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 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 to 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 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 to days after the swelling subsides Plain radiographs may be helpful at this time to determine whether malalignment exists Patients with nasal deformity to 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 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