Peter C.

Revenaugh Paul Kralwvitz

The last 25 years have seen dramatic changes in the the treatment of pediatric injuries is over $15 billion (2).
diagnosis and treatment of facial fractures driven by Despite the high prevalence of pediatric trauma, facial frac-
advances in imaging and the advent of internal rigid fixa- tures in this age group are relatively rare. accounting for
tion. Rapid acquisition of high-resolution images with 5% to 14% of all facial fractures (1,3,4). This percentage
three-dimensional (3-D) reconstruction techniques has has remained stable despite advances in motor vehicle and
facilitated more accurate definition of fracture patterns sport safety and accounts for a significant health care cost
and precise preoperative treatment planning. Advances at an average charge of $22,510 for pediatric patients hos-
in biocompatible materials with high tensile strength, pitalized with facial fractures (4).
low profile, and absorbable characteristics have allowed An age differential is generally noted, where patients
rigid fixation of complex injuries with minimal morbid- younger than 5 years of age are less likely to sustain facial
ity. These refinements in technology, along with increased fractures. Younger male patients are disparately affected at
understanding of facial biomechanics and growth patterns, a rate of 1.5 to 3.1:1 versus females (1,4,5).
have rendered complex injuries consistently amenable to Nasal bone fractures likely account for the most frequently
precise 3-D reconstruction. However, controversy still exists fractured fadal bone. but precise statistics are not available
regarding the suitability of rigid fixation for the developing as the majority of nasal fractures occur in isolation and are
pediatric craniofacial skeleton. treated in the outpatient setting. More routinely, large stud-
Despite controversies, the fundamental principles of ies report fracture incidence based upon emergency depart-
pediatric traumatology are similar to those in adults. Goals ment and hospital admissions. Mandible fractures comprise
include stable restoration of preinjury architecture with the majority of these fractures accounting for 20% to 50% of
minimal functional and aesthetic impairment. A unique facial fractures in the pediatric age group (5,6). The condyle
challenge to pediatrics is the need to reconcile acute injury is the most vulnerable and hence. most commonly involved
and functional limitations with the potential long-term site in 40% to 70% of mandible fractures (1,6). Rarely seen
growth consequences. Fortunately, there is an increasing in young children, fractures of other mandible sites increase
wealth of literature in this arena and this knowledge can as children approach adolescence, reflecting adult frequency
be used to formulate a reasonable treatment plan. The and anatomic location. Dentoalveolar trauma and fractures
evaluation and treatment of pediatric facial trauma should occur often in children but due to the same limitations in
include consideration for the differential injury mecha- data gathering, frequency may be higher than reported.
nisms and patterns as well as the potential growth implica- Midfacial fractures are less common in children, but orbital
tions on the developing facial skeleton. fractures are the next most frequent midfacial fracture after
nasal bone fractures accounting for 15% to 39% or pediatric
EPIDEMIOLOGY facial fractures (1,5,7). Isolated zygomaticomaxillary frac-
tures occur in 10% to 20% of patients (1,5). Even less com-
Trauma is the leading cause of death and major contribu- monly. complex midface fractures account for 5% to 10%
tor to long-term morbidity among children in the United of pediatric facial fractures. Panfadal and Lefort fracture
States (1). There are approximately 15,000 deaths annu- patterns are rarer still and the scarcity and diverse fracture
ally from trauma and 100,000 children are permanently patterns highlight the challenge in gaining experience in the
disabled (2). The estimated national health care cost for treatment of such injuries.

1272
 Chapter 85: Pediatric Facial Fractures 1273

Pediatric maxillofacial trauma frequently involves asso-

ciated injuries due to mechanism and force variability. An
estimated 30% to 75% of children with facial fractures have DIAGNOSIS AND EVALUATION
additional injuries (3,8). Frequently, pediatric patients
hospitalized with facial fractures have concomitant brain
injuries (32.3%), skull base fractures (27.7%), cranial Injuries inconsistent with the history should raise suspicion of child
abuse
vault fractures (13% to 30%), ocular injuries (7.2%), and
Secondary survey proceeds in an orderly fashion; neurologic
cervical injuries (3.3%) (1,3). Orthopedic, thoracic,. and assessment, manual palpation, inspection of the neck, spine,
abdominal injuries are also encountered, reinforcing the eyes, nose, face, and oral cavity
need for comprehensive initial assessment of pediatric Periorbital edema and hypoesthesia, ecchymoses, subconjunctival
trauma patients. Further, it may be necessary to delay frac- hemorrhage, diplopia, and mobility reduction are indicative of
orbital injury
ture management in lieu of neurologic stabilization. This
Suspected orbital trauma warrants an ophthalmologic evaluation
delay can complicate future treatment in the rapidly heal- Trapdoor or Hwhite-eyedH fracture can be subtle with limited
ing pediatric facial skeleton. supraduction mobility
Malocclusion is indicative of mandibular fracture
EMERGENCY MANAGEMENT Intranasal examination is essential for septal injury, particularly
septal hematoma
AND PHYSICAL EXAMINATION CT has revolutionized the evaluation of pediatric trauma

Initial assessment of all patients who have experienced

trauma should adhere closely to advanced trauma life-
support protocols (Table 85.1). Airway management can Once the patient has been stabilized according to
be approached using a variety of methods based upon the trauma protocols, the secondary survey should proceed in
patient's injury profile and mental status. For the major- an orderly fashion, keeping in mind that portions of the
ity of isolated maxillofacial injuries, adequate positioning exam may be difficult to accomplish in an uncooperative
of the patient is sufficient for airway management. given or neurologically injured child (Table 85.2).
appropriate consideration for cervical injuries. In addition Full neurologic evaluation should be pursued, followed
to positioning, oral suctioning to remove saliva, blood, by examination of the neck and cervical spine. Attention to
and tooth fragments can be beneficial. In some severe cases overall level of consciousness and cranial nerve integrity is
of bilateral mandibular fracture with tongue retrodisplace- crucial in this assessment Particular attention to sensation
ment, manual traction or midline tongue traction suture of all divisions of the cranial nerve V and the motor func-
can help maintain airway patency until definitive airway tion of the facial nerve are paramount. Ophthalmologic
management. examination should focus on overall visual integrity,
Orotracheal intubation may be necessary in situa- pupillary evaluation, range of motion examination,
tions where positioning is inadequate to maintain the ophthalmoscopy, or presence of diplopia or ophthalmo-
airway, there is neurologic impairment, significant oral plegia. Forced duction testing may be performed, usually
bleeding, or complicated maxillary fractures. Again, cer- under anesthesia in cases of suspected orbital trauma.
vical spinal injures should be considered and airway Otoscopy may reveal hemotympanum or cerebrospinal
management would ideally follow proper stabilization fluid (CSF) otorrhea associated with temporal bone frac-
of the spine. tures. External auditory canal lacerations associated with
If oropharyngeal or laryngeal injuries are present, intu- mandibular condylar fractures or displacement may also
bation should be approached in the operating room with be seen on otoscopy. Anterior rhinoscopy should focus on
rigid instrumentation available. Emergent cricothyroidoto- ruling out nasoseptal injuries, particularly hematomas and
mies or tracheotomies are avoided in favor of orotracheal CSF rhinorrhea. Full oral examination is crucial to assess
intubation. However, elective tracheotomy may be benefi- occlusion, dentoalveolar injuries, missing or broken teeth,
cial in patients with panfacial fractures or when fractures tongue injuries, or palatal fractures associated with mid-
are accompanied by severe neurologic injuries. face injuries.
The facial skeleton should be approached in a sys-
tematic fashion with observation followed by palpation.
Facial asymmetry, ecchymosis including '"raccoon eyes•
W EMERGENCIES or Battle sign, edema, periorbital edema, conjunctival
~.!.; PEDIATRIC FACIAL TRAUMA chemosis, epistaxis, malocclusion, trismus, and gingival
laceration all are signs of potential underlying fractures.
Adherence to the Airway, Breathing, Circulation (ABCs) Once the face has been thoroughly inspected, palpation
Emergent tracheotomies and cricothyroidotomies are ideally of the buttresses follows, usually beginning at the zygo-
avoided matic arches or supraorbital rims and proceeding caudally.
Septal hematoma requires urgent drainage
Asymmetry, tenderness, mobility, or crepitus should be
1274 Section V: Trauma

noted wherever present. Areas of frequent fracture should children are generally spared from facial fractures due in
be examined including the nasal bones, orbital rims, part to their protected environment and minimal engage-
and malar eminences. Assessment of midface stability is ment in activities known to be risk factors for fractures.
accomplished with attempted movement of the premaxilla When considering all types of pediatric facial fractures,
with one hand while stabilizing the head with the other including nasal and dentoalveolar, childhood play may
hand. Maxillary buttressing can also be palpated intra- account for the greatest percentage (11). Howeve~; motor
orally. Bimanual palpation of the mandible should focus vehicle collisions account for the vast majority of serious
on loose teeth or tooth segments, and attempted elicita- facial fractures (1,5). The risk of serious facial fracture is
tion of mobility in multiple vectors. Any missing teeth doubled by inappropriate motor vehicle restraint in chil-
should be catalogued and considered as a potential source dren (1, 12). Falls, interpersonal violence, and sporting
of airway foreign body. As with the facial skin. oral mucosa injuries are all common causes of fractures and vary in per-
and all oral structures should also be inspected. centage based upon the age group of the patient. Bicycles
As time and witness availability allows, an accurate his- have remained a common cause of pediatric facial frac-
tory should be obtained. Injury mechanism and assess- tures. Though helmets have contributed to a reduction in
ment of velocity may predict potential fracture patterns or intracranial injuries and midfacial injuries, they do not
concomitant injuries. Any suspicious stories or inconsis- protect against mandibular and dentoalveolar trauma ( 13).
tent injuries should raise the threshold of concern for child Fractures in young, especially preambulatory patients, or
abuse or nonaccidental injury. fractures of the mandible should be remembered as a pos-
sible indication of child abuse (3).
RADIOGRAPHIC EXAMINATION The anatomic development of the face is important to
understand the different patterns of fracture seen between
Computed tomography (CI) has revolutionized the diag- adults and children. At birth, the ratio of cranial to facial
nosis and treatment of facial fractures. Contemporary scan- volume is approximately 8:1 with the face set in a recessed
ners allow rapid image gathering. ultrafine cuts ( 1 mm ), position. The relative protection of the skull contributes to
multiplanar and even 3-D reconstructions for fracture a lower incidence of facial fractures, but a higher incidence
identification and treatment planning, especially in the of skull fracture and intracranial injury in young children
multiply injured children. Axial cuts provide a reasonable (14). Facial growth generally occurs in a downward and
starting point for overall facial assessment and are partic- forward direction and begins to outpace cranial growth
ularly useful in the mandible, midface, nasal bones, and after the second year of age. The orbit and brain near com-
frontal sinuses. Coronal cuts are necessary for evaluating pletion of growth by age 7, but facial growth continues
the orbital floor and may provide valuable information well into the second decade of life. In the developing face,
regarding the mandibular condyle. Sagittal cuts can pro- the bones have less mineralization with a greater propor-
vide additional information about the orbital floo~; roof, tion of cancellous bone, thinner cortices, and the sutures
and overall facial and mandibular projection. are not fused in infants. These factors, combined with the
Though cr is regarded as the gold standard for facial
H R presence of multiple tooth buds and the lack of paranasal
skeletal assessment, mandible panoramic x-rays (Panorex) sinus development, make the infant craniofacial complex
are still useful in the evaluation of the isolated mandible a solid yet elastic structure, resisting fracture. These factors
fracture. Care should be taken to ensure condyle inclusion also contribute to the higher proportion of greenstick frac-
and the clinician should understand that Panorex: may be tures observed in pediatric patients. Likewise, suture ossifi-
inferior to helical cr in evaluation of the condyle or mul- cation, sinus pneumatization, tooth eruption, and greater
tiply fractured mandible (9). Plain films are now of little independence contribute to the transition from pediatric
use in facial fracture workup and may delay diagnosis or to adult fracture patterns.
miss facial fractures (5, 10). Howeve~; nasal plain films are
still commonly encountered in the emergency department FACIAL GROWTH AND TRAUMA
setting. One should recognize the potential inadequacy of
facial plain films and the subsequent need for cr in cases Understanding of craniofacial growth and its relation to
of nasal fracture where there is significant deformity and trauma is limited. Coordination mechanisms of facial
flattening of the dorsum or a history of significant contrib- growth and the exact genetic and environmental contribu-
uting force. Howeve~; imaging in the vast majority of iso- tions are unclear. A complete discussion of the various the-
lated pediatric nasal injuries is unnecessary. ories of facial growth and regulation is beyond the scope of
this chapter. However, it is fairly accepted that facial skel-
ETIOLOGY/MECHANISM OF INJURY etal growth and development consists of remodeling and
displacement combined with inner table resorption and
The variable structural characteristics of the developing outer table deposition (15). Factors contributing to bony
face and skull in relation to the mechanism of trauma growth undoubtedly include finely regulated local and sys-
determines the risk and pattern of facial fractures. Young temic factors as well as vector forces acting on the bones.
 Chapter 85: Pediatric Facial Fractures 1275

A B
Figure 85.1 A; 3-D CT 1"8ClDnstruc:tion of a 3-year-old child with mandibular hypoplasia, retrogna-
thism, and right temporomandibular ankylosis. The dlild had a history of Cl\ISh injury to the right
mandibular condyle in the first year of life. B: 3-D CT 9Can of Ute child depicted in {A) shows a normal
left condyle and an abnormal, hyperplastic right condyle with a foreshortened condylar neck anky-
losed in the right temporomandibular joint.

The facial skeleton can be divided into two independent,. following trauma to this area (23). Surgical manipulation
yet related growth areas-the nasomaxillar:y complex of the nasoseptal area in the pediatric population auries the
and the mandible. Alterations in growth and remodeling same concerns for midfacial or nasal growth alte:Jation; how-
within and between these areas due to trauma contribute ~ evidenre is limited (24). Unless functional limitation or
to the deformities and dysfunction observed. gross deformity e:x:ists, minimal SUJgial manipulation of the
Mandible growth has long been associated with the con- area is recommended, especially in the area where the septal
dyle, although it is likely there are a series of growth centers cartilage contacts the bony sepWm. ( 25).
that contribute to overall growth. .& an area of continued The potential effects of trauma on growth should be a
growth throughout childhood the condyle seems to have counseling point with parents following injwy and care
an ability to remodel quickly (less than 12 months) under should be taken wherever possible to minimize additional
the strains of mastication ( 16,17). Howevex;. CJ'Wih injuries growth alteration risk during treatment. Minimizing addi-
to the condyle and injuries involving condylar head can tional risk would include careful restoration of the peri-
lead to mandibular and maxillary growth asymmetries osteum and other soft tissues with minimal periosteal
or ankylosis (Fig. 85.1) (18). Norh.olt et al. (19) demon- elevation. attention to realignment of the septal cartilage
strated that younger children have fewer deformities fol- where possible, and accurate reduction with correct suture
lowing trauma suggesting that growth may compensate for realignment. Long-term follow-up for pediatric trauma
the injury. Contrary, Rowe (2) found that injuries occurring patients is essential in identifying alterations in growth and
before 3 yeaa of age generally produced more severe defor- initiating appropriate orthodontic treatment if necessary.
mities. Despite these apparent disparities, there is consen-
sus that early return of mandibular mobility in pediatric RIGID FIXATION
patients is desirable to limit the risk of ankylosis and to
stimulate normal growth and remodeling. The role and best use of rigid fixation in children is still
The nasomaxillaxy complex appears more sensitive to the controversial, given the aforementioned concerns regard-
effects of trauma on normal growth. This may be due to the ing facial growth and other potential complications of
multiple suture sites, limited functional restorative mOYmient internal fixation (Thble 85.3).
compared to the mandible, or the importance of the septum As with traumatic injuries, animal studies have investi-
as a regional growth site. Numerous animal swdi.es involving gated the potential growth retardation related to plating.
septectomies and septoplasties in the last three decades have Plating across suwre lines and elevation of the perios-
continued the debate into the role of the septum as a growth teum has demonstrated restricted growth in several animal
center for the midface (20-22). Small case series and twin models (26,27). Laurenzo et al. (27) observed an equivo-
swdi.es in humans have demonstrated midfacial hypoplasia cal amount of growth restriction between rabbits that had
1276 Section V: Trauma

degradation times from 6 months up to 6 years (30). Physical

and biomechanical studies have demonstrated that available
'Ill COMPUCATIONS absorbable plates provide flexural and tensile strength com-
..... FACIAL FRACTURES parable to available titanium microplate systems ( 31 ). Ideally.
plate resorption should occur after the 4 to 6 weeks necessary
The nose, nasoethmoidal complex, and maxilla are susceptible to for full fracture healing and indeed, commercially available
growth abnormalities as a result of trauma
systems retain 60% to 80% of their strength at 10 weeks (30).
More severe types of pediatric facial trauma are associated with
concomitant injuries- especially neurologic in up to 60% of Complications observed with absorbable plating com-
patients monly include peri-implant edema, temporary visibility,
Fracture complications can include delayed sinus infections, and palpable hardware (30). Degradation appears to elicit
malunion, malocclusion, TMJ dysfunction, and delayed growth only a mild foreign body reaction in the surrounding tis-
disturbances
sue. As in permanent fixation, some controversy exists
Inadequate treatment of upper and midfacial injuries may result in
serious alterations of facial growth regarding the potential growth restrictive properties of
Bone growth can cause translocation of metallic implants absorbable plating procedures. To date there have been few
long-term studies to address this possibility.
Currently, resorbable plating systems are recommended
trauma and those that had trauma and subsequent fixation. for "non-load-bearing" areas of the upper face and mid-
They concluded that plating offers no additional growth face. Although plating of mandible fractures and saggital
restriction beyond that of the initial trauma. Their group split osteotomies have been described, their use in these
then reported that subsequent removal of the plates had contexts is still investigational in children with limited
additional detrimental effects to growth in rabbits (26). long-term data (32). The somewhat larger screws, thicker
Human studies have also demonstrated growth restric- plates, and limited malleability of absorbable systems can
tion in the setting of plated fractures (28). These data limit use in areas of thinner skin or in severely commi-
have caused some clinicians to recommend plate removal, nuted fractures. As technology improves, changes in prod-
although detractors would cite the animal evidence that uct properties and indications are expected.
removal may further traumatize growth centers and less While it has been demonstrated that open reduction
than 8% of patients who are observed eventually require and internal fixation (ORIF) for the treatment of mandibu-
plate removal (28). Independent of growth consider- lar and complex midface fractures is safe and efficacious,
ations, metallic hardware can be complicated by palpabil- especially in children older than 13 years, the risks and
ity, hypersensitivity. bone atrophy. tooth bud injury, and benefits of internal fixation must be weighed prior to inter-
potential interference with future imaging. Plate displace- vention (Table 85.4) (3).
ment, plate and screw migration (even intracranial), and Many minimally displaced or greenstick fractures can be
plate isolation are also complications to consider when managed conservatively. Management of moderately dis-
planning rigid fixation (29). placed fractures requires higher clinical arumen and can
To avoid the complications associated with permanent be guided by postreduction stability. However, in certain
plates and screws in the developing face, absorbable plat- complex cases, or load bearing segments, rigid fixation can-
ing systems have been developed. The safety and efficacy not be avoided. Whether rigid or absorbable, plates should
of these systems have been established and this technology be as small as possible without compromising stability. as
gained U.S. Food and Drug Administration (FDA) approval
in 1996. High molecular weight polyalphahydroxy adds are
the most commonly used craniofacial bioabsorbable mate-
rials including polylactic add (PLA) (both Lando enantio-
mers ), polyglycolic add (PGA), polydioxanone (PDS), and 11J11 TREATMENT
their copolymers. Biodegradation of PLA and PGA occurs in ~, PEDIATRIC FACIAL FRACTURES
two phases; a hydrolysis phase where water molerules cleave
the larger macromolecules, and a metabolic phase where Orotracheal intubation is ideally accomplished after securing the
cervical spine
macrophages phagocytize the polymer fragments (30). Careful restoration and resuspension of injured soft tissue
Substantial strength loss ocrurs during the hydrolysis phase Reduction of fractures into stable anatomic locations
and the space occupied by the absorbable screws is even- ORIF is indicated in unstable fractures
tually obliterated by bony ingrowth (30). During degrada- Correct realignment of suture lines
tion, PLA and PGA are metabolized into carbon dioxide and Minimal periosteal elevation
3-D, stable fixation
water and eliminated through respiration whereas PDS deg-
Use of bone grafts in areas of bone loss
radation products are primarily excreted in the urine (30). Mandibular fractures with normal occlusion and mobility treated
Pure polymers have disadvantageous properties in regard to with soft diet
strength, degradation time, and local tissue reactions. Malocclusion or movement limitation treated with MMF or ORIF
Currently available plating systems utilize copolymers Traumatic telecanthus associated with nasoorbitoethmoid frac-
tures is best treated with transnasal wiring
of PLA and PGA allowing a variety of strength profiles and
 Chapter 85: Pediatric Facial Fractures 1277

short as possible, and ideally not placed over more than Fracture risk increases with age and if present in younger
one suture. Periosteal elevation should be minimized and children, they can be of the greenstick variety. In addition
dissected tissues reapproximated precisely. to limited projection, the nasal bones are not fused in
the midline in young children, resulting in "open-book·
SURGICAL APPROACHES fractures where the nasal bones are separated in the mid-
line and splayed over the maxilla. Clinicians should have
Despite advances in rigid fixation, it is important to an index of suspicion for occult nasoorbitoethmoid frac-
remember that many pediatric fractures can be managed tures in children with fractures of the nose with "open-
with closed techniques. In cases of displaced or complex book" fractures or a history of direct trauma to the nasal
fractures where fixation may be necessary, much of the bridge.
facial skeleton can be exposed through a single incision or Initial examination is often of limited utility due to the
combination of several incisions. presence of midface edema from force dissipation and the
The upper third of the face can be approached through lack of external deformity. Several days of observation may
a coronal incision to access the upper orbital rims, fore- be necessary before the true cosmetic deformity can be
head, and nasoorbitoethmoid (NOE) complex. Subfascial appreciated. Initial examination must focus on evaluation
release of the temporalis fascia allows complete exposure for septal injury and hematoma. Nasal obstruction and
of the zygomatic arches. Exposure of the orbital rims can unilateral septal bulging are hallmarks of a hematoma.
be accomplished using a subciliary or more popularly a A septal hematoma will classically appear purplish and
transconjunctival incision with or without a lateral can- compress with manipulation but not resolve with decon-
thotomy. The medial orbit and apex can be approached gestion. Untreated and even treated hematomas can lead
via a transcaruncular incision (33). For important realign- to a variety of complications including a fibrotic septum or
ment of the midfacial nasomaxillary and zygomaticomax- loss of cartilage and resultant saddle-nose deformity (34 ).
illary buttresses, an upper gingivolabial sulcus incision Treatment of a septal hematoma is best approached
can provide access to the entire maxilla and zygoma with under anesthesia in the pediatric population. The hema-
care taken to identify the infraorbital nerve. In the case of toma is incised via a Killian incision, allowing exploration
especially complicated fractures requiring wide exposure, a of the septum and limited reduction of cartilaginous frag-
midfacial degloving approach can be used. ments. Through-and-through quilting suture should reap-
Fractures of the mandibular symphysis, body, and angle proximate the mucoperichondrial flaps. Septal splints can
can be approached through a lower gingivolabial sulcus be used for 2 to 3 days to prevent reaccumulation. Packing
incision. Rarely, plating of ramus fractures or comminuted can be poorly tolerated and only advised if there is strong
fractures of the angle and body can be reduced through an justification for its use. Perioperative antibiotics are rec-
external approach. ommended. Closed reduction can be accomplished in the
As always, tenets of limited periosteal dissection with same setting if dorsal nasal fractures are encountered.
careful restoration of soft tissue should be observed. In If no hematoma is encountered and there is no nota-
complex fractures, accurate reestablishment of facial but- ble nasal deformity, the patient can be reevaluated in
tresses to provide preinjury occlusion, facial width, and 3 to 5 days once edema has resolved enough to reveal any
height is fundamental. deformity. If bony or septal injuries are discovered caus-
ing a fixed nasal obstruction or poor cosmesis, definitive
NASAL FRACTURES management is recommended. Usually, dosed reduction
is sufficient. Greenstick fractures and septal fractures may
Visual examination of the pediatric nose reveals the differ- require open approaches to adequately reduce. Injuries
ences in anatomy from the adult nose. Children have lim- presenting 2 to 3 weeks postinjury may require open reduc-
ited nasal projection and the projecting tissue comprises tion due to rapid ossification. Timing of open reduction is
soft cartilage that is compliant to physical forces. As a result, debated and should take into account the deficit or defect,
the pediatric nose deforms readily, dissipating force across patient age, and potential for altered growth.
the maxillary soft tissues and lateral buttresses. Rarely are
the nasal cartilages injured. However, the underlying sep- NEWBORN NASAL DEFORMITY
tum is relatively rigid and prone to injury with trauma of
significant force. Three types of septal injuries are observed Occasionally newborns may be born with a grossly asym-
in children. The perichondrium can be sheared from the metric nasal tip. Intrauterine positioning and trauma while
septum creating a potential space for blood and resultant traversing the birth canal are two potential etiologies.
hematoma. Secondly, a dislocation of the caudal septum Classically, the septum is deviated to the same side of the
can lead to nasal deformity and obstruction. Lastly, separa- nasal tip and the nasal dorsum is unaffected. Since neo-
tion of the bony and cartilagenous septum can be observed, nates are obligate nasal breathers, nasal obstruction would
leading to nasal obstruction and growth abnormalities. be an indication for early septal relocation. Otherwise, the
Nasal bones have limited projection in young chil- nasal tip and septum eventually straighten in the majority
dren and therefore are rarely fractured in this age group. of cases and reassurance is all that is needed (35).
1278 Section V: Trauma

FRACTURES OF THE MANDIBLE eruption of the secondary dentition. Once children are
10 to 12 years old, an adequate compliment of secondary
Fmctures of the mandible account for 13% to 48.8% ofpedi- teeth for fixation is present.
atric facial fractures with increasing frequency u patients age Maxillomandibular fualtion (MMF) is used more spar-
(1,5, 7). Concerns aver the developing face and dentition ingly in the pediatric population given concerns for joint
dictate management decisions, which are somewhat differ- ankylosis, tooth development. and general airway concerns.
ent in pediatric versus adult patients. Although. treatment If deemed nea!Silary, 2 to 3 weeb of immobilization in chil-
modalities may differ, the avaall goal is accumte alignment dren less than 12 years ofage is adequate. When used. differ-
and reduction with restoration of preinjwy occlusion. ences in dentition phase may dictate MMF type. Patients who
Unique to the pediatric mandible are concerns pre- have no teeth or limited deciduous teeth. an acrylic splint
sented by the developing dentition. Until age 2 there is can be fabricated using plaster casts of the upper and lower
incomplete eruption of the deciduous teeth. In thia age dentition positioned in estimated occlusion to cast the final
group traditional methods ofimmobilization may be inad- splint.lhe acrylic splint can be seaued using circum-man-
equate. Age 2 to 5 ye;us, the deciduous incisors and molars dibular and transnual wires (Fig. 85.2). Alternativdy, screws
have firm roots for fixation if needed. From age 5 to 9 there can be placed in the zygoma and inferior mandibular bor-
is mixed resorption of the deciduous roots and incomplete der and serured with monofilament suture. However, this is

A B

D
Figure 85.2 A:. Towne view shows right parasymphyseal mandibular fracture In 8 3-yea!'oOid girl.
B: Clinical photograph shows 1he fract:ure depleted In (,\). C: Acrylic splint fabricated on 8 plastic
cast of 1he mandible. The original Impression of the mandibular arch was cut and the occlusion
established to the maxillary Impression before fabrication of the splint. D: Acrylic splint wired Into
place with drcummandlbular wires.
 Chapter 85: Pediatric Facial Fractures 1279

A B
Figure 85.3 Coronal (A) and 3-0 n~constructlon (B) CT Images of a 10.month-old Infant with
bilateral dlsplaa~d subcondylar fractures. Coronal view shows symphyseal greenstick fracture of the
lingual cortex. This child was treated expectantly.

inadvi8able in older patients as the masticatory musdea may Most clinical and experimental data suppon a conser-
be strong enough to resist the fixation. Once patients are 2 vative dosed approach to the majority of condylar frac-
to 5 years old, the deciduous teeth have firm enough roots tures. A primary clinical decision point is usually whether
for cap splints and ardl bars. Aidl bars may be difficult to or not to immobilize the patient. Often, unilateral con-
semre, howem;. due to the shape of the teeth. Ifusing MMF dylar fractures with normal range of motion and normal
from age 2 to 5, augmentation of :fixation may be obtained occlusion. a soft diet and movement exercises are all that
using pyriform aperture and cirolm-mandibular wiring. is necessary. If there is good occlusion, but deviation with
After 10 years of age, children generally have enough perma- movement. arch bars with elastic guiding bands may be
nent dentition to serurely place arch bars. helpful. Commonly, an open bite may be a sign of uni-
Consideration for the growing face cannot be over- lateral or bilateral condylar fracture (Fig. 85.3). If there is
emphasized in fracture management. Complicatiom of an open bite, mandibular retrusion, or movement limita-
pediatric mandibular fractures in general can include mal- tion, a shon course (2 to 3 weeks) of MMF may be help-
occlusion, malunion, nonunion. infection. tooth loss, and ful followed by elastic bands if needed. Open surgical
temporomandibular joint (TMJ) dysfunction. Greenstick repair of the condyle is rarely indicated except in instances
fractures are common and teeth are often encountered in of displacement into the middle cranial fossa or severely
the fracture line and should not be removed unless devital- restricted mandibular movement Preauricular and sub-
ized (36). Prolonged MMF places the patients at risk for mandibular approaches can be used.
TMJ ankylosis, which can be difficult to treat and ret~ult in
growth abnormalities. FRACTURES OF THE ARCH OF THE
MANDIBLE
FRACTURES OF THE CONDYLE
Fractures of the arch of the mandible can range from
Fractures of the condyle account for the majority of man- greenstick fractures to displaced bicortical fractures and
dibular fractures in children (6). These can be classified are commonly associated with fractures of other mandibu-
into three anatomic types: intracapsular CJ'Wih fracture of lar site in up to 30% of cases. Often, masticatory muscles
the condylar head, high condylar fracture above the sig- exJ:rt unfavorable forces on fractures of the anterior arch
moid notch, and low subcondylar fracwre. The low sub- causing displacement that can be carefully reduced under
condylar fracture is the most common type with many anesthesia.
being greenstick fract.ures. Although the condylar head has 'Ii'eatment of arch fractures ranges from soft diet to
rapid resorption capabilities, there is evidence to suggest MMF or ORIF with miniplate :fixation. Arch bar place-
that trauma to this growing area can result in growth arret~t ment can be complicated by dentition stage and unfavor-
or functional or radiologic deformity in up to 20% of able splaying of the inferior border of the fracture. If rigid
patients (37). Therefore, long-term follow-up and possible fixation is used, monocortical screws should be placed
orthodontic intervention is advised. with cognizance of the underlying developing tooth buds
1280 Section V: Trauma

are signs of an underlying fracture. cr with multiplanar

views is essential in diagnosis and treatment of midface
fractures. Ophthalmologic examination should be under-
taken with any fractures involving the o:rbit. Evaluation
for vision loss, enophthalmos, exophthalmos, globe rup-
ture, vertical dystopia, or elevated intraocular pressure is
necessaxy. Sensoty nerve integrity and intercanthal dis-
tance should also be inspected. Medial canthal stability
and forced duction tests are generally reserved for patients
under general anesthesia.
In midface fracture treatment, a multidiscipliruuy
approach is necessaxy with the goal of therapy to establish
facial symmetty, 3-D proportions, occlusion, and function.
Taking into account the overall medical condition of the
patient after a potentially severe trauma, fracture reduction
Figure 85.4 Proximity of the uncmJpted canine and bicuspid
teeth to the lower margin of the mandible. should be attempted within 10 days. Pediatric bone can
reossify rapidly, making future correction difficult. If nec-
essary, arute reduction can be attempted through existing
(F'tg. 85.4). Howner, once children have a full comple- lacerations.
ment of secondary dentition. adult treatment algorithms Lefort fracture patterns can be used to describe compli-
apply. Currently, absorbable plating systems are not FDA cated midface fraelllres. Howna;. these classifications are
approved for mandible fracture treatment {30). Fractures rarely adequate in pediatric midface fractures due to the
of the body and angle commonly are of the greenstick vari- variety of fracture patterns associated with variable para-
ety, typically with normal jaw movement and occlusion. nasal sinus development With high-velocity midface inju-
In these cases, soft diet and observation is appropriate. ries, fractures of the palate instead of Lefort I pattems can
Conservative plate placement again should be observed if be obsem!d due to lack of maxillary sinus development
internal :fixation is deemed necessary. and incomplete midline palatal fusion. Oblique fractures
extending through the frontal bone and fractures of the
DENTOALVEOLAR FRACTURES cranial vault are also observed with upper midface trauma
(39). Due to the variety of fractures, classification schemes
Dentoalveolar fractures are relatively common in pediatrics to describe treatment implications have been proposed ( 11).
involving the indscm and canine teeth most often (38). Type I fractures are minimally displaced, Type II are moder-
Treatment of these fractures should occur on an emexgent ately displaced with some areas of comminution. Type D
basis to stabilize the traumatized bone and teeth. Avulsion injuries can involve multiple buttresses, but the fragments
of primary teeth without bone is not serious, but it is often are IOO)gnizable and large enough to rigidly fix. Type Ill
diffiadt to determine if a tooth is primary or secondary; so fmctures are severely displaced with multiple areas of com-
reimplantation of any avulsed teeth is a safe strategy. Acute minution involving buttresses where 3-D stabilization and
treatment involves preserving and cleaning of the tooth bone grafting may be necessary for adequate reduction.
with replacement in the socket in cooperative patients
while arranging prompt dental consultation. If the child is FRACTURES OF THE
uncooperative, the tooth can be placed in a saline solution. ZVGOMATICOMAXILLARY COMPLEX
moist gauze, or submersed in milk until dental implanta-
tion. Every effort to implant within 1 hour of injwy should Zygomaticomaxillaxy complex fractures generally do not
be made to give the best chance for recovery. Theatment of occur under the age of 5 owing to the lack of maxillary
the loss of multiple teeth or alveolar bone is challenging sinus pneumatization. After this age, fracture patterns
and may require MMF or miniplate fixation, generally with re11emble those in adults although involvement of the
poor tooth survival rates (38). orbital floor and rim can be obse:l'\'led more frequently in
children (40). Greenstick fractures of the frontozygomatic
FRACTURES OF THE MIDFACE suture and zygomatic arch with medial displacement of
the malar fragment are commonly seen. In these cases,
Fractures involving the midface, orbit, and nasoethmoidal single-point fixation of the zygomaticomaxillary buttress
region are rare in children and often result from significant may be adequate. More often, two- or three-point :fixation
forces with associated intracranial injuries. Injuries can is required and proper reduction should be confirmed with
range from isolated o:rbital blow-out fractures to severely palpation at the zygomaticomaxillary, frontozygomatic,
comminuted fractures involving multiple facial buttresses. and even zygomaticosphenoid sutures. Fixation is often
Severe facial edema, orbital ecchymosis, and malocclusion undertaken at the zygomaticomaxillary buttress through a
 Chapter 85: Pediatric Facial Fractures 1281

gingivolabial incisio~ and at the orbital rim and/or fron- The trapdoor fracture is a linear orbital floor fracture,
tozygomatic suture through a subciliary or transconjunc- hinged medially that can allow herniation of orbital con-
tival incision with lateral canthotomy. If exposure of the tents into the maxillary sinus (43). These are more com-
zygoma is necessary for complex or comminuted fractures, monly seen in the pediatric populatio~ probably due to
a hemicoronal incision can be added. a higher incidence of greenstick fractures, where self-
Isolated zygomatic arch fractures without displacement reduction occurs. Trapdoor fractures are also known as
can be observed with institution of a soft diet. Minimally •white-eyed" fractures due to their subtle presentation.
displaced fractures can be reduced via the intraoral route, Extraocular mobility reduction with forced duction exami-
a Gillie approach or even directly through existing wound nation is diagnostic (44). cr may reveal linear fracture
or transcutaneously with a bone hook. Contingent upon along infraorbital nerve but is not necessary for diagnosis.
reduction and stability, isolated zygomatic fractures may Urgent surgical intervention is indicated in cases of entrap-
not require further fixation. ment with oculocardiac reflex resulting in emesis, brady-
cardia, and/or arrhythmia (45). True entrapped fractures
FRACTURES OF THE ORBIT, ORBITAL should be explored within 48 hours to reduce risk of per-
ROOF, AND FRONTAL BONE manent diplopia or symptomatic oculocardiac reflex (46).
Saucer fractures result in a depressed orbital floor with
Fractures involving the orbital and orbitoethmoid area can potential for herniation or orbital contents and resultant
range from simple to quite complex and result in severe enophthalmos. Surgical intervention in nonurgent cases is
functional deficit and poor aesthetic outcomes. Thirty per- based upon need for concomitant exploration with other
cent of orbital fractures are associated with other facial fractures, significant enopthalmos (greater than 2 mm),
fractures (41). As with midface fractures, ophthalmologic extraocular muscle restriction on forced duction, symp-
consultation is imperative and consideration for intracra- tomatic diplopia, or cr findings indicating large fracture
nial injuries should be maintained, especially in cases of (greater than 50% of the orbital floor or wall) ( 4 7). Patients
orbital roof, frontal bone, NOE, or bilateral orbital frac- not indicated for surgery can be observed for a period of
tures. Assessment of visual acuity should be primary as days to weeks for resolution of edema or diplopia. The
optic nerve injury can result from apex fracture or exten- orbital floor can easily be exposed through transconjunc-
sion of orbital wall buckling. Loss of visual acuity and the tival or subciliary incision with delicate reduction of bone
presence of an afferent pupil defect are hallmarks of optic fragments. An array of repair materials has been cited
neuropathy. Fractures of the orbital apex are exceedingly throughout the literature. The more commonly described
rare and usually associated with other nonsurvivable inju- absorbable gelatin film can be used for reconstruction of
ries due to the force required to injure this area. Attention floor defects and if necessary split calvarial bone for larger
should also be given to orbit position, extraocular move- defects.
ments, pupillary abnormalities, cranial nerve V integrity, Medial orbital wall fractures rarely occur in isolation
and intercanthal distance. and are commonly denoted by orbital emphysema on cr
Fracture patterns in this area tend to be age specific scan (33). Surgical repair is indicated for fixed enopthal-
paralleling paranasal sinus development. Maxillary sinus mos or entrapment of medial muscles. Exposure can be
pneumatization generally begins after age 5, when isolated facilitated through transcaruncular or external ethmoid
orbital floor fractures are more often seen. The ethmoid air incision, with a transcaruncular approach offering a more
cells continually expand throughout childhood, reaching inconspicuous scar (33).
70% of interorbital width by age 7 and frontal sinus devel-
opment generally begins around age 6 ( 42). FRACTURES OF THE NASOETHMOIDAL
COMPLEX
ORBITAL FLOOR AND MEDIAL WALL
FRACTURES Nasoorbitoethmoid fractures involve the central core of
the face including the nasofrontal suture, nasal bones,
Due to lack of sinus pneumatization, isolated orbital floor medial, and inferior orbital rim. These fractures can
fractures are infrequent in young children. In older chil- range from minimal displacement to complicated com-
dren, they are more commonly seen as a result of play or minution. cr is essential in operative planning with
sporting injuries. Coronal CT offers the best depiction of axial images demonstrating degree of posterior dis-
these fractures and ophthalmologic evaluation should be placement into the ethmoid sinuses and coronal images
included in the work-up, but serious ocular injury occurs displaying medial wall and orbital floor displacement
in less than 5% of isolated orbital blow-out fracture (43). (Fig. 85.5). Medial canthal tendon integrity should be
Diplopia, enophthalmos, periorbital edema, echymosis, investigated under general anesthesia with a hemostat
and infraorbital hypesthesia can be observed. Fracture inserted intranasally toward the medially orbital rim.
patterns have been described as •trapdoor• or ..saucer" Additionally, intercanthal distance should be mea-
patterns. sured to determine hypertelorism. Although there is
1282 Section V: Trauma

ophthalmologic consultation is required. While 1he Oibit

and the globe rarely suffer significant long-term damage,
concurrent intracranial injuries occur in upwards of 86%
of oibital roof fractures (3,50). This is especially true in
older children where more significant force is required to
fracture the orbital roof. Treatment of such injuries should
be handled in a multidisciplinacy fashion with neurologic
injuries at the forefront
A classification scheme based upon orientation of
the fractured segments has been proposed (50). Type
I fractures have comminution of the orbital roof with-
out displacement. type 11 have displacement of the frag-
ments toward the anterior cranial fossa whereas type
FiguN 85.5 Coronal CT reconstruction of a complex nasoeth-
moidal fracture in a 12-year-old child. Disruptions of the nasomiVIil- III fractures have displacement inferiorly into the omit.
lary buttress are evident on Ute right, the medially orbital wulls Most fractures of the oibital rim do not require opera-
bilaterally, and Ute orbital floor on the left. tive intervention. Type III fractures have been associated
with permanent exophthalmos, vertical dystopia and
considerable variability in intercanthal distance between encephalocele and therefore repair via combined intra-
individuals, the average distance at age 3 is 25, 28 mm cranial and extraaanial approach with calvarial bone
at age 12, and reaching 30 mm in adulthood (48). Five graft can be considered. A period of observation for 7 to
millimeter of widening is suggestive of a displaced frac- 10 days for any resolution of dystopia or exophthalmos
ture while 10 mm is diagnostic. may be prudent in less severe injuries. However, long-
Status of the fragments can aid in treatment planning. term follow-up with imaging is recommended due to the
Fractures can be categorized into three types based upon appearance of late encephalocele. Hallmarks of orbital
fragment status (49). In type I frac:t:urf!a 1he medial canthal encephalocele are vertical dystopia, axial proptosis, and
tendon remains attached to a central fragment of bone, globe pulsation.
type II fractures display comminution of the central frag-
ment without extending deep to 1he anterior lacrimal crest. FRACTURES OF THE FRONTAL SINUS
and type III fractures are severely comminuted.
ORIF is the most reliable method of treatment with Development of the frontal sinus occurs late in childhood;
correction of the intercanthal distance paramount 1herefore, fractures are not common until adolescence.
Overcorrection may result in superior results versus under- Isolated anterior table fractures can occur from sporting
correction. Existing lacerations or bicoronal incisions can injuries, but overall, frontal sinus fractures results from
be used for intervention. Plating, wiring, and calvarial high-impact ttauma and in 70% of cases the posterior table
bone grafts for domal reconstruction may be necessacy. is involved (51). Deformity of the anterior table must be
Wuing can be accomplished by drilling bilateral holes in addressed through reduction, which can be accomplished
the anterior lacrimal crest just above and posterior to the through bicoronal incisions. Careful assessment of the :fron-
anterior insertion of the tendon and in the posterior lac- tal recess should be accomplished both endoscopically and
rimal crest just behind 1he insertion of the posterior limb directly if possible. Posterior table reconstruction should
of 1he tendon. TWenty-eight-gauge Kirschner-wire can be be commenced based upon the same criteria as adults and
threaded through the holes and tightened to desired cor- often with neuroswgical consultation. Long-term follow-
rection. Additional plate stabilization may be required and up with periodic imaging is crucial. Complications can
small screw~ can be used to anchor 1he wires if desired. occur bo1h arutely and late, consisting of CSF leak, intra-
Complications can include poor aesthetic outcome or cranial abscess, and mucopyelocele formation.
rarely lacrimal system injw:y.
CONCLUSION
FRACTURES OF THE ORBITAL ROOF,
SUPRAORBITAL RIM, AND FRONTAL Pediatric patients suffer a somewhat different injury profile
BONE 1han adults with facial trauma Basic tenets of tmumatic sta-
bilization should be obseiVed followed by more directed
Fracture of the orbital roo£ ~ and frontal bone are more evaluation and treatment Under the age of S pediatric
common in young children due to 1he large cranium to patients suffer fewer fractures and a higher proportion of
face ratio and nonpneumadzed frontal sinuses. 'JYpical greenstick fractures due in part to 1he elastic nature of the
history is of a blow to the brow with a late-developing facial slreleton and the somewhat protected environment
hematoma. Other findings such as proptosis or dysto- As children age, fracture patterns begin to resemble those of
pia can occur later and as with other orbital injuries, adults with a higher proportion of mandible and midface
 Chapter 85: Pediatric Facial Fractures 1283

fractures. Howevex; partly due to the rapid healing ability 3. Koltai PJ, Rabkin D, Hoehn J. Rigid fixation of facial fractures in
children. J Craniomaxillofac Thmma 1995;1(2):32-42.
and constant gro~ many fractures can be managed con-
4. Vyas RM, Dickinson BP, Wasson KI. et al. Pediatric fadal fractures:
servatively. When necessary, rigid fixation should consider current national inddence, distribution. and health care resource
potential facial growth abnormalities, but basic principles of use. J Craniofac Swg 2008;19(2):339-349; discussion 350.
prope~; stable reduction should not be sacrificed. Continued
5. Ferreira PC, Amarante JM, Silva PN, et al. Retrospective study of
1251 maxillofacial fractures in children and adolescents. Plast
evolution of absorbable plating systems may help reduce Reconstr SulK 2005;115(6):1500-1508.
potentially deleterious effects of permanent rigid fixation. 6. Smartt JM Jr, Low DW, Bartlett SP. The pediatric mandible: II.
OveralL the evaluation and treatment of pediatric facial Management of traumatic injury or fracture. Plast Reconstr SulK
2005;116(2):28e-41e.
trauma should include consideration for the differential 7. Chapman VM. Fenton IZ, Gao D, et al. Fadal fractures in chil-
injury mechanisms and patterns as well as the potential dren: unique patterns of injury observed by romputed tomogra-
phy. J Comput Assist Thmogr 2009;33( 1) :70-72.
growth implications of the developing facial skeleton.
8. Zimmermann CE, 'Ii'oulis MJ, Kaban LB. Pediatric facial fractures:
recent advances in prevention. diagnosis and management. Int
I Oral Maxillofoc SUIX 2006;35(1):2-13.
9. Roth FS, Kokoska MS, Awwad EE, et al. The identification of
mandible fractures by helical romputed tomography and pan-
orex tomography. J CranWfac SulK 2005;16(3):394-399.
10. Holland AJ, Broome C, Steinberg A, et al. Facial fractures in
• Trauma is the leading cause of death and a major children. Pediatr Emerg Care 2001;17(3):157-160.
source of morbidity in children. 11. Manson PN, Markowitz B, Mirvis S, et al. Toward Cf-based
• Nasal fractures are the most common facial bone facial fracture treatment. Plast Reconstr SUTX 1990;85(2):202-212;
discussion 213-204.
fractured in children. Mandible fractures are the 12. Arbogast KB, Durbin DR. Kallan MJ, et al. The role of restraint
most common facial fracture among children hos- and seat position in pediatric fadal fractures. J 1tauma
pitalized for trauma. 2002;52(4 ):693 -698.
13. Thompson DC, Rivara FP, Thompson R. Helmets for preventing
• Facial growth and development is closely related to head and fadal injuries in bicyclists. CochramJ DatabasB Syst Rev
fracture patterns and the potential for future growth 2000(2):CD001855.
alteration. 14. Chan J, Putnam MA, Feustel PJ, et al. lhe age dependent rela-
tionship between fadal fractures and skull fractures. Int J Putiatr
• Midface and condylar fractures are associated with Owrhinolaryngol2004;68(7):877 -881.
the greatest risk for growth disturbances. 15. Enlow DH HM. Essentials of facial growth. Philadelphia, PA: WB
• Conservative approaches to reduction are more Saunders, 1996.
16. LeakeD, Doykos J IlL Habal MB, et al. Long-term follow-up of
desirable with 0 RIF reserved for fractures that can- fractures of the mandibular rondyle in children. Plast Reconstr
not be stabilized by less invasive methods. Surg 1971;47(2):127-131.
• If internal fixation is necessary under age 13, an 17. li z. Zhang W, li ZB, et al. Mechanism in favorable progno-
sis of pediatric condylar fractures managed by dosed proce-
understanding of tooth bud position and the role dures: an experimental study in growing rats. Dent Thmmatol
for monocortical screw placement is essential. 2010;26(3):228-235.
• In nasal injuries, septal hematoma should be ruled 18. Demianczuk AN, Ven:here C, Phillips JH. The effect on facial
growth of pediatric mandibular fractures. J Craniofoc SulK
out and edema may require observation to assess for 1999;10(4):323-328.
displaced bones. 19. Norholt SE, Krishnan V. Sindet-Pedersen S, et al. Pediatric ron-
• Nasooroitoethmoid fractures should be suspected dylar fractures: a long-term follow-up study of 55 patients. J Oral
Maxillofoc SUTX 1993;51(12):1302-1310.
with high force traumas, dorsal nasal flattening. or 20. Bernstein L. Early submucous resection of nasal septal cartilage.
CSF rhinorrhea. A pilot study in canine pups. An:h Otolaryngol1973;97 (3 ):2 73-278.
• Associated neurocrania! injuries are more common 21. Verwoerd CD, Urbanus NA, Nijdam DC. The effects of sep-
tal surgery on the growth of nose and maxilla. Rhinology
in the pediatric trauma patient and should be con- 1979;17(2):53-63.
sidered during the workup. 22. Cupem TM, Middleton CE, Silva AB. Effects of functional septo-
• If MMF is necessary, it should be limited to 2 to plasty on the facial growth of ferrets. An:h Otolaryngol Head Neck
SUIX 2001;127 (11):1367-1369.
3 weeks, followed by 6 to 8 weeks of elastic bands. 23. Aizenbud D, Morrill LR, Schendel SA. Midfadal trauma and
• Orbital fractures should consider muscular entrap- fadal growth: a longitudinal case study of monozygotic twins.
ment where early surgery is indicated. Observation Am J Ortlwd Dentofocial Orthop 2010;138(5):641-648.
24. Dispenza F. Saraniti C, Sdandra D, et al. Management of nasa-
may be appropriate in other isolated injuries. septal deformity in childhood: long-term results. Auris Nasus
Lai}"U 2009;36(6):665-670.
25. Koltai PJ, Rabkin D. Management of facial trauma in children.
Pediatr Clin North Am 1996;43(6):1253-1275.
26. Connelly SM, Smith RJ, Effects of rigid plate fixation and subse-
REFERENCES quent removal on craniofacial growth in rabbits. Arch Otolaryngol
Head Neck SUIX 1998;124(4):444-447.
1. Imahara SD, Hopper RA. Wang J, et al. Patterns and outromes 27. Laurenzo JF. Canady JW, Zimmerman MB, et al. Craniofacial growth
of pediatric facial fractures in the United States: a survey of in rabbits. Effects of midfad.al surgical trauma and rigid plate fixa-
the National Trauma Data Bank. JAm Coil SulK 2008;207(5): tion. Arr;h Otola1}'11gol Head Neck SUTX 1995;121(5):556-561.
710-716. 28. Berryhill WE, Rimell FL Ness J, et al. Fate of rigid fixation
2. Rowe I. The injured child. In: O'Neil J, ed. Essentials of pediatric in pediatric craniofacial surgery. Otolaryngol Head Neck SulK
SU1Xe1J'· St. Louis, MO: Mosby. 1995. 1999;121(3):269-273.
1284 Section V: Trauma

29. O'Connell J. Murphy C, Ikeagwuani 0, et al. The fate of titanium 39. EggenspergerWymann NM. Holzle A, Zachariou Z. et al. Pediatric
miniplates and screws used in maxillofacial surgery: a 10 year craniofacial trauma. J Oml Maxillofac Surg 2008;66(1):58-64.
retrospective study. Int J Oral Max~11ofac Surg 2009;38(7): 40. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygo-
731-735. matic fractures. Plast Ruurutr Surg 2007; 120(7 Suppl 2) :5S-15S.
30. Imola MJ. Hamlar DD, Shao W. et al. Resorbable plate fixation 41. Hatton MP, Watkins LM, Rubin PA Orbital fractures in children.
in pediatric craniofacial surgery: long-term outcome. An:h Facial Ophthal Plast Reconstr Surg 2001;17(3):174-179.
Plast Surg 2001;3(2):79-90. 42. Alcala-Galiano A, Arribas-Garcia IJ. Martin-Perez MA, et al.
31. Kasrai L. Hearn T. Gur E, et al. A biomechanical analysis of the Pediatric facial fractures: children are not just small adults.
orbitozygomatic complex in human ~: examination Radiographies 2008;28(2):441-461; quiz 618.
of load sharing and failure patterns following fixation with 43. Holt GR. Holt JE. Management of orbital trauma and foreign
titanium and bioresorbable plating systems. J Craniofac Surg bodies. Owlaryngol Oin NorthAm 1988;21(1):35-52.
1999;10(3):237-243. 44. Jordan DR, Allen LH.. White J. et al. Intervention within days for
32. Eppley BI. Use of resorb able plates and screws in pediatric facial some orbital floor fractures : the white-eyed blowout. Ophthal
fractures. J Oral Max~11ofac Surg 2005;63(3):385-391. Plast Reconstr Surg 1998;14(6):379-390.
33. Graham SM, Thomas RD, Carter KD, et al. The transcar- 45. Sires BS. Orbital trapdoor fracture and orul.ocardiac reflex.
unrul.ar approach to the medial orbital wall. Laryngoscope Ophthal Plast Reconstr Surg 1999;15(4):301-302.
2002;112(6):986-989. 46. Egbert JE, May K.. Kersten RC, et al. Pediatric orbital floor frac-
34. Alvarez H, Osorio J. De Diego JI. et al. Sequelae after nasal ture: direct extraorul.ar muscle involvement Ophthalmology
septum injuries in children. Auris Nasus LaiY"X 2000;27(4): 2000;107(10):1875-1879.
339-342. 47. Cole P, Kaufman Y, Hollier I. Principles of facial trauma: orbital
35. Lee wr, Koltai PJ. Nasal deformity in neonates and young chil- fracture management. J Craniofac SulK 2009;20 ( 1):101-104.
dren. Pediatr Clin NorthAm 2003;50(2):459-467. 48. Morin JD. Hill JC, Anderson JE. et al. A Study of growth in the
3 G. Kamboozia AH, Punnia-Moorthy A. The fate of teeth in mandib- interorbital region. Am J Ophthalmol1963;56:895-901.
ular fracture lines. A clinical and radiographic follow-up study. 49. Potter JK. Muzaffar AR. Ellis E, et al. Aesthetic management ofthe
Inti Oml Maxillofac Surg 1993;22(2):97-101. nasal component of nasa-orbital ethmoid fractures. Plast Reconstr
37. Thoren H, Hallikainen D, Iizuka T, et al. Condylar process frac- Surg 2006;117(1):10e-18e.
tures in children: a follow-up study of fractures with total dislo- 50. Messinger A, Radkowski MA, Greenwald MJ. et al. Orbital
cation of the oondyle from the glenoid fossa. J Oral Maxillofac roof fractures in the pediatric population. Plast Reconstr Surg
SulK 2001;59(7):768-773; discussion 773-764. 1989;84(2):213-216; discussion 217-218.
3 8. Casey RP, Bensadigh BM, Lake MT, et al. Dentoalveolar trauma in 51. Wright DL Hoffman HT, Hoyt DB. Frontal sinus fractures in the
the pediatric population. J Craniofac Surg 2010;21 (4): 1305-1309. pediatric population. Laryngoscope 1992;102(11):1215-1219.