The In’s and Out’s of Pediatric Maxillofacial Trauma
Wellington J. Davis III, MD, FACSSection of Plastic and Reconstructive Surgery
St. Christopher’s Hospital for ChildrenPhiladelphia, PA
Introduction
• Maxillofacial trauma evaluation• Key problems and Work-Up• Classification of fractures and associated
clinical problems• General management• Scar management
Initial Survey
• Control airway and breathing• Control bleeding
– Resuscitation• Head injury-GCS?• R/O C-spine injury
– Associated with 10% of maxillofacial injuries
Initial Survey
• Control airway– In-line stabilization– Oral intubation possible in almost all cases– Rarely tracheostomy needed
• Check for aspiration teeth/blood
Initial Survey
• Airway Issues• May revisit airway for surgery
– Nasotracheal intubation– Tracheostomy
• Wire cutters to bedside
Initial Survey
• Control bleeding– Address the scalp
• Whip-stitch vs. staples• Pressure dressing
– Nasal packing– Foley catheters– Fracture reduction
• Arch bars– Angiography and embolization
Initial Survey
• Resuscitate– Hb/Hct– 2 large bore IV’s
• Neurologic status– GCS?– C-spine injury
Secondary Survey• Systematic evaluation for:
– Lacerations– Palpate for bony step-off at bony prominences– Mid-facial stability– Check sensation in trigeminal distribution– Check facial nerve function
Secondary Survey
• Systemic Evaluation for:– Dentition– Occlusion– Ophthalmologic injury/vision– Recheck for C-spine injury– CSF leak
Secondary Survey
• Check for lacerations– Scalp– Retroauricular
• No real contraindication to closure based on time of injury
• Absorbable sutures acceptable and preferable
Secondary Survey
• Palpate step-offs– No step-off, CT scan may not be indicated
• Bimanual maxillary exam• Critical to document sensation and vision prior to
surgery• Facial nerve evaluation
– Raise brows– Eye closure– Puff cheeks– Smile
Secondary Survey
• Look in the mouth– Empty sockets?– Chipped teeth?
• Chest x-ray check for teeth• Check the bite
– Patient can detect a poppy seed b/w teeth– Occlusion test very sensitive for mandibular or
maxillary fractures
Secondary Survey
• Ophthalmology evaluation– All orbital fractures especially in operative cases– Check for entrapment
• Limited EOM• Generally painful• Emergent
– Hyphema emergency– Retinal tears– Corneal abrasions
Secondary Survey
• Re-check the neck• CSF leak, dural tear
– Beta-transferrin
QuickTime™ and a decompressor
are needed to see this picture.
Work-Up• Labs
– CBC– Type and Cross
• Imaging– CT scan with thin cuts– Axial– Coronal,– Sagittal views– Panorex
Work-Up
• Consultations– Maxillofacial surgeon
• Plastics• ENT• OMFS
– Dental– Ophthalmology– Neurosurgery
Types of Fractures
• Frontal sinus (anterior, posterior)• Naso-orbital-ethmoid• Orbit• Nasal fractures• Maxilla and zygoma
– ZMC– Lefort fracture
• Mandibular – Condyle, coronoid, ramus, body, symphysis
Types of Fractures
• Frontal Sinus Fractures– CSF leak– Dural Tear– Aesthetic deformity– Mucocele– Nasofrontal duct obstruction– Intervention: Immediate to 7 days
Types of Fractures
• Naso-orbital-ethmoid– Saddle nose deformity– Telecanthus– Widening of medial canthi– Enophthalmos– Intervention: Immediate to 7 days
NOE Fracture
Osler Archives
CT Scan.
Types of Fractures
• Orbital fracture– Eye exam– Step-off– Ophthalmology– Enophthalmos in unrepaired fracture– Retinal tear– Corneal abrasions– Intervention: 5-7 days
Orbital Floor Fracture
Imaging
Intra-op
Post-op
Medial Wall Fracture With Entrapment
Imaging
Types of Fractures
• Maxillary and zygomatic fractures– Occlusion problems– Facial lengthening or widening– Contour deformity– Intervention: 5-7 days
Panfacial Fracture
Courtesy of Tony Holmes Royal Children’s Hospital
3D CT scan
Intra-op
Intra-op
Types of Fractures
• Nasal Fractures– Aesthetic deformity– Airway obstruction– Isolated nasal fracture clinical diagnosis– Imaging not mandatory– Intervention: 5-7 days
Types of Fractures
• Mandible fractures– Occlusion problems– Aesthetic deformity– Antibiotics needed, considered an open fracture
in mouth– Generally warrant aggressive surgical
management– Intervention: 2-5 days
Associated Soft-Tissue Injuries
• Extensive lacerations eyelid, eyebrow, nose, lip, ear• Mucosal and tongue lacerations• Alveolar ridge fractures• Tear duct injuries• Stenson’s duct injury• Globe injuries• Hyphema• Retinal tears
Associated Soft-Tissue Injuries
• Facial nerve injury• Infraorbital nerve injury• Inferior alveolar nerve injury• Mental nerve injury• Supraorbital nerve injury• Sensory nerve function important for
documentation
General Management of Maxillofacial Fractures
• Management Based On:– Type of fracture– Location of fracture– Amount of displacement– Timing of injury– Age of patient (Mandible)– Surgical approach based on surgeon experience,
principles the same
General Management of Maxillofacial Fractures
• Only 15-20% of maxillofacial fractures are operative
• Non-displaced fractures– Consider outpatient management with early follow-up
24-48 hours with maxillofacial specialist– No surgery in almost all cases except mandible
• Mandible may require arch bars and wiring based on location of fracture
General Management of Maxillofacial Fractures
• Unstable patients– Arch bars minimum in maxillary or mandibular fractures
• If poor GCS but hemodynamically stable best to repair most severe fractures in the usual time frame 5-7 days
• Why?– Major functional problems if patient survives
• Occlusion• Visual • Aesthetics• Difficult to repair secondarily
General Management of Maxillofacial Fractures
• Displaced fractures– ORIF– Bone grafts in complex cases
• Complex cases may benefit from tracheostomy pre-op
• Resorbable plates preferred in pediatric patients
• Potential for growth restriction
General Management of Maxillofacial Fractures
• Timing– Ideally within 5-7 days before bony healing– Isolated orbital fracture could wait longer– Most surgeons prefer for edema to resolve prior
to surgery– Mandible fracture tend to be done early w/i 24-
48 hours to decrease risk of infectionQuickTime™ and a
decompressorare needed to see this picture.
General Management of Maxillofacial Fractures
• Unrepaired fractures may require osteotomies for correction especially if addressed 3 or more weeks after injury.
• Surgery is much more complex and accurate reduction more difficult.
General Management of Maxillofacial Fractures
• Minimal scarring due to craniofacial approaches:– Bicoronal incision– Transconjunctival/Subciliary/Orbital rim– Brow or upper lid incisions– Buccal sulcus incisions– Preauricular– Risdon incision– Gilles approach– Existing lacerations
General Management of Maxillofacial Fractures
• 2-5 hour cases depending on complexity• Generally minimal blood loss• Sometimes multiple teams• Post-op management overnight stay• Monitoring for retrobulbar hematoma in
orbital cases
General Management of Maxillofacial Fractures
• Surgical goals of ORIF:– Restoration of occlusion and aesthetic
appearance– Maintain height and width of face– Management of significant bone loss
• Bone grafting
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
General Management of Maxillofacial Fractures
• Prevent complications – Seizures (depressed skull fractures)– Mucocele – Tear duct obstruction – Enophthalmos – Ectropion– Malocclusion– Retrobulbar hematoma– Corneal abrasion
Scar Management
• Nonsurgical– Sunscreen– Scar massage– Silicone products– Start 3-4 weeks after wound closure– Facemask in severe cases
Scar Management
• Surgical- cases not responding to non-operative treatment– Steroid injection– Laser therapy– Dermabrasion– Scar revision– Serial excision– Tissue expansion
Scar Management
• Scars cannot be removed but most can be improved
• Even “minor” scarring warrants evaluation if only for re-assurance.
• Timing and intervention based on:– Features of scar– Time since injury– Usually minimum of 6 months post-injury
Questions?