2017 Sec 1 Green Book

Examination of Life-Threatening Injuries in 431 Pediatric

Facial Fractures at a Level 1 Trauma Center

Ian C. Hoppe, MD, Anthony M. Kordahi, BA,

Angie M. Paik, BA, Edward S. Lee, MD, and Mark S. Granick, MD

Purpose:

Pediatric facial fractures represent a challenge in manage-

ment due to the unique nature of the growing facial skeleton. Often-

times, more conservative measures are favored to avoid rigid internal

fixation and disruption of blood supply to the bone and soft tissues.

In addition, the great force required to fracture bones of the facial skel-

eton often produces concomitant injuries that present a management

priority. The purpose of this study was to examine a level 1 trauma

center's experience with pediatric facial trauma resulting in fractures

of the underlying skeleton with regards to epidemiology and con-

comitant injuries.

Methods:

A retrospective review of all facial fractures at a level 1

trauma center in an urban environment was performed for the years

2000 to 2012. Patients aged 18 years or younger were included. Pa-

tient demographics were collected, as well as location of fractures,

concomitant injuries, and surgical management strategies. A signif-

icance value of 5% was used.

Results:

During this period, there were 3147 facial fractures treated

at our institution, 353 of which were pediatric patients. Upon further

review, 68 patients were excluded because of insufficient data for

analysis, leaving 285 patients for review. The mean age of patients

was 14.2 years with a male predominance (77.9%). The mechanism

of injury was assault in 108 (37.9%), motor vehicle accident in

68 (23.9%), pedestrian struck in 41 (14.4%), fall in 26 (9.1%),

sporting accident in 20 (7.0%), and gunshot injury in 16 (5.6%).

The mean Glasgow Coma Scale (GCS) on arrival to the emergency

department was 13.7. The most common fractures were those of

the mandible (29.0%), orbit (26.5%), nasal bone (14.4%), zygoma

(7.7%), and frontal bone/frontal sinus (7.5%). Intracranial hemorrhage

was present in 70 patients (24.6%). A skull fracture was present in

50 patients (17.5%). A long bone fracture was present in 36 patients

(12.6%). A pelvic or thoracic fracture was present in 30 patients

(10.5%). A cervical spine fracture was present in 10 patients (3.5%),

and a lumbar spine fracture was present in 11 patients (3.9%).

Fractures of the zygoma, orbit, nasal bone, and frontal sinus/bone

were significantly associated with intracranial hemorrhage (

0.05).

Fractures of the zygoma and orbit were significantly associated with

cervical spine injury (

0.05). The mean GCS for patients with

and without intracranial hemorrhages was 11.0 and 14.6, respec-

tively (

0.05). The mean GCS for patients with and without cer-

vical spine fractures was 11.2 and 13.8, respectively (

0.05).

Conclusions:

Pediatric facial fractures in our center are often caused

by interpersonal violence and are frequently accompanied by other

more life-threatening injuries. The distribution of fractures parallels

previous literature. Midface fractures and a depressed GCS showed

a strong correlation with intracranial hemorrhage and cervical spine

fracture. A misdiagnosed cervical spine injury or intracranial he-

morrhage has disastrous consequences. On the basis of this study,

it is the authors

’

recommendation that any patient sustaining a

midface fracture with an abnormal GCS be evaluated for the afore-

mentioned diagnoses.

Key Words:

Adolescent, child, facial bones/injuries, infant,

humans, multiple trauma/epidemiology/etiology/mortality, skull

fractures/epidemiology/etiology/mortality, violence/statistics &

numerical data

(

J Craniofac Surg

2014;25: 1825

–

1828)

ediatric facial fractures are a fairly uncommon injury, representing

less than 15% of all facial fractures,

and present a challenge in

management. The goal of management in all pediatric patients pre-

senting with facial fractures is anatomic reduction and healing without

complication. Before treatment of the facial fracture, it is essential

to identify concomitant injuries, such as intracranial injury and spine

injury, that may pose a threat to life or quality of life if not identified

and appropriately treated. A large retrospective study found that al-

most 65% of pediatric patients with a facial fracture exhibited as-

sociated injury.

A recent study concluded that a concussion was

documented in almost one third of all pediatric patients presenting

with a facial fracture, with an increased risk if the skull, orbit, or

maxilla were involved.

A related study determined that more than

half of all pediatric patients diagnosed with a facial fracture also

presented with a serious associated trauma of a vital organ system.

In a survey of the National Trauma Data Bank, it was found that pe-

diatric patients with facial fractures exhibited a higher injury sever-

ity, longer length of hospital stay, longer time spent in an intensive

care setting, increased number of days on a ventilator, and increased

hospital charges compared with those without facial fractures.

Other

studies show varying degrees of concomitant injuries.

–

It has been suggested that the presence of facial fractures ac-

tually represents a protective mechanism for the brain to reduce in-

tracranial injury due to the force absorbing characteristics of the

facial skeleton.

A multicenter study examined this protective me-

chanism in injured bicyclists and discovered that facial fractures are

actually associated with an increased risk for brain injury.

The

From the Division of Plastic Surgery, Department of Surgery, New Jersey

Medical School, Rutgers University, Newark, NJ.

Received February 17, 2014.

Accepted for publication April 23, 2014.

Address correspondence and reprint requests to Ian C. Hoppe, MD, Division

of Plastic Surgery, Department of Surgery, New Jersey Medical School,

Rutgers University, Ambulatory Care Center, Suite E1620, 140 Bergen

St., Newark, NJ 07103; E-mail:

ianhoppe@gmail.com; hoppeic@njms.rutgers.edu

Presented at the 93rd Annual Meeting of the American Association of Plastic

Surgery, April 5

–

8, Miami, FL.

The authors report no conflicts of interest.

ISSN: 1049-2275

DOI: 10.1097/SCS.0000000000001055

LINICAL

TUDY

The Journal of Craniofacial Surgery

•

Volume 25, Number 5, September 2014

Reprinted by permission of J Craniofac Surg. 2014; 25(5):1825-1828.