2015 HSC Section 1 Book of Articles

Facial Fractures in Children

physical examination is normal. For postoperative evaluation of mandibular injuries, a panoramic radiograph is recommended instead of CT. Fronto-Orbital Fractures Because of the increased ratio of cranial vault to the facial skeleton, fractures of the frontal bone and superior orbital rim and roof are more common in children. 1,14 Thus, these fractures are more common in children younger than 5 years of age when the skull is at its largest. 14 Because the frontal sinus does not start to pneumatize substantially until age 6, these frontal bone fractures are more accurately cranial frac- tures, which may explain the increased frequency of intracranial injuries in the pediat- ric population. Without the “crumple zone” of the frontal sinus, forces to the frontal region may result more commonly in fractures of the supraorbital rim and the orbital roof. Because of this differential anatomy, orbital roof fractures are the most common orbital fractures seen in children younger than 10 years of age. 27,29 Although a fracture of the supraorbital rim can sometimes be palpated on physical examination, diagnosis of an orbital roof fracture can be difficult without CT imaging. However, a depressed fracture of the orbital roof can result in exophthalmos or muscle entrapment limiting extraocular movement. Superior orbital fissure syndrome is also possible in severe fracture patterns. These frontal and orbital roof fractures require a multidisciplinary effort with Neurosurgical and Ophthalmologic involvement. In general, orbital roof fractures rarely require surgical intervention, except for cases with muscle entrapment or when the defect is large-which may lead to orbital pulsations or a late encephalo- cele. 1,30 Frontal bone fractures that are displaced more than the full-thickness width of the bone are often repaired to reduce contour deformities. 1 This should be performed in concert with Neurosurgery to evacuate epidural hematomas, repair dural tears, and manage brain injuries. These patients need long-term follow-up because continued brain growth can push apart the fracture site and result in brain herniation that may require cranioplasty in the future. 31 As children age and the frontal sinus develops, true frontal sinus fractures are more common and are similar to their adult counterparts. However, it has been reported that frontal sinus fractures in children are twice as likely to sustain posterior table injuries and to develop a cerebrospinal fluid leak. 32 The treatment of these injuries is essen- tially the same as their adult counterparts. Displacement of the posterior table more than the full-thickness width of the bone is a general indication of the possibility for dural injury and mucosal displacement, thus necessitating operative intervention in the form of cranialization. 1 Significant disruption of the nasofrontal duct is another indi- cation for operative intervention. As in adults, there has been a shift away from frontal sinus obliteration and a move toward sinus preservation and delayed endoscopic sinus surgery if necessary. Therefore, follow-up clinic visits and imaging are needed at regular intervals. Naso-Orbito-Ethmoid Fractures Naso-orbito-ethmoid (NOE) fractures are often considered the most challenging facial fractures to repair. Fortunately, although reported incidences vary, they are consid- ered relatively rare in children. 28,33 One of the problems with diagnosing NOE fractures in children is that children already tend to have a low nasal dorsum and an overrotated nasal tip. Therefore, it is necessary to palpate the nasal dorsum to assess whether it is impacted into the midface. This part of the examination can help distinguish between simple nasal bone fractures and NOE fractures needing CT imaging. In addition to a saddle nose deformity, NOE fractures can also result in telecanthus from bony displacement or from medial canthal tendon (MCT) disruption. Disruption at the

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