Special consideration in

pediatric fractures,
edentulous, infected
fractures

PRESENTER: DR. ISHA KOCHAR

3RD YR PG

Special Considerations in
Children

General principles for resuscitating multiply injured

patients follow the advanced trauma life-support
principles created by the American College of Surgeons.

Infants obligate nasal breathers

Nasal air passages narrow and easily obstructed.

Chest wall in children is pliable

Major thoracic injuries exist with fewer than expected signs of

external trauma.

Children frequently swallow air when they are injured or frightened,

resulting in gastric dilatation.

Abdominal girth and volume of the peritoneal cavity in infants and

young children are relatively small.

Significant intra-abdominal bleeding results in a

rapid change in girth.

Children maintain a normal or borderline BP level

despite significant fluid loss and then
decompensate rapidly.

Children have a larger body surface area-to-overall

mass ratio than adults; therefore more prone to
hypothermia.

Children are generally injured in low velocity

accidents secondary to falls from low heights,
playground equipment, or riding toys.

PEDIATRIC FACIAL
FRACTURES
Structural and anatomic
differences:

Children have cranium-toratios of 8:1 at birth and

age 5

face
4:1 at

Adulthood 2.5:1 on average

Facial fat pads, buttressing tooth buds, and

unpneumatized sinuses function to stabilize the
pediatric facial skeleton.

ed elasticity of developing skeleton and relative

thickness of the periosteum higher proportion of
greenstick and nondisplaced fractures treatable with
conservative therapy.

INITIAL
MANAGEMENT

Focus on the ABCs of trauma.

High surface-to-volume ratio, metabolic

rate, oxygen demand, and cardiac output of
children along with their low total blood
volume create a propensity for rapid
decompensation with subsequent
hypotension, hypoxia, and hypothermia.

TIMING OF FRACTURE
REPAIR

In adults, 3 weeks approximate period in

which a fracture will begin to heal enough that
reduction becomes difficult.

Occurs much sooner in children

Mandibular fractures best treated within first

48 hours.

Periorbital fractures without EOM entrapment

after evaluation of hypoglobus and
enophthalmos should be treated within 7
days.

DIAGNOSIS
Comprehensive history :

Cause of injury,

Time frame from injury to evaluation

H/O LOC

Avulsed teeth

Location of the teeth,

Transport medium of the teeth, and

Whether the teeth were rinsed or swallowed or

aspirated.

Battered child complex

CLINICAL EXAMINATION
:

Facial edema

Periorbital ecchymosis

Subconjunctival hemorrhage

Subcutaneous emphysema

Nasal bleeding

Chin lacerations

Postauricular ecchymosis (Battles sign)

Ophthalmologic examination - pupillary reactivity,

visual screening, and extraocular movements

INTRAORAL :

Palpation for steps intraorally

Assessment of occlusion/dentition

Presence of ecchymosis in the floor of the mouth

Mobility of dental segments

RADIOLOGIC EXAMINATION :

Complete facial series of radiographs :

- Left and right lateral oblique views of the mandible

mandibular body and ramus
- Towne projection condylar injuries

PA view mandible and midface

Waters view midfacial and nasal fracture

detection

Submental vertex view zygomatic arches

3-mm axial, coronal, and sagittal computed

tomography (CT) - standard of care

Sagittal images are particularly useful for

evaluating orbital floor trauma

3-D CT assess facial fractures globally from

multiple angles and assist with surgical planning

TYPES OF
FRACTURES
ALVEOLAR FRACTURES :

An alveolar fracture may have a segment of teeth that are

mobile as a group, with associated soft tissue injury and
malocclusion.

Primary treatment is conservative

Immobilizing the arch segment using:

- arch bar,
- wire ligation, or

- composite supported orthodontic wire extended to stable

teeth in the injured arch.

Significant alveolar bone loss alveolar bone reconstructed via

autogenous bone grafting and standard dental reconstruction.

MIDFACIAL
FRACTURES
Nasal Fractures :

Signs & symptoms :

epistaxis

nasal-periorbital ecchymosis

nasal edema

nasal septal ecchymosis

associated lacerations

Treatment closed reduction if the injury is less than 1 week old

using nasal elevators (intranasal approach)

> 1 wk or there is an existing laceration open reduction

considered

Secondary rhinoplasty procedures can be considered after facial

growth is completed, generally after 16 years.

Maxillary Fractures

Physical examination reveals classic signs of a LeFort

fracture

maxillary vestibular ecchymosis,

facial edema,

malocclusion, and

gross mobility of the maxilla.

For higher level Le Fort fractures (type 2 or 3) periorbital

edema, traumatic telecanthus, and periorbital ecchymosis.

Closed reduction treatment of choice

Application of orthodontic brackets closed reduction

with heavy elastics or thin (26- or 28-gauge) wire

Alternatively, screw fixation of the piriform and

zygomatic buttresses bilaterally & in the symphyseal
region of the mandible for IMF and immobilization.

Limitations necessity for this to be done under general

anesthesia and the risk of damaging underlying tooth
buds.

Impressions may be taken and models poured and

sectioned to facilitate splint construction for closed
reduction.

Closed reduction for 2 to 3 weeks with 26-gauge wire

followed by 3 weeks of progressively lighter elastics

Orbital Fractures

< 7 years orbital roof # with extension to the frontal sinus

(underdevelopment of the sinuses)

> 7 years injury to the orbital roof, medial and lateral walls, floor,
and frontal sinus are more frequent

Complete ophthalmologic examination should precede orbital

exploration.

Classification :
Type 1: Pure Orbital Fractures

1afloor fractures

1bmedial wall fractures

1croof fractures

1dlateral wall fractures

1ecombined floor and medial wall fractures

Type 2: Craniofacial Fractures

2agrowing skull fractures

Type 3: Orbital Fractures Associated With Common Fracture Patterns

3afractures of floor in inferior orbital rim

3bzygomatic maxillary complex fractures

3cnaso-orbital-ethmoid (NOE) fractures

3dother fracture pattern

Physical examination

periorbital edema and ecchymosis,

subconjunctival hemorrhage,

enophthalmos,

diplopia, and

infraorbital nerve paresthesia

Forced duction test to evaluate for inferior rectus muscle

entrapment

Most common type of pediatric orbital fracture type 1

fracture (pure orbital)

Types 1 & 2 # Conservative management

Surgical intervention : entrapment, enophthalmos, or vertical

orbital dystopia.

Type 3 fractures treated surgically as part of the concomitant

fracture

Orbital fractures in children with evidence of muscle

entrapment treated sooner to avoid necrosis of the

extraocular musculature and associated oculorotary

dysfunction

FRACTURES OF THE
ZYGOMATIC COMPLEX
Physical findings :

Periorbital edema

Trismus if the arch is fractured and displaced

Infraorbital nerve hypoesthesia

Flattening of the malar process, and

Palpable bony steps

- Reduction of the fractured arch of the zygoma only treatment

necessary, if a cosmetic deformity exists or if notable trismus present

3-point stabilization is ideal : (Displaced/comminuted #)

- Zygomatico-frontal process,
- Infraorbital rim, and
- Zygomatic buttress

MANDIBULAR
FRACTURES
Fractures of the Mandibular Condyle :

< 6 yrs intracapsular #

> 6 yrs condylar neck region

2 issues unique to pediatric condylar fractures :

- Risk of temporomandibular joint (TMJ) ankylosis
- Potential progressive growth disturbances of the face.

Physical examination :
- Trismus
- Mandible deviates to the affected side
- Preauricular swelling
- Malocclusion (open bite malocclusion on the unaffected side)

Remodeling post-injury in the pediatric population.

Remodeling can be defined as an uprighting of the

condylar process and restoration of TMJ joint
function.

2 active mechanisms involved in remodeling

- resorption of the fractured, displaced condylar segment
- apposition of bone to create a new condyle.

TREATMENT :

Minimally displaced conservative management

Mandibular asymmetry MMF for 2 wks followed by physical

therapy

Absolute indications for open reduction:

Displacement of the condyle into the middle cranial fossa

Inability to obtain adequate occlusion by closed reduction

Lateral extra capsular condylar displacement

Presence of a foreign body

Relative indications for open reduction:

Severe seizure disorder

Mental retardation

Severe upper airway obstruction

Psychologically unable to tolerate MMF

Mandibular Angle, Body,

and Symphysis Fractures

Treated conservatively via closed reduction

2 to 3 weeks of MMF bonding orthodontic appliances

Lingual splint

Associated condylar fractures internal fixation of

symphysis # limits the need for MMF permits early
function of the condyles

Midface (1.5-mm profile) plates

Placed as inferiorly as possible to avoid tooth buds

Removal after 4 to 6 months to ensure no restriction

in mandibular growth

CONCLUSION

Children cannot be treated as little adults.

Although conservative management is best in

most cases, rigid fixation may be needed in more
severe injuries and care must be taken to avoid
compromising future dentition and skeletal
growth.

EDENTULOUS
FRACTURES

EDENTULOUS
FRACTURES
Treatment planning decisions influenced by :

Risks of prolonged or invasive surgery

Impact on function from intermaxillary fixation

Recuperation from open surgery

Psychological implications

Preexisting medical conditions

Bony changes Alveolar bone atrophy

MAXILLARY FRACTURES

Most common maxillary fracture junction of the horizontal

plate of the palatine bone and posterior part of the maxilla

Existing suitable dentures denture is altered to be useful

in positioning and immobilizing the maxilla.

Holes are drilled in the acrylic area of the denture to aid in

securing arch bars to the denture, making stabilization to
the underlying bone easier.

Gunnings splint can be fabricated

Secured to maxilla via :

Transalveolar wiring

Transalveolar pin placement or

Suspension wires from the malar buttress, piriform rims,

nasal spine, or zygoma

Circum-mandibular wires - securing a mandibular

prosthesis or full mandibular dentures

ORBITAL FRACTURES :

Infraorbital approach provides direct and easy access to

the infraorbital rim and orbital floor.

Aging causes laxity and downward shift of eyelid tissues

and atrophy of the orbital fat
- ectropion

- entropion
- dermatochalasis, and
- ptosis

Transconjuctival approach, with and without

lateral canthal extension for
reconstruction of ZMC and isolated orbital
fractures

Minimal postoperative complications

Cosmetically acceptable

Minimal incidence of ectropion compared

with cutaneous approaches.

MANDIBULAR
FRACTURES
Closed reduction :

Mandibular full denture stabilized with circummandibular

wires

Gunning splints

External fixation - Steinmann pins or Kirschner

wires

Open reduction and internal

fixation :

Use of larger plates, 2.4-mm mandibular fracture or

reconstruction plates and bicortical screws
atrophic mandibular body fracture

Severely atrophic mandibles, in which the

maximum bone height < 5 mm augmentation
using freeze-dried cadaveric mandible packed with
autogenous cancellous iliac bone

CONCLUSION

Recommendations about the triage and resuscitation of

older trauma patients:

1. Advanced age should lower the threshold for triage directly

to a trauma center.
2. Age alone is not a predictor of poor outcome and should not
be the determining factor in limiting care.
3. The presence of preexisting medical conditions adversely
affects the outcome in older trauma patients.
4. Older trauma patients (65 years) with a Glasgow Coma
Scale score less than 8 have a very poor prognosis.
If improvement is not possible within 72 hours, limitation of
continued aggressive therapy should be considered.

5. Low survival rates and longer lengths of stay are associated

with postinjury complications.
6. Given that 85% of older trauma patients will return to
independent function, resuscitation should be pursued
aggressively on patients who are not moribund on arrival.
7. Older patients with an admission base deficit less than 6
have a high mortality rate (66%) and may benefit from
inpatient acute care nursing.
8. Patients 65 years of age or older with a trauma score less
than 7 or a respiratory rate <10 have a 100% mortality rate; in
these patients, limitation of continued aggressive therapy
should be considered.

9. Despite meeting the criteria for triage to a trauma

center, trauma patients who are 55 years and older are
much more likely to be improperly triaged.
10. Invasive hemodynamic monitoring is indicated for
geriatric trauma patients with uncertain cardiovascular
or renal disease.
11. Effort should be made to optimize the cardiac index
(>4 liter/min/m2) and oxygen consumption index (170
mL/min/m2).

INFECTED
FRACTURES

INFECTED
FRACTURE

Risk of infection depends on 3 factors:

1.

Amount & type of microbial contamination of wound

2.

Condition of wound at the end of treatment (e.g., presence of

residual necrotic tissue, foreign bodies, bacterial no.)

3.

Host susceptibility

Infection of maxillo-mandibular fractures originate from :

- Inadequate interfragment stability
- Foreign bodies
- Loose hardware
- Tooth in the line of fracture
- Necrotic bone fragment

Factors influencing infection in the trauma

patient scheduled for surgery are as follows:

Length of the preoperative period of hospitalization

Use of razors to shave the operative site

Nature of preparation of the operative site

Maintaining normothermia

Oxygen therapy

Associated resuscitative procedures (allogeneic

blood transfusions)

FACIAL BONE
FRACTURES
Fractures not considered contaminated :

Closed # of subcondylar region

Closed # of zygoma & other facial bones

If definitive treatment delayed, temporary IMF indicated to

prevent mechanical pumping of saliva & bacteria into # site.

IMF screws or,

Bridle-type wire

Movement of # also causes rebleeding at the fracture site,

which increases the local hematoma & causes a more
anaerobic environment.

FACTORS
GUIDING
CHOICE OF ANTIBIOTIC

Identification of the causative agent or the usual

organism that may cause an infection if prophylaxis
is indicated

Use of the least toxic antibiotic

Patients drug historyto avoid known drugs to

which the patient has previously reacted adversely

Use of a bactericidal as opposed to a bacteriostatic

drug, because the bactericidal drug relies less on
the hosts resistance, kills the bacteria directly, and
works faster

Cost of the antibiotic regimen

MANAGEMENT
OF
TEETH
ASSOCIATED
WITH
MANDIBULAR FRACTURE

Contemporary fracture management supports removing

teeth in the line of # only if the following conditions exist:
The tooth is loose.
The tooth is grossly carious or periodontally involved.
More than 50% of the root is exposed in the fracture line.

Adequate reduction is mechanically blocked by its

retention.

Retention of healthy firm teeth may help in the reduction of

a fracture and preserve the dentition.

INFECTIONS ASSOCIATED
WITH FRACTURES

Infection of the mandible following a fracture is

known as post-traumatic osteomyelitis.

Early signs of an acute suppurative osteomyelitis :

Deep intense pain

High intermittent fever
Paresthesia or anesthesia of the mental nerve
(arising after the trauma and reduction of the
fracture)
A clearly defined cause

Osteomyelitis progresses to cellulitis leading to intraoral or

cutaneous sites of drainage, or both.

Systemic signs :

Mild leukocytosis with a shift to more immature (band)

forms of PMNs,

Rise in temperature, and

An increase in ESR

To plan the appropriate surgery and ensure adequate

treatment, scintigraphy is a useful adjunctive study.

Scintigraphy is also useful for monitoring the course of the

disease and efficacy of treatment and may also indicate
when treatment can be safely stopped.

MANAGEMENT

Combined surgical and medical approach.

Nonvital tissue, foreign bodies, and associated teeth must be

removed.

At the surgical procedure, specimens of bone should be

obtained using meticulous technique and submitted quickly
for culture and sensitivity testing, without secondary
contamination.

Dbriding infected areas and establishing drainage are

important.

Continuous irrigation and drainage systems can be placed

through a closed wound following appropriate dbridement if
the infection is extensive or refractory to conventional
drainage and irrigation.

A means of fixation must be used to prevent further

movement of the fracture segments.

Use of external pins to span the gap created by the

removal of the involved bone.

Reconstruction of bony defect is not attempted until all

signs of infection are gone, generally after at least 2
months.

Absence of infection is determined on the basis of lack

of local signs of infection, such as drainage or cellulitis.

A bone scan using the technetium and gallium

subtraction technique can be carried out to corroborate
the clinical impression that the infective process has
cleared.

MIDFACIAL
FRACTURES

Involvement of sinuses

Microbiologic characteristics - presence of Streptococcus

pneumoniae and H. influenza in infected sinus

Choice of antibiotics

Le Fort II and III fractures may communicate with the

cranial cavity, as evidenced by a cerebrospinal fluid
(CSF) leak from the nose or external ear canals (CSF
otorhinorrhea).

Risk of meningitis

Early reduction of the fractures is indicated, which will

normally stop the CSF leak.

TREATING THE PATIENT

WITH
VIRAL INFECTION
Predictors of a preexisting viral infection :

age 20 to 49 years,

IV drug abuse,

prior HIV testing,

shock, and

Death

IV drug abuse single most significant predictor

Patients who required resuscitation or eventually died of

the trauma had a 12% to 21% infection rate with HIV,
hepatitis B virus (HBV), or both

Single gloving 100% incidence of glove perforation

when using wires

37% with the use of double gloves.

Triple gloving eliminates the inner glove perforation

entirely during arch bar placement but causes paresthesia
of the surgeons fingers and reduced dexterity.

Procedures lasting longer than 3 hours or more than 300

mL of total blood loss

Increased pre-op and post-op infection rates.

Open reduction was associated with a 45% infection rate

closed reduction should be used if possible

"The man who says it

cannot be done should
not interrupt the man
doing it."

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