Thursday, June 1, 2017

Complications in Pediatric Facial Fractures


Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: John Diune                                                                                        Date: 6/1/2017

Article Title: Complications in Pediatric Facial Fractures
Author(s): Mimi Chao, MD and Joseph Losee, MD
Journal: Craniomaxillofacial Trauma Reconstruction
Date: 2009
Major Topic: Pediatric Trauma
Type of Article: Review of Literature
Main Purpose: Present classification system to evaluate adverse outcomes with ped facial trauma and present current adverse outcomes in literature dealing with management of pediatric facial trauma
Key Points/Summary:
 
Pediatric facial fractures comprise 3%-6% of all facial fractures
-          But complex due age-related facial anatomy and also growth biology
 
Current reported rates of post-injury adverse outcomes are likely biased and incorrect per authors
-          Need classification system to allow for more consistent reporting of adverse complications in pediatric facial fracture management
-          Proposed Classification system:
1.       Type 1 – those intrinsic to or concomitant with fracture itself
2.       Type 2 – those secondary to intervention and surgical management
3.       Type 3 – those resulting subsequent normal or abnormal growth and development
 
Adverse outcomes associated with facial fractures
-          Due to large cranium-to-body ratio Pediatric facial fractures are highly associated with injury to skull and brain (47%)
o   Skull fractures occur in 50% of craniofacial fractures in children (Wymann et al)
o   5% incidence of brain injury in children with craniomaxillofacial trauma (Gassner etal)
o   Ocular trauma – associated with increased likelihood especial fractures to midface and frontal region
§  reported 20%-24% incidence of blindness with orbital and midfacial fractures
§  50% incidence of ocular injuries with orbital fractures
§  Recommend formal ophthalmic consultation for children with facial fractures
o   Soft tissue injuries (39% and 55.6%) can lead to poor scarring
§  6.5% had unsightly scars as part of long-term morbidity after facial fracture
o   Dentoalveolar injuries often in combination (48% incidence) – more in children less than 10 years old
o   Post-traumatic nerve injury – sensory nerve disturbances range from 3.8% to 23.9%
 
Adverse outcomes associated with specific fracture


-          Frontal/Basal skull fractures
o   Before development of frontal sinus – trauma to frontal skull results in “craniofacial” fractures extending to facial bones and posteriorly to cranial base/orbital floor
§  In pediatric population – frontal bone, superior orbital roof and anterior cranial base comprise upper half of orbit
o   Basal skull fractures/cribriform plate fractures highest risk of CSF rhinorrhea or otorrhea
§  85% of CSF leaks following craniofacial fractures resolve spontaneously within 1 week with conservative treatment
-          Orbital Roof Fractures
o   Incidence as high as 13%
o   Temporal periorbital edema and ecchymosis
o   More serious pneumocephalus, dural tears, cerebral hemorrhages and contusions
o   Acute management dictated by ocular and neurological signs and symptoms
-          Growing skull fractures
o   Late complication of skull fracture – occurs well after initial time of injury
o   Seemingly benign bony fracture can be associated with silent dural tear or partial dural disruption – resulting in brain being driven through an enlarging fracture
o   Study by Prior – incidence 0.03% to 1 % and mainly in children < 3yo
o   Typical presentation: diplopia, proptosis, pulsatile exophthalmos, eyelid swelling, orbital asymmetry
o   Prompt imaging and treatment if suspected
-          Orbital floor fractures
o   Pure orbital fractures (not involving orbital rim or zygoma) higher in pediatric patients
§  May not require repair in majority of case – 3 of 32 children required surgery (Losee et al)
o   Diplopia
o   Another adverse complication is entrapment of inferior rectus muscle or orbital soft tissue in a “trapdoor”-type fracture
§  Present with oculocardiac reflex (decrease heart rate) and bradycardia, nausea, and syncope and extraocular muscle motility restriction and pain
§  Ischemic necrosis of the entrapped tissue can occur 72 hours after injury
o   Prompt surgical interevention
 
-          Zygomaticomaxillary complex fractures
o   Greenstick facial fractures especially common in pediatric zygoma and midface fractures
o   Complications: persistent hypothesia in infraorbital nerve (V2) distribution, enophthalmos, facial widening, flattening of malar region
o   Lower eyelid surgical approach risk of poor scarring and ectropion (eyelid away from eyeball)
o   6.2% complication rate (Gomes et al) for ZMC fractures
§  Infection, hypertrophic scar, ectropion, scleral show
-          Nasal fractures
o   Some pediatric series report this as most common pediatric facial fracture while others consider associated injury
o   Pediatric population – avoid aggressive open septorhinoplasties until skeletal maturity; early closed reductions recommended (seen in Hasbro)
o   Secondary corrections may be needed at skeletal maturity
-          Le Fort/Maxillary/Midfacial fractures
o   Most common midfacial fractures isolated to maxillary alveolar ridge fractures and possibly nasal fractures
§  <6 yo children incidence of alveolar fracture as high as 60% of all facial fractures
§  With increasing age, incidence of alveolar ridge fracture decreases with increase of typical maxillary fractures (changes in maxilla and enlargement of sinuses)
o   Le Fort pattern rarely seen in younger children prior to permanent dentition
o   Placement of internal fixation hardware challenging and risky in patients in primary or mixed dentition
 
-          Mandibular fractures
o   Type of condylar fractures  varies with age
§  <5 yo likely to sustain intracapsular fractures and condylar neck fractures
§  With increasing age fracture sites shift inferiorly
o   Greatest risk for significant growth distrubances (Demianczuk et al)
§  4-7 yo and 7-11 yo (24% and 16% needing surgery)
§  Prior to 4yo condylar region receives increased blood flow à regeneration
§  After 12yo majority of growth attributed to condyles complete
o   Long-term mid-line deviation possible
o   TMJ ankylosis infrequent
§  Caused by delayed diagnosis and treatment, prolonged maxilla-mandibular fixation (MMF), and crush-type injury to condylar head
 
Adverse outcomes associated with surgical repair of the fracture
-          Resorbable plates and screws offer potential solution to growing pediatric facial bone
o   Initially not recommended for holding reductions
o   But gaining in use with time and experience
o   Surgical complication incidence with reduction and fixation of facial fractures <5%
 
 
Useful resource:
https://www2.aofoundation.org/wps/portal/surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment of Article:  Level of Evidence/Comments:
 
 
 
 
 
 
 
 
 
 

 

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