TITLE: Pediatric Facial Fractures
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: April 26, 2010
RESIDENT PHYSICIAN: David M. Gleinser, MD
FACULTY PHYSICIAN:
DISCUSSANT:
DISCUSSANT: Harold Pine, MD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Quinn, MS(ICS)
"This material was prepared by resident
physicians in partial fulfillment of educational requirements established f=
or
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 sho=
uld
not be used for purposes of diagnosis or treatment without consulting
appropriate literature sources and informed professional opinion."
INTRODUCTION
Trauma accounts for significant morbidity and mor= tality amongst the pediatric population. It is estimated that trauma is responsible for nearly 1/2 of all dea= ths amongst children, which is about 15,000 deaths per year. Although uncommon, pediatric facial fractures have the potential to result in significant morbidity. For this reason, all physicians in= volved in the care of the pediatric trauma patient should have knowledge of pediat= ric facial fractures.
EPIDEMIOLOGY
Pediatric facial fractures represent roughly 5% o= f all facial fractures (pediatric and adult).&nb= sp; They are very rare amongst children less than 5 years of age, with r= oughly 10% of these fractures occurring in that age group. Males suffer more of these injurie= s than females, with a reported ratio of about 1.5:1 (male:female). The reason for this difference is = mainly due to the fact that males are more often involved in interpersonal violence and sports related injuries.
ETIOLOGY
The etiology of pediatric facial fractures varies= with age. Children less than five = tend to suffer fewer injuries, and have fewer reasons for such injuries. This is because this age group ten= ds to be under more supervision, with less independence. As children become older than 5 ye= ars, the incidence as well as the reasons for injury increases. This is due to the fact that this = age group is given more independence and is involved in many more activities.
Amongst children less than 3 years of age, falls = are the most common cause of facial fractures.&nbs= p; From 3-5 years of age, motor vehicle accidents and falls are nearly equal. Once children are olde= r than 5, motor vehicle accidents become the most common reason for suffering a fa= cial fracture. Other etiologies th= at increase significantly as age increases are interpersonal violence and inju= ries related to recreational activities. In all age groups, the physician must be aware of child abuse.
GENERAL GROWTH AND DEVELOPMENT
In order to fully understand pediatric facial tra= uma, and the patterns of fractures seen, one must first understand pediatric fac= ial growth and development. At birth, a child’s cranium to facial ratio is 8:1. Around 5 years of age, it is 4:1.<= span style=3D'mso-spacerun:yes'> By adolescence, the ratio is 2:1; = the adult ratio. Facial growth oc= curs through two general concepts, displacement and remodeling. Displacement is the movement of bo= ne in relation to the rest of the facial skeleton. Remodeling is the change of shape = of the bone by deposition of bone at one end with resorption of bone at the other.=
Growth at the nasomaxillary complex occurs in an inferior and anterior direction, and mainly involves the lower midface. Overall, the septum is the coordin= ating center of midfacial growth. A= study was performed on primates where the septum of the young primate was removed early in life. This removal resulted in midface hypoplasia. For this reason, any injury affecting the integrity of the septum in a pediatric patient should be taken seriously, and intervention undertaken early.
Growth of the mandible occurs in a lateral and an= terior direction, widening and elongating the face. The condylar growth center is the = main coordinator of mandibular growth. Any injury here may result in delayed growth, facial asymmetry, mandibular deviation, and malocclusion.&nb= sp; Of all the facial bones, the mandible is the last to complete its growth.
The sinuses are also important to the discussion = of pediatric facial fractures. I= t is believed that the sinuses help to provide a cushioning effect for traumatic forces delivered to the facial skeleton.&n= bsp; In addition, specific facial fracture patterns and their management = are based on how well developed certain sinuses are. For the purpose of this discussion= , we will focus mainly on the maxillary, ethmoid, and frontal sinuses.
At birth, the maxillary and ethmoid sinuses are present. However, they are typically not visible. The maxillary sinus undergoes significant growth around 3 years of age, at which time it becomes visible on imaging studies. The inferior floor of the maxillar= y sinus undergoes significant development around 7-8 years of age when the permanent teeth begin erupting. The max= illary sinus completes its growth around 16. The ethmoid sinuses undergo significant growth around 3-7 years of a= ge, and complete their growth by 12-14 years of age. The frontal sinuses, unlike the et= hmoid and maxillary sinuses, are not present at birth. They typically begin development a= round 3 years of age, becoming visible around 6 years of age. The completion of growth is relate= d to puberty, and as such is completed sooner in females around 12-14 years of age. In males, the frontal si= nuses do not complete growth until 16-18 years of age.
Tooth development begins with the eruption of dec= iduous teeth around 6 months of age. A full set of deciduous teeth are typically present by 2 years of age. These teeth remain stable until ar= ound 6 years of age when their roots being to resorb. Around the same time, the permanent teeth begin to erupt. The fir= st permanent teeth are the 1st molars and central incisors. The 2nd permanent molars erupt around 12 years of age.
The pediatric bony skeleton is also worth mention= ing in this discussion as it differs greatly from adults in many areas. Pediatric bones contain more carti= lage, and the bone that is present is less mineralized. This leads to greater elasticity o= f the bones. There is also a higher proportion of cancellous to cortical bone.= In addition, the medullocortical junction is usually indistinct. All of these properties result in = more greenstick and irregular fracture patterns.
PRESENTATION AND INITIAL MANAGEMENT
All trauma victims should be approached in a simi= lar manner, and this begins with the ABCs – airway, breathing, and circulation. Details about th= is can be found in many trauma references, and is beyond the scope of this discuss= ion, but there are some areas worth noting.
Airway
The pediatric airway is much smaller than the adu= lt airway. For this reason, even modest edema may lead to significant airway compromise. Children also have larger tongues = that may more easily obstruct the airway. To help prevent this, a traction suture may be needed in certain instances to = help bring the tongue anteriorly, opening the airway.
One should always assume a c-spine injury when de= aling with a trauma patient, and thus proper precautions should be taken to avoid further injury. The proper positioning of a child is also very important as it may be the only maneuver needed to maintain a proper airway. The child should be placed in the supine position with his head in a neutral position. A jaw thrus= t may be applied to further improve the patency of the airway. The oral cavity should also be suc= tioned of all debris and blood so that this material does not lead to obstruction.=
If intubation is deemed appropriate for airway co= ntrol, there are a few things that can be done to help with better visualization of the airway. If the child is l= ess than 2 years of age, a small towel may be placed under the shoulders. If the patient is older than 2 yea= rs of age, the towel should be placed under the head. The equation (age + 16)/4 is utili= zed when selecting the appropriate size endotracheal tube, while the proper dep= th of the tube is roughly 3 times the endotracheal tube size. Always consider fiberoptic intubat= ion in cases where the child cannot be intubated orally (severe trismus).
If all other airway methods have failed, and a su= rgical airway is required, age must be considered when determining which method to utilize. If the patient is le= ss than 12, the physician should avoid a cricothyrotomy as landmarks are very difficult to assess, and there is a higher incidence of late airway stenosi= s in this age group following this procedure.&n= bsp; Therefore, a tracheotomy is the preferred surgical airway method in = this age group. If the child is ol= der than 12, a cricothyrotomy is appropriate.&= nbsp; Another option for all age groups is the needle cricothyrotomy. It will allow the physician more t= ime (10-30 minutes) to perform other methods to obtain a definitive airway unde= r a more controlled environment.
Circulation
It is worth mentioning that the face and scalp ha= ve an abundant blood supply. As suc= h, a child with a wound in this area could lose a significant amount of blood if proper measures are not taken to control the bleeding. Use direct pressure and suture lig= ature, if needed, to help control the bleeding.&n= bsp; Close all facial and scalp wounds as soon as possible to help decrea= se blood loss.
Secondary Assessment
The secondary survey is where the physician exami=
nes
all aspects of the patient’s body looking for other injuries. This portion of the exam is typica=
lly more
difficult in children since they are less cooperative than adults. When assessing the face, the physi=
cian
should examine and palpate all aspects of the head and neck region. Signs of underlying fracture inclu=
des
step-offs, asymmetry, crepitance, tenderness, eccyhmosis, and hematomas.
A very important examination to perform is the na= sal examination as children are at a higher risk of septal injuries, and thus septal hematomas. Oral examin= ation should make note of missing teeth (may be able to replace), open mandibular fractures, midface stability, and occlusion. Occlusion is more difficult to ass= ess in children as the number and type of teeth present are variable from patient = to patient. In addition to this,= wear facets are less apparent. Ano= ther important part of the examination is the ophthalmologic examination. Visual acuity and extraoccular mus= cle function should be assessed. = Entrapment noted here could be the sign of a serious orbital fracture. Any patient with an underlying orb= ital injury should undergo formal ophthalmologic assessment.
Imaging
Computed Tomography (CT) scans have replaced plain films in the evaluation of almost all facial fractures except isolated mand= ible fractures. The reason for thi= s is that CT scans are readily available and allow for much better visualization= of fractures and surrounding structures. Both axial and coronal scans should be obtained. When a patient is suspected of hav= ing an isolated mandible fracture, most physicians would recommend obtaining a Pan= orex as this simple, and easily obtained film provides the best view of the mand= ible when compared to other plain films. However, condyle injuries can be difficult to detect on Panorex film= s, thus a second view such as a Town’s view (occipitofrontal) may be needed to assess the mandibular condyles.
GENERAL OVERVIEW OF FACIAL FRACTURES
Nasal fractures are the most common pediatric fac= ial fractures, representing 45% of all facial fractures in this age group. The 2nd most common fra= ctures are the mandible fractures accounting for 32% of all pediatric facial fract= ures. Twelve percent of these occur in children less than 6 years of age. <= /span>Orbital fractures are the 3rd most common pediatric facial fracture accounting for roughly 15% of these fractures.
There are some general considerations the treating physician must take into account when managing pediatric facial fractures.<= span style=3D'mso-spacerun:yes'> First, pediatric facial bones tend= to heal much faster than adults, thus intervention, if required, must be performed sooner. Most pediatric facial fractures can be managed through observation or closed techniques alone with pretty good results. If open reduction and internal fixation are deemed necessary, the surgeon should ob= tain proper alignment of all suture lines and avoid extensive periosteal elevati= on as this may lead to growth disturbances.
Plating Systems
The use of alloplastic materials in the treatment= of pediatric facial fractures is controversial. Most controversy surrounds the use= of metallic materials, especially metallic plating systems. The use of these materials in the pediatric population could potentially lead to metal hypersensitivity, bone atrophy, allergy to the specific metal used, growth restrictions, and migra= tion of plates into the cranium. O= ne study performed examining outcomes when metal plates were used to treat fac= ial fractures in pediatric patients found that only 8% of patients actually suf= fered from one of the complications previously stated. However, the current recommendatio= n is to consider other methods for fixation prior to the use of metallic materials. If they are deemed necessary, the surgeon should use the smallest plates possible, and should = not cross more than one suture line with the plate. Some surgeons have actually recomm= ended removal of these plates in all pediatric patients 4-6 weeks after placement when the bone has likely healed. However, this may lead to further deleterious effects on growth.
The trend in the repair of pediatric facial fract= ures is moving toward the use of resorbable plating systems. These systems are made of high mol= ecular weight poly-alphahydroxy acids, which are broken down into by-products thro= ugh hydrolysis and phagocytosis. The degrada= tion products are then excreted by respiration and/or urine. Multiple studies involving humans = and animals have been performed in an attempt to compare resorbable plating sys= tems to metallic plating systems. = The findings are that resorbable systems have similar functional outcomes as we= ll as similar fixation stability and strength when compared to the metallic systems. The resorbable plate= s and screws retain full strength for 4-6 weeks, and are completely resorbed by 1= 2-36 months. They also do not inte= rfere with radiographic studies. Si= milar complications are noted amongst the two plating systems, but the most common complications associated with resorbable systems are edema of the tissue ar= ound the plate and visibility of the plate since they are bulkier. However, both= of these resolve with time.
Maxillomandibular Fixation
A very common form of treatment utilized in facial fracture repair is maxillomandibuler fixation or MMF. When it comes to the pediatric population, how it is performed is determined by that patient’s age.<= span style=3D'mso-spacerun:yes'> If the patient is less than 2 year= s of age, it is likely that the patient has very few, if any teeth to work with. For this reason, the pa= tient is approached as an edentulous patient.&nb= sp; One method used for MMF in this age group is the use of acrylic splints. These can be made by= a dentist and given to the treating surgeon for use in placing the patient in MMF. It is important that the= se splints be thinned along their posterior edge so as to prevent premature posterior closure once in place. If left unaltered, the patient may have an open bite. The splints can be secured in plac= e with circummandibular wires, and the jaw immobilized with both circummandibular wires and wires through the pyriform aperture. When a patient is 2-5 years of age= , a full complement of deciduous teeth are usually present. For this reason, arch bars or cap splints can be utilized. If f= urther support is needed, circummandibular wires and wires through the pyriform aperture are good options. Fr= om 6-12 years of age, the pediatric patient’s teeth are variable, and th= us options for MMF vary. If the patient is 6-7 years of age, the deciduous molars may be used for fixation = as they tend to be stable. From = 8-10 years of age, the permanent first molars and central incisors are usually present, thus they can be utilized in this age group for fixation. When the child reaches the age of = 10, there are typically enough permanent teeth available for proper fixation wi= th arch bars. Another option for fixation involves the use of orthodontic devices already in place.
NASAL FRACTURES
The pediatric nasal bone is very compliant, and t= hus bends more readably when force is applied. These forces tend to dissipate into the surrounding maxillary tissue= and lateral buttresses resulting in a significant amount of edema. This makes it very difficult to as= sess underlying fractures.
As stated previously, the pediatric septum is more prone to injury than the nasal bones. The reason for this is that the septum is more rigid, held very tigh= tly in place by the perichondrium and surrounding bone. There are three common patterns of pediatric septal injuries seen. The first is where the perichondrium is torn from the underlying cartilage leav= ing a potential space for blood to accumulate.= This leads to a septal hematoma.&nb= sp; The second type is where the caudal septum becomes dislocated, leadi= ng to acute nasal obstruction. I= f left untreated, this injury will likely result in a twisting deformity of the na= sal septum. The third type of sep= tal injury involves the separation of the bony and cartilaginous septum. This too leads to acute airway obstruction, but if left untreated in a developing patient, could lead to m= idfacial growth abnormalities.
The management of pediatric nasal fractures depen= ds on whether a septal hematoma is present or not. The septal hematoma will present a= s a purple, compressible bulge on the nasal septum, and does not shrink with Afrin. If this is present, it must be dra= ined acutely to avoid late complications that result from necrosis of the nasal septum. When draining a septal hematoma, the child should first be placed under general anesthesia. Next, a hemitransfixion incision i= s made to allow for drainage of the hematoma.&nbs= p; A quilting stitch is then used to close the space between the perich= ondrium and septal cartilage to prevent reaccumulation of blood. The surgeon should avoid the use o= f splints, if possible, as these will be extremely difficult to remove in later. While the child is under general anesthesia, other nasal fractures should be addressed with closed technique= s.
If no septal hematoma is present, the recommendat= ion is to wait 5 days to allow for the swelling to improve and then re-examine the patient focusing on any cosmetic or functional (obstruction) defects. If present, closed reduction under general anesthesia should be attempted, and is usually all that is required= for treatment. This is performed through internal and external manipulation or the nasal bones. If the septum is fractured or dislocated, it may reduce with the nasal bone manipulation. If not, one may consider using Asch forceps in an attempt to reduce a closed septal fracture. However, many times further interv= ention will be required. This may in= volve a septoplasty or even a septorhinoplasty.&= nbsp; Open approaches should be consider in cases where closed reduction h= as failed, fractures are 2-3 weeks old, or further septal work needs to be performed.<= span style=3D'mso-spacerun:yes'> The open approach is also good for greenstick fractures causing morbidity as these are very difficult to addre= ss without a completion osteotomy.
MANDIBLE FRACTURES
The mandibular condyle is the most commonly fract= ured site in the pediatric mandible with the subcondyle being the most common subsite involved. The condyle fracture represents 55-72% of all pediatric mandible fractures. The symphyseal/parasymphyseal area= is the second most commonly fractured site, accounting for 27% of pediatric mandible fractures. Less comm= on are the body and angle regions, accounting for 9% and 8% of fractures respectively. However, the incidence of fractures involving the body and angle increases with age, as = does the incidence of multiple mandible fractures.
General Treatment Considerations
The primary goal in the treatment of mandible fra= ctures is to restore occlusion, function, and facial balance. When it comes to the repair of fra= ctures in the pediatric population, it must be noted that callus formation may be present as early as 5-7 days. This callus will need to be removed in order to obtain proper reduction if an op= en approach is needed for fixation.
Condyle Fractures
Pediatric mandibular condyle fractures are typica= lly considered “self correcting,” thus the treatment of these fract= ures is nearly always conservative. The extent of therapy, however, varies with the extent of injury. If there is a unilateral condyle fracture and the patient has normal occlusion and function, then observation with pain control, soft diet, and range of motion exercises is all that is required for the treatment. I= f, however, a unilateral condyle fracture has occurred and the patient has mild deviation from the midline with no open bite, or the patient has suffered bilateral condyle fractures with normal occlusion and function, then the treatment must include the use of elastic guiding bands for 6-8 weeks along with the range of motion exercises. Any condyle fracture where the patient has an open bite deformity, severe functional impairment, or severe deviation from the midline must be = immobilized (MMF) for 2-3 weeks followed by the use of guiding elastics for 6-8 weeks.<= span style=3D'mso-spacerun:yes'> Open repair of condyle fractures is reserved for cases where the condyle has been displaced into the middle cra= nial fossa or is prohibiting the movement of the mandible. Some authors recommend open treatm= ent whenever the condyle growth center is involved as these fractures may lead = to growth disturbance.
Arch Fractures
The majority of mandibular arch fractures are non=
-displaced
or greenstick fractures. Pati=
ents
suffering these types of fractures should be placed on a soft diet and foll=
owed
very closely. If any change o=
ccurs
where the patient begins to have worsening pain or new functional impairmen=
ts
(open bite, malocclusion), new films should be obtained with the suspicion =
that
the fracture has now become displaced and requires further intervention.
For dentoalveolar fractures, the teeth are the pr= imary concern. Tooth avulsion= is very common with these fractures, thus the treating physician should have a good understanding of how to manage this scenario. If the tooth that has been avulsed= is a deciduous tooth, it does not need to be replaced. However, if a permanent tooth is involved, it should be replaced within 1 hour of avulsion. In some cases the fractured bony s= egment may make it difficult to return the avulsed tooth. For this reason, it should be redu= ced by manipulation followed by replacement of the tooth. The fractured segment should then = be plated, if needed, while the tooth is secured into place with wires as the patient is placed in MMF for 2-3 weeks.&nb= sp; All patients with avulsed teeth should see a dentist as further dent= al work will be required.
ORBITAL FRACTURES
Orbital floor and roof fractures are the most com= mon orbital fractures that occur in children.&= nbsp; In children less than 7 years of age, the roof is the most common site. In children older than 7 years, the floor is the most common site.&= nbsp; The medial orbital wall is fractured in anywhere from 5-19% of cases, while mixed fractures are seen in nearly 35% of cases.
Orbital Roof Fractures
The classic presentation of a pediatric patient
suffering an orbital roof fracture is one who has sustained a blow to the u=
pper
face with a late developing periorbital hematoma. These fractures are commonly assoc=
iated
with neurocranial injuries, thus neurosurgery should be involved in every
case. Orbital roof fractures =
can be
classified into three types. =
Type I
is a comminuted fracture of the orbital roof without displacement of the
fragments. A type II fracture=
is
considered a “blow-out” fracture as the comminuted pieces of bo=
ne
are displaced superiorly. The=
type
III orbital roof fracture involves the displacement of the comminuted fragm=
ents
into the orbit, and thus is considered a “blow-in” fracture.
Orbital Floor Fractures
A pediatric patient with an orbital floor fractur= e may present with multiple signs and symptoms that include periorbital ecchymosis and edema, entrapment, enopthalmus, diplopia, severe nausea and emesis, bradycardia, and infraorbital anesthesia.&= nbsp; The incidence of these fractures increases with age and the developi= ng maxillary sinus. Initial mana= gement of these fractures typically begins with a period of observation for 7-10 days. If after this time the = patient is suffering from enopthalmus, diplopia, or severe pain, then surgical intervention will be required. If at any time entrapment has occurred or the patient is suffering from bradycard= ia or severe emesis, acute surgical intervention is required.
A special consideration must be made for the pedi=
atric
trapdoor fracture, or “white-eyed” fracture. The floor of the orbit in the pedi=
atric
patient is very weak over the infraorbital canal. When a force is applied, the elast=
ic
bone may fracture in this area leading to displacement of the fractured
segments inferiorly into the canal.
Orbital soft tissue may then prolapse through the fracture site and
become trapped when the fractured bony segments snap back superiorly. This causes the patient to suffer =
from
entrapment that manifests as decreased supraduction of the involved orbit.<=
span
style=3D'mso-spacerun:yes'> The patient may also experience
bradycardia as well as severe nausea and emesis with any attempted movement=
of
the involved eye.
The approach to the repair of orbital floor fract= ures in the pediatric population is very similar to adults, and involves the tra= nsconjunctival, subciliary, subtarsal, or endoscopic approaches. If an endoscopic approach is being considered, the patient must be evaluated for an adequately sized maxillary sinus. As with orbital roof fracture repair, the use of materials in the orbit for repair is controversial. However, if the orbit has been entered to repair an orbital floor fracture, the fracture sh= ould be properly covered to prevent future morbidity.
ZYGOMATICOMAXILLARY COMPLEX FRACTURES
Zygomaticomaxillary complex (ZMC) fractures are v= ery rare in children, especially those younger than 5 years of age. However, the incidence of these fractures increases with the development of the maxillary sinuses. Some common signs and symptoms of = ZMC fractures include a depressed zygomatic arch, pain, periorbital hematoma, epistaxis, subconjunctival hemorrhage, and ecchymosis of the overlying skin= .
ZMC fractures are managed according to the fractu= re pattern present. Since most o= f the fractures seen are non-displaced or greenstick fractures, management is typically conservative with observation and comfort measures. When displacement is present, the = most common fracture pattern is a displaced fracture of the zygomaticomaxillary buttress with greenstick fractures of the zygomatic arch and frontozygomatic suture. The treatment of this fracture pattern is reduction of the zygomaticomaxillary fracture with sing= le point fixation at the fracture site. The greenstick fractures do not require exposure, manipulation, or fixation. If an isolated zygo= matic arch fracture is present resulting in a cosmetic deformity, a Gillies appro= ach may be utilized for reduction. For other types of displaced fracture patterns involving the ZMC, 2 or even 3 p= oint fixation should be utilized, and involves the frontozygomatic suture, infraorbital rim, and/or the zygomaticomaxillary suture. Multiple approaches can be utilize= d for proper exposure of each fracture site.&nbs= p; These include the gingivobuccal sulcus, extended blepharoplasty, transconjunctival, subciliary, and coronal/hemicoronal approaches.
MIDFACE FRACTURES
Midface fractures are another set of fracture pat= terns that are rarely seen in children. This is mainly due to the fact that children have underdeveloped sin= uses and unerupted maxillary teeth. They also have more soft tissue overlying their midface that helps to provide a cushioning effect for traumatic forces.&nb= sp; The majority of midface fractures in children are the result of a tremendous amount of force, and as such these children nearly always have associated injuries.
Midface fractures can be further divided into zygomatic, dentoalveolar, nasal, and LeFort fractures. The first three fracture types have already been discussed above, and thus LeFort fractures will be covered in = this section. There are three type= s of LeFort fractures. A LeFort I fracture involves the separation of the palate and alveolus from the rest of the maxilla. The structures involved include the anterolateral and medial maxillary walls, septum at the floor of the nose, nasal floor, and pterygoid plate. A LeFort II fracture is a pyramidal fracture that involves the nasofrontal suture, medial and inferior orbital walls, anterior maxillary wall, frontal process of the maxilla, high septum, and pterygoid plate. A LeFort= III fracture involves the complete separation of the facial skeleton from the skull base= . The structures involved in this fr= acture pattern include the nasofrontal suture, medial and lateral orbital walls, o= rbital floor, frontozygomatic suture, zygomatic arch, nasal septum, and pterygoid plate.
The primary goals in the management of LeFort fra= ctures are to obtain proper occlusion and normal facial proportions and symmetry.<= span style=3D'mso-spacerun:yes'> As with ZMC fractures, the forces involved with LeFort fractures are extreme and result in significant facial edema. For this reason, it is= best to wait a few days prior to performing an operation to allow time for some = of the swelling to decrease. How= ever, these fractures should be repaired within one week of injury.
When repairing a LeFort I fracture, a common appr= oach is to create a gingivobuccal sulcus incision with proper exposure of the fracture line. The fracture i= s then reduced, and the patient is placed in MMF.= Four plates are ideal for proper fixation. This includes placing a plate on e= ach side of the pyriform aperture, as well as plating both zygomaticomaxillary sutures. Once complete, the p= atient is taken out of MMF.
LeFort II fractures are a bit more complex, and r=
equire
multiple approaches. The pati=
ent
should be initially placed in MMF to provide a stable base to work from.
A LeFort III fracture is very complex and will re= quire extensive planning prior to surgical correction. Multiple approaches will be requir= ed. The patient should initially be pl= aced in MMF to provide a stable base. The fractures should then be approached from a lateral to medial direction, beginning with the zygoma and zygomaticomaxillary buttress.
NASO-ORBITO-ETHMOID FRACTURES
As with other midface fractures, naso-orbito-ethm= oid (NOE) fractures are very rare in children for the same reasons as the midfa= ce fractures. The NOE complex is= made up of the nasal, lacrimal, ethmoid, maxillary (frontal process), and frontal bones. The medial canthal ten= don (MCT), an extension of the obicularis oculi muscle, is involved in this com= plex with its attachment to the lacrimal crest.= In addition to acting as a pump for the lacrimal sac, the MCT also h= elps to maintain the proper intercanthal distance. The proper intercanthal distance in pediatric patients varies with age. In infants, it is slightly less than 22mm. By 4 years of age, the distance is around 25mm. At 12 years of a= ge, the distance is nearly 28mm, and above 12 years of age, the distance is tha= t of adults (~30mm). An intercanthal distance variation of 5mm from normal is considered abnormal, = and thus an injury to the MCT should be suspected. A distance of 10mm or more from no= rmal is diagnostic of an MCT injury.
The signs of an NOE injury include a flattened na=
sal
root, telecanthus, rounding of the medial canthus, periorbital edema and
ecchymosis, epistaxis, and CSF leak.
During the physical examination, a bowstring sign may be present.
MCT injury can be classified into three types. A = type I injury involves a single, non-comminuted fracture of the central bony segme= nt with the MCT remaining attached. The fracture can either be displaced or non-displaced. A type II injury involves a commin= uted fracture of the central bony segment, but the MCT remains attached. This injury is considered unstable= , and will require repair. A type I= II injury involves a severely comminuted fracture with detachment of the MCT.<= /p>
NOE fractures are typically complex and are assoc= iated with other injuries. As such, multiple approaches and treatment guidelines will be required, and typically involve multiple surgical sub-specialties.= For the purpose of this discussion, focus will be directed toward the management of MCT injuries, as correcting these injuries should take preced= ence over other NOE injuries.
As stated earlier, type I MCT injuries may involve displaced or non-displaced fractures of the central bony segment. The non-displaced fractures do not require any intervention. How= ever, the displaced fractures require reduction and fixation. Fixation comes in the form of two plates. The first plate is pl= aced from the frontal bone to the central bony segment, and the other plate is placed= from the maxilla to the central bony segment.&n= bsp; Type II MCT injuries require the use of 28 gauge wires connecting the comminuted central bony segment to the opposite medial orbital wall. If bilateral type II injuries exis= t, the segments can be wired to each other in the midline. In a type III fracture, the MCT mu= st be reattached to the central segment. If the fracture is so comminuted that a proper piece does not exist = for attachment, the wall must be reconstructed with calvarial bone. The MCT is then attached to the bo= ne and the bony segment is wired to the opposite medial orbital wall. If bilateral type III fractures ex= ist, the segments are wired to each other in the midline.
CONCLUSION
Facial fractures are a rare type of injury suffer= ed by pediatric trauma patients, but can result in significant morbidity if not properly managed. The majorit= y of these fractures can be managed conservatively. If surgery is required, care must = be taken to avoid further morbidity in the form of growth disturbances that may resu= lt from extensive periosteal elevation or improper fracture reduction. The use of alloplastic material in treatment of pediatric facial fractures remains controversial due to fact t= hat there are very few long term studies involving their use in this age group. However, some reports = have shown good results with minimal complications when alloplastic materials ar= e properly utilized. Metallic materials = remain an option for pediatric fracture repair, but other options should be consid= ered prior to their use.
Discussant’s=
Remarks
by Dr. Shraddha Mukerji
The majority of facial fractures in children ca=
n be
managed conservatively and this should be tried before doing any open
reduction. The anatomy and the
pliancy of the facial bones in children make them more amenable to conserva=
tive
treatment. If open reduction =
and
internal fixation is attempted for nasal fractures, the septum should be
managed conservatively and with care since it the pivotal area for midfacial
growth and any damage or excessive removal of this structure can lead to
hypoplasia. For the same reason, septal hematomas should be drained as soon=
as
possible.
Whenever considering plating for mandibular fra=
ctures
or facial fractures, resorbable plates should be used if possible, because
there are no long term studies for metallic plates or metallic implants.
Discussant’s=
Remarks
by Dr. Harold Pine:
I second Dr. Mukerjee’s important point a=
bout
getting Oromaxillofacial Surgery involved.=
In fact, I will go as far as to say if my two little boys came in wi=
th a
mandible fracture, I don’t care if OMFS is not on call for facial tra=
uma,
we’ll consult OMFS. And
that’s how strongly I feel about it.
Secondarily, this is just a small point that
didn’t come up but there’s an entity known as septal deviation =
in
the newborn in these traumatic deliveries where the Newborn ICU folks will =
call
us and say, “Golly, the kid’s septum is way over in the nose=
221;
and it doesn’t happen often but it is something I’ve seen a cou=
ple
of times which you can fix right in the nursery just with some forceps with
tape on them. You can basical=
ly
just stick the instrument in there and move the septum right over. I don’t tend to make a big d=
eal
over it or try to localize or anything- I just sort of hold the kid and do
it. And I think you can save
yourself some grief if you correct it early on versus letting it sit and
stabilize in that area.
Dr. Quinn raised the possibility of using a Bar=
ton
bandage for temporary, even indefinite stabilization of mandibular fractures
with minimal displacement and where deciduous occlusion remains
acceptable.
Dr. Pine:
Does anybody know how to put on a Barton bandage anymore? That’s Old School, professor=
!
(Laughter)
SOURCES
1. Yoon KC, Seo MS, Park YG. Orbital Trapdoor Fracture in Children. = J Korean Med Sci 2003;18:881-5.=
2. Faust RA and Youness A= A. Mandible Fracture in Children. eMedicine from WebMD [Internet]. 2009 Jun 25 [cited 2010 Mar 22]; 5 p. Available from: http://emedicin= e.medscape.com/article/872662-print.
3. Pachigolla R. Pediatric Facial Trauma. Dr. Quinn’s Online Textbook of Otolaryngology [Internet]. 1999 May 12 [cited 2010 Mar 22]; 2 p. Available from: http://www.utmb.edu/otoref/Grnds/Ped-facial-trauma-9905/Pe= d-facial-trauma-9905.htm.
4. Costello BJ, Papadopoulos H, and Ruiz R. Pediatric Craniomaxillofacial Trauma. Cl= in Ped Emerg Med 2005;6:32-40.
5. Eppley BL. Use of Resorbable Plates and Screws in Pediatric Facial Fractures. J Oral Maxillofac Surg [Internet]. 2005 [cited 2010 Mar 22]; 7 p. Available from: = http://www.biometmicrofixa= tion.com/downloads/JOMS,%20use%20of%20resorbable%20plates%20and%20screws%20= in%20ped..pdf.
6. LeBoeuf HJ. Nasal-Septal Fracture. Dr. Quinn’s Online Textbook of Otolaryngology [Internet]. 1998= May 6 [cited 2010 Mar 22]; 2 p. Available from: h= ttp://www.utmb.edu/otoref/Grnds/Nasal-fx-9805/Nasal-fx-9805.htm.=
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7.&n=
bsp;
Ohjimi H, Taniguchi Y, Tanah=
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S, et al. Accessing the Orbital Roof via an Eyelid Incision: The Transpalpe=
bral
Approach. Skull base surgery.
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