HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Original Investigation Research

Management of Mandible Fracture in Children

Table 1. Demographic Features of 150 Pediatric Patients With Mandible Fracture Demographic Patients, No. (%) Sex Male 108 (72.0) Age, y 0-5.99 18 (12.0) 6-11.99 33 (22.0) 12-17.99 99 (66.0) Race/ethnicity White 107 (71.3) African-American 34 (22.7) Hispanic 4 (2.7) Other/unknown 5 (3.3) Insurance Medicaid 74 (49.3) Managed care 59 (39.3) Self-pay 8 (5.3) Commercial 8 (5.3) Other 1 (0.7) Encounter type Routine ED admission 127 (84.7) Transfer from OSH 23 (15.3) Abbreviation: ED, emergency department; OSH, outside hospital.

Table 2. Location of 310Mandible Fractures

No. (%) Fractures 78 (25.2) 75 (24.2) 69 (22.3) 78 (25.2) 10 (3.2)

Fracture Site

Patients 60 (40.0) 69 (46.0) 62 (41.3) 76 (50.6) 10 (6.7)

Condyle or subcondyle

Angle or ramus

Body

Symphysis or parasymphysis

Coronoid

Figure 1. Mandible Fracture Mechanisms by Percentage

Assault/Battery

Motor Vehicle Collision

Sport

Falls/Play

Bicycle-Related

ATV/Moped/Motorcycle

Other Blunt Trauma

Pedestrian Struck

Mandible Fracture Mechanisms Animal-Related

Gunshot Wound

0

5

10

15

20

25

Fractures, %

ATV indicates all-terrain vehicle.

andbody fracturesmore likely causedby sports (sports vs falls: difference in means, 0.42 [95% CI, 0.02-1.15]; P = .04; sports vs motor vehicle collision, 0.72 [95% CI, 0.02-1.15]; P < .001). One hundred thirteen (75.3%) receivedmaxillofacial com- puted tomography to evaluate the fracture. Thirty-five (23.3%) received only radiography of the mandible, with 2 (1.3%) re- ceiving computed tomography of the cervical spine. With respect tomanagement, 38 patients (25.3%) were ob- served and prescribed a soft diet. Univariate analysis showed that patientswith an isolated singlemandible fracturewas sta- tisticallymore likely to be treatedwith observation than to un- dergo operation ( P = .007). Of 112 patients who received operations, 63 (56.2%) re- ceived MMF; 24 (21.4%) received ORIF, and 20 (17.9%) re- ceived both MMF and ORIF ( Figure 2 ; Table 3 ). Four patients had closed reduction only, and 1 had open reduction only. Uni- variate analysis showed that patients with 3 or more frac- turesweremore likely to receive bothMMF andORIF ( P = .01). Twenty-four of the 83 patients (28.9%) who underwent MMF, either alone or with ORIF, had documented hardware re- moval, and hardware was in place for a mean (SD) 31.0 (15.9) days. Nonabsorbable titanium plating was used in all but 1 of the fractures treatedwith ORIF. Five of 44 (11.4%) patients re- ceiving ORIF or ORIF and MMF had follow-up beyond 6 months. Eight (18.2%) of the patients who received ORIF or ORIF and MMF had documented plating hardware removal, whichwas in place for amean (SD) 180 (167) days. Three of the 24 (12.5%) patients who receivedORIF only had follow-up be- yond 6months. All 3 patients had hardware removal at amean (SD) 484 (17) days.

With respect to age, ORIFor ORIFwithMMFwas usedwith increasing frequency with age by group, with 2 of 18 children younger than 6 years (11.1%), 6 of 33 children 6 to 11.99 years (18.2%), and 36 of 99 children 12 years or older (36.4%) receiv- ing either treatment (Table 1 and Table 3). Conversely, obser- vation followed the opposite trend, with young children younger than 6 years more likely to be observed (χ 2 = 14.5; P < .001). Of the patients receiving ORIF, 40 (90.9%) were 12 years and older, and these patients were more likely to re- ceive ORIF (χ 2 = 9.83; P = .002). The most common mecha- nisms for injury were falls (28%) and motor vehicle collision (21%) in children younger than 6 years, falls (24%) and motor vehicle collision (21%) in children 6 to 11.99 years, and assault and battery (32%) and motor vehicle collision (20%) in chil- dren 12 years or older. Sixty of the 150 patients (40%) had some form of follow- up, amean (SD) 90 (113) days after initial presentation. Ninety patients (60.0%) had no follow-up after initial presentation. Complications occurred in 13 patients, for a total docu- mented complication rate of 8.7%. Of these, all patients had 2 or more fractures, and 11 (84.6%) had body fractures. Compli- cations consisted of malunion (2 patients [15.4%]), nonunion (2 patients [15.4%]), deformity (1 patient [7.7%]), infection or abscess (3 patients [23.1%]), hardware extrusion (2 patients [15.4%]), facial numbness (2 patients [15.4%]), and trismus (1 patient [7.7%]). Patients with 3 or more fractures were statis- ticallymore likely to have complications (univariate analysis, P = .005). Body fractures were also associated with a higher complication rate ( P = .02).

(Reprinted) JAMA Facial Plastic Surgery Published online June 6, 2019

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