2015 HSC Section 1 Book of Articles

Facial Fractures in Children

would warrant aggressive steroid therapy. If visual acuity does not respond or if bony fragments impinge on the optic canal, optic nerve decompression can be considered, although results have been mixed in pediatric trauma patients. 37,38 Fractures of the orbital floor remain controversial in regard to which ones require repair. However, most surgeons agree on the criteria of large floor defects (>1 cm 2 ) or extraocular muscle entrapment. 1,39 Muscle entrapment is the most pressing cause for early repair, and those with an oculocardiac reflex require emergent repair. Chil- dren heal quickly; therefore, muscle entrapment in a child may result in fibrosis and shortening of the muscle within a couple days. As a result, diplopia can be present for months after the initial injury, or it may be permanent. 40 Fractures of the medial wall should also be considered. A transcaruncular approach can allow for access to place an implant to reduce the intraorbital volume; however, some surgeons prefer to compensate with augmentation of the orbital floor instead. 39 Repair of an orbital floor fracture can be performed through a variety of approaches; however, the transconjunctival approach is favored from a cosmetic standpoint and also may reduce the incidence of postoperative ectropion. 41 A variety of implants can be used to reconstruct the orbital floor. Split calvarial bone grafts have classically been used, and some surgeons continue to advocate for their use in children younger than 7 years of age who may continue to undergo further orbital growth. 1 Otherwise, titanium and porous polyethylene are commonly used with significantly less donor site morbidity. Nasal Fractures Nasal bone fractures are suspected to be the most common facial bone fracture in children, because their true incidence is very likely underreported in the literature. 42 Because these fractures are often isolated and occur without concomitant injuries, they are more likely to be treated on an outpatient basis. These fractures can also remain undiagnosed if swelling obscures the assessment of nasal bone symmetry. An initial intranasal examination is key to diagnosing airway obstruction and to defining concomitant septal fracture or septal hematoma. Most nasal bone fractures can be diagnosed on physical examination alone, thus conserving radiologic examinations for those patients in whom the history or physical examination warrants further inves- tigation. The finding of a septal hematoma should prompt urgent surgical evacuation to prevent cartilage necrosis and saddle nose deformity. Long-term growth disturbance is a cause for concern. The septum is thought to harbor important growth zones, which if injured may result in a lack of nasal projec- tion. 43 Because full growth of the nose is not achieved until age 16 to 18 years in girls and 18 to 20 years in boys, damage to these growth centers from either the initial trauma or from surgery can have long-lasting effects. Early closed reduction of nasal bone fractures within a few days of the injury is usually recommended. 44,45 This can be accomplished under sedation or general anes- thesia. However, the results of closed nasal reduction are often dissatisfying for the surgeon and the patient. Grymer and colleagues 46 examined the long-term results of nasal bone fractures treated in childhood, and found that by adulthood these pa- tients tended to have a higher incidence of dorsal humps, saddle nose deformities, and deviations of the dorsum, despite most patients being satisfied with the outcomes after the initial closed reduction. Therefore, there is some indication that despite best efforts to correct these injuries, there may be deformities that develop gradually with growth. Parents should be counseled regarding this possibility. Septal fractures can also be managed conservatively with a closed reduction technique. In those children with significant nasal airway obstruction, a limited,

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