The In s and Out s of Pediatric Maxillofacial Trauma

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: – 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

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

3 D 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 2448 hours to decrease risk of infection

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

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?