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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.)
Boyette
34