Pediatric patients rarely encounter injury to the mandible, although this injury is more common than fractures to the midface. This is likely due to the unsupported structure of the mandible. Most injuries are caused by blunt trauma from falls or motor vehicle accidents. Some suggest that the mandible is at extra risk due to the presence of permanent tooth buds, which may lead to a relative thinning of the bone as well as the curvature of the mandible. Mandible injuries are usually accompanied by injury to the tooth, described in the Dental Injuries section of this chapter. The frequency of mandibular fractures increases with age in the pediatric population. The astute clinician will suspect mandibular injury in a patient with pain, swelling, asymmetry, trismus, malocclusion, or the presence of sublingual ecchymosis. Patients may also have damage to the inferior alveolar nerve producing loss of sensation along the mandible to the midline of the lower lip. A laceration should be evaluated to exclude an open fracture. Any finding suggestive of mandibular fracture should prompt suspicion of associated facial or intracranial injury.
Assess and stabilize the patient’s airway and breathing first. CT scan of the mandible alone or in conjunction with maxillofacial views is considered the imaging modality of choice. Dedicated views of these structures will help determine the extent of the injury and may help the specialist plan appropriate treatment options. The most common mandibular fracture in the pediatric patient is “greenstick” fracture (Figure 24–3). This occurs when one cortex wall is broken and the other cortex wall is bent. Pediatric patients have a high healing rate of the periosteum, which leads to faster healing.
Confirmed mandible fracture should be considered open, given the adjacent teeth, and broad-spectrum antibiotics are typically recommended. Consultation with an oral surgeon or maxillofacial surgeon is indicated.
Greenstick fracture of the mandible: The CT demonstrates bilateral mandibular condylar fractures in a 12-year-old. The left fracture (arrow) is an incomplete (greenstick) fracture. (Reproduced, with permission, from Shah BR, Lucchesi M (eds): Atlas of Pediatric Emergency Medicine, 2nd ed. McGraw-Hill, 2013. Copyright © McGraw-Hill Education LLC.)
Management of a greenstick fracture without displacement or malocclusion is conservative.
Reduction of a mandibular fracture does pose a challenge and should be performed by an oral or maxillofacial surgeon. Closed reduction with splinting is preferred in most patients with mandibular fracture. Open reduction may need to be performed in some patients, and with recent advances in materials, complications are fewer.
et al.: Management of mandibular body fractures in pediatric patients: A case report and review of the literature. Contemp Clin Dent
R: Pediatric mandibular fractures: Introduction of a novel therapeutic modality. J Trauma
Patients who sustain fractures to the midface or mandible often have associated dental injury. The incidence is higher in the anterior teeth, and is common in younger children learning to mobilize and with less developed coordination. Regaining occlusion is important in caring for the patient with dental injury, as well as identifying any potential underlying fracture.
Patients may present to the emergency department after isolated trauma results in damage to one or more of the primary or secondary teeth. Damage may range from a small crack or chip to complete avulsion. Understanding how to manage the pediatric patient is critical. Treatment of dental injuries is focused primarily on survival of the secondary tooth. Damage to a primary tooth is not critical, as it will normally be replaced by the emergence of the secondary tooth. Figure 24–4 diagrams the anatomy of a tooth.
Tooth anatomy in cross-section. (Reproduced with permission from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
Dental fractures through the enamel are usually managed as an outpatient with dental referral. However, damage that goes through to the dentin or pulp should be addressed in the emergency department. Untreated, these injuries may result in necrosis or infection and timely management is indicated.
Ellis classification is commonly used to describe the dental layers involved in the fracture. Ellis I fractures involve the enamel, whereas Ellis II and Ellis III fractures involve the dentin and pulp, respectively (Figure 24–5).
Ellis classification of dental fractures. (Reproduced with permission from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
Dental Fractures and Temporary Seals
A fractured tooth warrants a temporary seal placed in the emergency department. Prior to attempting temporary seal of the tooth, provide adequate analgesia as the exposed pulp and dentin are very sensitive. Consider performing a nerve block or providing systemic analgesics. Several commercially available preparations may be placed over the fractured tooth to seal it, with calcium hydroxide being one of the more common applications. Apply the mixture over the fractured tooth and allow to dry, forming a seal over the fracture site.
Replacement of a Tooth Avulsion
Dental avulsion, displacement of a tooth from its normal anatomical position, may also occur. The first step in managing the patient is locating the missing tooth. Avulsed teeth pose an aspiration hazard to the patient. Attempts at reimplanting an avulsed tooth should be made with a secondary tooth only. Time is critical in replacing a secondary tooth as the periodontal ligament may become necrotic. Scrubbing the avulsed tooth may damage the periodontal ligament and is not recommended. Placing the avulsed tooth in a container of milk may help slow the death of the cells associated with the periodontal ligament.
Attempting to replace the avulsed tooth is usually painful. Provide the patient with sufficient analgesia or anesthesia. If the buccal evaluation reveals significant trauma, attempting to replace the avulsed tooth should not occur. Gently suction the socket to remove any blood clot and gently irrigate the area with saline. Blood clot that remains in the dental socket may inhibit anatomic alignment of the tooth. It is important not to damage the periodontal ligament that is lining the socket. Gently, and with firm pressure, insert the tooth into the socket in anatomic alignment. The tooth will need to be splinted in place, typically with temporary adhesive and a short section of wire.
On occasion dental trauma may be associated with a fracture of the alveolar ridge, the section of the maxilla or mandible where the teeth normally reside. This is more common when multiple teeth are displaced or undergo luxation. These injuries may be noted on physical examination as a section of teeth, or an individual tooth that is misaligned and partially mobile. If the section is mobile and poses an aspiration risk, splinting should be performed in the emergency department before disposition.
Most patients with dental injuries with appropriate hemostasis can be discharged home. After placement of a temporary seal over a fractured tooth, follow-up with a dentist for definitive care is indicated. Reassessment after secondary tooth avulsion and emergency department replacement is urgent and definitive dental follow-up care should be arranged. Repair of alveolar ridge fractures should be done by an oral surgeon or dentist as soon as possible, preferably within the first 24 hours after injury. Definitive care with a dentist or oral surgeon should be arranged prior to discharge.
et al.: Dental Injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofac Surg
et al.: Dental injuries in association with facial fractures. J Oral Maxillofac Surg
MAXILLARY (LE FORT) FRACTURES
Midface fractures in the young pediatric patient are rare. Some authors have hypothesized that this finding is due to the elasticity of the skeletal structure as well as the midface being less prominent than in the adult. In addition, the pediatric patient younger than 5 years does not have a well-aerated sinus system, likely adding to the protection of the midface. Midface fractures in children younger than 5 years are reported to be fewer than 1% of fractures and are primarily caused by blunt trauma.
As the pediatric patient enters adolescence, the skeletal structure develops to resemble that of an adult and the sinus cavities become aerated. This is believed to play a role in the increase of sinus fractures in adolescent patient population. The presence of a facial fracture following blunt trauma, primarily from motor vehicle collisions, is associated with a higher injury severity score and longer hospital stay in patients requiring admission.
The Le Fort classification system is classically used to describe typical patterns of injury to the maxilla. Three different types are described, and all involve the pterygoid plate. The fracture may be unilateral or bilateral. The classification system is useful when discussing a patient’s injuries with a specialist. Le Fort fractures are associated with a significant mechanism of injury, and require a broader consideration of associated injuries, particularly to the brain and cervical spine.
Le Fort I fractures are roughly horizontal in nature, across the maxilla above the dental structures and teeth. These fractures communicate with the nasal opening(s) inferiorly. These fractures lie below the zygomaticomaxillary complex (ZMC) junction. Essentially, the upper jaw and teeth are disassociated from the upper midface.
Le Fort II fractures involve the maxilla as in a Le Fort I fracture, but extend superiorly and through the zygomaticomaxillary buttress, including the orbital floor and inferior rim. They may involve the medial orbital wall and nasal septum and have a pyramidal shape. The nasal region and maxilla are separated from the other facial bones.
Le Fort III fractures includes the entire zygomatic arch, across the orbit(s), and through the nasal and ethmoid bones. These fractures are referred to as craniofacial disjunctions, as the maxilla, zygoma, and naso-orbital-ethmoid complex are divided from the cranium. Figure 24-6 demonstrates the different appearances of Le Fort fractures.
Le Fort fracture classification system. (Reproduced with permission from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
Patients with Le Fort fractures usually present with obvious apparent facial trauma. Swelling, ecchymosis, mobility, and deformity vary according to underlying injury. Malocclusion is commonly reported. In a Le Fort I fracture, the patient may have a swollen upper lip and grating sensation when the hard palate is palpated. If the fracture is bilateral, the maxilla may feel unstable to the examiner.
A Le Fort II fracture may have worse deformity, including a widening of the intercanthal space. Infraorbital ecchymosis is likely. Mobility of the maxilla and hard palate will be notable mobile on examination.
A Le Fort III fracture will reveal more significant and complete facial mobility when manipulated. Significant swelling and ecchymosis are usually present, as well as elongation and flattening of the facial appearance.
Assess the face on each side for orbital entrapment, nerve deficits, and mobility. Examine the patient carefully for associated injuries.
Most fractures to the maxilla and zygoma are identified on a dedicated maxillofacial CT scan. As these injuries result primarily from blunt trauma, a thorough evaluation of the patient is indicated. Head and cervical spine CT scans are usually indicated. Involve a facial surgeon early when a Le Fort fracture is identified.
Le Fort I and II fractures are rarely associated with airway complications. A Le Fort III fracture may have airway involvement due to edema and dissection of expanding hematomas. Consider securing the airway early, but avoid use of nasotracheal or nasogastric tubes.
The facial surgeon should determine the disposition of patients with a Le Fort fracture. Cosmetic and functional damages are usually surgically repaired. Most patients are admitted for observation, if surgical repair is not immediately planned.
et al.: Management of midface maxillofacial trauma. Atlas Oral Maxillofac Surg Clin N Am
ZYGOMATICOMAXILLARY COMPLEX FRACTURE
The zygomaticomaxillary complex (ZMC) is composed of the lateral and inferior orbital rims, as well as the ZMC buttress and zygomatic arch. The fracture lines are through the inferior rim, zygomatic-temporal junction, and zygomatic-frontal suture (Figure 24–7). The fracture through the three areas is commonly termed, “tripod fracture.” Because of the involvement of two sides of the orbit, injury in this area has potentially significant impact on the integrity of the orbit, intraorbital structures, and eye.
Tripod (zygomaticomaxillary complex) fracture. (Reproduced with permission from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
Dramatic swelling, pain, and local ecchymosis are common in a ZMC fracture. Subconjunctival hemorrhage and a malpositioned globe point to this injury. Diplopia on examination is possible. The infraorbital nerve may be damaged causing decreased sensation. Palpable emphysema and step-offs may be noted on careful examination. A majority of paresthesias noted on examination may become permanent, and careful documentation of sensory loss is warranted.
A CT scan of the maxillofacial structures and orbits is warranted. Fractures and soft tissues, including the globe, extraocular muscles, and nerves can be seen with modern scans. Three-dimensional reconstruction images, when available, offer a clearer picture of the damage. Evaluation by a specialist is indicated when diagnosis is confirmed. Early surgical fixation is indicated with displaced fracture fragments or extraocular muscle entrapment.
Consultation with a maxillofacial surgeon should both be arranged in the emergency department for patients with a ZMC fracture. An ophthalmologist should be consulted, especially if intraorbital complications such as ruptured glove or retrobulbar hematoma occur. Most patients should be admitted if immediate surgical repair is not planned.
et al.: Assessment for treatment of tripod fractures of the zygoma with microcompressive screws. J Oral Maxillofac Surg
Orbital fractures present with various symptoms dependent on the fracture, associated swelling and displacement. Associated injuries range from simple contusion, to adjacent laceration, to globe injury. Most orbital fractures are the result of physical assault or motor vehicle collision.
At minimum, examination should test visual acuity, as well as presence of visual field deficit or diplopia throughout all extraocular movements. Pupillary response and integrity of the globe should be assessed. Palpate the orbital rim for deformity, and observe for enophthalmos and exophthalmos.
As the pediatric patient becomes the adolescent patient, injury patterns resemble those in adults. However, in the younger pediatric patient, injuries that are sustained may differ from adults. The orbital roof is more likely to be fractured in the younger pediatric patient because of the relatively large size of the cranium and absence of pneumatization of the sinuses. There is a strong association of orbital roof fractures with intracranial abnormality and frontobasal fractures.
Apparent injury to the globe should prompt noncompressing coverage of the eye and emergent ophthalmologic consultation. Additional orbital wall injuries may occur in the pediatric patient. Fractures of the medial or inferior orbital wall may occur as the patient enters adolescence because of the pneumatization of the sinuses. Both orbital floor and medial wall fractures may lead to ocular-muscle entrapment. Detailed physical examination will allow for these fractures to be suspected prior to imaging. A slit lamp examination with fluorescein staining will help evaluate for globe injury. The positive presence of a Seidel sign (fluorescein flowing at the site of injury) indicates a penetrating globe wound.
CT imaging is indicated for suspected orbital wall injuries. Complete maxillofacial and head CT scans are usually performed, but some hospitals have dedicated orbital CT protocols with greater precision. Evaluation for entrapment of extraocular muscles, in addition to assessment for fractures and globe injury, may require coronal and sagittal images.
Pupillary defect, apparent entrapment, or open globe injury are indications for emergency ophthalmologic consultation. All orbital fractures should be discussed in consultation with an ophthalmologist to form a plan of care.
Most pediatric patients with diagnosed orbital fractures are admitted for observation and detailed examination. Nondisplaced, closed orbital roof fractures are usually managed nonoperatively in children. However, thorough ophthalmic evaluation may be required to exclude ocular injury. This may prove difficult in younger children, who often require examination under sedation. If a specialist is unavailable, or examination cannot be reliably performed, transfer of the patient to a trauma center is recommended. Isolated and nondisplaced fractures with no evidence of entrapment rarely require surgical intervention. However, evaluation for concomitant traumatic injury is prudent.
et al.: Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg
SR: Overview of pediatric orbital fractures. J Craniofac Surg
D, Di Rocco
et al.: Complex pediatric orbital fractures combined with traumatic brain injury: Treatment and follow-up. J Craniofac Surg
RC: Medial wall fracture: An update. Craniomaxillofac Trauma Reconstr
Patients with nasal fractures commonly present after anterior-posterior directed blunt trauma to the face. Injury may be either isolated or in conjunction with other midface injuries. Unilateral or bilateral epistaxis, nose pain, nasal septal deviation and hematoma, nasal deformity, and septal mucosal injury are likely clinical findings associated with a nasal fracture.
Nasal fractures may exist in combination with other injuries to the midface. Simple nasal injuries do not require imaging to diagnose. However, associated adjacent injuries should be excluded when the mechanism or examination suggests additional injury. Primarily caused by blunt trauma, naso-orbito-ethmoid fractures may result from significant force (Figure 24–8). The literature suggests that these types of injuries may account for up to 15% of pediatric facial fractures. The affected area is usually significantly swollen, and may have ipsilateral increased lacrimation and loss of structural nasal support. A CT scan of the maxillofacial structures will reliably confirm or exclude such fractures.
With all nasal injuries, the clinician should evaluate the patient for evidence of other traumatic findings. It is important to stabilize the patient’s airway as some fractures may result in a significant amount of epistaxis or airway compromise. Avoid insertion of objects (nasotracheal or nasogastric tubes) into the nose until a complete evaluation of the extent of the injury can be obtained. Control epistaxis with nasal packing, if underlying penetrating injury has been excluded. A nasal septal hematoma should be drained prior to disposition, unless immediate (same day) follow-up is available. Follow-up should be confirmed prior to disposition.
Isolated nasoseptal injuries are primarily managed by a facial surgeon. Depending on the patient’s age at the time of the injury, one of the concerns is long-term skeletal development of the nose and midface if the reduction is not performed properly. Most patients with a significantly displaced fracture will require a repeat surgical procedure. Simple, minimally displaced nasal fractures include follow-up on an urgent basis with an otolaryngologist or plastic surgeon; Most authors recommend antibiotic prophylaxis in consideration of the usual nasal colonization with bacteria. Appropriate analgesics should be prescribed.
Significant overlying wounds (open fractures) and nasal deformities warrant consultation in the emergency department. A patient with a naso-orbito-ethmoid fracture should be evaluated by a specialist in the emergency department, or transferred to a facility which has specialist availability.
SR: Pediatric nasal fractures: Evaluation and management. J Craniofac Surg
J, van Aalst
JA: Pediatric nasoorbitoethmoid fractures. J Craniofac Surg
Jr: Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg
et al.: Nasal septal hematoma: Using tubular nasal packs to achieve immediate nasal breathing after drainage. Int J Med Science. 2011;3(7):233–235.
BT: Pediatric nasal injuries and management. Facial Plast Surg
Frontal sinus fractures result from significant force, most commonly motor vehicle collisions. Fracture is to the frontal bone, and therefore considered a skull fracture. The sinus begins forming in children between 1 and 2 years of age, and typically completes development by 12 years of age. Associated intracranial and facial injuries should be expected, and a thorough evaluation is required. Neurologic injury is likely. The anterior table of the sinus lies just beneath the skin, whereas the posterior table is behind the sinus and adjacent to the brain. Frontal sinus fractures typically involve the anterior table, with more significant injuries also involving the posterior table. Posterior table fractures are considered open fractures and a CSF leak may result. The inferior aspect of the sinuses is formed by the bilateral superior orbital rims.
Apparent swelling to the forehead in the setting of a significant mechanism of injury should prompt concern for frontal sinus fracture. Crepitus over the sinus may be present. Adjacent injuries to the orbits, scalp, and midface may also be present. Many patients have underlying neurologic or intracranial injury from the force of injury, and a detailed neurologic examination may not be possible.
A CT scan of the head and maxillofacial structures will confirm frontal sinus fractures. The cervical spine should also be imaged for injury. Displacement of the anterior table correlates with cosmetic deformity and need for surgical correction. The greater the displacement of the posterior table, the more likely associated intracranial injury has occurred. Rhinorrhea should be considered a CSF leak until excluded. Ocular injuries may result if the frontal sinus fracture involves the superior orbital rim. Severe frontal sinus fractures may also extend into the temporal bone, with additional signs of injury.
Significantly deformed anterior table fractures, as well as all posterior table fractures, indicate need for surgical correction. CSF rhinorrhea and open fractures are also surgical indications. A facial surgeon should be consulted on all frontal sinus fractures, and a neurosurgeon consulted in patients with posterior table fractures or with associated intracranial injury. Isolated nondisplaced frontal sinus fractures may be discharged if the specialist deems outpatient management appropriate. Pediatric patients with frontal sinus fractures are admitted for close observation and surgical repair as needed.
KA: Management of facial fractures. Emerg Med Clin N Am
The majority of basilar skull fractures include associated or extension of fracture in the temporal bone. The temporal bone surrounds and encompasses several delicate structures, including the cochlea, vestibule, internal carotid artery, jugular vein, and facial nerve canal. Significant head injury may limit clinical examination.
Awake patients may complain of facial nerve deficit, dizziness, hearing loss, or fluid leakage from the ear. Evaluate the patient’s hearing and facial nerve function when possible. Examine the ear canal and tympanic membrane, paying close attention for hemotympanum, or any leakage of CSF or blood from the canal. Postauricular hematoma (Battle sign) or periorbital ecchymosis (often bilateral, “raccoon eyes”) may be present.
CT scans of the head and maxillofacial structures are warranted. Fractures may be longitudinal along the temporal bone’s long axis, or transverse to this axis. Transverse fractures cause more severe injuries compared with longitudinal. Significant force is usually associated with these fractures, and other injuries should be suspected in accordance with the mechanism. Cervical spine precautions should be followed. Do not manipulate or pack the auditory canal, as open injury can cause direct contamination to the inner ear, with spread to the cerebrospinal fluid, meninges, and brain.
Patients with temporal bone fractures should be admitted. A maxillofacial or ear, nose, and throat (ENT) surgeon should be consulted for evaluation. Temporary and long-term hearing complications may result. A neurosurgeon should be consulted for associated intracranial injuries.