2015 HSC Section 1 Book of Articles

Boyette

cartilage-sparing septoplasty can be performed, although the risk of growth impair- ment is always a concern. If the nasal obstruction is without secondary consequences then delay until the teenage years is recommended. An unusual fracture pattern that is typically only seen in children is that of the “open book.” 42 Direct frontal impact to the nose can cause blood to develop and spread apart the nasal bones centrally ( Fig. 2 ). This is suspected to occur in children more readily because of incomplete fusion of the nasal bones at the midline. This type of injury has been treated in young children with the conservative technique of frequent bimanual compression in the clinic. 47 Midface and Zygomaticomaxillary Fractures Because of the aforementioned small paranasal sinuses and unerupted tooth buds in children, midface fractures of the classical Le Fort patterns are unusual. Therefore, they are usually the result of high-impact trauma, such as motor vehicle accidents. 48 Goals of repair are similar to those in adults, such as restoration of facial contour, height, and dental occlusion. Many fractures in children are nondisplaced and can be treated conservatively. Maxillomandibular fixation can be applied to stabilize many of these fractures. Despite concerns that subperiosteal elevation can cause long-term maxillary growth restriction, fractures resulting in significant displacement of the buttresses typically require open reduction and internal fixation. 49 Screw place- ment can injure the unerupted tooth follicles and should be used judiciously and as far away from the dentition as possible. In cases of severely comminuted fractures at the buttresses, primary bone grafting can be considered. 3 Because of growth concerns, some authors recommend removing titanium hardware at 3 to 4 months postopera- tively. 50 Resorbable plating can also be effectively used to stabilize midface fractures, especially at the zygomaticomaxillary buttress where the elevated profile of the plates is less noticeable. Indications for zygomaticomaxillary complex fracture repair in children are similar to adult indications: mainly cheek asymmetry and functional concerns related to the orbital component. Nondisplaced fractures can be observed, but comminuted fractures should be addressed with fixation. Minimally invasive approaches, such as the transconjunctival approach to the orbital rim, are recommended. In children, one-point fixation of noncomminuted zygomaticomaxillary complex fractures has been reported as sufficient. 39 Outcome studies of one- and two-point fixation have

Fig. 2. “Open-book” nasal fracture pattern that can be encountered in pediatric patients. ( A ) Splayed appearance of the nasal bones on frontal view. ( B ) Treatment of splayed nasal bones with sequential manual compression in clinic and no surgical intervention. ( Courtesy of Dr Frederick Stucker, Shreveport, LA.)

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