Pediatric emergency medicine trisk 825

Current Evidence
To target the use of CT among children with facial trauma, a few studies have
identified clinical predictors of orbital fracture. These studies have identified that
orbital fractures requiring operative intervention are uncommon in the absence of
orbital tenderness, swelling, ecchymosis, nausea/vomiting, or painful extraocular
movements.
Studies suggest that early repair (within 24 to 48 hours) of orbital trapdoor
fracture and release of the entrapped muscles may help avoid muscle ischemia
and fibrosis, and result in better functional recovery. A few studies have also
demonstrated that corticosteroids may decrease swelling and hasten resolution of
diplopia among patients with limitation of extraocular movement.

Nasal Fracture
Goals of Treatment
The primary goals in treatment of nasal fractures in the emergency setting are
immediate recognition and drainage of septal hematoma, and in children,
reduction of nasal fractures with deformity within 7 days.
CLINICAL PEARLS AND PITFALLS
Nasal fractures may be difficult to detect clinically because of significant
swelling.
Septal hematomas require urgent incision and drainage to avoid
necrosis of the avascular septal cartilage.
Patients with nasal deformity 4 to 5 days after injury require urgent
consultation with a subspecialist to restore anatomic alignment.
Clinical Considerations
The nasal bones are among the most commonly fractured bones of the facial
skeleton because of their prominent location on the face. Nasal fractures may be
difficult to detect because of significant swelling associated with such injuries.
Imaging is rarely needed in the emergent care of children with nasal trauma
because, in most cases, it does not contribute to subsequent care and
management. Most nasal injuries can be managed as an outpatient, and evaluation

after the swelling subsides dictates the need for further intervention.
Two particular nasal injuries that deserve specific comment are the intractable
nosebleed and septal hematomas. Because of the rich vascular network in the


nose, supplied by branches of both the internal (anterior ethmoidal) and external
(superior labial, palatine) carotid arteries, nasal hemorrhage can be difficult to
stop despite usual conservative measures (e.g., anterior compression). Treatment
of persistent epistaxis may require anterior and/or posterior nasal packing with
gauze or tampon, or the placement of an epistaxis balloon catheter. If a bleeding
vessel can be identified, silver nitrate cauterization can be performed.
Septal hematomas arise because of hemorrhage from an artery beneath the
mucoperichondrium, separating it from the septal cartilage. Because the septal
cartilage is avascular and relies on the overlying mucoperichondrium for its blood
supply, a hematoma may result in cartilage necrosis and eventual septal
perforation. Septal hematomas require urgent incision and drainage (see Chapter
106 ENT Trauma ).
Nasoorbital ethmoid fractures involve complete separation of the nasal bones
and medial walls of the orbits from the stable frontal bone superiorly and
infraorbital rim laterally. These injuries are usually the result of high-velocity
trauma to the central midface. The bones are often fragmented and telescoped
posteriorly into the ethmoid region. These patients display a characteristic
flattened nose, with the loss of anterior projection on the lateral view of the face.
Because the medial canthal tendons attach firmly to the medial walls of the orbits,
lateral drift of the fracture segments results in traumatic telecanthus. Normal
mean intercanthal distance is 16 mm at birth, which increases to 25 mm in a
female and 27 mm in a male at full facial growth. A significant increase in
intercanthal distance or gross asymmetry in the medial canthal to facial midline
distance should raise suspicion of this fracture. Traumatic telecanthus suggests
the diagnosis of a nasoorbital ethmoid fracture, which unlike a nondisplaced nasal

fracture, requires urgent subspecialist input.
Current Evidence
Nasal fractures are largely a clinical diagnosis. Though rarely required for
diagnosis, CT is the optimal modality for complex fractures. More recent studies
suggest that high-resolution ultrasonography may be more sensitive than CT or
plain radiography for the detection of simple nasal fractures.
While repair of nasal fractures can be successfully performed within a few
hours after the injury, immediate repair is usually not possible because of the
significant swelling that often develops rapidly with such injuries. The optimal
timing after the immediate injury period is controversial. Some reports have
demonstrated improved cosmetic outcome when repair is performed within 5
days of injury, while other studies have not demonstrated a difference in cosmesis


with early (≤7 days) versus late (>7 days) repair. Patients suspected of having
nasal fractures should be reevaluated within 4 to 5 days after the swelling
subsides. Plain radiographs may be helpful at this time to determine whether
malalignment exists. Patients with nasal deformity 4 to 5 days after injury require
urgent consultation with a subspecialist to restore anatomic alignment.

Zygoma and Maxilla Fractures
CLINICAL PEARLS AND PITFALLS
Particular attention to the airway is of paramount importance in children
with midface fractures as significant bleeding and disruption of normal
anatomic structures may compromise airway patency.
Clinical Considerations
The zygoma is composed of a body or malar eminence and the zygomatic arch. A
complete fracture of the zygoma often extends through the floor of the orbit. This
may result in an inferior displacement of the zygoma because of the strong
inferior forces applied by the masseter muscle, which attaches to the malar

eminence. Zygoma fractures often produce a flattened appearance to the cheek,
with inferior displacement of the globe, and conjunctival hemorrhage. Decreased
sensation along the distribution of the infraorbital nerve is also common, as
zygomaticomaxillary fractures usually include the infraorbital foramen. Unilateral
zygomatic arch fractures can cause a decrease in temporal width, which is best
visualized when viewing the face from the front as a result of buckling of the
zygomatic arch. If this buckling is severe, the mandibular condyle may be
impinged, with resultant difficulty in mouth opening.


FIGURE 107.5 The Le Fort classification of fractures. With type I, the maxilla is separated
from its attachments. Type II (pyramidal) produces a mobile maxilla and nose. With type III
(craniofacial disjunction), all attachments of the midface to the skull have been separated.
Traction on the anterior maxilla produces motion up to the inferior orbital rims and zygoma.
These fractures are not mutually exclusive. For example, Le Fort II fracture may exist on the
one side with type III on the other side.

In 1901, Le Fort described three fracture patterns that occurred in patients with
midface trauma ( Fig. 107.5 ). The Le Fort I fracture pattern involves only the
maxilla and extends through the zygomaticomaxillary region to the base of the
pyriform aperture. It allows motion of a segment of alveolar bone and teeth when
examined. The Le Fort II pattern, also called a pyramidal fracture, is similar but
extends more superiorly to the infraorbital rims and across the nasofrontal
sutures. The maxilla, nasal bones, and the medial orbital wall are separated from
the facial skeleton. The nose and the upper jaw are movable, whereas the
zygomas are stable. The Le Fort III pattern, also called craniofacial dissociation,
extends across the zygomatic arch, zygomaticofrontal region, floor of the orbit,
and nasofrontal sutures, effectively separating the midface from the skull base.
When the nose or upper jaw is moved, the entire midface, including the zygoma,
moves with it. These fractures are quite rare in children, and when they do occur,

they are most often asymmetric because impact is sustained from the side rather
than head on.
Patients with midface fractures typically have significant swelling over the
maxilla and severe epistaxis. Particular attention to the airway is of paramount
importance in these children because significant bleeding and a disruption in the
normal anatomic structures may threaten the patency of the airway. Nasal
manipulation should be avoided because these fractures may be associated with
cribriform plate injuries and passage of a nasogastric or endotracheal tube may