eyelet wires or arch bars for IMF. c. 5-8 years old: greatest problems arise in this stage of mixed dentition. 1) Reliance must be placed on deciduous molars with partial loss and eruption of anterior dentition. 2) Gunning splints, occlusal blocks, circum-mandibular wires, pernasal wires all considerations. d. 9-11 years old: roots of canines and first molars well developed enough for use in IMF. e. > 11 years old: all dentition will support fixation. 3. Open reduction reserved for patients who have failed closed reduction techniques or who have excessively displaced, unstable, or unfavorable fracture segments. 4. Permanent teeth involved in the fracture line need not be removed as readily as in the adult. 5. Condylar fractures a. Frequently greenstick b. Swelling will be present over the temporomandibular joint. c. Anterior open bite deformity common with displaced bilateral condyle fractures. d. Reconstitution of normal anatomy the rule. e. Conservative management usually indicated. f. Soft diet for unilateral nondisplaced fractures. Some authors treat nondisplaced bilateral fractures with soft diet alone. g. Fixation for three weeks for displaced or bilateral fractures. h. Open reduction reserved for condylar fractures which mechanically prevent jaw movement. 6. Complications of mandible fracture a. Growth arrest, ankylosis. b. Facial deformity. c. Delayed eruption or malformation of teeth. d. Malocclusion. e. Nonunion or fibrous union extremely uncommon in children. D. Teeth, Alveolar Process 1. Anterior teeth more commonly injured. 2. Every effort to preserve teeth and bone, especially anteriorly. If in doubt, preserve the tooth. 3. Identification of primary vs. permanent teeth difficult for the nondentist. Therefore all displaced or avulsed teeth are replanted within 30 minutes if possible. 4. Wash tooth gently with saline; handle only by crown, and replant in socket. If there is a concern of aspiration or swallowing, wrap tooth in saline-soaked gauze sponge until a dentist can perform replantation. 5. If parent calls with a report of an avulsed tooth, instruct to place the tooth back in the socket or in milk and see a dentist immediately. 6. Primary teeth a. Traumatic impaction: if completely submerged, primary tooth must be extracted. b. Avulsion: usually not replanted unless tooth still necessary for space maintenance. c. Luxation (displacement with or without loosening): repositioned and stabilized. d. Fracture: pulp intact vs. exposed. Extraction required for crown- root fracture or retained crown with coronal third of pulp fractured. 7. Permanent teeth a. Traumatic impaction: if greater than 1/2 crown submerged, reposition and wire to an arch bar. b. Avulsion: See above description of tooth replantation. Good prognosis associated with an avulsion of 30 minutes or less. c. Fracture: leave teeth with pulp exposed out of IMF if possible. Extraction criteria same as with primary teeth. 8. Teeth in the line of fracture. a. Management controversial. b. Tooth root or 3rd molar within a fracture line frequently exerts a keystone effect on fracture reduction. c. Guidelines proposed by Dierks: extract tooth if any of the following present. 1) Gross mobility within the bony fragment. 2) Presence of periapical radiolucency (nonvital pulp). 3) Root fracture. 4) Severe dental caries. 5) Interference with fracture reduction. E. Maxilla 1. Anatomical pillars a. Anterior canine pillar. b. Middle zygomatic pillar. c. Posterior pterygoid pillar. 2. Uncommon in children, although the incidence of LeForte fractures increases with increasing pneumatization of the sinuses. 3. Signs include malocclusion, retrusion or elongation of the face, ecchymosis, periorbital swelling, mobility of upper dental arch. 4. Association with intracranial injury. 5. Management a. LeForte I fractures: minimal or no displacement- observation. displacement- IMF and piriform aperture wires for two to three weeks. b. LeForte II, III fractures: IMF, suspension to frontal bone, ORIF. Consider degloving approach. c. Use of zygomatic arch in fixation contraindicated. F. Orbit 1. Floor fractures a. Blow-out fracture rare due to poorly pneumatized antrum. b. Compensatory edema and hematoma of the orbit may mask displacement of the intraorbital contents. c. Forced duction test, facial films, tomography. d. Ophthalmologic consultation essential. e. Tendency to conservatism. f. Surgical intervention 1) Indicated for persistent diplopia or enophthalmos. 2) Open exploration of the orbital floor. 3) Caldwell-Luc approach contraindicated before age 11 due to potential for damage to tooth buds. 4) Conchal cartilage may be used for floor defects in those over six years of age. 2. Roof fractures a. Type I: nondisplaced. Treat conservatively. b. Type II: superiorly displaced. Repeat CT scan 24 hours later to rule out a subdural hematoma. Treat fracture conservatively. c. Type III: inferiorly displaced. Combined extracranial and intra- cranial approach with restoration of continuity by split calvarial bone graft. If observation employed, significant risk of encephalocele. G. Zygoma, Malar Area. 1. Rare fracture in children. 2. Isolated zygoma fracture seldom occurs before the age of eight. 3. Signs of fracture include periorbital ecchymosis, flattening of the malar eminence, depression of the infraorbital rim, hypesthesia, variable diplopia. 4. Ophthalmologic consultation essential. 5. Malar fractures present a greater problem in children. a. Long term deformity not uncommon. b. Greenstick fracture necessitates open reduction. c. Treatment preferably within 48 hours of injury. d. Rigid plating systems preferable. e. Craniofacial approach used for fractures close to the orbital apex or involving the lateral orbital wall. H. Frontal Sinus 1. Usually does not become clinically significant until age of 10 to 12. 2. Indications for exploration of a frontal sinus fracture. a. Depressed anterior table. b. Radiologic evidence of involvement of the nasofrontal recess. c. Posterior table fracture. 3. In young children with lack of pneumatization, treatment is that of a depressed skull fracture requiring elevation. V. Soft Tissue Injuries A. Principles 1. Early and proper wound care to minimize scarring and need for further revision. 2. Photographic documentation. 3. Assessment of preanesthetic facial movement. 4. Thorough cleansing and wound preparation. a. Ether for petroleum-based contaminants. b. Dermabrasion for minute embedded particles. 5. Conservative debridement with excision of ragged edges. 6. Absolute hemostasis to prevent complications associated with hematoma. 7. Rule out injury to deep structures before closure. B. Special Considerations 1. Parotid duct injury repaired over polyethylene catheter which is left in place for 10 days. 2. Parotid gland injury repaired with meticulous closure to prevent salivary fistula. 3. Facial nerve repair under magnification with fine suture within 72 hours of injury. 4. Eyelid injury a. Repair of canthal ligaments. b. Layer closure of orbicularis oculi, levator palpebra. c. Cannulation of lacrimal system for 10-14 days. 5. Tendency to hypertrophic scar in children. 6. Trapdoor lacerations should be treated by excision or Z-plasty. 7. Lacerations across concave surfaces predispose to hypertrophic scar which may go on to limit bony growth. 8. Suture removal in children can be a harrowing experience for all those involved. Consider use of fast absorbing suture for the skin. VI. Birth Injury A. Predisposing Factors 1. Birth weight greater than 3.5 kg. 2. Second stage of labor greater than 60 minutes. 3. Primiparity 4. Forceps delivery B. Facial Nerve Injury 1. Superficial position of the nerve and lack of development of the mastoid process predispose to nerve injury with forceps delivery. 2. Usually transient in nature. C. Nasal/Septal Dislocation 1. Luxation of caudal septum from premaxilla. 2. External nasal pyramid deformity and loss of tip support. 3. Occurs in less than 1% of births. 4. Treatment best performed 1-2 days after birth by closed reduction with elevator. -------------------------------------------------------------------------- Bibliography Perkins, C.S., and Layton, S.A. The Aetiology of Maxillofacial Injuries and the Seat Belt Law. British Journal of Oral and Maxillofacial Surgery, 1988, 26, pg. 353-363. McGraw, B.L., and Cole, R.R. Pediatric Maxillofacial Trauma. Archives of Otolaryngology-Head and Neck Surgery, 1990, 116, pg. 41-45. Siegal, M.B., et al. Mandibular Fractures in the Pediatric Patient. Archives of Otolaryngology-Head and Neck Surgery, 1991, 117, pg. 533-536. Rowe, N.L. Fractures of the Jaw in Children. Journal of Oral Surgery, 1969, 27, pg. 497-507. James, D. Maxillofacial Injuries in Children. In: Rowe, N.L., Williams, J.L., editors. Maxillofacial Injuries. New York, New York: Churchill Livingstone Inc., 1985, pg. 538-558. Thaller, S.R., and Mabourakh, S. Pediatric Mandibular Fractures. Plastic and Reconstructive Surgery, 1991, 26, #6, pg. 511-513. Crockett, D.M., et al. Maxillofacial Trauma. Pediatric Clinics of North America, 1989, 36, #6, pg. 1471-1494. Gussack, G.S., et al. Pediatric Maxillofacial Trauma: Unique Features in Diagnosis and Treatment. Laryngoscope, 1987, 97, pg. 925-930. Schellhas, K.P., et al. Three-Dimensional Computed Tomography in Maxillofacial Surgical Planning. Archives of Otolaryngology-Head and Neck Surgery, 1988, 114, pg. 438-442. Crockett, D.M., and Funk, G.F. Management of Complicated Fractures Involving the Orbits and Nasoethmoid Complex in Young Children. Otolaryngology Clinics of North America, 1991, 24, #1, pg. 119-136. Dierks, E.J. Management of Associated Dental Injuries in Maxillofacial Trauma. Otolaryngology Clinics of North America, 1991, 24, #1, pg. 165-179. Messinger, A., et al. Orbital Roof Fractures in the Pediatric Population. Plastic and Reconstructive Surgery, 1989, 84, #2, pg. 213-216. -----------------------------------END------------------------------------------