The In`s and Out`s of Pediatric Maxillofacial Trauma

Report
The In’s and Out’s of
Pediatric Maxillofacial Trauma
Wellington J. Davis III, MD, FACS
Section of Plastic and Reconstructive Surgery
St. Christopher’s Hospital for Children
Philadelphia, PA
Introduction
• Maxillofacial trauma evaluation
• Key problems and Work-Up
• Classification of fractures and associated
clinical problems
• General management
• Scar management
Initial Survey
• Control airway and breathing
• Control bleeding
– Resuscitation
• Head injury-GCS?
• R/O C-spine injury
– Associated with 10% of maxillofacial injuries
Initial Survey
• Control airway
– In-line stabilization
– Oral intubation possible in almost all cases
– Rarely tracheostomy needed
• Check for aspiration teeth/blood
Initial Survey
• Airway Issues
• May revisit airway for surgery
– Nasotracheal intubation
– Tracheostomy
• Wire cutters to bedside
Initial Survey
• Control bleeding
– Address the scalp
• Whip-stitch vs. staples
• Pressure dressing
– Nasal packing
– Foley catheters
– Fracture reduction
• Arch bars
– Angiography and embolization
Initial Survey
• Resuscitate
– Hb/Hct
– 2 large bore IV’s
• Neurologic status
– GCS?
– C-spine injury
Secondary Survey
• Systematic evaluation for:
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Lacerations
Palpate for bony step-off at bony prominences
Mid-facial stability
Check sensation in trigeminal distribution
Check facial nerve function
Secondary Survey
• Systemic Evaluation for:
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Dentition
Occlusion
Ophthalmologic injury/vision
Recheck for C-spine injury
CSF leak
Secondary Survey
• Check for lacerations
– Scalp
– Retroauricular
• No real contraindication to closure based on
time of injury
• Absorbable sutures acceptable and
preferable
Secondary Survey
• Palpate step-offs
– No step-off, CT scan may not be indicated
• Bimanual maxillary exam
• Critical to document sensation and vision prior to
surgery
• Facial nerve evaluation
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Raise brows
Eye closure
Puff cheeks
Smile
Secondary Survey
• Look in the mouth
– Empty sockets?
– Chipped teeth?
• Chest x-ray check for teeth
• Check the bite
– Patient can detect a poppy seed b/w teeth
– Occlusion test very sensitive for mandibular or
maxillary fractures
Secondary Survey
• Ophthalmology evaluation
– All orbital fractures especially in operative cases
– Check for entrapment
• Limited EOM
• Generally painful
• Emergent
– Hyphema emergency
– Retinal tears
– Corneal abrasions
Secondary Survey
• Re-check the neck
• CSF leak, dural tear
– Beta-transferrin
QuickTime™ and a
decompressor
are needed to see this picture.
Work-Up
• Labs
– CBC
– Type and Cross
• Imaging
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CT scan with thin cuts
Axial
Coronal,
Sagittal views
Panorex
Work-Up
• Consultations
– Maxillofacial surgeon
• Plastics
• ENT
• OMFS
– Dental
– Ophthalmology
– Neurosurgery
Types of Fractures
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Frontal sinus (anterior, posterior)
Naso-orbital-ethmoid
Orbit
Nasal fractures
Maxilla and zygoma
– ZMC
– Lefort fracture
• Mandibular
– Condyle, coronoid, ramus, body, symphysis
Types of Fractures
• Frontal Sinus Fractures
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CSF leak
Dural Tear
Aesthetic deformity
Mucocele
Nasofrontal duct obstruction
Intervention: Immediate to 7 days
Types of Fractures
• Naso-orbital-ethmoid
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Saddle nose deformity
Telecanthus
Widening of medial canthi
Enophthalmos
Intervention: Immediate to 7 days
NOE Fracture
Osler Archives
CT Scan.
Types of Fractures
• Orbital fracture
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Eye exam
Step-off
Ophthalmology
Enophthalmos in unrepaired fracture
Retinal tear
Corneal abrasions
Intervention: 5-7 days
Orbital Floor Fracture
Imaging
Intra-op
Post-op
Medial Wall Fracture
With Entrapment
Imaging
Types of Fractures
• Maxillary and zygomatic fractures
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Occlusion problems
Facial lengthening or widening
Contour deformity
Intervention: 5-7 days
Panfacial Fracture
Courtesy of Tony Holmes Royal Children’s Hospital
3D CT scan
Intra-op
Intra-op
Types of Fractures
• Nasal Fractures
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Aesthetic deformity
Airway obstruction
Isolated nasal fracture clinical diagnosis
Imaging not mandatory
Intervention: 5-7 days
Types of Fractures
• Mandible fractures
– Occlusion problems
– Aesthetic deformity
– Antibiotics needed, considered an open fracture
in mouth
– Generally warrant aggressive surgical
management
– Intervention: 2-5 days
Associated
Soft-Tissue Injuries
• Extensive lacerations eyelid, eyebrow, nose, lip,
ear
• Mucosal and tongue lacerations
• Alveolar ridge fractures
• Tear duct injuries
• Stenson’s duct injury
• Globe injuries
• Hyphema
• Retinal tears
Associated
Soft-Tissue Injuries
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Facial nerve injury
Infraorbital nerve injury
Inferior alveolar nerve injury
Mental nerve injury
Supraorbital nerve injury
Sensory nerve function important for
documentation
General Management of
Maxillofacial Fractures
• Management Based On:
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Type of fracture
Location of fracture
Amount of displacement
Timing of injury
Age of patient (Mandible)
Surgical approach based on surgeon experience,
principles the same
General Management of
Maxillofacial Fractures
• Only 15-20% of maxillofacial fractures are
operative
• Non-displaced fractures
– Consider outpatient management with early follow-up
24-48 hours with maxillofacial specialist
– No surgery in almost all cases except mandible
• Mandible may require arch bars and wiring based
on location of fracture
General Management of
Maxillofacial Fractures
• Unstable patients
– Arch bars minimum in maxillary or mandibular
fractures
• If poor GCS but hemodynamically stable best to
repair most severe fractures in the usual time
frame 5-7 days
• Why?
– Major functional problems if patient survives
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Occlusion
Visual
Aesthetics
Difficult to repair secondarily
General Management of
Maxillofacial Fractures
• Displaced fractures
– ORIF
– Bone grafts in complex cases
• Complex cases may benefit from
tracheostomy pre-op
• Resorbable plates preferred in pediatric
patients
• Potential for growth restriction
General Management of
Maxillofacial Fractures
• Timing
– Ideally within 5-7 days before bony healing
– Isolated orbital fracture could wait longer
– Most surgeons prefer for edema to resolve prior
to surgery
– Mandible fracture tend to be done early w/i 2448 hours to decrease risk of infection
QuickTime™ and a
decompressor
are needed to see this picture.
General Management of
Maxillofacial Fractures
• Unrepaired fractures may require
osteotomies for correction especially if
addressed 3 or more weeks after injury.
• Surgery is much more complex and
accurate reduction more difficult.
General Management of
Maxillofacial Fractures
• Minimal scarring due to craniofacial approaches:
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Bicoronal incision
Transconjunctival/Subciliary/Orbital rim
Brow or upper lid incisions
Buccal sulcus incisions
Preauricular
Risdon incision
Gilles approach
Existing lacerations
General Management of
Maxillofacial Fractures
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2-5 hour cases depending on complexity
Generally minimal blood loss
Sometimes multiple teams
Post-op management overnight stay
Monitoring for retrobulbar hematoma in
orbital cases
General Management of
Maxillofacial Fractures
• Surgical goals of ORIF:
– Restoration of occlusion and aesthetic
appearance
– Maintain height and width of face
– Management of significant bone loss
• Bone grafting
QuickTime™ and a
decompressor
are needed to see this picture.
QuickTime™ and a
decompressor
are needed to see this picture.
General Management of
Maxillofacial Fractures
• Prevent complications
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Seizures (depressed skull fractures)
Mucocele
Tear duct obstruction
Enophthalmos
Ectropion
Malocclusion
Retrobulbar hematoma
Corneal abrasion
Scar Management
• Nonsurgical
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Sunscreen
Scar massage
Silicone products
Start 3-4 weeks after wound closure
Facemask in severe cases
Scar Management
• Surgical- cases not responding to non-operative
treatment
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Steroid injection
Laser therapy
Dermabrasion
Scar revision
Serial excision
Tissue expansion
Scar Management
• Scars cannot be removed but most can be
improved
• Even “minor” scarring warrants evaluation
if only for re-assurance.
• Timing and intervention based on:
– Features of scar
– Time since injury
– Usually minimum of 6 months post-injury
Questions?

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