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Pediatric Maxillofacial Trauma
PEDIATRIC EMERGENCY MEDICINE
0031-3955/92 $0.00 + .20
PEDIATRIC MAXILLOFACIAL TRAUMA John G. Hunter, MD
Head trauma is a leading cause of death among children, with approximately 10 of every 100,000 children dying each year from head injuries. 2 The United States Health Interview Survey for 1975 estimated that the incidence rate for head injuries in children aged 0 to 5 was 18,000 per 100,000 population and 6140 per 100,000 for children aged 6 to 16. The vast majority of these injuries were lacerations and contusions of the scalp and face. 2 Serious maxillofacial trauma, with the exception of animal bites, occurs less frequently in children than in adults. Decreased exposure to trauma combined with children's small size, weight, and other physical characteristics all contribute to this finding. 22 By the early teen years, however, the frequency and pattern of maxillofacial injuries seen in children begin to mirror those seen in adults. 9 Minor head injuries, however, are suffered by children with unfortunate regularity. Motor vehicle-related trauma is responsible for a significant number of deaths and serious injuries in older childhood. Children under 14 years of age account for approximately 6% of automobile deaths. Of interest is the finding that of those children aged 5 to 14 years injured in motor vehicle accidents, only 56% were actual occupants of the vehicles. 9 Facial trauma in younger children is commonly sustained during falls, usually associated with running or jumping. A greater degree of motor skills than coordination may in part be responsible (Hunter JG, Song IC: Facial injuries in children: An analysis. Submitted From the Department of Surgery (Plastic), State University of New York Health Science Center at Brooklyn College of Medicine; Division of Plastic Surgery, St. Luke's/ Roosevelt Hospital Center; Beth Israel Hospital North; New York Downtown Hospital; and Methodist Hospital, New York, New York
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for publication). As noted earlier, animal bites are also a common cause of facial injuries in children. Although the basic principles of treatment of pediatric maxillofacial injuries are similar to those used in adults, techniques and approaches must be modified to accommodate for children's immature maxillofacial structures and the difficulty in obtaining their cooperation. The seriousness of facial injuries in children is compounded by the effect of the injury on future growth and development. Facial fractures, especially of the mandibular condyle and nasomaxillary complex, in addition to the deformity resulting from the fracture itself, may result in arrested development of the injured area. Developmental malformations seen in adolescence and adulthood are often secondary to injuries occurring in early childhood. The mandible is the facial bone most frequently involved in posttraumatic developmental deformities. 9
EXAMINATION OF THE INJURED CHILD
Evaluation of the child with a maxillofacial injury is often difficult and requires patience and compassion on the part of the examiner. Young children are often frightened more by their own apprehension and the apprehension of adults than by the pain of the injury. Young children are usually unaware of the extent of their injury.22 Obtaining a history of the injuring event is not always possible or complete. The initial contact with the child is extremely important in establishing trust and cooperation. Most children older than age 4 are reasonably cooperative with clinical examinations and procedures if they are explained simply and done gently. The child should not be lied to, such as being told that a portion of an examination or procedure is painless when it is in fact uncomfortable. The child's questions also should be answered simply but truthfully. Once the child's trust has been lost, obtaining further (or future) cooperation may be difficult. Sedation, most commonly chloral hydrate or meperidine HCIchlorpromazine-promethazine HCl in the outpatient setting, or even general anesthesia may be required to allow adequate evaluation and treatment of maxillofacial injuries. Sedation should not be used in those children requiring observation for a concomitant head injury. In the evaluation and treatment of minor facial injuries, such as most lacerations, sedation should only be required in a small percentage of children for control of behavior or production of a more positive psychological response to treatment. I strongly believe that sedation is overused in the treatment of minor pediatric facial injuries, most often for expedience rather than for a legitimate indication. When required, I only use sedation in the hospital setting, and only when adequate repair absolutely cannot be accomplished without it (less than 1% of cases). The use of conscious or deep sedation in the office setting, especially by non-pediatricians, is potentially hazardous because properly trained personnel and appropriate resuscitation equipment to manage any
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"reasonably foreseeable emergency" may not be available.! Sedation, however, is commonly required when special diagnostic procedures, such as a computed tomographic (CT) scan or magnetic resonance image, are needed. The physical examination should consist of an orderly inspection of all facial areas by observation, palpation, and evaluation of function. Facial wounds may be classified into three catagories: wounds of soft tissue alone, wounds of soft tissue with associated fracture(s), and fracture(s) without an associated wound. 8 Lacerations and contusions should be evaluated for an underlying fracture or injury to other deep structures (nerves or parotid). Orderly gentle palpation of all bony surfaces, including the skull, forehead, orbital rims, nose, zygomatic arches, malar eminences, and jaws, should be performed to identify tenderness, asymmetry, "step off" or level discrepancy, or abnormal motion or crepitus. Intraoral examination is performed to identify lacerations, hematomas, loose or missing teeth, or oropharyngeal obstruction. Mandibular range of motion should be evaluated while palpating the condyles bilaterally. The occlusal relationship should be evaluated. Ophthalmologic evaluation should be undertaken for evidence of diplopia, visual acuity change, exophthalmos or enophthalmos, and globe injury. Pupil response, visual fields, and extraocular muscle movements should be assessed. The nose should be examined for intranasal lacerations, cerebrospinal fluid leakage, or septal hematoma. Facial and trigeminal nerve functions should be evaluated and compared bilaterally. Facial nerve function is grossly assessed by having the patient grimace, raise the eyebrows, tightly close the eyelids, and smile. Sensory function in the supraorbital, infraorbital, and mental nerve distributions are tested by gentle stroking with a cotton-tip applicator, using the contralateral side as control. Evaluation for concomitant but perhaps less dramatic injuries, especially head injuries, is mandatory. Radiologic evaluation is required to adequately and accurately assess significant facial injuries. The quality of the films obtained, especially of special studies such as CT scans, depends on the level of cooperation obtainable from the injured child. As mentioned earlier, sedation is often required for younger children. Although the craniofacial CT scan has become the definitive diagnostic test for precise evaluation of maxillofacial fractures of the upper and middle face, initial plain facial radiographs are appropriate in most cases and are discussed later. Treatment priorities in the management of the child with major maxillofacial trauma are the same as for any other serious injury, namely, preservation of life, maintenance of function, and restoration of form.24 Emergency treatment may have to be initiated prior to, or concurrent with, clinical evaluation when life-threatening injuries or conditions are present. The control of hemorrhage, maintenance or restoration of an adequate airway, and prevention of aspiration are absolute priorities in children with maxillofacial injuries. Airway patency may be compromised by the presence of blood clots, fractured
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teeth, or foreign bodies within the oropharynx. The tongue, especially in the presence of a mandible fracture, may obstruct the hypopharynx. Edema or hematoma of the floor of the mouth also may compromise the child's airway. The airway can usually be protected by early intubation (either orally or nasal~y, depending on the nature of the facial injuries). Emergency tracheostomy is rarely required; it is usually reserved for cases with massive facial trauma involving both the midface and the mandible. 9 Control of hemorrhage from lacerations is usually achieved with digital compression and direct ligation of the bleeding vessel or by temporary approximation of the wound edges. Blind clamping of bleeding vessels in a bloody field invites inadvertent injury to nerve branches and other structures and should be avoided. Persistent nasopharyngeal hemorrhage from closed maxillofacial fractures is usually controllable by one of several maneuvers. The internal maxillary artery is most frequently the source of the bleeding. Intranasal tamponade is usually effective: a Foley catheter (30-40 mL balloon) is passed into the nasopharynx via each nostril, the balloon is inflated and then pulled anteriorly to occlude the posterior nasopharyngeal opening. Antibioticimpregnated gauze is packed into the nasal cavity anteriorly. Caution is required if cranial base fractures are suspected. Persistent hemorrhage is often controlled by emergent closed reduction of displaced or impacted fractures, especially of the maxilla. Selective arterial ligation or embolization is occasionally needed in the rare cases in which the aforementioned measures fail to control nasopharyngeal bleeding. Selective artery ligation may include the internal maxillary or ethmoidal arteries. Rarely, bilateral external carotid and superficial temporal artery ligation is required to control hemorrhageY
SOFT-TISSUE INJURIES
Facial soft-tissue injuries, especially minor lacerations, contusions, abrasions, and minor burns, are suffered by children with unfortunate regularity. Massive soft-tissue injuries, although uncommon, do occur and are usually associated with motor vehicle accidents, major burns, and animal maulings. Despite their relatively common occurrence, little has been written about facial lacerations in children. The goals of treatment of pediatric facial soft-tissue injuries are no different than those for trauma elsewhere, namely, preservation of life and restoration of normal function and form.24 The seriousness of softtissue injuries in children is compounded by the effect of the injury on future growth and development. This may be obvious in cases of avulsed soft tissue, but permanent disfigurement also may result from subcutaneous tissue damage in the form of a hematoma or fat atrophy following injury.22 Most commonly, however, inadequate treatment simply results in a more noticeable, less aesthetically acceptable scar. Scar depression frequently results when lacerated muscle layers are not
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repaired, and widening results when gaping wounds are approximated using a single layer, simple skin closure or using surgical tapes. Proper assessment of the extent of tissue damage is therefore quite important. Anatomic layer repair of wounds in children may be even more important than in adults for the reasons noted earlier. Careful atraumatic exploration of the wound to determine the full extent of injury is mandatory. Fine quality, delicate surgical instruments are essential, and sterile, prepackaged instrument sets should be assembled and kept readily available in treatment areas (Fig. 1). Devitalized tissue should be conservatively debrided. Lacerated muscle fascia and periosteum should be reapproximated anatomically and subcutaneous dead space obliterated using a minimal number of well-placed absorbable sutures. Accurate anatomic repair of facial lacerations requires patience and compassion. Adequate but comfortable restraint, such as is provided by a Papoose board (Olympic Medical Corp, Seattle, WA), is essential for young children. Adequately "swaddled," young children often fall asleep during the procedure. As stated earlier, sedation is rarely needed if patience is exercised and trust established. Lacerations may be simple incised wounds or they may be beveled, jagged, stellate, or avulsion injuries, with or without tissue loss. Most facial lacerations sustained by younger children (aged 1 to 4 years) are small, burst-type lacerations, usually sustained during a fall (Fig. 2). Often these wounds appear rather trivial, but careful exploration reveals
Figure 1. Fine surgical instruments are required to adequately repair pediatric facial lacerations. Recommended instruments include curved iris scissors, fine tooth Adson tissue forceps, Webster needle holder, baby mosquito hemostats, and skin hooks.
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Figure 2. Typical pediatric forehead laceration sustained during a fall. Despite superficial appearance, the laceration extended to bone.
that they are usually quite deep, often extending into or through deeper layers (i.e., muscle, periosteum). Falls into stationary objects, especially while running, generate considerable force. The soft tissue is compressed between the object and the underlying bone, resulting in a full-thickness burst injury. This is particularly common in forehead and chin lacerations. Failure to recognize and anatomically repair these deep injuries can have significant aesthetic and functional consequences (Hunter JG, Song IC: Facial trauma in children: An analysis. Submitted for publication, 1992). Special care should be exercised in treating abrasions containing dirt or other foreign particles. When initially evaluated, a child with a superficial abrasion may not appear to have an injury of consequence. Upon healing, however, permanent "traumatic tattooing" will be present if all dirt, road particles, and other matter have not been completely removed from the wound. All such abrasions must be thoroughly scrubbed under local anesthesia, and all foreign matter must be removed before healing occurs.8 Complete evaluation and treatment of significant soft-tissue wounds and lacerations require adequate pain control. After cursory inspection of the injury and evaluation of nerve function, the wound should be anesthetized. Because administration of local anesthetic solution is generally painful, efforts have been made to reduce the discomfort associated with obtaining wound anesthesia and therefore reduce the need or desire to use sedation in the treatment of minor maxillofacial wounds. It is well known that slow infiltration of local anesthetics can reduce the pain associated with the process. 21 Most local anesthetic solutions are acidic, with a pH between 5.0 and 7.0. It has been demonstrated clearly that pH buffering of local anesthetic solutions with bicarbonate, thus raising the solution pH toward a more physiologic range of 7.0 to 7.4, can dramatically reduce the amount of pain associated with infiltration without compromising anesthetic effi-
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cacy.5 Because the buffered solution is unstable, however, the local anesthetic should be mixed with sodium bicarbonate in a 10:1 ratio immediately prior to use. I have found this technique to be quite effective. It permits one to achieve the desired goal of near painless anesthesia without the toxicity associated with topical anesthetics, such as tetracaine-adrenalin-cocaine (TAC). The efficacy of TAC topic anesthetic for repair of facial lacerations has been well established in both adults and children. 3, 11 It has recently been demonstrated that the tetracaine component of TAC, however, is superfluous for obtaining topical anesthesia and may be omitted without compromising anesthetic efficacy. 4 Although TAC is seemingly quite safe to use, there are as yet no data that delineate the dosage of cocaine that may be safely applied to wounds in children. 3 Recurrent seizures requiring intensive care unit admission have been reported after mucosal application of TAC, presumably secondary to cocaine toxicity.7 Furthermore, death has been reported after misuse of TAC solution. 6 Although TAC use may render the procedure practically painless in most cases, it probably should not be used in the office setting, especially by non-pediatricians. It is, however, a reasonable alternative for use for nonmucosal wounds in the pediatric emergency department, where adequate monitoring and support are available. The pH buffering of local anesthetic solution, however, is probably a safer alternative in most cases. Once adequate local anesthesia has been obtained, careful exploration of the wound can be performed and definitive treatment initiated. The following is a recommended treatment protocol for pediatric facial lacerations. The skin surrounding the laceration is prepped with a dilute povidine-iodine solution. It is not used in the wound itself because it is tissue toxic. Pulsatile saline irrigation of the wound is usually quite adequate for fresh injuries. Heavily soiled wounds can be cleansed with a nontoxic solvent, such as poloxamer-188, if needed, not povidone-iodine or hydrogen peroxide. 16 The pH buffered local anesthetic is then slowly infiltrated through the laceration margins (except in contaminated wounds and bites) using a 27 gauge needle. After waiting 7 to 10 minutes for. the epinephrine effect to occur (if used), the wound is gently explored, preferably retracting the margins with skin hooks, and foreign matter and blood clots are removed. The wound is then copiously irrigated with saline using pulsatile irrigation. Beveled or jagged wound margins and devitalized subcutaneous tissue are conservatively excised. Conservative undermining, if needed to obtain a tension-free closure, is performed in the subcutaneous plane. Hemostasis is obtained by digital pressure, electrocautery or ophthalmic cautery, or fine (5.0 or 6.0) Vicryl (polyglactin 910, Ethicon, Inc., Somerville, NJ) ties. Nongaping wounds involving only skin and subcutaneous tissue can be closed in a single layer using interrupted or continuous simple sutures; 6.0 nylon is recommended (silk and absorbable sutures are quite reactive and are not recommended for general facial skin closures). If the wound is gaping, however, or if deeper structures are involved,
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then a multiple layer, anatomic repair is usually advisable. Muscle fascia and periosteum are reapproximated using 5.0 or 6.0 absorbable sutures, such as Vicryl. In gaping wounds in which there is tension on the skin closure, the deep dermis should be approximated using longlasting absorbable sutures such as 6.0 Vicryl or 6.0 PDS (polydioxanone, Ethicon). Interrupted sutures, with inversion of the knots, should be used. Only the minimum number of sutures required to coapt the wound margins should be used, and care must be taken to place the sutures deep in the dermis to reduce the chance of suture "spitting." Alternatively, the deep dermis may be approximated using an intradermal continuous pullout suture (subcuticular suture) of 4.0 or 5.0 nylon or Prolene (polypropylene, Ethicon). This technique is best reserved for long, relatively linear incised wounds, such as knife lacerations (Fig. 3A and B). If excellent wound margin coaptation has been achieved with the deep closure, the superficial dermis and epidermis can be approximated using surgical tapes. Otherwise, 6.0 or 7.0 nylon should be used. Although it has been demonstrated that dressings are not required over sutured lacerations and that sutures can get wet without increasing the risk of infection or adversely affecting healing,15 it is generally advisable to apply a sterile nonadherent dressing, where feasible, for
Figure 3. A, Razor-induced incised wound of the preauricular region of a teenage female. Postoperative view. Deep dermis has been approximated using an intradermal pull-out suture; 6.0 nylon interrupted sutures coapt superficial skin layer.
a,
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24 hours in children. Skin sutures are removed in Sto 7 days, and pullout sutures in 10 to 14 days. Splinting of the repaired wound for an additional week, using surgical tapes, is advised if possible. Lacerations of several regions of the face, including the external ear, eyelids, eyebrows, lips, and nose, merit special consideration. Lacerations through the eyebrow, eyelid margin, and vermilion border of the lip demand meticulous realignment of those structures. The eyebrow should never be shaved, and its borders should be aligned across the wound and tacked in place using a simple skin suture prior to repair of deeper layers (Fig. 4). Similarly, the vermilion border is exactly realigned using a single suture prior to lip repair. The muscle is then repaired before the skin, vermilion of mucosa. Lacerations through structures containing cartilage, such as the external ear and nose, also require special care. The lacerated cartilage should be anatomically repositioned and stabilized using a minimum number of absorbable sutures prior to layer closure (Fig. SA and B). Hematomas of the external ear, either associated with a laceration or a closed blunt injury, require evacuation. Failure to do so may result in significant perichondrial scar fibrosis and the development of a "cauliflower ear. "19 Complex facial soft-tissue injuries, such as those involving the facial nerve, parotid duct, or significant soft-tissue loss, require early evaluation by a plastic surgeon, otolaryngologist, or maxillofacial surgeon. Lacerations of branches of the facial nerve can be repaired primarily, provided the wound is clean and adequate soft-tissue coverage can be obtained. Otherwise, secondary repair is advisable, and the proximal and distal nerve segments are tagged to facilitate easier identification. Facial nerve lacerations anterior to a vertical line drawn from the lateral canthus usually need not be repaired. 8 Parotid duct injuries should be suspected in deep lacerations of the cheek that cross
Figure 4. Laceration bisecting eyebrow. Exact approximation of anatomic landmarks is essential.
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Figure 5. A, Avulsion injury of the external ear and mastoid region of a teenage girl. Note the exposed, fractured concha cartilage. Despite appearance, no soft·tissue loss has occurred. 8, Postoperative view.
a line drawn from the tragus to the mid-portion of the upper lip. If lacerated, injury to the buccal branch of the facial nerve should be ruled out, because the nerve branch and the parotid duct are in close proximity to each other. The parotid duct should be repaired over a stent. Avulsion injuries or gunshot wounds with major soft-tissue loss require early evaluation by the appropriate surgical specialist. The wounds should be gently irrigated with saline to remove all gross contamination, and actively bleeding vessels carefully identified and ligated. While awaiting treatment, saline gauze dressings should be applied, appropriate antibiotics and tetanus prophylaxis given, and lifepreserving measures, as delineated earlier, instituted. Bite wounds also demand special consideration. Dog bites are the
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most common animal bite wound, with young males the usual victim. Three types of bite wounds are commonly encountered: avulsion tears, punctures, and scratches. Puncture wounds seem to have the greatest risk of becoming infected, probably because of the difficulty of adequately irrigating or debriding the wound to decrease the bacterial inoculum. Pasteurella multocida is an important pathogen in dog bite wounds, although isolatable in only 20% to 25% of wounds. It is a more frequent and important pathogen in cat bites, which more frequently become infected. Human bites are the third most common type of bite wound, with a high incidence of subsequent infection.ll Bite wounds of the head and neck can usually be sutured safely after appropriate wound debridement and copious pulsatile irrigation if treated within 6 to 8 hours of injury and appear uninfected (no purulence or cellulitis). Cultures of wounds that appear uninfected and are seen in this early period may be omitted. Empiric antibiotic coverage should be provided in these cases for organisms commonly present in bite wounds, including P. multocida, Staphylococcus aureus, Staphylococcus intermedius, streptococci, Center for Disease Control alphanumeric bacteria, and oral anaerobic bacteria. Penicillin usually suffices for all of these organisms except S. aureus. Erythromycin, clindamycin, dicloxacillin, and first-generation cephalosporins may not be effective against P. multocida. Recently, increasing numbers of penicillin-resistant strains of P. multocida have been seen clinically. Amoxicillin and clavulanic acid should be active against the entire spectrum of bite wound organisms, including penicillin-resistant P. multocida, and is the drug of choice for bite wounds. Ciprofloxacin, which in vitro data suggest is active against P. multocida and S. aureus, is an alternative for the penicillin-allergic adult patient. ll It should not, however, be used in children. Bite wound lacerations, if closed, should be done so with the minimum number of simple, interrupted nylon sutures required to loosely approximate the wound margins. Deep sutures are foreign bodies and, in the face of a contaminated wound, a potential nidus of infection. They therefore should be avoided, if possible, in bite wounds. Puncture wounds should generally not be closed. Close observation of all bite wounds is required to monitor for development of infection. In the current medicolegal environment, all bite wound victims treated as outpatients should have follow-up evaluation within 24 to 48 hours. Additionally, a single intramuscular or intravenous dose of an appropriate antibiotic should be considered.ll Hospital admission should be considered in cases involving unreliable patients (or parents), established infections, immunocompromised patients, and all significant human bites. With the exception of bite wounds and clearly infected wounds, which require therapeutic antibiotic therapy, antibiotics are usually not needed for facial lacerations. The head and neck region is well vascularized, and fresh, clean wounds rarely become infected. Prophylactic antibiotic coverage (24 hours), however, should be considered in several
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cases: through-and-through lacerations of the lips or cheek; wounds with exposure of nasal or ear cartilage, crush injuries, with massive edema; and in nutritionally or immunologically-compromised patients. Facial fractures involving the sinuses, nose, and tooth-bearing segments of the jaws as well as all open fractures are potentially contaminated and should receive antibiotic coverage. For wounds into the oral cavity, nose, and paranasal sinuses, penicillin, ampicillin, or erythromycin is appropriate. For cutaneous wounds and open fractures, streptococci and S. aureus coverage is needed. Dicloxacillin, erythromycin, or a firstgeneration cephalosporin is usually adequate.
FACIAL FRACTURES
Maxillofacial fractures occur infrequently in children. Life in a protected environment, falls from short distances, a high ratio of cancellous-to-cortical bone, and proportionally thick overlying soft tissue all contribute to this finding. Rudimentary parana sal sinuses, larger cartilaginous growth centers, and a large cranium in relation to facial bones also are responsible for the reduced incidence of pediatric facial fractures.9, 14, 23 Facial fractures in adults, especially of the midface, tend to be comminuted, whereas incomplete, or "greenstick," fractures predominate in childhood. Only 1 % of facial fractures occur before age 6; 5% occur in children under age 12. Midface fractures are especially uncommon in young children. The frequency, distribution, and pattern of facial bone fractures, however, begin to mirror those observed in adults by age 10 to 12.9 In most large series, fractures of the nasal bones and mandible account for the majority of pediatric maxillofacial fractures (Fig. 6).10,12 In a review of 188 children with facial fractures treated by one surgeon, vehicular trauma accounted for 40% of the fractures, with 32% being secondary to falls and athletic injuries. Thirty-six percent of the children had significant associated injuries.23 It must be emphasized that one of the principal reasons for the rarity of facial fractures in young children is the large size of the cranium in relation to the facial skeleton. This finding makes the cranium more vulnerable to injury than the facial bones in children. Therefore, whenever a facial fracture is diagnosed in a child, careful evaluation is required to exclude a concomitant head injury. In one analysis of 86 children with maxillofacial fractures, 35 (40.8%) had associated skull fractures. 14 It must always be kept in mind in the evaluation of children with facial trauma that the relatively small facial skeleton, not yet weakened by sinuses and protected by thick soft tissue, is less subject to fractures than the skull. The history of the injuring event may indicate the mechanism and direction of force applied to the face and thus aid in focusing the clinical examination. Bony injury is suggested by ecchymosis, edema,
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Figure 6. Bilateral mandible angle fracture, with displacement, in 10year-old boy. Caldwell view.
or superficial contusions or abrasions over a bony prominence. Subconjunctival hematoma, with periorbital ecchymosis and edema, suggests fracture of the zygoma, nasal bone, or frontal bone. Ecchymosis and edema over the lower third of the face suggest a mandible fracture. Fractures of facial bones may be diagnosed on the basis of malocclusion or an open bite caused by displacement of the maxilla or mandible. Functional disability suggests fracture of the mandible condyle; trismus may be caused by fracture of the zygoma or the mandible. Unequal pupil height, diplopia, and enophthalmos are indicative of fractures of the zygoma, maxilla, or orbital floor. 8 Bimanual palpation of the supraorbital, lateral, and inferior orbital margins may reveal asymmetry, indicating a fracture. Fractured nasal bones are diagnosed by tenderness, irregularity, mobility, and crepitation on digital palpation. Mobility of the middle third of the face when the maxillary anterior teeth are grasped between the fingers and pressure applied indicates a pyramidal fracture of the maxilla (LeFort II) or craniofacial disjunction (LeFort III). Epistaxis may indicate nasal or septal fractures, septal hematoma, or maxillary fracture. Fractures of the body of the mandible can be detected by supporting the angle of the jaw and applying up and down manual pressure on its anterior portion. Instability and crepitation may be noted. 8 Protection of the airway, control of hemorrhage, and careful evaluation for associated injuries, especially head and neck injuries, are of paramount importance and take precedence over diagnostic maneuvers to confirm suspected facial fractures. Radiologic evaluation, however, is essential in the examination of children with significant facial injuries. Most frequently, radiographs confirm the clinical diagnosis of a facial fracture. In many cases,
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however, the radiographs provide the only evidence of a fracture. Because skull injuries are commonly associated with facial fractures in children, skull films should be obtained whenever significant maxillofacial injuries are suspected. The most valuable and frequently used views of the face are the facial bone series, which includes the Caldwell, Waters, Towne, submentovertex, and lateral skull views. 13 The Waters view is the single most useful routine radiographic study for evaluating the midface, especially the zygoma, maxilla, maxillary sinuses, orbital floors, and the nasal pyramid (Fig. 7).17 The Caldwell view is primarily used to demonstrate the frontal sinuses, frontal bone, anterior ethmoidal cells, and zygomatic-frontal suture. Towne and lateral oblique views are used to evaluate the mandible. Panoramic mandible films are especially useful for evaluating the condyles and alveolar segments. Orbital and nasal films are useful for those areas. 13 In children, fracture lines are often difficult to visualize because of the high ratio of cancellous-to-cortical components of their bones,9 making the interpretation of plain facial films more difficult than in adults. As stated earlier, the craniofacial CT scan has become the diagnostic test of choice for precise delineation of facial fractures, especially of the upper and middle thirds of the face. 13 Unparalleled visualization of the frontal bone, sinuses, orbits, maxilla, and zygomas is obtained (Fig. 8). In the child with a concomitant head injury, scanning of the skull and face may be performed in one session, eliminating the need for plain facial films in many cases. Two facial injuries merit special consideration because of their potential profound impact on future maxillofacial development, namely injuries to the mandibular condyle and the nasal septum. Fractures or injuries to the articular surface of the temporomandibular joint should be suspected in all children suffering a severe blow to
Figure 7. Left zygomatico-maxillary complex (ZMC) fracture in 16year-old boy. Note clouding of left maxillary sinus and medially dis, placed fracture of frontal process of left zygoma. Waters view.
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Figure 8. Computed tomographic scan of patient in Figure 7. Note detailed delineation of extent of fractures of the left ZMC.
the chin. Condylar fractures and injuries always should be viewed with concern because of the possibility of secondary growth disturbances, with subsequent deformity resulting from damage to the condylar growth centers. Such injuries may subsequently result in bony ankylosis; this possible sequela of condylar injury should be discussed with the child's parents. Crushing injuries before age 5 appear to have the greatest potential for subsequent developmental arrest and resulting deformity. Fractures of the condylar neck occurring in later childhood, if properly treated, appear to be self-correcting, with a low incidence of secondary deformity. 9, 2U Nasal injuries may have a profound effect on subsequent nasomaxillary growth and development, even after accurate diagnosis and proper treatment. Septal cartilage injuries may occur with nasal bone fractures or independently. Any child presenting with a nasal injury must be evaluated for the presence of a septal hematoma. Septal hematomas present as a bulging collection between the septal cartilage and the overlying mucoperichondrium and may obstruct the nasal airway. They must be promptly evacuated to prevent possible pressure necrosis of the septal cartilage, with possible sUbseq.6.ent collapse of the nasal dorsum, resulting in a saddle nose deformity.2s Although the definitive management of facial fractures is beyond the scope of this article, the currently accepted treatment goals epitomize the dictum "form follows function." The goals of fracture management are fourfold: (1) achieve anatomic reduction and stabilization of the fracture; (2) reestablish the patient's pre traumatic, functional occlusion; (3) restore facial contour and symmetry; and (4) balance facial height and projection. 24
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SUMMARY
The accurate diagnosis and timely, appropriate treatment of softtissue and bony maxillofacial injuries in children are of critical importance due to the potential adverse impact of maxillofacial trauma on subsequent facial growth and development. Guidelines are provided to assist the pediatrician in the evaluation and treatment of minor and major facial injuries.
References 1. American Academy of Pediatrics Committee on Drugs, Section on Anesthesiology:
2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 76:317, 1985 Annegers JF: The epidemiology of head trauma in children. In Shapiro K (ed): Pediatric Head Trauma. New York, Futura Publishing Co, 1983, p 2 Bonadio WA, Wagner V: Efficacy of TAC topical anesthetic for repair of pediatric lacerations. Am J Dis Child 142:203, 1988 Bonadio WA, Wagner V: Efficacy of tetracaine-adrenalin-cocaine topical anesthetic without tetracaine for facial laceration repair in children. Pediatrics 86:856, 1990 Christoph RA, Buchanan L, Begalla K, et al: Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 17:117, 1988 Daily RH: Fatality secondary to misuse of TAC solution. Ann Emerg Med 17:159, 1988 Daya MR, Burton BT, Sckleiss MR, et al: Recurrent seizures following mucosal application of TAe. Ann Emerg Med 17:147, 1988 Dingman RO, Converse JM: The clinical management of facial injuries and the fracture of facial bones. In Converse JM (ed): Reconstructive Plastic Surgery, ed 2. Philadelphia, W.B. Saunders, 1977, p 599 Dufresene CR, Manson PN: Pediatric facial trauma. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, p 1142 Fortunato MA, Fielding AF, Guernsey LH: Facial bone fractures in children. Oral Surgery 53:225, 1982 Goldstein EJC: Infectious complications and therapy of bite wounds. J Am Podiatr Med Assoc 79:486, 1989 Kaban LB, Mulliken JB, Murray JE: Facial fractures in children: An analysis of 122 fractures in 109 patients. Plast Reconstr Surg 59:15, 1977 Manson PN: Facial injuries. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, p 867 McCoy FJ, Chandler RA, Crow ML: Facial fractures in children. Plast Reconstr Surg 37:209, 1966 Noe JM, Keller M: Can stitches get wet? Plast Reconstr Surg 81:82, 1988 Oberg MS, Lindsey 0: Do not put hydrogen peroxide or povidone iodine into wounds! Am J Dis Child 141:27, 1987 Pollack RA, Rohrich RJ, Sheffield RW: Facial fractures II: Upper and middle face (overview). Selected Readings in Plastic Surgery 4:2, 1987 Pryor GI, Kilpatrick WR, Opp DR: Local anesthesia in minor lacerations: Topical TAC vs lidocaine infiltration. Ann Emerg Med 9:568, 1980 Reil B, Kranz S: Traumatology of the maxillofacial region in childhood. J Maxillofac Surg 4:197, 1976 Rowe NL: Fractures of the jaws in children. Journal of Oral Surgery 27:497, 1969 Rund DA: Essential of Emergency Medicine. Norwalk, Appleton-Century-Crofts, 1986, p 274 Schultz RC: Facial trauma in children. In Schultz RC (ed): Facial Injuries, ed 3. Chicago, Year Book Medical Publishers, 1988, p 471
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23. Schultz RC, Meilman J: Complications of facial fractures. In Goldwyn RM (ed): The Unfavorable Result in Plastic Surgery, ed 2. Boston, Little Brown, 1984, p 359 24. Sinn DP, Rohrich RJ, Pollack RA, et al: Facial fractures I: Lowerface (overview). Selected Readings in Plastic Surgery 4:13, 1987 25. Stucker FI, Bryarly C, Shockley WW: Management of nasal trauma in children. Arch Otolaryngol 110:190, 1984
Address reprint requests to John G. Hunter, MD 47 East 63rd Street New York, NY 10021
0031-3955/92 $0.00 + .20
PEDIATRIC MAXILLOFACIAL TRAUMA John G. Hunter, MD
Head trauma is a leading cause of death among children, with approximately 10 of every 100,000 children dying each year from head injuries. 2 The United States Health Interview Survey for 1975 estimated that the incidence rate for head injuries in children aged 0 to 5 was 18,000 per 100,000 population and 6140 per 100,000 for children aged 6 to 16. The vast majority of these injuries were lacerations and contusions of the scalp and face. 2 Serious maxillofacial trauma, with the exception of animal bites, occurs less frequently in children than in adults. Decreased exposure to trauma combined with children's small size, weight, and other physical characteristics all contribute to this finding. 22 By the early teen years, however, the frequency and pattern of maxillofacial injuries seen in children begin to mirror those seen in adults. 9 Minor head injuries, however, are suffered by children with unfortunate regularity. Motor vehicle-related trauma is responsible for a significant number of deaths and serious injuries in older childhood. Children under 14 years of age account for approximately 6% of automobile deaths. Of interest is the finding that of those children aged 5 to 14 years injured in motor vehicle accidents, only 56% were actual occupants of the vehicles. 9 Facial trauma in younger children is commonly sustained during falls, usually associated with running or jumping. A greater degree of motor skills than coordination may in part be responsible (Hunter JG, Song IC: Facial injuries in children: An analysis. Submitted From the Department of Surgery (Plastic), State University of New York Health Science Center at Brooklyn College of Medicine; Division of Plastic Surgery, St. Luke's/ Roosevelt Hospital Center; Beth Israel Hospital North; New York Downtown Hospital; and Methodist Hospital, New York, New York
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for publication). As noted earlier, animal bites are also a common cause of facial injuries in children. Although the basic principles of treatment of pediatric maxillofacial injuries are similar to those used in adults, techniques and approaches must be modified to accommodate for children's immature maxillofacial structures and the difficulty in obtaining their cooperation. The seriousness of facial injuries in children is compounded by the effect of the injury on future growth and development. Facial fractures, especially of the mandibular condyle and nasomaxillary complex, in addition to the deformity resulting from the fracture itself, may result in arrested development of the injured area. Developmental malformations seen in adolescence and adulthood are often secondary to injuries occurring in early childhood. The mandible is the facial bone most frequently involved in posttraumatic developmental deformities. 9
EXAMINATION OF THE INJURED CHILD
Evaluation of the child with a maxillofacial injury is often difficult and requires patience and compassion on the part of the examiner. Young children are often frightened more by their own apprehension and the apprehension of adults than by the pain of the injury. Young children are usually unaware of the extent of their injury.22 Obtaining a history of the injuring event is not always possible or complete. The initial contact with the child is extremely important in establishing trust and cooperation. Most children older than age 4 are reasonably cooperative with clinical examinations and procedures if they are explained simply and done gently. The child should not be lied to, such as being told that a portion of an examination or procedure is painless when it is in fact uncomfortable. The child's questions also should be answered simply but truthfully. Once the child's trust has been lost, obtaining further (or future) cooperation may be difficult. Sedation, most commonly chloral hydrate or meperidine HCIchlorpromazine-promethazine HCl in the outpatient setting, or even general anesthesia may be required to allow adequate evaluation and treatment of maxillofacial injuries. Sedation should not be used in those children requiring observation for a concomitant head injury. In the evaluation and treatment of minor facial injuries, such as most lacerations, sedation should only be required in a small percentage of children for control of behavior or production of a more positive psychological response to treatment. I strongly believe that sedation is overused in the treatment of minor pediatric facial injuries, most often for expedience rather than for a legitimate indication. When required, I only use sedation in the hospital setting, and only when adequate repair absolutely cannot be accomplished without it (less than 1% of cases). The use of conscious or deep sedation in the office setting, especially by non-pediatricians, is potentially hazardous because properly trained personnel and appropriate resuscitation equipment to manage any
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"reasonably foreseeable emergency" may not be available.! Sedation, however, is commonly required when special diagnostic procedures, such as a computed tomographic (CT) scan or magnetic resonance image, are needed. The physical examination should consist of an orderly inspection of all facial areas by observation, palpation, and evaluation of function. Facial wounds may be classified into three catagories: wounds of soft tissue alone, wounds of soft tissue with associated fracture(s), and fracture(s) without an associated wound. 8 Lacerations and contusions should be evaluated for an underlying fracture or injury to other deep structures (nerves or parotid). Orderly gentle palpation of all bony surfaces, including the skull, forehead, orbital rims, nose, zygomatic arches, malar eminences, and jaws, should be performed to identify tenderness, asymmetry, "step off" or level discrepancy, or abnormal motion or crepitus. Intraoral examination is performed to identify lacerations, hematomas, loose or missing teeth, or oropharyngeal obstruction. Mandibular range of motion should be evaluated while palpating the condyles bilaterally. The occlusal relationship should be evaluated. Ophthalmologic evaluation should be undertaken for evidence of diplopia, visual acuity change, exophthalmos or enophthalmos, and globe injury. Pupil response, visual fields, and extraocular muscle movements should be assessed. The nose should be examined for intranasal lacerations, cerebrospinal fluid leakage, or septal hematoma. Facial and trigeminal nerve functions should be evaluated and compared bilaterally. Facial nerve function is grossly assessed by having the patient grimace, raise the eyebrows, tightly close the eyelids, and smile. Sensory function in the supraorbital, infraorbital, and mental nerve distributions are tested by gentle stroking with a cotton-tip applicator, using the contralateral side as control. Evaluation for concomitant but perhaps less dramatic injuries, especially head injuries, is mandatory. Radiologic evaluation is required to adequately and accurately assess significant facial injuries. The quality of the films obtained, especially of special studies such as CT scans, depends on the level of cooperation obtainable from the injured child. As mentioned earlier, sedation is often required for younger children. Although the craniofacial CT scan has become the definitive diagnostic test for precise evaluation of maxillofacial fractures of the upper and middle face, initial plain facial radiographs are appropriate in most cases and are discussed later. Treatment priorities in the management of the child with major maxillofacial trauma are the same as for any other serious injury, namely, preservation of life, maintenance of function, and restoration of form.24 Emergency treatment may have to be initiated prior to, or concurrent with, clinical evaluation when life-threatening injuries or conditions are present. The control of hemorrhage, maintenance or restoration of an adequate airway, and prevention of aspiration are absolute priorities in children with maxillofacial injuries. Airway patency may be compromised by the presence of blood clots, fractured
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teeth, or foreign bodies within the oropharynx. The tongue, especially in the presence of a mandible fracture, may obstruct the hypopharynx. Edema or hematoma of the floor of the mouth also may compromise the child's airway. The airway can usually be protected by early intubation (either orally or nasal~y, depending on the nature of the facial injuries). Emergency tracheostomy is rarely required; it is usually reserved for cases with massive facial trauma involving both the midface and the mandible. 9 Control of hemorrhage from lacerations is usually achieved with digital compression and direct ligation of the bleeding vessel or by temporary approximation of the wound edges. Blind clamping of bleeding vessels in a bloody field invites inadvertent injury to nerve branches and other structures and should be avoided. Persistent nasopharyngeal hemorrhage from closed maxillofacial fractures is usually controllable by one of several maneuvers. The internal maxillary artery is most frequently the source of the bleeding. Intranasal tamponade is usually effective: a Foley catheter (30-40 mL balloon) is passed into the nasopharynx via each nostril, the balloon is inflated and then pulled anteriorly to occlude the posterior nasopharyngeal opening. Antibioticimpregnated gauze is packed into the nasal cavity anteriorly. Caution is required if cranial base fractures are suspected. Persistent hemorrhage is often controlled by emergent closed reduction of displaced or impacted fractures, especially of the maxilla. Selective arterial ligation or embolization is occasionally needed in the rare cases in which the aforementioned measures fail to control nasopharyngeal bleeding. Selective artery ligation may include the internal maxillary or ethmoidal arteries. Rarely, bilateral external carotid and superficial temporal artery ligation is required to control hemorrhageY
SOFT-TISSUE INJURIES
Facial soft-tissue injuries, especially minor lacerations, contusions, abrasions, and minor burns, are suffered by children with unfortunate regularity. Massive soft-tissue injuries, although uncommon, do occur and are usually associated with motor vehicle accidents, major burns, and animal maulings. Despite their relatively common occurrence, little has been written about facial lacerations in children. The goals of treatment of pediatric facial soft-tissue injuries are no different than those for trauma elsewhere, namely, preservation of life and restoration of normal function and form.24 The seriousness of softtissue injuries in children is compounded by the effect of the injury on future growth and development. This may be obvious in cases of avulsed soft tissue, but permanent disfigurement also may result from subcutaneous tissue damage in the form of a hematoma or fat atrophy following injury.22 Most commonly, however, inadequate treatment simply results in a more noticeable, less aesthetically acceptable scar. Scar depression frequently results when lacerated muscle layers are not
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repaired, and widening results when gaping wounds are approximated using a single layer, simple skin closure or using surgical tapes. Proper assessment of the extent of tissue damage is therefore quite important. Anatomic layer repair of wounds in children may be even more important than in adults for the reasons noted earlier. Careful atraumatic exploration of the wound to determine the full extent of injury is mandatory. Fine quality, delicate surgical instruments are essential, and sterile, prepackaged instrument sets should be assembled and kept readily available in treatment areas (Fig. 1). Devitalized tissue should be conservatively debrided. Lacerated muscle fascia and periosteum should be reapproximated anatomically and subcutaneous dead space obliterated using a minimal number of well-placed absorbable sutures. Accurate anatomic repair of facial lacerations requires patience and compassion. Adequate but comfortable restraint, such as is provided by a Papoose board (Olympic Medical Corp, Seattle, WA), is essential for young children. Adequately "swaddled," young children often fall asleep during the procedure. As stated earlier, sedation is rarely needed if patience is exercised and trust established. Lacerations may be simple incised wounds or they may be beveled, jagged, stellate, or avulsion injuries, with or without tissue loss. Most facial lacerations sustained by younger children (aged 1 to 4 years) are small, burst-type lacerations, usually sustained during a fall (Fig. 2). Often these wounds appear rather trivial, but careful exploration reveals
Figure 1. Fine surgical instruments are required to adequately repair pediatric facial lacerations. Recommended instruments include curved iris scissors, fine tooth Adson tissue forceps, Webster needle holder, baby mosquito hemostats, and skin hooks.
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Figure 2. Typical pediatric forehead laceration sustained during a fall. Despite superficial appearance, the laceration extended to bone.
that they are usually quite deep, often extending into or through deeper layers (i.e., muscle, periosteum). Falls into stationary objects, especially while running, generate considerable force. The soft tissue is compressed between the object and the underlying bone, resulting in a full-thickness burst injury. This is particularly common in forehead and chin lacerations. Failure to recognize and anatomically repair these deep injuries can have significant aesthetic and functional consequences (Hunter JG, Song IC: Facial trauma in children: An analysis. Submitted for publication, 1992). Special care should be exercised in treating abrasions containing dirt or other foreign particles. When initially evaluated, a child with a superficial abrasion may not appear to have an injury of consequence. Upon healing, however, permanent "traumatic tattooing" will be present if all dirt, road particles, and other matter have not been completely removed from the wound. All such abrasions must be thoroughly scrubbed under local anesthesia, and all foreign matter must be removed before healing occurs.8 Complete evaluation and treatment of significant soft-tissue wounds and lacerations require adequate pain control. After cursory inspection of the injury and evaluation of nerve function, the wound should be anesthetized. Because administration of local anesthetic solution is generally painful, efforts have been made to reduce the discomfort associated with obtaining wound anesthesia and therefore reduce the need or desire to use sedation in the treatment of minor maxillofacial wounds. It is well known that slow infiltration of local anesthetics can reduce the pain associated with the process. 21 Most local anesthetic solutions are acidic, with a pH between 5.0 and 7.0. It has been demonstrated clearly that pH buffering of local anesthetic solutions with bicarbonate, thus raising the solution pH toward a more physiologic range of 7.0 to 7.4, can dramatically reduce the amount of pain associated with infiltration without compromising anesthetic effi-
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cacy.5 Because the buffered solution is unstable, however, the local anesthetic should be mixed with sodium bicarbonate in a 10:1 ratio immediately prior to use. I have found this technique to be quite effective. It permits one to achieve the desired goal of near painless anesthesia without the toxicity associated with topical anesthetics, such as tetracaine-adrenalin-cocaine (TAC). The efficacy of TAC topic anesthetic for repair of facial lacerations has been well established in both adults and children. 3, 11 It has recently been demonstrated that the tetracaine component of TAC, however, is superfluous for obtaining topical anesthesia and may be omitted without compromising anesthetic efficacy. 4 Although TAC is seemingly quite safe to use, there are as yet no data that delineate the dosage of cocaine that may be safely applied to wounds in children. 3 Recurrent seizures requiring intensive care unit admission have been reported after mucosal application of TAC, presumably secondary to cocaine toxicity.7 Furthermore, death has been reported after misuse of TAC solution. 6 Although TAC use may render the procedure practically painless in most cases, it probably should not be used in the office setting, especially by non-pediatricians. It is, however, a reasonable alternative for use for nonmucosal wounds in the pediatric emergency department, where adequate monitoring and support are available. The pH buffering of local anesthetic solution, however, is probably a safer alternative in most cases. Once adequate local anesthesia has been obtained, careful exploration of the wound can be performed and definitive treatment initiated. The following is a recommended treatment protocol for pediatric facial lacerations. The skin surrounding the laceration is prepped with a dilute povidine-iodine solution. It is not used in the wound itself because it is tissue toxic. Pulsatile saline irrigation of the wound is usually quite adequate for fresh injuries. Heavily soiled wounds can be cleansed with a nontoxic solvent, such as poloxamer-188, if needed, not povidone-iodine or hydrogen peroxide. 16 The pH buffered local anesthetic is then slowly infiltrated through the laceration margins (except in contaminated wounds and bites) using a 27 gauge needle. After waiting 7 to 10 minutes for. the epinephrine effect to occur (if used), the wound is gently explored, preferably retracting the margins with skin hooks, and foreign matter and blood clots are removed. The wound is then copiously irrigated with saline using pulsatile irrigation. Beveled or jagged wound margins and devitalized subcutaneous tissue are conservatively excised. Conservative undermining, if needed to obtain a tension-free closure, is performed in the subcutaneous plane. Hemostasis is obtained by digital pressure, electrocautery or ophthalmic cautery, or fine (5.0 or 6.0) Vicryl (polyglactin 910, Ethicon, Inc., Somerville, NJ) ties. Nongaping wounds involving only skin and subcutaneous tissue can be closed in a single layer using interrupted or continuous simple sutures; 6.0 nylon is recommended (silk and absorbable sutures are quite reactive and are not recommended for general facial skin closures). If the wound is gaping, however, or if deeper structures are involved,
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then a multiple layer, anatomic repair is usually advisable. Muscle fascia and periosteum are reapproximated using 5.0 or 6.0 absorbable sutures, such as Vicryl. In gaping wounds in which there is tension on the skin closure, the deep dermis should be approximated using longlasting absorbable sutures such as 6.0 Vicryl or 6.0 PDS (polydioxanone, Ethicon). Interrupted sutures, with inversion of the knots, should be used. Only the minimum number of sutures required to coapt the wound margins should be used, and care must be taken to place the sutures deep in the dermis to reduce the chance of suture "spitting." Alternatively, the deep dermis may be approximated using an intradermal continuous pullout suture (subcuticular suture) of 4.0 or 5.0 nylon or Prolene (polypropylene, Ethicon). This technique is best reserved for long, relatively linear incised wounds, such as knife lacerations (Fig. 3A and B). If excellent wound margin coaptation has been achieved with the deep closure, the superficial dermis and epidermis can be approximated using surgical tapes. Otherwise, 6.0 or 7.0 nylon should be used. Although it has been demonstrated that dressings are not required over sutured lacerations and that sutures can get wet without increasing the risk of infection or adversely affecting healing,15 it is generally advisable to apply a sterile nonadherent dressing, where feasible, for
Figure 3. A, Razor-induced incised wound of the preauricular region of a teenage female. Postoperative view. Deep dermis has been approximated using an intradermal pull-out suture; 6.0 nylon interrupted sutures coapt superficial skin layer.
a,
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24 hours in children. Skin sutures are removed in Sto 7 days, and pullout sutures in 10 to 14 days. Splinting of the repaired wound for an additional week, using surgical tapes, is advised if possible. Lacerations of several regions of the face, including the external ear, eyelids, eyebrows, lips, and nose, merit special consideration. Lacerations through the eyebrow, eyelid margin, and vermilion border of the lip demand meticulous realignment of those structures. The eyebrow should never be shaved, and its borders should be aligned across the wound and tacked in place using a simple skin suture prior to repair of deeper layers (Fig. 4). Similarly, the vermilion border is exactly realigned using a single suture prior to lip repair. The muscle is then repaired before the skin, vermilion of mucosa. Lacerations through structures containing cartilage, such as the external ear and nose, also require special care. The lacerated cartilage should be anatomically repositioned and stabilized using a minimum number of absorbable sutures prior to layer closure (Fig. SA and B). Hematomas of the external ear, either associated with a laceration or a closed blunt injury, require evacuation. Failure to do so may result in significant perichondrial scar fibrosis and the development of a "cauliflower ear. "19 Complex facial soft-tissue injuries, such as those involving the facial nerve, parotid duct, or significant soft-tissue loss, require early evaluation by a plastic surgeon, otolaryngologist, or maxillofacial surgeon. Lacerations of branches of the facial nerve can be repaired primarily, provided the wound is clean and adequate soft-tissue coverage can be obtained. Otherwise, secondary repair is advisable, and the proximal and distal nerve segments are tagged to facilitate easier identification. Facial nerve lacerations anterior to a vertical line drawn from the lateral canthus usually need not be repaired. 8 Parotid duct injuries should be suspected in deep lacerations of the cheek that cross
Figure 4. Laceration bisecting eyebrow. Exact approximation of anatomic landmarks is essential.
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Figure 5. A, Avulsion injury of the external ear and mastoid region of a teenage girl. Note the exposed, fractured concha cartilage. Despite appearance, no soft·tissue loss has occurred. 8, Postoperative view.
a line drawn from the tragus to the mid-portion of the upper lip. If lacerated, injury to the buccal branch of the facial nerve should be ruled out, because the nerve branch and the parotid duct are in close proximity to each other. The parotid duct should be repaired over a stent. Avulsion injuries or gunshot wounds with major soft-tissue loss require early evaluation by the appropriate surgical specialist. The wounds should be gently irrigated with saline to remove all gross contamination, and actively bleeding vessels carefully identified and ligated. While awaiting treatment, saline gauze dressings should be applied, appropriate antibiotics and tetanus prophylaxis given, and lifepreserving measures, as delineated earlier, instituted. Bite wounds also demand special consideration. Dog bites are the
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most common animal bite wound, with young males the usual victim. Three types of bite wounds are commonly encountered: avulsion tears, punctures, and scratches. Puncture wounds seem to have the greatest risk of becoming infected, probably because of the difficulty of adequately irrigating or debriding the wound to decrease the bacterial inoculum. Pasteurella multocida is an important pathogen in dog bite wounds, although isolatable in only 20% to 25% of wounds. It is a more frequent and important pathogen in cat bites, which more frequently become infected. Human bites are the third most common type of bite wound, with a high incidence of subsequent infection.ll Bite wounds of the head and neck can usually be sutured safely after appropriate wound debridement and copious pulsatile irrigation if treated within 6 to 8 hours of injury and appear uninfected (no purulence or cellulitis). Cultures of wounds that appear uninfected and are seen in this early period may be omitted. Empiric antibiotic coverage should be provided in these cases for organisms commonly present in bite wounds, including P. multocida, Staphylococcus aureus, Staphylococcus intermedius, streptococci, Center for Disease Control alphanumeric bacteria, and oral anaerobic bacteria. Penicillin usually suffices for all of these organisms except S. aureus. Erythromycin, clindamycin, dicloxacillin, and first-generation cephalosporins may not be effective against P. multocida. Recently, increasing numbers of penicillin-resistant strains of P. multocida have been seen clinically. Amoxicillin and clavulanic acid should be active against the entire spectrum of bite wound organisms, including penicillin-resistant P. multocida, and is the drug of choice for bite wounds. Ciprofloxacin, which in vitro data suggest is active against P. multocida and S. aureus, is an alternative for the penicillin-allergic adult patient. ll It should not, however, be used in children. Bite wound lacerations, if closed, should be done so with the minimum number of simple, interrupted nylon sutures required to loosely approximate the wound margins. Deep sutures are foreign bodies and, in the face of a contaminated wound, a potential nidus of infection. They therefore should be avoided, if possible, in bite wounds. Puncture wounds should generally not be closed. Close observation of all bite wounds is required to monitor for development of infection. In the current medicolegal environment, all bite wound victims treated as outpatients should have follow-up evaluation within 24 to 48 hours. Additionally, a single intramuscular or intravenous dose of an appropriate antibiotic should be considered.ll Hospital admission should be considered in cases involving unreliable patients (or parents), established infections, immunocompromised patients, and all significant human bites. With the exception of bite wounds and clearly infected wounds, which require therapeutic antibiotic therapy, antibiotics are usually not needed for facial lacerations. The head and neck region is well vascularized, and fresh, clean wounds rarely become infected. Prophylactic antibiotic coverage (24 hours), however, should be considered in several
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cases: through-and-through lacerations of the lips or cheek; wounds with exposure of nasal or ear cartilage, crush injuries, with massive edema; and in nutritionally or immunologically-compromised patients. Facial fractures involving the sinuses, nose, and tooth-bearing segments of the jaws as well as all open fractures are potentially contaminated and should receive antibiotic coverage. For wounds into the oral cavity, nose, and paranasal sinuses, penicillin, ampicillin, or erythromycin is appropriate. For cutaneous wounds and open fractures, streptococci and S. aureus coverage is needed. Dicloxacillin, erythromycin, or a firstgeneration cephalosporin is usually adequate.
FACIAL FRACTURES
Maxillofacial fractures occur infrequently in children. Life in a protected environment, falls from short distances, a high ratio of cancellous-to-cortical bone, and proportionally thick overlying soft tissue all contribute to this finding. Rudimentary parana sal sinuses, larger cartilaginous growth centers, and a large cranium in relation to facial bones also are responsible for the reduced incidence of pediatric facial fractures.9, 14, 23 Facial fractures in adults, especially of the midface, tend to be comminuted, whereas incomplete, or "greenstick," fractures predominate in childhood. Only 1 % of facial fractures occur before age 6; 5% occur in children under age 12. Midface fractures are especially uncommon in young children. The frequency, distribution, and pattern of facial bone fractures, however, begin to mirror those observed in adults by age 10 to 12.9 In most large series, fractures of the nasal bones and mandible account for the majority of pediatric maxillofacial fractures (Fig. 6).10,12 In a review of 188 children with facial fractures treated by one surgeon, vehicular trauma accounted for 40% of the fractures, with 32% being secondary to falls and athletic injuries. Thirty-six percent of the children had significant associated injuries.23 It must be emphasized that one of the principal reasons for the rarity of facial fractures in young children is the large size of the cranium in relation to the facial skeleton. This finding makes the cranium more vulnerable to injury than the facial bones in children. Therefore, whenever a facial fracture is diagnosed in a child, careful evaluation is required to exclude a concomitant head injury. In one analysis of 86 children with maxillofacial fractures, 35 (40.8%) had associated skull fractures. 14 It must always be kept in mind in the evaluation of children with facial trauma that the relatively small facial skeleton, not yet weakened by sinuses and protected by thick soft tissue, is less subject to fractures than the skull. The history of the injuring event may indicate the mechanism and direction of force applied to the face and thus aid in focusing the clinical examination. Bony injury is suggested by ecchymosis, edema,
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Figure 6. Bilateral mandible angle fracture, with displacement, in 10year-old boy. Caldwell view.
or superficial contusions or abrasions over a bony prominence. Subconjunctival hematoma, with periorbital ecchymosis and edema, suggests fracture of the zygoma, nasal bone, or frontal bone. Ecchymosis and edema over the lower third of the face suggest a mandible fracture. Fractures of facial bones may be diagnosed on the basis of malocclusion or an open bite caused by displacement of the maxilla or mandible. Functional disability suggests fracture of the mandible condyle; trismus may be caused by fracture of the zygoma or the mandible. Unequal pupil height, diplopia, and enophthalmos are indicative of fractures of the zygoma, maxilla, or orbital floor. 8 Bimanual palpation of the supraorbital, lateral, and inferior orbital margins may reveal asymmetry, indicating a fracture. Fractured nasal bones are diagnosed by tenderness, irregularity, mobility, and crepitation on digital palpation. Mobility of the middle third of the face when the maxillary anterior teeth are grasped between the fingers and pressure applied indicates a pyramidal fracture of the maxilla (LeFort II) or craniofacial disjunction (LeFort III). Epistaxis may indicate nasal or septal fractures, septal hematoma, or maxillary fracture. Fractures of the body of the mandible can be detected by supporting the angle of the jaw and applying up and down manual pressure on its anterior portion. Instability and crepitation may be noted. 8 Protection of the airway, control of hemorrhage, and careful evaluation for associated injuries, especially head and neck injuries, are of paramount importance and take precedence over diagnostic maneuvers to confirm suspected facial fractures. Radiologic evaluation, however, is essential in the examination of children with significant facial injuries. Most frequently, radiographs confirm the clinical diagnosis of a facial fracture. In many cases,
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however, the radiographs provide the only evidence of a fracture. Because skull injuries are commonly associated with facial fractures in children, skull films should be obtained whenever significant maxillofacial injuries are suspected. The most valuable and frequently used views of the face are the facial bone series, which includes the Caldwell, Waters, Towne, submentovertex, and lateral skull views. 13 The Waters view is the single most useful routine radiographic study for evaluating the midface, especially the zygoma, maxilla, maxillary sinuses, orbital floors, and the nasal pyramid (Fig. 7).17 The Caldwell view is primarily used to demonstrate the frontal sinuses, frontal bone, anterior ethmoidal cells, and zygomatic-frontal suture. Towne and lateral oblique views are used to evaluate the mandible. Panoramic mandible films are especially useful for evaluating the condyles and alveolar segments. Orbital and nasal films are useful for those areas. 13 In children, fracture lines are often difficult to visualize because of the high ratio of cancellous-to-cortical components of their bones,9 making the interpretation of plain facial films more difficult than in adults. As stated earlier, the craniofacial CT scan has become the diagnostic test of choice for precise delineation of facial fractures, especially of the upper and middle thirds of the face. 13 Unparalleled visualization of the frontal bone, sinuses, orbits, maxilla, and zygomas is obtained (Fig. 8). In the child with a concomitant head injury, scanning of the skull and face may be performed in one session, eliminating the need for plain facial films in many cases. Two facial injuries merit special consideration because of their potential profound impact on future maxillofacial development, namely injuries to the mandibular condyle and the nasal septum. Fractures or injuries to the articular surface of the temporomandibular joint should be suspected in all children suffering a severe blow to
Figure 7. Left zygomatico-maxillary complex (ZMC) fracture in 16year-old boy. Note clouding of left maxillary sinus and medially dis, placed fracture of frontal process of left zygoma. Waters view.
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Figure 8. Computed tomographic scan of patient in Figure 7. Note detailed delineation of extent of fractures of the left ZMC.
the chin. Condylar fractures and injuries always should be viewed with concern because of the possibility of secondary growth disturbances, with subsequent deformity resulting from damage to the condylar growth centers. Such injuries may subsequently result in bony ankylosis; this possible sequela of condylar injury should be discussed with the child's parents. Crushing injuries before age 5 appear to have the greatest potential for subsequent developmental arrest and resulting deformity. Fractures of the condylar neck occurring in later childhood, if properly treated, appear to be self-correcting, with a low incidence of secondary deformity. 9, 2U Nasal injuries may have a profound effect on subsequent nasomaxillary growth and development, even after accurate diagnosis and proper treatment. Septal cartilage injuries may occur with nasal bone fractures or independently. Any child presenting with a nasal injury must be evaluated for the presence of a septal hematoma. Septal hematomas present as a bulging collection between the septal cartilage and the overlying mucoperichondrium and may obstruct the nasal airway. They must be promptly evacuated to prevent possible pressure necrosis of the septal cartilage, with possible sUbseq.6.ent collapse of the nasal dorsum, resulting in a saddle nose deformity.2s Although the definitive management of facial fractures is beyond the scope of this article, the currently accepted treatment goals epitomize the dictum "form follows function." The goals of fracture management are fourfold: (1) achieve anatomic reduction and stabilization of the fracture; (2) reestablish the patient's pre traumatic, functional occlusion; (3) restore facial contour and symmetry; and (4) balance facial height and projection. 24
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SUMMARY
The accurate diagnosis and timely, appropriate treatment of softtissue and bony maxillofacial injuries in children are of critical importance due to the potential adverse impact of maxillofacial trauma on subsequent facial growth and development. Guidelines are provided to assist the pediatrician in the evaluation and treatment of minor and major facial injuries.
References 1. American Academy of Pediatrics Committee on Drugs, Section on Anesthesiology:
2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 76:317, 1985 Annegers JF: The epidemiology of head trauma in children. In Shapiro K (ed): Pediatric Head Trauma. New York, Futura Publishing Co, 1983, p 2 Bonadio WA, Wagner V: Efficacy of TAC topical anesthetic for repair of pediatric lacerations. Am J Dis Child 142:203, 1988 Bonadio WA, Wagner V: Efficacy of tetracaine-adrenalin-cocaine topical anesthetic without tetracaine for facial laceration repair in children. Pediatrics 86:856, 1990 Christoph RA, Buchanan L, Begalla K, et al: Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 17:117, 1988 Daily RH: Fatality secondary to misuse of TAC solution. Ann Emerg Med 17:159, 1988 Daya MR, Burton BT, Sckleiss MR, et al: Recurrent seizures following mucosal application of TAe. Ann Emerg Med 17:147, 1988 Dingman RO, Converse JM: The clinical management of facial injuries and the fracture of facial bones. In Converse JM (ed): Reconstructive Plastic Surgery, ed 2. Philadelphia, W.B. Saunders, 1977, p 599 Dufresene CR, Manson PN: Pediatric facial trauma. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, p 1142 Fortunato MA, Fielding AF, Guernsey LH: Facial bone fractures in children. Oral Surgery 53:225, 1982 Goldstein EJC: Infectious complications and therapy of bite wounds. J Am Podiatr Med Assoc 79:486, 1989 Kaban LB, Mulliken JB, Murray JE: Facial fractures in children: An analysis of 122 fractures in 109 patients. Plast Reconstr Surg 59:15, 1977 Manson PN: Facial injuries. In McCarthy JG (ed): Plastic Surgery. Philadelphia, W.B. Saunders, 1990, p 867 McCoy FJ, Chandler RA, Crow ML: Facial fractures in children. Plast Reconstr Surg 37:209, 1966 Noe JM, Keller M: Can stitches get wet? Plast Reconstr Surg 81:82, 1988 Oberg MS, Lindsey 0: Do not put hydrogen peroxide or povidone iodine into wounds! Am J Dis Child 141:27, 1987 Pollack RA, Rohrich RJ, Sheffield RW: Facial fractures II: Upper and middle face (overview). Selected Readings in Plastic Surgery 4:2, 1987 Pryor GI, Kilpatrick WR, Opp DR: Local anesthesia in minor lacerations: Topical TAC vs lidocaine infiltration. Ann Emerg Med 9:568, 1980 Reil B, Kranz S: Traumatology of the maxillofacial region in childhood. J Maxillofac Surg 4:197, 1976 Rowe NL: Fractures of the jaws in children. Journal of Oral Surgery 27:497, 1969 Rund DA: Essential of Emergency Medicine. Norwalk, Appleton-Century-Crofts, 1986, p 274 Schultz RC: Facial trauma in children. In Schultz RC (ed): Facial Injuries, ed 3. Chicago, Year Book Medical Publishers, 1988, p 471
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23. Schultz RC, Meilman J: Complications of facial fractures. In Goldwyn RM (ed): The Unfavorable Result in Plastic Surgery, ed 2. Boston, Little Brown, 1984, p 359 24. Sinn DP, Rohrich RJ, Pollack RA, et al: Facial fractures I: Lowerface (overview). Selected Readings in Plastic Surgery 4:13, 1987 25. Stucker FI, Bryarly C, Shockley WW: Management of nasal trauma in children. Arch Otolaryngol 110:190, 1984
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