Nasal fractures are the most commonly encountered pediatric facial fracture, accounting for up to 50% of the total.4 External digital pressure controls hemorrhage in most cases. If nasal packing is used, care must be taken to avoid intracranial placement of packing in the patient with midface trauma or signs of a basilar skull fracture. A particularly severe type of nasal fracture that occurs in children is the “open book” type, where nasal bones separate in the midline along the suture.
Early edema and pain with intranasal speculum examinations complicate the diagnosis of nasal fractures.4,5 A repeat examination is generally recommended 3 to 4 days after the initial injury in children.6 For optimal repair of displaced nasal fractures, consultation should take place within 5 to 6 days postinjury, after which time fractures begin to unite and manipulation becomes increasingly difficult. Of note, early reduction of pediatric nasal fractures has been challenged in the recent literature.18 Surgical reconstruction remains controversial in the growing child until the nasal growth centers close.19 Closed reduction with packing or splinting establishes anatomic realignment and hemostasis in the majority of displaced nasal fractures.4
Nasal fractures produce specific complications. These include nasal deviation, dorsal hump, obstructed breathing from septal malalignment, and saddle nose deformity. Untreated septal hematoma results in collapse of the septum and a “saddle” deformity due to septal cartilage necrosis. These hematomas may, on rare occasion, become infected and lead to septal perforation. Upon diagnosing a septal hematoma, the physician should anesthetize the area and then use a No. 11 blade to make an L-shaped incision through the mucoperiosteum along the floor of the nose and extend the incision vertically. The hematoma will then be evacuated through the flap (Fig. 28-4). Subsequent packing of the nasal antrum prevents reaccumulation, and the child must be referred to the appropriate specialist. Timely referral of nasal fractures and treatment of nasal septal hematoma are of significant medical and legal concern, as these injuries may have a profound effect on subsequent nasal and maxillofacial development.5
How to drain and pack a nasal hematoma. A. Apply topical anesthetic. B. Incise hematoma. C. Place packing in nasal antrum
The most common orbital fracture is the blowout fracture, which occurs when a blunt object, often a ball or fist, strikes the globe (Fig. 28-5). The intraorbital pressures increase suddenly and contents decompress through the orbit, most commonly the floor. Blowout fractures can also occur through the medial wall, the roof, and even the greater wing of the sphenoid bone. This may lead to entrapment of the inferior ocular muscles, with subsequent diplopia on upward gaze.10 Urgent consultation is required in the presence of exophthalmus or extraocular muscle entrapment. If not treated early, ischemic muscle necrosis leads to muscle fibrosis, restriction of ocular motion, and persistent diplopia.20 In these situations, orbital contents must be surgically released and the area of blowout covered with implants or bone grafts.
Orbital blowout fracture. Fracture of the orbital floor can lead to entrapment of fat and ocular muscles.
Evaluate for entrapment by examination and orbital CT scan.10 Enophthalmos, vertical orbital dystopia, and symptomatic muscle entrapment provide more useful indications for surgical intervention.21 Evaluation for associated ocular injury such as hyphema, retinal contusion, lens dislocation, and corneal lacerations must be performed and visual acuity documented.
Frontal Sinus and Supraorbital Fractures
Supraorbital fractures involve the superior orbital rim or orbital roof. Exophthalmus and ptosis may be present with impairment of upward gaze. The superior orbital fissure syndrome results in paralysis of extraocular muscles, ptosis, and anesthesia in the ophthalmic division of the trigeminal nerve. The orbital apex syndrome is a combination of the superior orbital fissure syndrome plus optic nerve damage and results in blindness. These syndromes represent surgical emergencies and require immediate consultation and decompression.
Linear nondisplaced fractures of the anterior wall of the frontal sinus may be treated with observation and antibiotics in either an inpatient or an outpatient setting. If the posterior wall is involved, a CT scan will evaluate the possibility of depression and underlying brain injury. Posterior wall fractures should prompt neurosurgical as well as maxillofacial consultation.
Frontal sinus fractures cause significant complications without proper management. These complications include cosmetic deformity, mucoceles, occult or delayed CSF leaks, and meningitis.22 Antibiotics are still routinely recommended for CSF leak in frontal sinus fracture but antibiotic prophylaxis does not routinely prevent meningitis.8 The increased risk of meningitis persists even after the fracture heals in some patients.8 Frontal sinus fracture is associated with ocular injury 26% of the time and ophthalmologic evaluation should be considered.8 Recommendations also include coronal evaluation of the skull base once patients are stable.22
Maxillary fractures are very uncommon in young children, but the incidence increases with age, as the paranasal sinuses develop. Because of the high degree of energy required to fracture the pediatric face, associated injuries, particularly intracranial, must be suspected.6 Maxillary fracture complications include malocclusion, tooth loss, and growth arrest.9
The malar complex is often broken in a tripod fashion, with fractures at the infraorbital rim, across the zygomatic–frontal suture, and along the zygomatic–temporal junction. Inward displacement of this fragment may result in impingement upon the mandible, causing difficulty opening the mouth and trismus. The zygomatic arch is frequently fractured in isolation. If a zygomatic complex fracture has no displacement, diplopia, or sensory deficits, the patient's injury may be managed by observation. Open reduction and internal fixation is necessary for comminuted fractures.4
NEO and LeForte Fractures
LeForte fractures and nasal–ethmoidal–orbital fractures (NEO) are rare in children. NEO fractures occur when the bony structures of the nose are driven backward into the intraorbital space. The NEO complex joins the upper and middle thirds of the face. Careful clinical examination combined with three-dimensional CT scans diagnose this fracture type. On examination, NEO collapse causes shortened palpebral fissure, telecanthus from lateral migration of the medial canthus, and a shortened nose with possible saddle deformity.1 CT offers superior sensitivity and specificity for accurately distinguishing fractures from open suture lines.1
Associated injuries include orbital and optic nerve problems, as well as lacrimal system disruption.23
Patients with NEO or orbital fractures should be instructed not to blow their nose. Many practitioners prescribe antibiotics to cover common sinus pathogens. First-generation cephalosporins, trimethoprim/sulfamethoxazole, amoxicillin, or erythromycin is frequently used in outpatients. Such prophylaxis, however, has not conclusively proven to reduce complications.10
Children with LeForte fractures require admission and careful assessment for associated injury. A maxillofacial specialist should be involved in their care. LeForte I is a transverse fracture that separates the hard palate from the lower portion of the pterygoid plate and nasal septum. Traction on the upper incisors produces movement of only the hard palate and dental arch. LeForte II or pyramidal fracture separates the central maxilla and palate from the rest of the craniofacial skeleton. Mobilization of the upper incisors will move the central pyramid of the face, including the nose. LeForte III, also known as craniofacial dysjunction, separates the facial skeleton from the rest of the cranium. The entire face including inferior and lateral portions of the orbital rim moves as a unit with this fracture. “Pure” LeForte fractures are less common and are usually a mixed pattern—perhaps a LeForte II on one side and a LeForte III on the other. LeForte fractures may result in lengthening of the midface, occlusal abnormalities, orbital ecchymosis, and may be associated with basilar skull fractures.6
Mandible fractures are the second most common facial fracture, following nasal bone injury. Because of its U-shaped structure, fractures of the mandible are often multiple. Blows or falls to the chin result in symphyseal or perisymphyseal injury, whereas lateral blows are more likely to produce body or angle fractures on the injured or contralateral side. The most frequently injured areas are the condyle (70%), followed by the body, angle, and symphysis.10
Physical examination may raise suspicion for mandibular injuries. Younger children suffer isolated condylar fractures and may present with deviation of the jaw to the affected side and trismus. Chin lacerations may herald condylar injuries. Dislocation of the TMJ rarely occurs in this age group.
Facial CT scan diagnoses suspected mandible fracture in this age group with maximum accuracy.17 CT scan compared with panoramic radiographs in children 2 to 15 years old provided diagnostic accuracy of 90% and 73%, respectively. For patients 16 years and older, oral pan tomogram (Panorex) and posteroanterior mandible radiographs provide appropriate initial tests.24 Consultants, however, may request a facial CT scan for follow-up care. Treatment of mandibular fractures is based on age, state of dentition, fracture location, bony integrity, and the presence of associated injuries. In general, mandibular fractures without displacement and malocclusion are managed by a liquid/soft diet, pain control, avoidance of physical activities, and close observation. Displaced mandibular fractures require reduction and immobilization.4
Arrested development occurs most often with mandibular fractures and results in severe facial deformity, micrognathia, and ankylosis of the TMJ.9 Crush injuries to the condyle prior to the age of 5 years have the greatest potential for developmental arrest, whereas condylar fractures in later childhood may be self-correcting. Inform the parents about the possibility of subsequent growth disturbances—the younger the child is, the more likely are the complications.25
Devitalized tissues need conservative debridement. Soft tissues require irrigation, foreign-body removal, and cosmetic approximation of important landmarks such as the vermilion border of the lip and margins of the eyebrows. Eyebrows must not be shaved, as their regrowth is unpredictable. Hematomas of the pinna must be relieved to avoid a permanent cosmetic defect, cauliflower ear. Drain hematomas of the external ear by needle aspiration or formal incision, and then apply a pressure dressing to prevent reaccumulation.
Repair of lacerations to the salivary duct or to the lacrymal drainage system must be performed by a specialist. These repairs are achieved over a stent. Despite the possibility of brisk bleeding, never blindly clamp inside a facial laceration due to the risk of injury to nerves or parotid duct. Direct pressure will control bleeding. Children may require sedation to ensure cooperation in the treatment of either complex or intraoral lacerations. Control of the tongue is necessary in glossal injury, and a large stitch placed in the tip of the tongue will retract it during suturing.
Penetrating wounds to the posterior pharynx occur when a child falls while carrying a pencil or foreign body in his or her mouth. Such wounds endanger carotid artery, jugular vein, and cranial nerves. Imaging studies, such as color-flow Doppler, angiography, CT angiography, or MRI may be indicated. Delayed thrombosis of carotid or jugular vessels can occur.