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The assessment begins with a thorough history and physical examination. Fear and
pain can make this evaluation especially challenging in children. Interviewing the par-
ents or any witnesses to the trauma is likely necessary. The physical examination is
commonly compromised by poor cooperation from the child, and therefore, should
be approached gently and with as little trauma as possible. Caution is advised in
regards to sedated examinations during the primary evaluation. A comprehensive
orbital examination is indicated in all patients and should include pupil reactivity and
size, visual acuity if possible, assessment for diplopia, and evaluation of extraocular
muscle function. Assessment of extraocular movement is even more important in chil-
dren because of the so-called “white eye” syndrome, in which the eye looks otherwise
completely normal except for extraocular movement limitation. Because greenstick
fractures are more common in children, orbital floor fractures causing a trapdoor effect
and muscle impingement are more likely to be seen in the pediatric population. These
patients may also have pain with eye movement, nausea, vomiting, and bradycardia
that can mimic the symptoms of a closed head injury. Enophthalmos or hypoglobus
should also be noted. The orbital rims can be palpated for bony step-offs but these
are often difficult to feel in the pediatric patient. Presence of lateral subconjunctival
hemorrhage is a good indicator of an underlying periorbital fracture. A cranial nerve
examination can reveal numbness of the V2 or V3 distributions suggesting a fracture.
Facial nerve function should also be documented initially because intervention for
peripheral or temporal segment injuries may be indicated. Assessing the contour of
the zygomatic arch and the symmetry of malar emminences may be difficult because
of the increased fat distribution of this region in children. A good nasal examination
focusing on symmetry and support of the nasal dorsum and assessing for a septal
hematoma should also be part of the initial evaluation. Examination of the oral cavity
includes assessing for dental trauma, trismus, malocclusion, and visible step-offs.
Remember that the history and physical examination guides the use of further diag-
nostic testing, not the other way around—this is especially true in the pediatric
population.
After suspicion is raised for a fracture a radiologic evaluation is indicated. Although
there are many plain film options, these are notoriously unreliable in children because
the undeveloped sinuses, unerupted tooth buds, propensity for greenstick fractures,
and incompletely ossified areas make identifying fractures difficult.
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However, pano-
ramic radiography (panorex) continues to be useful in the evaluation of mandibular
fractures. Ultimately, computed tomography (CT) remains the gold standard for
assessing facial fractures in adult and pediatric patients. Coronal and sagittal format-
ting of the images allows for improved evaluation of displacement and volume
changes around the midface and orbits. CT offers the distinct advantage of providing
the operating surgeon with a visible conceptualization of the reconstruction needing to
occur in the operating room; this is further aided by three-dimensional reformatting.
Recently there have been significant concerns regarding excess radiation exposure
in children. The multiplanar techniques that allow for excellent, detailed images also
incur a higher radiation dose.
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As a result, many institutions have been exploring pro-
tocols that lower the dose of radiation with a sacrifice in image quality. This requires a
certain balance between the ability to identify subtle greenstick fractures and the need
to decrease radiation exposure. Unfortunately, there is insufficient data regarding the
diagnostic sensitivity and specificity of these low-dose CT scans in pediatric maxillo-
facial trauma. However, because many nondisplaced pediatric facial fractures can be
treated conservatively, these low-dose CT scans should be considered as a means to
diagnose large disruptions in the facial skeleton that require operative intervention.
Furthermore, additional postreduction scans are discouraged if the postoperative
Boyette
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