55 / 280
would warrant aggressive steroid therapy. If visual acuity does not respond or if bony
fragments impinge on the optic canal, optic nerve decompression can be considered,
although results have been mixed in pediatric trauma patients.
37,38
Fractures of the orbital floor remain controversial in regard to which ones require
repair. However, most surgeons agree on the criteria of large floor defects (>1 cm
2
)
or extraocular muscle entrapment.
1,39
Muscle entrapment is the most pressing cause
for early repair, and those with an oculocardiac reflex require emergent repair. Chil-
dren heal quickly; therefore, muscle entrapment in a child may result in fibrosis and
shortening of the muscle within a couple days. As a result, diplopia can be present
for months after the initial injury, or it may be permanent.
40
Fractures of the medial
wall should also be considered. A transcaruncular approach can allow for access to
place an implant to reduce the intraorbital volume; however, some surgeons prefer
to compensate with augmentation of the orbital floor instead.
39
Repair of an orbital floor fracture can be performed through a variety of approaches;
however, the transconjunctival approach is favored from a cosmetic standpoint and
also may reduce the incidence of postoperative ectropion.
41
A variety of implants
can be used to reconstruct the orbital floor. Split calvarial bone grafts have classically
been used, and some surgeons continue to advocate for their use in children younger
than 7 years of age who may continue to undergo further orbital growth.
1
Otherwise,
titanium and porous polyethylene are commonly used with significantly less donor site
morbidity.
Nasal Fractures
Nasal bone fractures are suspected to be the most common facial bone fracture in
children, because their true incidence is very likely underreported in the literature.
42
Because these fractures are often isolated and occur without concomitant injuries,
they are more likely to be treated on an outpatient basis. These fractures can also
remain undiagnosed if swelling obscures the assessment of nasal bone symmetry.
An initial intranasal examination is key to diagnosing airway obstruction and to defining
concomitant septal fracture or septal hematoma. Most nasal bone fractures can be
diagnosed on physical examination alone, thus conserving radiologic examinations
for those patients in whom the history or physical examination warrants further inves-
tigation. The finding of a septal hematoma should prompt urgent surgical evacuation
to prevent cartilage necrosis and saddle nose deformity.
Long-term growth disturbance is a cause for concern. The septum is thought to
harbor important growth zones, which if injured may result in a lack of nasal projec-
tion.
43
Because full growth of the nose is not achieved until age 16 to 18 years in girls
and 18 to 20 years in boys, damage to these growth centers from either the initial
trauma or from surgery can have long-lasting effects.
Early closed reduction of nasal bone fractures within a few days of the injury is
usually recommended.
44,45
This can be accomplished under sedation or general anes-
thesia. However, the results of closed nasal reduction are often dissatisfying for the
surgeon and the patient. Grymer and colleagues
46
examined the long-term results
of nasal bone fractures treated in childhood, and found that by adulthood these pa-
tients tended to have a higher incidence of dorsal humps, saddle nose deformities,
and deviations of the dorsum, despite most patients being satisfied with the outcomes
after the initial closed reduction. Therefore, there is some indication that despite best
efforts to correct these injuries, there may be deformities that develop gradually with
growth. Parents should be counseled regarding this possibility.
Septal fractures can also be managed conservatively with a closed reduction
technique. In those children with significant nasal airway obstruction, a limited,
Facial Fractures in Children
33