Oblique craniofacial fractures in children

Pediatric Orbital Fractures

The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures.

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management

BACKGROUND

Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures.

METHODS

A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups.

RESULTS

A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus.

CONCLUSIONS

Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.

Pediatric Craniofacial Fractures: Trajectories and Ramifications

BACKGROUND

The pediatric craniofacial skeleton fractures in patterns distinct from those typical in adults; this has implications pertinent to management that may go unrecognized. The authors reviewed multilevel pediatric craniofacial fractures presenting to their institution, surmising that they would display an oblique trajectory of fracture patterns, and would be at increased risk of growing skull fractures (GSFs), compared with adults.

METHODS

A retrospective review was performed of pediatric patients presenting with multilevel craniofacial fractures between 2004 and 2010. Demographics, cause of injury, fracture patterns, associated injuries, management, and follow-up information were gathered. Computed tomography scans were reviewed to characterize fracture length, displacement, and trajectory. Adverse outcomes were documented, with particular attention to GSFs.

RESULTS

One hundred fifty-one patients met our inclusion criteria, which included a follow-up of >3 years. Average age at injury was 9.5 ± 4.7 years. Patterns of fracture displayed near consistent obliquity, with only 4 patients (2.6%) displaying a LeFort-type facial fracture. LeFort patterns were associated with older patients over the age of 12, but without statistical significance (P = 0.07). Five patients (3.3%) died as a result of their injuries. 3.3% of patients developed a GSF. All craniofacial fracture patients demonstrated radiographic and/or clinical evidence of healed fractures at their last follow-up.

CONCLUSIONS

This series of pediatric craniofacial fractures near consistently demonstrated oblique fracture patterns, in contrast to the typical adult fracture patterns described by LeFort. Pediatric craniofacial fractures are also at increased risk of GSFs. Understanding of these principles is fundamental to successful therapy in this population.

A novel classification of frontal bone fractures: The prognostic significance of vertical fracture trajectory and skull base extension

PURPOSE

The broad spectrum of frontal bone fractures, including those with orbital and skull base extension, is poorly understood. We propose a novel classification scheme for frontal bone fractures.

METHODS

Maxillofacial CT scans of trauma patients were reviewed over a five year period, and frontal bone fractures were classified: Type 1: Frontal sinus fracture without vertical extension. Type 2: Vertical fracture through the orbit without frontal sinus involvement. Type 3: Vertical fracture through the frontal sinus without orbit involvement. Type 4: Vertical fracture through the frontal sinus and ipsilateral orbit. Type 5: Vertical fracture through the frontal sinus and contralateral or bilateral orbits. We also identified the depth of skull base extension, and performed a chart review to identify associated complications.

RESULTS

149 frontal bone fractures, including 51 non-vertical frontal sinus (Type 1, 34.2%) and 98 vertical (Types 2-5, 65.8%) fractures were identified. Vertical fractures penetrated the middle or posterior cranial fossa significantly more often than non-vertical fractures (62.2 v. 15.7%, p = 0.0001) and had a significantly higher mortality rate (18.4 v. 0%, p < 0.05). Vertical fractures with frontal sinus and orbital extension, and fractures that penetrated the middle or posterior cranial fossa had the strongest association with intracranial injuries, optic neuropathy, disability, and death (p < 0.05).

CONCLUSIONS

Vertical frontal bone fractures carry a worse prognosis than frontal bone fractures without a vertical pattern. In addition, vertical fractures with extension into the frontal sinus and orbit, or with extension into the middle or posterior cranial fossa have the highest complication rate and mortality.

Pediatric orbital fractures

It is wise to recall the dictum "children are not small adults" when managing pediatric orbital fractures. In a child, the craniofacial skeleton undergoes significant changes in size, shape, and proportion as it grows into maturity. Accordingly, the craniomaxillofacial surgeon must select an appropriate treatment strategy that considers both the nature of the injury and the child's stage of growth. The following review will discuss the management of pediatric orbital fractures, with an emphasis on clinically oriented anatomy and development.

Pediatric facial fractures and potential long-term growth disturbances

Fractures of the pediatric craniofacial skeleton can be challenging to manage. The initial injury and subsequent treatment can cause long-term growth disturbances yielding problematic secondary deformities. This review considers the normal growth of the craniofacial skeleton and typical facial fracture presentations in children and discusses the potential long-term sequelae from these injuries and their management.

Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme

A comprehensive study of adverse outcomes after pediatric facial fractures has not been published. This study aimed to determine the incidence and classify adverse outcomes after facial fractures in children while reporting our early results. A retrospective chart review was performed on facial fracture patients identified in the Craniofacial Trauma Database of the Children's Hospital of Pittsburgh and seen in follow-up from 2003 to 2007. An Adverse Outcome Classification Scheme was developed: type 1, outcomes resulting from the fracture; type 2, outcomes resulting from fracture treatment; and type 3, outcomes resulting from the interaction between the fracture, its treatment, and subsequent growth and development. Fisher exact or χ analyses were completed. A total of 177 pediatric facial fracture patients were identified with 13.3 months of average follow-up. Mean age was 9.8 years (range, 0.4-18.7 y). Of these patients, 41.8% underwent surgery and 57 patients (32.2%) had adverse outcomes (type 1, 14.1%; type 2, 11.3%; and type 3, 15.8%); 26.3% of these had multiple adverse outcomes. Isolated fractures resulted in fewer adverse outcomes and fewer multiple adverse outcomes compared with combined fractures (26.6% versus 45.3%, P = 0.015; 4% versus 18.9%, P = 0.002). Patients treated operatively exhibited more types 1, 2, and 3 and multiple adverse outcomes compared to those treated conservatively (P < 0.01). In our pediatric cohort, 32.2% of patients had an adverse outcome. With longer follow-up and growth and development studies, we will likely see an increase in the incidence of type 3 adverse outcomes. We recommend, whenever possible, conservative treatment of pediatric facial fractures.

Multidetector and three-dimensional CT evaluation of the patient with maxillofacial injury

Interpretation of images associated with the traumatically injured face is challenging. The complexity of facial anatomy, coupled with the superimposition of numerous bony structures on plain radiographs, poses specific obstacles to accurate interpretation of facial injury. Although plain radiographs can be helpful in cases of isolated injuries, CT is the most useful modality for evaluating facial injury. This article reviews facial anatomy as it pertains to traumatic injury, emphasizes the clinical findings associated with various types of facial injury, and simplifies the diagnosis of facial injury on CT.

Facial fractures in children: unique patterns of injury observed by computed tomography

OBJECTIVE

To determine the patterns of facial fractures observed in pediatric patients after acute trauma.

MATERIALS AND METHODS

The computed tomography studies of 338 patients (63% male, 37% female; 7 months to 18 years of age) performed after acute nonpenetrating facial trauma were retrospectively reviewed to evaluate for facial fractures and associated orbital hematomas or contiguous skull fractures. Fracture patterns were characterized as orbital roof, orbital floor, medial orbital wall, nasal bone, naso-orbital-ethmoid, zygomatic complex, isolated zygomatic arch, Le Fort type (I, II, or III), maxillary sagittal, alveolar ridge, or mandibular. The frequency of the various fracture types was determined. The correlation between fracture type and orbital hematomas or contiguous skull fractures was assessed (Kendall tau rank correlation).

RESULTS

Computed tomography demonstrated facial fractures in 188 (54%) patients. The number and frequency of the fractures observed were as follows: orbital roof, 67 (36%); zygomatic complex, 38 (20%); naso-orbital-ethmoid, 30 (16%); orbital floor, 28 (15%); nasal bone, 25 (13%); mandibular, 24 (13%); medial orbital wall, 16 (9%); maxillary sagittal, 11 (6%); alveolar ridge, 8 (4%); isolated zygomatic arch, 3 (2%); Le Fort type I, 4 (2%); Le Fort type II, 4 (2%); and Le Fort type III, 0 (0%). Fifty children (27%) had multiple fractures. Orbital hematomas were seen in 28 patients (15%), and contiguous skull fractures were seen in 54 patients (29%). There was strong correlation between orbital hematomas and orbital roof fractures (0.62, P < 0.0001), orbital hematomas and naso-orbital-ethmoid fractures (0.18, P = 0.001), contiguous skull and orbital roof fractures (0.57, P < 0.0001), and contiguous skull and naso-orbital-ethmoid fractures (0.39, P < 0.0001).

CONCLUSIONS

Fractures of the orbital roof are the most common facial fractures observed in pediatric patients after acute nonpenetrating trauma. Orbital roof and naso-orbital-ethmoid fractures are frequently associated with orbital hematomas and contiguous skull fractures.

Pediatric craniofacial fractures: long-term consequences

Pediatric craniofacial fractures are distinct from adult fractures because of the anatomical differences that result in unique fracture patterns and challenges in management. The unanswered question remains the outcome with regards to subsequent growth and development. Upon review of all primary craniofacial fractures treated at the Children's Hospital of Philadelphia, the authors find that the majority are associated with favorable long-term outcome. Severe centrofacial bony and cartilaginous injury may result ingrowth and developmental anomalies in up to 40% of patients.

Maxillofacial injuries in the pediatric patient

Approximately 22 million children are injured in the United States annually. Children are uniquely susceptible to craniofacial trauma because of their greater cranial-mass-to-body ratio. The pediatric population sustains 1% to 14.7% of all facial fractures. The majority of these injuries are encountered by boys (53.7% - 80%) who are involved in motor vehicle accidents (up to 80.2%). The incidence of other systemic injury concomitant to facial trauma is significant (10.4% - 88%). The management of the pediatric patient with maxillofacial injury should take into consideration the differences in anatomy and physiology between children and adults, the presence of concomitant injury, the particular stage in growth and development (anatomic, physiologic, and psychologic), and the specific injuries and anatomic sites that the injuries affect. This comprehensive review, based on the last 25 years of the world's English-speaking surgical literature, presents current thoughts on the anatomic and physiologic differences between adults and children, a synopsis of childhood growth and development, and an overview of state-of-the-art management of the pediatric patient who has sustained maxillofacial injury.

Helical CT and three-dimensional CT of facial and orbital injury

Knowledge of the regions of the face and their buttresses and knowledge of the types of facial injuries frequently encountered simplifies the diagnostic task. The indications for CT include detection of suspected fractures and preoperative planning. The cost of facial CT to the hospital has declined and is little different than the cost of plain films. CT may become the screening modality of choice depending on the cost structure at any given hospital.