Prospective analysis of mid-facial fractures in a single-center pediatric-adolescent cohort

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

Contents lists available at ScienceDirect

International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl

Prospective analysis of mid-facial fractures in a single-center pediatricadolescent cohort

T

Waldemar Reicha,∗, Oliver Austb, Alexander Eckerta a b

Department of Oral and Plastic Maxillofacial Surgery, Martin Luther University Halle-Wittenberg, Ernst-Grube Str. 40, D-06120, Halle (Saale), Germany Dental Practice, Waldkerbelstraße 12, D-04329, Leipzig, Germany

ARTICLE INFO

ABSTRACT

Keywords: Children Complications Facial fracture Maxillofacial injuries Mid-facial fractures Pediatric trauma

Background: The complex architecture of the midface renders diagnosing and treating fractures challenging, especially for young patients who present the additional risk of suffering growth and development deficiencies, which is to be avoided at all costs. Objectives: This study sought to characterize pediatric mid-facial fractures considering the possible complications. Methods: Between September 2008 and September 2018, data was collected on inpatients aged < 18 years, treated for mid-facial fractures at the Halle University Hospital. Evaluated parameters were age, gender, cause and type of fracture, associated injuries, treatment, and complications. Results: In total, 31 patients were examined; 20 were boys. The most common cause of injury was road traffic accident (41.9%). Orbital floor fracture was the most common type of injury (58.1%). In 54.8% of cases, surgery was performed. Conclusion: The incidence of complications associated with mid-facial fractures was low (n = 7), requiring treatment in only three cases (orthodontic, ophthalmological).

1. Introduction

Furthermore, unerupted teeth stabilize the jaws [7]. Nevertheless, age-dependent psychological development is a factor of potential accidents that can result in facial injuries. As underlined by Limbourg (1995) [8], awareness of danger in daily life is only developed at approximately 6 years old, while anticipation of dangers develops at 8, and ability to arrange preventive measures is observed at 9–10 [8].

Just like adults, children can be victims of accidents, and according to the World Health Organization (WHO), injury is unfortunately the most common cause of death for children and adolescents [1]. When treating facial bone fractures in this population, it is essential to consider the possibilities of growth disturbance. Whereas these types of fractures in adulthood are well investigated, there is little data concerning fractures in childhood. Furthermore, there are significant differences in these studies, namely regarding the surgery rates (Ferreira et al.: 78% [2], Imahara et al.: 25.1% [3]) and the frequencies of involved anatomical regions. For Grunwaldt et al., the most common type of facial fracture was orbital fracture [4], at all ages; for Tetsiju Yabe et al., it was nasal fracture [5], and for Posnick et al., it was mandible fracture [6]. The anatomic features of young individuals possess numerous special characteristics that protect the facial bones. Children have a low face-to-head ratio, so the neurocranium can predominantly absorb traumatic forces that have significant risk of neurocranial injury. The higher elasticity of their bones, greater adipose tissue, and lack of pneumatization of the paranasal sinuses additionally prevent fractures.

∗

2. Material and methods We analyzed the medical records of inpatients under 18 years old who received treatment at the Halle University Hospital's Department of Oral and Plastic Maxillofacial Surgery due to mid-facial fractures, from September 2008 to September 2018 (study cohort). For that reason, first the incidence of pediatric-adolescent neurocranial fractures and respectively, the incidence of mid-facial fractures for the German population and the population of the Federal state Saxony Anhalt were calculated that included the following ICD-10 codes (German modification, version 2018): S02.0 (cranial vault), S02.1 (skull base), S02.2 to S02.4 (nasal pyramid, orbita, zygoma), S02.7 and S02.8 multiple fractures of the neurocranium and viscerocranium [9]. Additionally,

Corresponding author. E-mail addresses: [email protected] (W. Reich), [email protected] (O. Aust), [email protected] (A. Eckert).

https://doi.org/10.1016/j.ijporl.2019.01.028 Received 20 October 2018; Received in revised form 19 January 2019; Accepted 19 January 2019 Available online 22 January 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

the trauma statistics of the Halle University Hospital were studied focusing on the same patient group. In this study, only inpatients who received treatment primarily at the Department of Oral and Plastic Maxillofacial Surgery were included. Patients with mandibular fractures, pathological and isolated dentoalveolar fractures, along with outpatients and patients with neurologicalpsychiatric comorbidity were excluded. Evaluated parameters were age, gender, cause (e.g. road traffic accident etc.), medical imaging, location of the fracture, associated injuries, and provided treatment (surgical or non-surgical), as well as associated complications. Following acute care, yearly clinical follow-up examinations were prospectively arranged to monitor any long-term complications. The classification of local complications used was according to Rottgers et al. (2011) [10]: Type I - trauma-associated (e.g. loss of vision), Type II – therapy-associated (e.g. lower eyelid ectropion), Type III – interaction of trauma, therapy, and growth disturbance (dysgnathia). All patients were pseudonymized and parameters were attached to a databank to be analyzed statistically. Statistical analyses were performed using statistics software (IBM SPSS statistics, Version 20, Chicago, IL, USA). The descriptive statistics presented the frequencies and distribution of several occurrences as well as combinations of certain features. All procedures performed in the study were in accordance with the ethical standards of the institutional research committee (registration number: 2017-99) and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all individual participants included in this study.

Table 1 Epidemiologic data from the health report of the German federal statistic agency (Statistisches Bundesamt) for pediatric and adolescent inpatients suffering from mid-facial fractures (10-year period 2008–2017). Age (years) 1–5

Age (years) 5–10

Age (years) 10–15

Age (years) 15–20

Traumatized regions (ICD10 code)

Average number of patients who received surgical treatment per year

Lateral midface (S02.4) Central midface (S02.2) Orbita (S02.3) Centrolateral midface/ Combined midfacial fractures

2.4 33 7.8 0.9

9.8 33 30.4 3.4

34,3 44,8 68 10.1

328 130,1 423,8 83.8

Table 2 Epidemiologic data from the health report of the German federal statistic agency (Statistisches Bundesamt) for pediatric and adolescent inpatients suffering from neurocranial and viscerocranial fractures from the Federal state Saxony Anhalt (10-year period 2000, 2005, 2010–2017). Age (years) 1–5

Age (years) 5–10

Age (years) 10–15

Age (years) 15–20

Traumatized regions (ICD-10 code)

Average number of patients who received nonsurgical and surgical treatment per year

Cranial vault (S02.0 Skull base (S02.1) Central midface (S02.2) Orbita (S02.3) Lateral midface (S02.4) Multiple fractures of the neurocranium and viscerocranium (S02.7 and S02.8)

12.8 3.6 4.1 0.3 2 2

4.2 3.9 14.2 1.7 1.6 1

2.3 3.2 25 2.3 3.4 2

3.8 8.1 57.9 8.7 15.4 7.4

3. Results Representative epidemiologic data from the health report of the German federal statistic agency (Statistisches Bundesamt) of the last decade (2008–2017), focusing on pediatric and adolescent inpatients is shown in Table 1. Average numbers of patients per year who received surgical treatment in Germany due to any mid-facial fracture are Fig. 1. Monocentric pediatric-adolescent trauma population suffering from cranial and mid-facial fractures (2009–2018). Within the 10-year period a total of n = 251 patients (male n = 167, female n = 84; mean age 8 ± 6.5 years) received treatment at the University hospital Halle (Germany) due to cranial fractures as follows: nasal bone n = 52, zygomatic bone n = 20, orbital floor n = 8, skull base n = 28, cranial vault n = 109, combined (neurocranium and viscerocranium) n = 34. The proportion of neurocranial to mid-facial fractures is 1.2: 1.

152

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Fig. 2. Age distribution of 31 pediatric patients related to dentition. In the first two subgroups male and female patients were equally distributed, while in the third subgroup male patients were overrepresented (9 vs. 1).

Fig. 3. Topographical distribution of midfacial fractures in the present study The three most frequent fractures involved the orbital wall (n = 18), nasal bone (n = 10) and zygomatic bone (n = 8). The pediatric skull of a 4.5 year-old child, Meckel Anatomical Collection, Department for Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, demonstrates the high proportion of neurocranium/viscerocranium.

summarized. Furthermore, epidemiologic data for pediatric and adolescent inpatients suffering from neurocranial and viscerocranial fractures from the Federal state Saxony Anhalt (10-year period 2000, 2005, 2010–2017) is summarized in Table 2. Especially in children aged 1–5 years the predominance of neurocranial fractures is evident, while in adolescent patients mid-facial fractures are highly prevalent. Recent trauma statistics of the Halle University Hospital (last 10year period) equally focusing on pediatric-adolescent trauma population who suffered from mid-facial fractures (nasal pyramid, orbita, zygoma etc.), cranial fractures (cranial vault, skull base) or combined cranial and mid-facial fractures are visualized in Fig. 1. A total of n = 251 patients (mean age 8 ± 6.5 years; male n = 167, female n = 84) suffered from fractures as follows: neurocranial fractures n = 137 (skull base n = 28, cranial vault n = 109) vs. viscerocranial fractures n = 80 (nasal bone n = 52, zygomatic bone n = 20, orbital floor n = 8) vs. combined fractures (neurocranium and viscerocranium) n = 34. The ratio of these three injury types yielded 0.58 vs. 1 vs. 0.25.

In this study, only inpatients who received treatment primarily at the Department of Oral and Plastic Maxillofacial Surgery were included. Over a 10-year period, a total of 31 patients were included (study cohort). Most of the pediatric patients with mid-facial fractures were boys (n = 20, 64.5%; girls n = 11, 35.5%). The average age was 10.2 ± 4.9 years (95% confidence interval [CI] 8.5; 11.9); the dentition-related distribution is shown in Fig. 2. Peaks are evident at ages 9, 15, and 17. Almost one third (32.1%) of the patients were at least 15 years old. The most common types of fracture were orbital floor fractures (n = 18, 58.1%) then nasal bone (n = 10, 32.3%), zygomatic bone (n = 8, 29%), and zygomatic arch fractures (n = 4, 12.9%). There were three maxilla fractures (n = 3, 9.7%) and two cases (n = 2, 7.1%) each of lateral orbital wall, orbital roof, and nasal septum fractures. There was one case involving ethmoidal cells (3.2%, Fig. 3). As demonstrated in Fig. 4, road traffic accident (RTA) was the most common cause among all analyzed mid-facial fractures (n = 13, 41.9%), followed by sports and leisure accidents (n = 6, 19.4%), falls

153

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Fig. 4. Trauma mechanism in pediatric mid-facial fractures. The graphic visualizes the distribution of the different trauma mechanisms in our study cohort, road traffic accidents (RTA) are the most common cause (41.9%).

Fig. 5. Distribution of the age dependent therapy. In younger patients the conservative treatment was preferrably applied.

(n = 5, 16.1%), and assaults (n = 4, 12.9%). Other causes (e.g. collisions or animal attacks) represented 9.7% (n = 3). In this study cohort, only 11 patients (35.5%) had concomitant injuries: neurocranial fractures (n = 5), dentoalveolar injuries (n = 2), and extracranial fractures (n = 6; femur, radius and ulna, clavicle, tibia and fibula). Radiological imaging was indicated in the majority of patients (n = 25, 89.28%). This imaging was not necessary in only three cases (n = 3, 10.71%; two nasal bone fractures - sonography, one nasal

septum fracture – only clinical examination, Fig. 6a and b). The principal used imaging method was computed tomography (CT) (n = 19, 67.9%), followed by conventional skull x-ray (n = 13, 46.4%), magnetic resonance imaging (MRI) (n = 2, 7.1%), cone beam CT (CBCT) (n = 2, 7.1%), and panoramic radiography (n = 1, 3.2%). Conventional x-ray was also used in five patients (17.86%, n = 3: thorax; n = 3: cervical spine; n = 1 each: knee, stomach, hand, femur, radius, and ulna). Most of the fractures were treated surgically by open reduction and

154

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Fig. 6. Nasal septum fracture and luxation (leisure accident). 6a Caudal preoperation view. 6b Detail view of the right posttraumatic vestibulum nasi stenosis caused by a septum luxation. 6c Intraoperative aspect of the repositioned nasal septum. 6d-6f Postoperation view 3 years after septoplasty. Fig. 7. Orbital floor fracture (sports accident). 7a-7b Preoperation computer tomography (coronal section, soft tissue and bone window) demonstrating a trap door fracture of right orbita. 7c-7d Postoperation computer tomography (coronal section, soft tissue and bone window). 7e Postoperation clinical imaging demonstrating physiological bulb position, mild hyposphagma and resorbed monocle hematoma.

155

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

internal fixation (n = 17, 54.8%), the remaining ones were treated by non-surgical therapy (n = 14, 45.2%). As presented in Fig. 5, the more conservative treatment was preferred in younger patients. Typical preoperation and postoperation clinical and radiological images of 6 patients are provided of every relevant type fracture in Figs. 6–11. In some cases preoperation figures were not available for publication. We therefore added appropriate radiological images to demonstrate the relevant issues. Registered complications were (Rottgers et al. 2011) [10]: as follows: Type I (trauma-associated, n = 2): delayed diagnosis of fracture and luxatio septi nasi, entrapment of the inferior rectus muscle, permanent tooth germ fracture; Type II (therapy-associated, n = 2): intranasal synechia, asymmetry in the malar region following closed reduction of the zygomatic bone; Type III (interaction of trauma, therapy, and growth disturbance, n = 4): diplopia in the upgaze position > 30°, columella keloid, telecanthus, and palsy of the oculomotor nerv associated with severe centrolateral mid-facial fracture (Fig. 12b and c). A total of 15 patients received regular check-up examinations (48.4%), seven of which revealed minor complications: n = 5: diplopia without impairment in daily life; n = 3: discreet cranial asymmetry; n = 2 each: hypoglobus and chronic pain. These cases with minor complications are outlined in Table 3. Major complications like malunion, malocclusion or facial nerve palsy did not occur at all. 4. Discussion In our study, we analyzed the data of 31 pediatric patients with midfacial fractures from September 2008 to September 2018. In the same period at the Halle University Hospital a total of n = 251 pediatricadolescent inpatients were treated (ENT surgery, Oral and Plastic Maxillofacial surgery, Neurosurgery, Pediatric surgery) who suffered from n = 137 cranial fractures (cranial vault, skull base), n = 80 midfacial fractures (nasal pyramid, orbita, zygoma etc.) or n = 34 combined fractures (cranial and mid-facial). The small number of nearly three inpatients per year in our department already shows that mid-facial fractures are, fortunately, rare in childhood. Nevertheless, at the same time neurocranial injuries are a serious occurrence especially in little trauma patients. Thaller and Huang suggest that mid-facial fractures are rare because the skull and mandible absorb the traumatic forces [11]. More boys than girls seem to sustain mid-facial fractures, according to

Fig. 8. Zygomatic bone and zygomatic arch fractures (road traffic accident). 8a8b Preoperation CT imaging (axial and coronal section, bone window) visualising the displaced lateral midface. 8c-8d Clinical follow-up examination showing a slight asymmetry of the left malar region in the craniocaudal view after percutaneous reduction (1 year after surgery). 8e-8f Postoperation plane radiograms visualising a mild impression of the zygomatic bone.

Fig. 9. Anterior maxillary fracture (road traffic accident). 9a-9c Preoperation view of the open maxillary fracture associated with upper lip and nasal soft tissue laceration. 9d Postoperation plane radiogram showing the internal fixation by a titanium microplate (1.5 mm) which was removed 3 months later. 9e-9g Clinical follow-up examination showing an uneventful soft tissue healing and traumatic tooth loss (1 year after surgery).

156

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Fig. 10. Combined fractures of the cranial vault, orbital roof and lateral orbital wall (road traffic accident). 10a-10b Preoperation CT imaging (axial and coronal section, bone window) visualising the displaced lateral comminuted fracture. 10c-10d Clinical follow-up examination showing an uneventful soft tissue healing after craniotomy (5 years after surgery). 10e-10f Postoperation magnetic resonance imaging (MRI) showing regular anatomy of the neurocranium and left orbita (2 years after surgery).

Fig. 11. Centrolateral mid-facial fracture involving zygomatic bone, orbita, maxilla and naso-orbitoethmoidal complex (road traffic accident). 11a Enface view 1 month after surgery showing an oculomotor nerv palsy (exotropia, hypotropia, upper eyelid ptosis, mild mydriasis) and telecanthus. 11b Follow-up examination 3 years posttraumatically. Exotropia and hypotropia are partially compensated. Nevertheless, the patient claimed the asymmetry and diplopia due to persistent oculomotor nerv palsy.

Fig. 12. Mid-facial fracture associated with traumatic head injury (road traffic accident). 12a Cranial CT scan (axial section, bone window) showing temporal bone fracture and pneumatocephalus on the right side. 12b Cranial CT scan (soft tissue window) showing epidural hematoma, pneumatocephalus and a significant compression of the right lateral cerebral ventricle. 12c CT scan (axial section, bone window) demonstrating a zygomatic arch fracture in the same patient.

157

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

f: female, m: male; (*) double vision without impairment of the habitual field of view.

No therapy, septoplasty and lateral canthoplasty recommended Surgical, osteosynthesis, antral balloon, nasal splint Orbital floor, zygomatic bone, zygomatic arch, nasal septum m 7

15

f 6

17

Le-Fort III

Orbital floor Orbital floor m m 4 5

1 11

Surgical, transconjunctival approach, collagen membrane Non-surgical Surgical, transconjunctival approach, muscle liberation, resorbable foil Surgical, osteosynthesis Orbital floor m 3

6

our data. Possible explanations are that males participate in more physical activities or aggressive behavior in adolescence. This is in accordance with the results of other studies [12–15]. While two studies have reported mandible fractures as being the most common fractures [14,15], Grunwaldt et al. (2011) reported that orbital fractures are the most common in a large series of 772 pediatric facial fractures [4]. In our study, which is focused on mid-facial fractures, orbital floor fractures were also found to be the most common. Maxillary-zygomatic fractures are not typical in childhood as greater forces are required and the jaws of young individuals are buttressed by developing dentition [16]. Regarding age distribution, a slight increase can be assumed, with peaks at 9, 15, and 17 years. This aligns with the suggestion of Imahara et al. that the proportion of patients with facial fractures increases substantially with age [3]. Sang Hun Kim et al. also reported that the frequency of fractures increases with age [7]. One reason for this could be the fact that the lifestyle of adolescents approaches that of adults, for example taking part in contact sports [17]. There is also a higher risk of being a victim of physical aggression. In our study, RTA was the most common cause of injury, which correlates with several other studies [3,13–15]. One study, however, found violence to be the most common cause [7]. Possible reasons for this high number of road traffic accidents could be children not wearing seatbelts in the car or inexperienced and helmetless bicycle usage. As for adults, pediatric and adolescent facial fractures can also feature as part of multiple traumas. Other areas of the head or even body may be fractured, too. In a large cohort study (n = 1252 fractures), it was evident that when facial fractures were involved the mortality risk was higher [2]. Therefore, CT scans were the most frequently used medical imaging method in our study. This is exactly what Holland et al. recommend in order to find undiscovered fractures [18]. The mid-facial anatomy is very complex, so a CT scan with appropriate age-dependent scan protocols makes it easier to verify detailed diagnoses. Even in cases of expected moderate or no bony displacement (Fig. 12a and c and Fig. 13a and b), accurately imaging of relevant adjacent soft structures is essential. As mentioned above, there are differences in the way adolescents and children are treated compared with adult patients suffering from the same trauma. Nevertheless, complex traumata require similar procedures (Fig. 14a and h). In our study, most of the patients underwent surgery. This supports the results of Ferreira et al. [2]. Younger children are known to have a higher proliferative and remodeling capacity. Furthermore, an operation can also damage tissue, while surgical fixation can cause growth disturbances [16]. The special features of surgery involving the mid-facial area of a patient who is still growing are summarized in Table 4. The complication rate in our study was, in general, low. The observed mild diplopia related to orbital floor fractures involved only the peripheral areas of the visual field. In a study by Su et al. [19], even 16.5% of pediatric patients with blowout fractures suffered persisting diplopia following surgery.

13

50 Strabismus therapy, correction of lip scar

Double vision (oculomotor nerv palsy), facial asymmetry (telecanthus), chronic pain Double vision, facial asymmetry, respiratory sounds at night

71 45 No therapy No therapy Double vision∗, hypoglobus Double vision∗

60 Strabismus therapy

60 53 Orthodontic treatment No therapy, follow-up

Tooth loss (11) Slight asymmetry, traumatic loss of vision, periorbital tenderness on palpation Double vision∗ Non-surgical Non-surgical Orbital floor Lateral orbital wall and orbital roof f f 1 2

6 10

Therapy Mid-facial fractures Age (years) sex Patient

Table 3 Patients suffering from midfacial fractures and presenting minor complications.

Complications

Therapy of complications

Follow-up period (months)

W. Reich et al.

5. Conclusion While mid-facial fractures represent a rare injury in childhood, they nevertheless require surgical treatment in over 50% of cases. Within a 10-year follow-up, no therapy-associated severe complications were evident.

158

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Fig. 13. Orbital floor fracture with incarceration of the left inferior rectus muscle. 13a Cranial CT scan (soft tissue window) showing a trap door fracture of the left orbital floor associated with an incarceration of the adjacent muscle. Patient presented bradycardia and reduced general condition due to oculocardial reflex requirering monitoring and immediate surgical intervention. 13b Magnetic resonance imaging (MRI) with contrast agent verifying the severe edema of the inferior rectus muscle.

Fig. 14. Combined fractures of the naso-orbito-ethmoidal complex and anterior skull base (sports accident). 14a-14b Preoperation clinical photos visualising the severe impression of nasal dorsum and glabella. 14c-14e Preoperation CT imaging (axial, coronal and sagittal sections, bone window) visualising the displaced central midface and skull base comminuted fractures. 14f-14 h Postoperation CT imaging (axial, coronal and sagittal sections, bone window) after craniotomy, open reduction, internal fixation and frontobasal coverage. Table 4 Special principals of pediatric mid-facial traumatology Region

Displaced fractures

Comminuted fracture

Orbital floor

Mid-facial trauma before the age of 7 years more often associated with neurocranial injury. Following the development of maxillary sinuses more orbital floor fractures [20], usage of biodegradable material

Nasal bone, Naso-orbito-ethmoidal complex Zygomatic bone, zygomatic arch

Special techniques e.g. nasal bone clip [23]

Definite orbital volume from the age of 15 years (24–27 cm3) Bentley et al., 2002 [21] (usage of non-biodegradable material e.g. titaniummesh possible), Early operation in cases of trapdoor-fracture and muscle incarceration to avoid permanent muscle damage [22] Closed reduction, if necessary septoplasty [24]

Maxilla

Closed reduction or intraoral approach [25]

Treatment of fractures depending on dentition (first, second period), closed reduction and maxillo-mandibular fixation for 2–3 weeks [25]

One point fixation in the lateral midface, Micro- and miniplates, short screw length (3,5-4 mm), Cranial position of osteosynthesis material till the age of 12 years and monocortical osteosynthesis (tooth germs), (biodegradeable material) Risk of tooth injury, retention, hypoplasia, Atrophia of the alveolar ridge, (transplantation), Orthodontic treatment, Distraction osteogenesis (ankylosis), Dental implants beyond the age of 17–18 years Removal of osteosynthesis material due to PIT-effect (passive intraosseous transmission) [26]

Priority of conservative and functional treatment (not displaced and green stick fractures) over semisurgical (displaced fractures of the nasal and zygomatic arch/bone, closed reduction) and surgical treatment (comminuted fractures); PIT: passive intraosseous transmission. 159

International Journal of Pediatric Otorhinolaryngology 119 (2019) 151–160

W. Reich et al.

Declarations of interest

treatment, J. Oral Maxillofac. Surg. 51 (1993) 836–844. [7] S.H. Kim, S.H. Lee, P.D. Cho, Analysis of 809 facial bone fractures in a pediatric and adolescent Population, Arch. Plast. Surg. 39 (2012) 606–611 https://doi:10.5999/ aps.2012.39.6.606. [8] M. Limbourg, Entwicklungspsychologische Voraussetzungen für das sicherheitsorientierte Verhalten von Kindern, Kindersicherheit: Was wirkt? – Ursachen und Vermeidung von Unfällen im Kindesalter, German) Wien, 1995, pp. 46–58. [9] Health report (Gesundheitsberichterstattung des Bundes) of the German federal statistic agency (Statistisches Bundesamt) for the last decade, (2008-2017) Accessed 10th January 2019, German) www.gbe-bund.de/gbe10/pkg_isgbe5.prc_isgbe?p_ uid=gast&p_aid=0&p_sprache=D. [10] S.A. Rottgers, G. DeCesare, M. Chao, et al., Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme, J. Craniofac. Surg. 22 (2011) 1260–1265 https://doi.org/10.1097/SCS.0b013e31821c6ab7. [11] S.R. Thaller, V. Huang, Mid-facial fractures in the pediatric population, Ann. Plast. Surg. 29 (1992) 348–352. [12] R. Gassner, T. Tuli, O. Hächl, R. Moreira, H. Ulmer, Craniomaxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 Years, J. Oral Maxillofac. Surg. 62 (2004) 399–407. [13] P. Ferreira, M. Marques, C. Pinho, J. Rodrigues, J. Reis, J. Amarante, Midfacial fractures in children and adolescents: a review of 492 cases, Br. J. Oral Maxillofac. Surg. 42 (2004) 501–505 https://doi:10.1016/j.bjoms.2004.06.006. [14] S. Iida, T. Matsuya, Paediatric maxillofacial fractures: their aetiological characters and fracture patterns, J. Cranio-Maxillo-Fac. Surg. 30 (2002) 237–241. [15] R.H. Haug, J. Foss, Maxillofacial injuries in the pediatric patient, Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 90 (2000) 126–134 https://doi:10.1067/ moe.2000.107974. [16] S. Maqusi, D.E. Morris, P.K. Patel, R.F. Dolezal, M.N. Cohen, Complications of pediatric facial fractures, J. Craniofac. Surg. 23 (4) (2012) 1023–1027 https://doi:10. 1097/SCS.0b013e31824e7106. [17] S. Shaikh, S.F. Worrall, Epidemiology of facial trauma in a sample of patients aged 1-18 years, Injury 33 (2002) 669–671. [18] A.J. Holland, C. Broome, A. Steinberg, D.T. Cass, Facial fractures in children, Pediatr. Emerg. Care 17 (2001) 157–160. [19] Y. Su, Q. Shen, M. Lin, X. Fan, Diplopia of pediatric orbital blowout fractures: a retrospective study of 83 patients classified by age groups, Medicine 94 (2015) e477 https://doi.org/10.1097/MD.0000000000000477. [20] J. Wheeler, J. Phillips, Pediatric facial fractures and potential long-term growth disturbances, Craniomaxillofacial Trauma Reconstr. 4 (2011) 43–52 https://doi. org/10.1055/s-0031-1272901. [21] R.P. Bentley, S. Sgouros, K. Natarajan, M.S. Dover, A.D. Hockley, Normal changes in orbital volume during childhood, J. Neurosurg. 96 (2002) 742–746 https://doi.org/ 10.3171/jns.2002.96.4.0742. [22] A.R. Cobb, N.O. Jeelani, P.R. Ayliffe, Orbital fractures in children, Br. J. Oral Maxillofac. Surg. 51 (2013) 41–46 https://doi.org/10.1016/j.bjoms.2012.03.006. [23] M. Kosaka, K. Sai, Y. Shiratake, H. Ohjimi, Nasal bone clip: a novel approach to nasal bone fixation, J. Craniofac. Surg. 21 (2010) 552–554 https://doi.org/10. 1097/SCS.0b013e3181d024cc. [24] K.S. Park, S.S. Kim, W.S. Lee, W.S. Yang, The algorithm-oriented management of nasal bone fracture according to Stranc's classification system, Arch. Craniofac. Surg. 18 (2017) 97–104 https://doi.org/10.7181/acfs.2017.18.2.97. [25] N.J.V. Hogg, B.B. Horswell, Hard tissue pediatric facial trauma: a review, J. Can. Dent. Assoc. 72 (2006) 555–558. [26] H.J. Becker, J. Wiltfang, H.A. Merten, H.G. Luhr, Biodegradierbare Miniplatten (Lactosorb®) bei Kranioosteoplastik – experimentelle Ergebnisse am schnell wachsenden, juvenilen Miniaturschwein, (German), J. Oral Maxillofac. Surg. 3 (1999) 275–278 https://doi.org/10.1007/s100060050150.

None. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgements The authors thank Prof. Dr. R. Schulka and Prof. Dr. H. Kielstein for providing the opportunity to take a picture from a skull of a 4-and-ahalf-year-old child from the Meckel Anatomical Collection, Department for Anatomy and Cell Biology, Martin Luther University HalleWittenberg, Germany. Authors acknowledge all involved colleagues participating in trauma care from the Department of Anesthesiology, Department of Neurosurgery, Department of Oral and Plastic Maxillofacial Surgery, Department of Ophthalmology, Department of Otorhinolaryngology, Department of Pediatric Surgery, Department of Radiology, Emergency room and Intensive Care Unit. We also would like to acknowledge Dr. Gabrielle Cremer Consulting (https:// cremerconsulting.com) for providing English language editing and formatting of the manuscript. In addition, we thank Matthias Gerlach (University hospital Halle, finance and controlling), Ute Hannemann (Statistic agency of the Federal state Saxony Anhalt (Statistisches Landesamt Sachsen-Anhalt) for their kind support in data acquisition and Nancy Horn for taking clinical photos. References [1] World Health Organization, WHO Faktenblatt: Prävention von Verletzungen, der häufigsten Todesursache bei Kindern, (2008) (German), http://www.euro.who. int/__data/assets/pdf_file/0008/98603/FS_TacklingInjuries_Children_ger.pdf?ua= 1 , Accessed date: 18 May 2017. [2] P.C. Ferreira, J.M. Amarante, P.N. Silva, et al., Retrospective study of 1251 maxillofacial fractures in children and adolescents, Plast. Reconstr. Surg. 115 (2005) 1500–1508. [3] S.D. Imahara, R.A. Hopper, J. Wang, F.P. Rivara, M.B. Klein, Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank, J. Am. Coll. Surg. 207 (2008) 710–716. [4] L. Grunwaldt, D.M. Smith, N.S. Zuckerbraun, et al., Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients, Plast. Reconstr. Surg. 128 (2011) 1263–1271. [5] T. Yabe, T. Tsuda, S. Hirose, T. Ozawa, Comparison of pediatric and adult nasal fractures, J. Craniofac. Surg. 23 (2012) 1364–1366 https://doi:10.1097/SCS. 0b013e31824dfb7b. [6] J.C. Posnick, M. Wells, G.E. Pron, Pediatric facial fractures: evolving patterns of

160