Management of Complex Pediatric Mid-face Fractures
Ian L. Valerio, MD, MS, MBA1, Gary DeCesare, MD1, Joe Madia, BS1, Tae Chong, MD1, Sanjay Naran, BS1, Lisa Vecchione, DMD, MDS2, Shao Jiang, MD2, Frederic WB Deleyiannis, MD, MPhil, MPH1, Joseph Losee, MD2.
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA, 2Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
BACKGROUND: Pediatric facial trauma varies from adult facial trauma patterns secondary to important anatomical differences. Given the larger proportions occupied by the mandible and cranium in the pediatric craniofacial skeleton, pediatric mid-face facial fractures tend to be significantly less common injuries. However, principles of mid-face fracture management remain an important component of maximizing the potential reconstructive and aesthetic results for the pediatric facial trauma patient.
METHODS: A single center retrospective review of all pediatric facial fractures treated from 2000-2007 at a major metropolitan Children’s Hospital was performed. Demographics, fracture patterns and types, mechanism of trauma, computerized tomography (CT scans), fracture management, and complication rates were analyzed. Further critical analysis was given to mid-face fractures with focus on the comprehensive care, management, and sequelae of complex mid-face fractures in the pediatric population.
RESULTS: Over an eight-year period spanning 2000-2007, a total of 919 pediatric facture fractures were treated. Consistent with prior studies, the majority of these fractures were seen in males (65% versus 35% in females). Demographically, Caucasians accounted for 82%, African Americans for 12%, and other ethnicities for the remaining 6% of all patients suffering facial fracture trauma. Of the 919 total fractures treated, 225 patients (24%) underwent surgical correction. Mid-face facial fractures consisted of the following patterns: isolated nasal fractures 158 (17.1%), comminuted maxillary fractures 100 (10.8%), isolated maxillary sinus 78 (8.4%), ZMC 21 (2.3%), isolated zygoma 23 (2.5%), NOE fractures 17 (1.8%), and Lefort fractures 10 (1.1%). In reviewing CT scans of pediatric mid-face fracture patterns, pediatric fracture patterns varied from established adult patterns in that they more often displayed greenstick type injuries. Additionally, pediatric Lefort fracture patterns tended to occur more superior or higher in the mid-face as well as display more oblique fracture patterns as compared with typical adult Lefort fracture patterns.
CONCLUSIONS: This review critically assessed pediatric facial fractures with special attention to the management of complex pediatric mid-face factures. Pediatric mid-face fracture patterns differed from adult patterns in multiple aspects. First, pediatric mid-face fractures displayed more greenstick type injuries, likely due to the more pliable and "softer" pediatric craniofacial skeleton. Second, pediatric Lefort fractures tended to be oriented more superiorly and obliquely as compared with typical adult Lefort fracture patterns. These findings may be attributed to not only the softer craniofacial skeleton but also to the presence of tooth buds in the pediatric mid-face, which alter the anatomical form and dimensions of the pediatric mid-face. While complex mid-face fractures are a small percentage of the facial fracture patterns seen in children, a thorough understanding of mid-face fractures is critical in an effort to restore form, function, and aesthetics in these injuries.