Pediatric Facial Fractures

Outcomes of Surgical Repair of Adult Naso-Orbital-Ethmoid Fractures: A Systematic Review and Meta-Analysis

OBJECTIVES

Adult naso-orbital-ethmoid (NOE) fractures are estimated to account for 5% of all adult facial fractures without published consensus on management. The purpose of this investigation was to assess the available literature regarding the treatment and outcomes of adult naso-orbital-ethmoid fractures.

DATA SOURCES

Cochrane Library, PubMed, Scopus, and CINAHL.

METHODS

Following PRISMA guidelines, databases were searched from inception through July 25, 2024 for studies pertaining to the treatment of NOE fractures. Measures of interest included patient demographics, associated fractures, type of intervention, and complications.

RESULTS

A total of 16 studies were included for meta-analysis, consisting of 459 patients. The patients included in the analysis had a mean age of 30.6 years (95% CI: 26.9-34.3 years) with a male-to-female gender ratio of 2.7:1. Operative intervention, specifically open reduction and internal fixation (ORIF) (90.1%; 95: CI: 76.6-98.1%), was the most commonly performed management. Closed reduction has been reported for all three types. The most frequently reported complications included nasolacrimal duct obstruction (38.6%; 95% CI: 10.6-71.7%), postoperative epiphora (24.9%; 95% CI: 6.4-50.4%), and telecanthus (20.9%; 95% CI: 1.7-53.5%).

CONCLUSIONS

Surgical intervention can be considered for all NOE types. Despite surgical intervention, NOE fractures remain difficult to treat, and inadequate repair may result in complications. Laryngoscope, 135:991-999, 2025.

Pediatric Craniofacial Ballistic Injuries

Pediatric ballistic injuries are a public health crisis in the United States. Younger children are more likely to sustain craniofacial injuries, which are associated with higher mortality rates. An understanding of the timeline of craniofacial development and the variation in pediatric facial proportions over time is important to guide further treatment of these patients. Management of these patients includes initial stabilization according to the Advanced Trauma Life Support protocol followed by management of time-sensitive injuries. Ballistic injuries often result in soft tissue and bone defects, requiring fixation and coverage. As children experience faster rates of bone healing, fixation should be done promptly. Soft tissue coverage is dependent on the size of the defect; whereas smaller wounds can be closed with primary closure or local tissue rearrangement, larger wounds may require free tissue transfer.

National Trends in Non-Accidental Pediatric Craniofacial Fractures Requiring Inpatient Admission

INTRODUCTION

Pediatric craniofacial trauma, particularly from non-accidental trauma (NAT), is a significant cause of injury with enduring physical and psychological impacts. This study analyzes demographic patterns, injury characteristics, and trends in NAT-related craniofacial injuries to inform early identification, intervention, and prevention efforts.

METHODS

Analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database was performed for the years 2009 to 2019. Patients aged 0 to 17 with craniofacial injuries and a diagnosis of non-accidental trauma were identified based on current procedural codes; demographic and temporal trends were analyzed.

RESULTS

Overall, 306,115 patients with craniofacial injuries and 20,540 patients with non-accidental trauma (NAT) were identified. Patients with NAT represented 2.6% of all craniofacial injuries, with a greater proportion of males affected. On average, 39% of all NAT cases involved a craniofacial injury. The most common injury patterns were intracranial (50.1%), superficial head injuries (37.7%), and craniofacial fractures (31.9%. Isolated facial fractures were rare, comprising <1% of all cases. Although the average in-hospital mortality was 6.78%, temporal analysis demonstrated significant reductions in in-hospital mortality and length of hospitalization (P<0.001).

CONCLUSIONS

Pediatric craniofacial injuries from NAT remain a significant public health concern. However, the observed decrease in both hospitalization length and in-hospital deaths suggests improvements in early intervention and treatment outcomes. Continued efforts to refine diagnostic strategies, enhance provider awareness, and strengthen prevention initiatives are essential to mitigate the devastating impacts of NAT in the pediatric population.

Defining pediatric trauma center resource utilization: Multidisciplinary consensus-based criteria from the Pediatric Trauma Society

BACKGROUND

Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services.

METHODS

Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained.

RESULTS

The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee.

CONCLUSION

This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a criterion standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Pediatric Head and Neck Trauma

The pediatric patient population has unique anatomic characteristics that bring challenges and increased risk to management. The purpose of this article is to guide the head and neck trauma surgeon in decision making for the treatment of pediatric head and neck trauma with an emphasis on facial fracture management.

Craniofacial Growth and Development: A Primer for the Facial Trauma Surgeon

Understanding craniofacial growth and development is important in the management of facial trauma in the growing pediatric patient. This manuscript is a review of craniofacial growth and development and clinical implications of pediatric facial fractures.

Pediatric Panfacial Fractures

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Assessing the risks of children with preoperative comorbidities undergoing comminuted fracture surgery

Introduction

Comminuted fractures are characterized by bones broken in at least two places, destabilizing the bone and requiring surgery. Children whose bones are still developing and maturing tend to have a higher risk of sustaining comminuted fractures as the result of trauma. Trauma is a major cause of death in children and constitutes a major issue in orthopedics because of the unique properties of children's bones compared to adult bones and the associated complications.

Methods

This retrospective, cross-sectional study aimed to refine the association between comorbid disease and comminuted fractures in pediatric subjects using a large, national database. All data were extracted from the National Inpatient Sample (NIS) database from 2005 to 2018. Logistic regression analysis was used to evaluate associations between comorbidities and comminuted fracture surgery and between various comorbidities and LOS or unfavorable discharge.

Results

A total of 2,356,483 patients diagnosed with comminuted fractures were selected initially, of whom 101,032 patients aged younger than 18 years who underwent surgery for comminuted fractures were included. Study results suggest that patients with any comorbidities undergoing orthopedic surgery for comminuted fracture appear to have longer LOS and a higher proportion of discharge to long-term care facilities.

Discussion

Almost all comorbidities were significantly associated with poor in-hospital outcomes and longer LOS. The analysis of comminuted fractures in children may provide useful information to help first responders and medical personnel evaluate and manage comminuted fractures appropriately.