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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 - PowerPoint PPT Presentation
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The In’s and Out’s of Pediatric Maxillofacial Trauma
Wellington J. Davis III, MD, FACSSection of Plastic and Reconstructive Surgery
St. Christopher’s Hospital for ChildrenPhiladelphia, 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:
– 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:– 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
– 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– CT scan with thin cuts– Axial– Coronal,– Sagittal views– Panorex
Work-Up
• Consultations– Maxillofacial surgeon
• Plastics• ENT• OMFS
– Dental– Ophthalmology– Neurosurgery
Types of Fractures
• 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– CSF leak– Dural Tear– Aesthetic deformity– Mucocele– Nasofrontal duct obstruction– Intervention: Immediate to 7 days
Types of Fractures
• Naso-orbital-ethmoid– 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– 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– 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– 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
• 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:– 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
• 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 24-
48 hours to decrease risk of infectionQuickTime™ and a
decompressorare 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:– 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
• 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 – Seizures (depressed skull fractures)– Mucocele – Tear duct obstruction – Enophthalmos – Ectropion– Malocclusion– Retrobulbar hematoma– Corneal abrasion
Scar Management
• Nonsurgical– 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– 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?