The In’s and Out’s of
Pediatric Maxillofacial Trauma
Wellington J. Davis III, MD, FACS
Section of Plastic and Reconstructive Surgery
St. Christopher’s Hospital for Children
Philadelphia, 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:
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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:
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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
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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
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CT scan with thin cuts
Axial
Coronal,
Sagittal views
Panorex
Work-Up
• Consultations
– Maxillofacial surgeon
• Plastics
• ENT
• OMFS
– Dental
– Ophthalmology
– Neurosurgery
Types of Fractures
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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
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CSF leak
Dural Tear
Aesthetic deformity
Mucocele
Nasofrontal duct obstruction
Intervention: Immediate to 7 days
Types of Fractures
• Naso-orbital-ethmoid
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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
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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
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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
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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
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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:
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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
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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 2448 hours to decrease risk of infection
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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:
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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
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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
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Seizures (depressed skull fractures)
Mucocele
Tear duct obstruction
Enophthalmos
Ectropion
Malocclusion
Retrobulbar hematoma
Corneal abrasion
Scar Management
• Nonsurgical
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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
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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?