The In’s and Out’s of Pediatric Maxillofacial Trauma

1. 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

2. Introduction • Maxillofacial trauma evaluation • Key problems and Work-Up • Classification of fractures and associated clinical problems • General management • Scar management

3. Initial Survey • Control airway and breathing • Control bleeding • Resuscitation • Head injury-GCS? • R/O C-spine injury • Associated with 10% of maxillofacial injuries

4. Initial Survey • Control airway • In-line stabilization • Oral intubation possible in almost all cases • Rarely tracheostomy needed • Check for aspiration teeth/blood

5. Initial Survey • Airway Issues • May revisit airway for surgery • Nasotracheal intubation • Tracheostomy • Wire cutters to bedside

6. Initial Survey • Control bleeding • Address the scalp • Whip-stitch vs. staples • Pressure dressing • Nasal packing • Foley catheters • Fracture reduction • Arch bars • Angiography and embolization

7. Initial Survey • Resuscitate • Hb/Hct • 2 large bore IV’s • Neurologic status • GCS? • C-spine injury

8. 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

9. Secondary Survey • Systemic Evaluation for: • Dentition • Occlusion • Ophthalmologic injury/vision • Recheck for C-spine injury • CSF leak

10. Secondary Survey • Check for lacerations • Scalp • Retroauricular • No real contraindication to closure based on time of injury • Absorbable sutures acceptable and preferable

12. 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

13. 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

14. 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

15. Secondary Survey • Re-check the neck • CSF leak, dural tear • Beta-transferrin

16. Work-Up • Labs • CBC • Type and Cross • Imaging • CT scan with thin cuts • Axial • Coronal, • Sagittal views • Panorex

17. Work-Up • Consultations • Maxillofacial surgeon • Plastics • ENT • OMFS • Dental • Ophthalmology • Neurosurgery

18. 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

19. Types of Fractures • Frontal Sinus Fractures • CSF leak • Dural Tear • Aesthetic deformity • Mucocele • Nasofrontal duct obstruction • Intervention: Immediate to 7 days

20. Types of Fractures • Naso-orbital-ethmoid • Saddle nose deformity • Telecanthus • Widening of medial canthi • Enophthalmos • Intervention: Immediate to 7 days

21. NOE Fracture Osler Archives

22. CT Scan.

27. Types of Fractures • Orbital fracture • Eye exam • Step-off • Ophthalmology • Enophthalmos in unrepaired fracture • Retinal tear • Corneal abrasions • Intervention: 5-7 days

28. Orbital Floor Fracture

29. Imaging

30. Intra-op

31. Post-op

32. Medial Wall Fracture With Entrapment

33. Imaging

34. Types of Fractures • Maxillary and zygomatic fractures • Occlusion problems • Facial lengthening or widening • Contour deformity • Intervention: 5-7 days

35. Panfacial Fracture Courtesy of Tony Holmes Royal Children’s Hospital

36. 3D CT scan

37. Intra-op

38. Intra-op

39. Types of Fractures • Nasal Fractures • Aesthetic deformity • Airway obstruction • Isolated nasal fracture clinical diagnosis • Imaging not mandatory • Intervention: 5-7 days

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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 infection

48. 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.

49. 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

50. 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