The management of pediatric craniomaxillofacial trauma requires the additional dimension of understanding growth and development. The surgeon must appreciate the considerable influence of the soft tissue envelope and promote function when possible. Children heal well but with an exuberant tissue response that may contribute to greater scarring, therefore, careful and prudent attention given to meticulous soft tissue repair and support is critical. Support must also be given and sought from the family of the injured child. Follow-up management of children must continue to ensure that the growth of the craniomaxillofacial skeleton continues within the normal parameters of development.
Appreciate the anatomy and physiology unique to pediatric patients.
Understand the potential implications of surgical insult on future growth and development.
Emphasize the importance of early rehabilitative physiotherapy on future growth and function.
The management of maxillofacial trauma has changed over time. These changes are caused by the evolving complexity of injuries secondary to higher-impact mechanisms and advances in imaging, instrumentation, and fixation. The greatest influence on surgical management of pediatric craniomaxillofacial disease likely came from the contribution of Dr Paul Tessier in his principles of cranio-orbital surgery first introduced in 1967. Others have additionally provided the many operative principles of maxillofacial trauma used today, such as the sequencing of panfacial injuries, autogenous bone grafting, and the important role of rigid fixation in re-establishing facial height, width, and projection. These principles have provided the fundamental underpinnings of modern facial fracture treatment. More recently, these principles that work so well in adult patients have been applied in the management of pediatric maxillofacial trauma. Posnick and Kaban have more clearly described the epidemiology and further clarified the advantages of rigid internal fixation for these injuries.
The current understanding of complex facial injuries has primarily been through the observation of adult patients. However, one must recognize that the treatment of pediatric patients requires additional considerations and that the application of adult-type treatment can be inappropriate in many circumstances. There is still a place for conservatism in the treatment of craniomaxillofacial injuries in children.
The maxillofacial trauma surgeon will best serve pediatric patients with a combination of age-appropriate sensitivity and a fundamental understanding of the complex issues surrounding the growth of the craniofacial skeleton and the potential for traumatic and surgical injury to negatively alter it.
Craniofacial Growth and Development
The role of the human face is significant, both functionally and esthetically. This role is secondary to the highly evolved and specialized functions of the face in vision, breathing, mastication, speech, smell, and hearing, among others. Indeed, it is the culmination of an extremely complex process of growth and development that provides the functional and aesthetic framework of the human face. Interruption of this process, such as insult from maxillofacial injury, may produce deleterious alterations of the facial framework resulting in aesthetic and functional deficits. For the surgeon who treats pediatric facial fractures, an understanding of this process becomes crucial in developing and exercising sound surgical judgment.
The cranial vault at birth is comprised of flat plates of intramembranous bone separated by connective tissue. The interposing areas or sutures allow for the deformation of the head through the pelvis during delivery and then to accommodate rapid brain growth during the first year of life. This process is largely accomplished through the apposition of bone at the sutural areas and, to a lesser degree, remodeling of the inner and outer cortex of the skull. Head circumference reaches greater than 90% of its adult size between 3 and 5 years of age. In contrast, the bones of the skull base are formed from areas of endochondral ossification. In between these areas of ossification, synchondroses are formed that continue to allow for growth through the replacement of cartilage with bone. The orbit, although comprised of numerous bones, reaches skeletal maturity between the ages of 5 and 7 years. This growth mirrors the growth of the soft tissue orbital contents. The midface is comprised of intramembranous bone and its growth vector is downward and forward, which is propelled by the apposition of bone at the cranial base and deep sutures of the maxilla and remodeling of the surface of the midface. The mandible, on the other hand, has both a component of endochondral ossification at the temporomandibular joint regions bilaterally and remodeling and apposition of bone in the corpus. The mandibular body and alveolus again follows the downward and forward vector of movement the midface takes, but the rami and condyles grow upward and backward to maintain contact with the skull base. Vertical height is gained at the condyle through endochondral replacement and length is added through an active remodeling of the ramus. Skeletal maturity of the maxilla and mandible is reached by approximately 14 to 16 years of age in girls and 16 to 18 years of age in boys.
The functional matrix concept of growth first proposed by Moss has gained general acceptance. This theory postulates that growth occurs as a result of expanding functional requirements of the cranial, nasal, and oral cavities and that these requirements are transmitted to the bone and cartilage by the soft tissue envelope of the face. The bones grow in response to the expansion of the cranial and facial capsule. The nasal septum and mandibular condyles react to growth requirements and, therefore, should not be considered the primary centers of growth. Therefore, surgical attention in managing injuries of the mandibular condyle, for example, should be directed at preserving as scar-free an envelope of soft tissue as possible and promoting function of the joint. The application of this theory to other craniofacial problems leads to similar conclusions. A classic example of the influence of the soft tissue envelope on growth resides in patients with cleft palates. Maxillary growth restriction in these patients is the result of scarring from palatal surgery. The cleft palate itself, if left unoperated until skeletal maturity, would have little to no effect on maxillary growth. The importance of understanding the deleterious effects of scar tissue, traumatically or surgically induced, and the restricted function on growth and development is fundamental to the management of children with facial fractures.
Critical examination of the stages of gross anatomic craniofacial development leads to several particular issues that have an impact on the epidemiology and management of facial bone injuries in children ( Fig. 1 ). First, during infancy and early childhood, rapid brain and ocular growth causes a significant increase in cranio-orbital dimensions as noted in the previous discussion regarding growth and development. This increase provides for the characteristic appearance of the prominent forehead and orbits seen in infancy and early childhood. The later-maturing lower facial skeleton remains protected behind a prominent forehead during this period, therefore, this region is more exposed and prone to injury. During the early years of development, bone has a high osteogenic potential and is characterized by a thick medullary space and thin bony cortices that tend to greenstick fracture. Unerupted teeth also tend to buttress fractures and prevent fracture displacement. In addition, the eruption of the permanent teeth in conjunction with loose exfoliating primary teeth makes maxillomandibular wiring and fracture reduction and stabilization more difficult. The paranasal sinuses also continue to pneumatize and expand, which may alter fracture patterns in the midfacial skeleton secondary to decreased bone bulk and brittleness ( Fig. 2 ). As the permanent dentition erupts at about 12 years of age and growth continues into adolescence, the craniofacial skeleton becomes more adultlike. During this stage of development, adultlike surgical management becomes increasingly more appropriate.
It has been estimated that 11.3% of all pediatric emergency department visits are the result of pediatric maxillofacial injury. Overall, children have a lower incidence of facial injury than adults. For the most part, they reside in a protective social environment. In the early years of life, parental supervision and a child-friendly environment mitigate the likelihood of serious injury. Although falls during these years are common, a low center of gravity ensures that little harmful force is generated that might cause injury. As they reach the later childhood years, children become involved in numerous activities, such as school and play with other peers. Participation in athletic activity later in life is also a cause of facial injury proximate to a developing neuromuscular coordination system and decreased situational awareness. Balls, hockey pucks and sticks, lacrosse sticks, bats, elbows, and knees are all commonly cited as the cause of pediatric facial injuries during athletic events, especially when the appropriate personal protective equipment is not worn.
There have been several excellent studies regarding the epidemiology of pediatric facial trauma. Posnick and colleagues reviewed 137 pediatric patients with facial fractures; most of the patients were boys, and the largest group of patients was found in the 6- to 12-year age range. The most common cause of trauma was motor-vehicle related, followed by falls, sports injuries, and interpersonal violence. Mandibular fractures composed most of the injuries (55%), followed by orbital fractures (30%), dentoalveolar fractures (23%), midface fractures (17%), nasal fractures (15%), complex fractures (14%), and cranial fractures (6%). Among the reported mandibular fractures, condyle fractures were the most common, followed by the symphyseal region, the body, and the angle of the mandible. However, the incidence will naturally vary geographically depending on multiple factors. In addition, many more minor injuries, such as nasal and dentoalveolar fractures, are likely underreported because they can be commonly managed on an outpatient basis. There were no cervical spine injuries in this study. In a recent, large, epidemiologic study of more than 12,000 pediatric fractures over 4 years, Imahara and colleagues recorded in the National Trauma Data Bank the common mechanisms of injury as motor vehicle collision (55.1%), violence (11.8%), and falls (8.6%). The most common fractures were the mandible (32.7%), nasal bones (30.2%), and maxillary bones/zygoma (28.6%). Toddlers and infants are more likely to experience midfacial and cranial injuries, and mandibular fractures are more common in the adolescent population.
As previously noted, children are ensconced in a well-protected social environment with close adult supervision during their early years. However, as they begin to engage in social and athletic activity, their exposure to situations in which injury might occur heightens. The use of personal protective equipment is critical to lowering the incidence of facial injuries in children. Specifically included is the use of helmets, face shields, and mouth guards during sports play. Protective equipment during noncontact activities, such as bicycling and skateboarding, is equally important. Recently, there has been significant social momentum to change the composition of playground equipment and the surfaces of athletic fields to further lessen the chance of injury. Adults supervising children, either indirectly or directly, engaged in these activities must assume the responsibility of ensuring that appropriate safety equipment is used.
Perhaps the single most important factor in reducing the incidence of pediatric trauma overall is the correct mandatory use of seat belts and safety seats in vehicles for infants and children. According to recommendations from the National Highway Traffic Safety Administration (NHTSA), a rear-facing seat in the back seat of a vehicle should be used until 1 year of age and the attainment of at least 20 pounds. Car seats facing forward in the back should then be used until 4 years of age and the attainment of 40 pounds. Newer recommendations with a campaign for public awareness from the NHTSA have been advocated for children aged 4 to 8 years and at least 4 ft 9 in tall to be secured in a booster seat with a seat belt in the rear of the vehicle. The common use of air bag restraint systems in the modern vehicle is a concern for any child younger than 10 years of age seated in the front seat. Deployed air bags during a collision may apply tremendous forces to the cervical and chest regions of young children, with reports of severe injuries and fatalities sustained after being struck by an air bag.
All-terrain vehicles (ATV), especially in rural areas, also represent a significant potential for maxillofacial injury in the pediatric population. Little federal or state regulation exists for the operation of these motorized vehicles, and older children with little to no experience and questionable judgment are often operating these vehicles. Risk-taking behavior in youth, particularly adolescent boys, places them at an increased risk for serious injury with ATV and motorcycle use. Close adult supervision and responsibility is critical to ensure that safety measures are followed.
Other areas of focus regarding prevention include the alarming incidence of gun violence directed at or involving children. Educational efforts directed at firearm safety in the home and at schools and the heightened awareness of the public to this issue are important.
A meticulous treatment plan must be designed for the examination, resuscitation, and intraoperative and postoperative care of pediatric patients with maxillofacial injuries. Children in general have tremendous resiliency to stress from surgical procedures but they are not tolerant of inappropriate fluid and drug administration. Delays in the evaluation and management of major trauma are thought to contribute to approximately 30% of early deaths in seriously injured children, making thorough and expedient triage and management crucial.
Surgical preoperative management begins with the initial examination. The physical examination and history is not significantly different than in adult patients with the exception that much of the history must be obtained from the parents or other caretakers. Gaining cooperation for the physical examination can be difficult, especially with children shortly after experiencing a traumatic injury. Gentle examination with encouragement from the child’s parents is usually sufficient. Examination under general anesthesia or sedation should be approached with caution during initial management because this may obfuscate neurologic injury. In addition, because of the difficulty with movement during radiological procedures, such as computed tomography (CT) scans, sedation or anesthesia maybe necessary to ensure the diagnostic value of the study obtained. In severe pediatric maxillofacial trauma, particularly when central nervous system involvement is suspected, CT is the preferred method of radiographic evaluation. In the management of the injured child in extremis, adherence to the prescribed trauma life support algorithm is mandatory. In addition, specific pediatric protocols exist for the evaluation of possible cervical spine injury in children. Although airway embarrassment secondary to craniomaxillofacial trauma in children is uncommon, airway preservation with adequate respiratory exchange must be maintained. Intubation is preferred if there is any question of airway integrity. Also, cricothyroidotomy for surgical maintenance of the airway is contraindicated in children less than 12 years of age because of the risk of subglottic stenosis.
Hypothermia in trauma resuscitation of children is common, therefore, elevated room temperature, patient warming devices, and warmed normal saline is recommended for the initial resuscitation. Rapid intravenous access can be challenging in pediatric patients making intraosseous or central access more commonplace. In situations with major volume loss, the surgeon should seek to resuscitate the child with 20 mL/kg boluses of appropriate crystalloid fluids in a 3 mL to 1 mL ratio to blood loss. If subsequent blood transfusions are required, these are generally administered in 10- to 20-mL/kg increments. In addition, as a result of the smaller amount of intravascular volume, the surgeon should be cognizant that coagulopathy is more likely with massive transfusion. Acidosis is a particularly ominous sign in children that reflects inadequate tissue perfusion and should be managed early and aggressively. Maintenance intravenous fluids should be calculated using the 4-2-1 rule: 4 mL/kg/h for the first 10 kg of weight, 2 mL/kg/h for the second 11 to 20 kg of weight, followed by 1 mL/kg/h for each additional kilogram of weight thereafter. Maintenance fluids in babies and toddlers are usually given as one-quarter normal saline with dextrose; one-half normal saline should be reserved for older children and teenagers. Urine output is normally 1 to 2 mL/kg/h in the child and should be recorded to ensure adequate volume. The importance of weight-based administration and monitoring of fluids and medications in pediatric patients cannot be overemphasized.
Frontal Bone and Superior Orbital Fractures
As a result of rapid brain growth in infancy, the upper third of the facial skeleton remains prominent in early childhood. For this reason, injury to this anatomic region is a common fracture pattern. Neurosurgical and ophthalmologic concerns must come first before the management of the facial bone injuries. Operative intervention for neurologic injury, such as repair of dural tears, should be viewed by the craniomaxillofacial trauma surgeon as an opportunity to collaborate with the neurosurgeon and simultaneously reduce and stabilize the fractured segments. In the absence of a cerebrospinal fluid (CSF) leak and significant displacement of the fractured segments, frontal bone injuries can be conservatively managed in a closed fashion without significant functional or aesthetic sequelae. As a rule of thumb, the displacement of the anterior cranial vault or superior orbital rim by the full-thickness width of the bone involved is a reasonable indication that there will be postinjury aesthetic concerns prompting the need for operative intervention. Growing skull fracture is a unique entity of calvarial fracture in young children, which is caused by the herniation of the leptomeninges or brain at the site of dural tears. Despite normal intracranial pressure, brain swelling and subsequent growth and CSF pulsations allow calvarial displacement along the fracture (or sutural) seam. Formal cranioplasty may be necessary for the repair of the defect, and definitive neurosurgical care is required for management of herniated brain tissue.
The disruption of the orbital roof causing direct contact of the dura with the periorbita is a significant concern. If left untreated, this may cause orbital pulsations and potentially increase intraorbital pressure. The roof itself is thin, especially in the young child, and is often not amenable to fixation even with a large fracture segment. Reconstruction of the roof with split calvarial grafts (children with a developed diploe) remains the gold standard for treatment.
Frontal Sinus and Fronto-Basilar Injuries
The frontal sinus, which begins as a cephalic evagination of the middle meatus, develops around 1 to 2 years of age. Radiographically, it becomes visible around 6 to 7 years of age and continues to expand into early adulthood. The management of these injuries in children when the sinus is present is similar to adult patients and is most often dictated by neurosurgical concerns. For posterior table fractures with dural tears, cranialization is the treatment of choice. Every effort must be made to seal the anterior cranial fossa at the conclusion of these craniofacial approaches to prevent a CSF leak and minimize the risk of postoperative meningitis. The placement of a pericranial flap with autogenous bone as necessary and fibrin glue on the anterior skull base is an effective maneuver to isolate the anterior fossa from the ethmoids and nasal cavity ( Fig. 3 ). Osteomyelitis of the skull in children is a rare postoperative complication but can have devastating consequences. Maintaining the sterility and integrity of the operative field is of paramount importance. For anterior table fractures, simple elevation and stabilization is appropriate. Sinus preservation is preferred in children, therefore, sinus obliteration is generally not undertaken, particularly with the advent of the endoscopic control of sinus disease should that eventuate after injury. The follow-up with serial CT scans to rule out pathologic conditions and demonstrate sinus function is mandatory.
The management of naso-orbito-ethmoid (NOE) fractures in children is similar to adult patients. Ophthalmology consultation is essential to rule out injury to the globe and assess vision. Sedation or assessment in the operating theater may be necessary to adequately evaluate lacrimal integrity. If the fractures extend into the anterior cranial fossa, neurosurgical consultation should also be obtained. If sinus drainage is compromised by bone displacement, the reduction and restoration of nasofrontal drainage is necessary. For the most part, when there is minimal displacement of the medial canthus and medial orbital fractures, NOE fractures in children can be managed in a closed fashion with one caveat: the nasal reduction must be stable. If the nose can be reduced, but will not stay elevated or cannot be reduced, internal fixation is necessary. If the nasal reduction is stable, the use of a nasal cast to compress the tissues medially and maintain the nasal reduction is usually all that is required. Rarely, the reduction of the impacted fractures will allow for CSF leakage from the previously injured anterior cranial fossa and will necessitate open reduction.
Open reduction and internal fixation of NOE fractures should be performed through a coronal incision or through an overlying laceration. Severe comminution of the nose is uncommon but, when present, requires strut bone grafts harvested from the calvarium or ribs and placed on the dorsum to help prevent posttraumatic saddle nose deformity. It is unusual to see avulsion of the medial canthal tendon because usually it is attached to a significant fragment of bone. Care must be taken not to strip the canthal attachment from the fragment. This practice will allow the surgeon to reduce and plate the fracture and, thus, reposition the tendon. Many have found that recreating the pretrauma contour of this region is extremely difficult and it becomes even more troublesome if formal wire canthopexy is performed. Meticulous attention should be paid to the anatomic reduction of the fracture segment. Even when internal fixation is used for operative treatment, the placement of a nasal cast to compress the overlying stripped soft tissues in place is helpful in controlling nasal width and recreating contour of the soft tissue in the region between the nose and the lacrimal lake on each side.
Fractures of the orbit are common in children because of its anterior projection and size. Ophthalmologic consultation is recommended to rule out ocular injury and assess vision. Vision, pupillary responses, and movement should be recorded and rechecked. Proper intraocular examination of the globe in children requires specialty-level skill and experience for accurate diagnosis. CT scans (axial, coronal, and sagittal views) is required to properly evaluate the extent of fractures, particularly those that extend posteriorly to the orbital apex. Fractures that seem to approach the optic canal should be studied with 1-mm coronal cuts to properly evaluate canal integrity and possible optic neurovascular compromise. If there are fractures involving the optic canal area and visual compromise is recorded, neurosurgical consultation with a view toward canal decompression or administration of corticosteroids or acetazolamide to control swelling and decrease intracranial/orbital pressure should be given consideration.
Surgical access to the orbit is the same as adult patients. Overlying lacerations, if present and appropriately positioned, should be used if possible. From an aesthetic standpoint, a transconjunctival approach to the orbit remains particularly appealing. If the treatment of the orbital fracture is combined with other upper facial fractures, access to the superior, medial, and lateral walls can be achieved through the coronal incision. Blow-in fractures of the orbit may result in increased intraocular pressure and cause permanent visual compromise. In addition, sharp fragments of bone protruding into the periorbital tissue should be identified and removed. The exploration and reduction of these fractures should proceed as rapidly as possible. Blowout orbital fractures in children should be managed conservatively and nonoperatively in the case of minimal displacement, excellent globe mobility, and no ophthalmologic indications. Late enophthalmos rarely occurs in children with minimal orbital wall blowout. In the setting of significant disruption of the orbital floor or inferior orbital rim, the exploration and reduction of the fractures is necessary. The rare instance of true muscle entrapment should be regarded as a surgical emergency in children ( Fig. 4 ). Bony entrapment of the inferior rectus muscle can cause scarring, and shortening of the muscle leads to permanent restriction of ocular motility. Eye muscle repair of this problem is extremely difficult and has limited success. As in adults, the correction of late enophthalmos is challenging and requires overcorrection with orbital grafts, which is generally undertaken as soon as the condition is diagnosed.
The reconstruction of the skeletally immature orbit should be performed with autogenous bone grafts. Although somewhat controversial, resorbable mesh can also be used to restore orbital volume, with or without bone grafts ( Fig. 5 ). After 7 years of age, the orbit is generally of adult size and development and reconstruction can be achieved with the use of several different materials, including autogenous bone; titanium mesh; or implants, such as porous polyethylene.
Zygomaticomaxillary Complex Fractures
Fractures of the malar or zygomaticomaxillary (ZMC) complex are uncommon in children but increase in adolescence because of sports and violence. High-velocity injuries generally result in the ZMC unit being fractured or comminuted. Minimally displaced fractures with little or no loss of facial projection and no ophthalmologic concerns should be conservatively managed. Fractures that require reduction and fixation may be accessed through inferior and superior orbital incisions and transconjunctival and transoral approaches. From an aesthetic viewpoint, the transconjunctival and upper blepharoplasty approaches are preferred. Less commonly, access through a coronal incision is required for severely comminuted fractures. Coronal access also provides for calvarial harvest if desired.
Fixation at 2 points is usually adequate for stabilization in children with ZMC fractures ( Fig. 6 ). Caution must be exercised when placing internal fixation at the zygomaticomaxillary buttress area in younger children to prevent screw placement in unerupted teeth. In addition, wide stripping of the periosteal envelope should be limited in the immature skeleton to avoid possible adverse consequences of periosteal scarring and inhibition of future growth.
Nasal fractures in children are fairly common. Their incidence is underreported because a significant number of parents seek outpatient care through direct referral at the time of injury. Plain film radiographic examination of the fracture may be all that is necessary if there is no suspicion of additional fractures or a lack of unusual findings on clinical examination. Intranasal inspection with a speculum must be performed to rule out the deviation or distortion of the nasal septum, with a particular focus on the identification of a septal hematoma if present. Hematomas must be evacuated and the septum stabilized with compressive stents to support the cartilage, eliminate dead space and blood reaccumulation, and provide for perichondrial healing ( Fig. 7 ). The nose is inspected for symmetry and projection; if displacement is present, closed reduction is performed. The surgeon should alert the parents to the possibility of growth disturbance of the midface and the potential for nasal stenosis or obstruction and emphasize the need for long-term follow up.
As mentioned previously, most pediatric nasal fractures are managed in a closed fashion with nasal splints or cast. Unfortunately, for many surgeons, closed reductions of nasal fractures in children are perfunctory procedures and consequently have less-than-ideal outcomes. The aesthetic component becomes extremely important to self-esteem as the child moves into adolescence and the management of these injuries requires strict attention to detail. A custom-molded splint or cast is indispensable in properly supporting the reduced nose and stabilizing the fracture. If the reduction is not adequate and there is residual deformity after healing, selected and focused nasal surgery may be undertaken during growth; however, most nasal deformities should be deferred to adolescence when formal rhinoplasty can be performed more safely.
Facial fractures in children that involve the midface are uncommon. In early childhood, the midface is protected by a prominent forehead, it is small compared with the other skeletal units, and there is little sinus development. The sinuses begin to accelerate their development after 6 years of age, with the further downward and forward growth of the maxilla as the mixed dentition erupts.
The treatment of minimally displaced midface fractures in children is closed reduction with maxillomandibular fixation. Fractures with significant malocclusion or displacement are often associated with other injuries and usually require open reduction with rigid or semirigid internal fixation. The surgeon must be careful to not injure the developing dentition with screw placement at the Le Fort I level when internal fixation is used. In extreme cases of buttress comminution and facial foreshortening, bone grafts may need to be placed to assist in restoring facial height and projection.