Management Of Pediatric Facial Fractures Research Articles

Utility of Antibiotic Use in Pediatric Facial Fractures: A Systematic Review.

Background: In regard to antibiotic stewardship, it is important to understand the appropriate time to prescribe antibiotics in pediatric facial fracture management. Objective: To evaluate the utility of antibiotics in pediatric facial fractures and determine situational variables influencing appropriate antibiotic prescription. Methods: A comprehensive literature search was conducted in PubMed, Cochrane, and Web of Science databases for articles published from 2000 to 2022. Inclusion criteria consisted of all studies assessing pediatric facial fractures that mentioned antibiotic use. Results: A total of 13 studies were included in the full review. The reviewed studies comprised 31 pediatric patients ranging from 6 months to 18 years old. Most studies were case reports and case series (N = 9). Antibiotics were prescribed for the majority (96.7%) of patients. Antibiotic regimens varied by timing of administration, antibiotic used, and dosage. Fracture locations also varied widely, including orbital, zygomatic, nasal, mandibular, and maxillary fractures. Conclusions: Additional studies with more substantial evidence are needed to fully understand the situational appropriateness of antibiotic use in pediatric facial fractures.

Pediatric Mandible Fractures.

The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.

Characteristics of Facial Fractures in Critically Injured Children

Background: Treatment of facial fractures in pediatric patients requiring intensive care unit (ICU) care has not been well categorized. The purpose of this study is to describe a single-institution experience with the management of pediatric facial fractures in patients requiring ICU-level care. Methods: We performed a retrospective review of patients under 18 years old who presented to a level I trauma center with facial fractures between 2006 and 2021. Types of facial fractures, mechanisms of injury, operative treatment, GCS score, and associated injuries were evaluated in ICU patients compared to patients who were admitted to the hospital, but not ICU. Results: Facial fractures were diagnosed in 3334 patients. Of them, 1080 were admitted to the hospital and 207 patients (19.2%) required ICU-level care. Among these patients, the average age was 9.7 ± 4.9 years. The average length of stay was 9.2 ± 10.9 days and the average lowest GCS score was 10.3 ± 4.6. The most common mechanism of injury was a motor vehicle accident (n = 122, 59.5%). Compared to non-ICU admitted patients, patients admitted to the ICU were significantly more likely to present with skull (n = 124, 60.5%, P < .001), orbital (n = 140, 68.3%, P < .001), and maxillary fractures (n = 96, 46.8%, P < .001) and significantly less likely to present with mandibular fractures (n = 47, 22.9%, P = .020). ICU patients had significantly more associated injuries, particularly neurological injuries (91.2% vs 47.8%, P < .001). ICU patients underwent operative treatment at the same rate as non-ICU admitted patients (OR, 0.7 [95% CI, 0.5-1.0]). Conclusions: Pediatric facial fracture patients requiring ICU-level care are a poorly characterized population. Our data suggest that high impact mechanisms of injury and specific fracture patterns are associated with ICU admission as these patients require particular attention and management.

Management of pediatric facial fractures during COVID-19 pandemic

ObjectiveThe coronavirus disease 2019 (COVID-19) pandemic caused delays in medical and surgical interventions in most health care systems worldwide. Oral and maxillofacial surgeons (OMSs) delayed operations to protect themselves, patients, and staff. This article (1) presents one institution's experience in the management of pediatric craniomaxillofacial trauma during the COVID-19 pandemic and (2) suggests recommendations to decrease transmission.MethodsThis was a retrospective review of children aged 18 years or younger who underwent surgery at Children's Healthcare of Atlanta in Atlanta, GA, between March and August 2020. Patients (1) were aged 18 years old or younger, (2) had one or more maxillofacial fractures, and (3) underwent surgery performed by an OMS, otolaryngologist, or plastic surgeon. Medical records were reviewed regarding (1) fracture location, (2) COVID-19 status, (3) timing, (4) personal protective equipment, and (5) infection status. Descriptive statistics were computed.ResultsFifty-eight children met the inclusion criteria. The most commonly injured maxillofacial location was the nose. Operations were performed 50.9 hours after admission. Specific prevention perioperative guidelines were used with all patients, with no transmission occurring from a patient to a health care worker.ConclusionsWith application of our recommendations, there was no transmission to health care workers. We hope that these guidelines will assist OMSs during the COVID-19 pandemic.

Facial Fractures and Mixed Dentition – What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center. A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed. A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition. The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.

What Factors Are Associated With Open Treatment of Pediatric Mandibular Fractures?

There is a paucity of data with respect to management of pediatric facial fractures. The purpose of this study was to describe the population of pediatric patients with mandibular fractures at our institution and to assess predictors of fractures requiring open reduction and internal fixation (ORIF). This was a retrospective cohort study of patients aged ≤17years presenting with mandibular fractures. The primary predictor variable was age ≥13years and <13years. The primary outcome variable was ORIF (yes or no). Epidemiologic factors and complications were also assessed. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between predictor variables and ORIF. The study sample was composed of 84 subjects with 61 subjects aged ≥13years and 23 subjects aged <13years. ORIF was used for 21.4% of subjects. Increased age was associated with ORIF (P=.009). After adjusting for the effects of concurrent variables, age (P=.047, OR=2.30, 95% CI=1.01 to 5.24), fracture displacement between 2 and 4mm (P=.032, OR=18.1, 95% CI=1.29 to 254), fracture displacement >4mm (P=.019, OR=16.9, 95% CI=1.60 to 179), and the presence of 3 fractures (P=.027, OR=30.8, 95% CI=0.001 to 0.641) were positive independent predictors of ORIF. Concomitant facial, skull, or skull base fractures (P=.039, OR=0.027, 95% CI=0.001 to 0.641) were a negative independent predictor of ORIF. Secondarily, both mechanism of injury and fracture location varied significantly by age and gender. Complication rate was 6.33%. Most pediatric mandibular fractures were managed nonoperatively. Increased age, fracture displacement, presence of 3 fractures, and concomitant craniofacial injuries were independent predictors of ORIF. Complication rates were low regardless of treatment modality.

National Trends in Pediatric Facial Fractures: The Impact of Health Care Policy.

Traumatic injuries are significant sources of morbidity and mortality in the pediatric population. Using a national database, this study aims to characterize pediatric facial fracture management and the effect of health care policy changes on populations receiving treatment. A retrospective cohort study was performed using Healthcare Cost and Utilization Project Kids' Inpatient Database databases from 2000 to 2016. Pediatric patients admitted with a facial fracture diagnosis were included. Clinical outcomes include mortality, reduction of fracture during hospital stay, and open fracture reduction. The impact of the Affordable Care Act on patient demographics and management was assessed. Between 2000 and 2016, 82,414 patients were managed for facial fractures, 8.3 percent of whom were managed after implementation of the Affordable Care Act (n = 6841). Mean age was 15.2 years, and the male-to-female ratio was 2.9:1. Significant racial disparities were identified before the Affordable Care Act: African American and Native American patients had decreased odds of having facial fracture reduction during the initial hospital stay (OR, 0.84 and 0.86, respectively), and identifying as either Hispanic or Native American was associated with higher odds of mortality (OR, 1.4 or 2.4, respectively). Race was not contributory to patient mortality after the Affordable Care Act. Before Affordable Care Act implementation, patients receiving care with no charge (including charity care/charity research) had lower odds of having an open reduction or any reduction; insurance status was not contributory to management after the Affordable Care Act. Although the Affordable Care Act may have increased access to care for certain populations, race- and sex-associated differences in mortality rate and fracture management should be further investigated to ensure a national standard of equitable patient care.

Abstract: Pediatric Facial Fracture Surgical Management at a Level 1 Trauma Center

BACKGROUND: Management of pediatric facial fractures is unique to that of the adult population due to the greater cranium to face ratio, lack of developed sinuses, greater elasticity, and their continued growth. Our study is one of the largest single institution studies performed looking at the surgical management of pediatric facial fractures. METHODS: We performed an IRB approved retrospective review of pediatric patients (age≤18years) who presented to a level one pediatric trauma center with ≥1 facial fractures from January 2006 to December 2015. Data abstracted included demographics, fracture location, mechanism of injury, concomitant head and neck injuries, and surgical management. Statistical analysis employed Chi Square tests for categorical variables with p<0.05 for significance. Univariate logistic regression was conducted and variables with a p<0.20 were included in multivariate analysis. RESULTS: 1277 patients met inclusion criteria, of which 517 (40.5%) patients underwent surgical management for their facial fractures. Comparison of operation rates between gender, ethnicity, and median income based on zip code showed no significant difference. Surgery occurred at a median of 2 days (IQR 1–4 days) following admission with 467 patients (90.3%) receiving intervention during their primary admission. Mandible fractures had the highest operation rate (70.3%) and orbital fractures had the lowest (26.5%) (p<0.001). Other operative rates by bony location were nasal fractures 27.6%, maxillary fractures 46.0%, and zygomatic fractures 48.9%. 314 (24.6%) patients presented with a concomitant skull fracture and showed a lower operative rate (28.3%) for the management of their facial fractures as compared to patients without skull fractures (44.4%, p<0.001). Univariate analysis demonstrated that age, mechanism, type of fracture, and violence were associated with a higher risk of surgical intervention. Concomitant injuries of the skull and cervical spine, need for intensive care, traumatic brain injury, and Hispanic ethnicity were associated with reduced likelihood of surgery. Following multivariate analysis, associations for increased likelihood of surgery remained for increased age and mandible and LeFort pattern fractures. Decreased likelihood for surgery remained for traumatic brain injury. A ROC of the multivariate analysis yielded an area under the curve of 0.82. Looking closer at the patients with traumatic brain injury, they were found to have a higher mortality rate (13.3%) compared to non-TBI patients (1.1%) as well as significantly fewer mandible fractures and more orbital fractures (p <0.001). CONCLUSION: As patients age, their need for surgical management increases as their bones lose their more absorptive porous nature. Mandible and Le Fort fractures are associated with higher odds of surgical intervention. Presentation with concomitant traumatic brain injury is associated with reduced odds of operative management of facial fractures due to a higher mortality as well as a different fracture pattern such that orbital fractures are more common and mandible fractures are less common.

Differences in the Management of Pediatric Facial Trauma.

Craniofacial trauma is common in the pediatric population, with most cases limited to soft tissue and dentoalveolar injury. Although facial fractures are relatively rare in children compared with adults, they are often associated with severe injury and cause significant morbidity and disability. Initial evaluation of a child with facial trauma generally involves stabilizing the patient and identifying any severe concomitant injuries before diagnosing and managing facial injuries. The management of pediatric facial fractures is relatively more conservative than that of adults, and nonsurgical management is preferred when possible to prevent the disruption of future growth and development. Outcomes depend on the site of the injury, management plan, and subsequent growth, so children must be followed longitudinally for monitoring and the identification of any complications.

Use of biodegradable plates and screws in the treatment of pediatric facial bone fractures

BackgroundPediatric patients with facial fractures are a unique challenge in terms of their treatment planning, which is different from that of adult patients. Early literature has advocated conservative closed management of pediatric facial fractures to prevent complications. However, recent advanc

Pediatric Facial Fractures as a Result of Gunshot Injuries

Facial fractures are relatively uncommon in the pediatric population, especially those inflicted as a result of interpersonal violence in the form of gunshot injuries. Few studies have examined the unique management of such high-energy injuries in the pediatric population. Oftentimes the resultant damage to soft tissue and bony structures is so great that it challenges the previously accepted standards in the management of pediatric facial fractures. This study will examine a level 1 trauma center's experience with these unique injuries. A retrospective review of all facial fractures occurring in a pediatric population (those 18 years of age or younger) as a result of gunshot wounds in a level 1 trauma center in an urban environment was performed for the years 2000 to 2012. Descriptive information was collected regarding each case as well as information regarding concomitant injuries, treatment modalities, and selected outcomes. During this time period, there were 3147 facial fractures treated at our institution, 353 of which were in pediatric patients. Of these, 17 were the results of gunshot wounds. Three patients were excluded due to insufficient data, leaving a total of 14 patients. The average age of patients was 16.5 (range 14-18); all patients were African-American males. The most common fracture was that of the mandible (n = 10), with 2 of those patients exhibiting panfacial fractures. The average Glasgow Coma Scale on admission was 13.5 (range 3-15). Six of the patients were intubated in the emergency department. The most common concomitant injury was a skull fracture (n = 3), followed by cervical spine fractures (n = 2) and intracranial hemorrhages (n = 2). All patients were admitted to the hospital for reasons other than fracture management. Seven patients ultimately went to the operating room for fracture management. The treatment modalities employed were conservative management with closed techniques (n = 11), rigid internal fixation (n = 2), and the use of an external fixator device (n = 1). Minimal to no soft-tissue debridement was performed in 10 of the 14 patients, 2 of which presented between 6 months and 10 years post-injury with soft-tissue complications related to retained material. The mean hospital length of stay was 8.2 days (range 1-18 days). One patient expired. Pediatric facial fractures as a result of gunshot wounds represent a unique and fortunately rare entity that presents a challenge to all disciplines involved in treatment. In our patients, there was a tendency towards conservative management, with only 3 patients undergoing some form of fixation and only 7 undergoing some form of operative debridement. Concomitant injuries and the high-energy nature of gunshot wounds often preclude traditional management with rigid fixation to ensure adequate bony healing. However, it is important to adequately debride devitalized soft tissue and remove all foreign material to avoid future soft tissue-related complications.

Complications of Pediatric Facial Fractures

Pediatric facial fractures account for only 5% of all facial fractures, with even a much lower incidence in children younger than 5 years (1%-1.5%). The evolution of principles in the management of pediatric facial fractures and the differences in management between adult and pediatric patients have been well documented in the literature. Pediatric facial fracture management presents unique challenges because it might affect growth in the area specific to the trauma segment. Children are, in several ways, at a regenerative advantage: greater osteogenic potential, faster healing rate, primary dentition that is thereby temporary, and the capacity for significant dental compensation. Perhaps because of this, complications such as infection, malunion, nonunion, and postinjury malocclusion are relatively rare compared with the adult population. In this article, we will focus on different approaches to complications that arise after pediatric fracture management.

Contemporary management of pediatric facial trauma

Facial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Children are not 'small adults', and the management of facial fractures in this population is unique. Injuries tend to be less severe, and can often be managed with soft diet and restriction of activity. Maxillomandibular fixation should be used only when indicated, as it can result in temporomandibular joint (TMJ) disturbances; to minimize this risk, it should be in place no longer than 7 days. Open reduction and internal fixation is indicated in severe injuries, and the surgeon must be cognizant of developing teeth. Small plates and screws are useful in this patient population. In this review of modern management of the pediatric facial trauma patient, several issues germane to pediatric facial fractures are discussed. Thorough ophthalmologic and dental/occlusive examinations must be undertaken. Conservative management is optimal for many injuries, as the pediatric fracture is typically not as severe as those seen in the adult facial skeleton. When wiring the jaw to allow for noninvasive fixation, treatment time must be short in order to avoid TMJ ankylosis. Rigid fixation is indicated in the rare comminuted, displaced fracture; when employed, the surgeon must use small plates and screws, and avoid injury to developing teeth. These are challenging cases, but with appropriate knowledge and understanding, they can be appropriately managed.

Managing the Pediatric Facial Fracture

Facial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their incidence in adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Here, we discuss several issues germane to pediatric facial fractures and review significant factors in their evaluation, diagnosis, and management.

Pediatric facial fractures: analysis of differences in subspecialty care.

At the University of Michigan, the pediatric facial fracture call schedule rotates through the plastic surgery, otolaryngology, and oral surgery services. This situation provides an opportunity to evaluate differences in the management of pediatric facial fractures between subspecialty groups. At this hospital, a retrospective review of all pediatric facial fracture cases within a 5-year period was undertaken. Sixty patients with 82 facial fractures were studied along subspecialty lines. Differences in patient groups, practice patterns, and treatment strategies based on subspecialty assignment were found. Overall treatment followed traditional lines, with plastic surgeons involved in all types of pediatric facial fractures, whereas otolaryngology and oral surgeons were more limited in their operative scope, despite equal call responsibilities. It is believed that the managed care arena is a competitive environment in which it will be important to know the strengths and weaknesses of the plastic surgery specialty, as well as those of competing specialties, as patient contracts are negotiated. The overlap of plastic surgery, otolaryngology, and oral surgery in the care of facial trauma could result in plastic surgeons being left off of managed care participant lists. This study highlights plastic surgeons as efficient deliverers of quality care for pediatric facial fractures. Although the treatment of these fractures has fallen into the duties shared by all three subspecialties, data such as those presented here should strengthen our ability to succeed in the evolving environment of managed care.

Pediatric maxillofacial trauma

The management of facial fractures has undergone a revolution, with advances such as computed tomographic-guided diagnosis, craniofacial exposure, and rigid fixation. Although these advanced techniques have been widely accepted for adult trauma victims, their use remains controversial for children because of concerns over facial growth. High energy facial fractures in children are uncommon; therefore, few surgeons have a large experience or long-term follow-up with the newer reconstructive choices. The reliability of time-tested conservative management for simple pediatric injuries is not in question; however, with severe and complex fractures, traditional interventions do not yield consistently excellent results. In this report, we review current concepts of pediatric facial fracture management and conclude that most pediatric maxillofacial trauma can be managed conservatively, ie, maxillomandibular fixation for mandibular fractures, closed reduction of nasal fractures, and observation of orbital fractures. Nevertheless, complex injuries require three-dimensional reconstruction, which is currently best accomplished with rigid fixation.

Controversies in the management of pediatric facial fractures : Bartlett S.P.; DeLozier J.B. IIICLIN. PLAST. SURG. (1992) 19/1 (245–258)

Controversies in the management of pediatric facial fractures : Bartlett S.P.; DeLozier J.B. IIICLIN. PLAST. SURG. (1992) 19/1 (245–258)