Management of Pediatric Nasoorbitoethmoid Fractures: Is Trans-Nasal Wiring Necessary?
Joseph Lopez, MD MBA1, JD Luck, BA1, Muhammad Faateh, MBBS1, Alexandra MacMillan, MBBS1, Robin Yang, DDS MD1, Gabriel Siegel, BA1, Srinivas M. Susarla, DMD MD MPH1, Howard Wang, MD1, Arthur J. Nam, MD2, Jacqueline N. Milton, PhD3, Richard Redett, MD1, Anthony P. Tufaro, DDS MD1, Anand R. Kumar, MD4, Paul Manson, MD1, Amir H. Dorafshar, MBChB1.
1Johns Hopkins Hospital, Baltimore, MD, USA, 2R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 3Boston University School of Public Health, Boston, MA, USA, 4University Hospital Rainbow Babies and Children’s Hospital, Cleveland, OH, USA.
Purpose Currently, there is a paucity of information on the presentation, etiology, and proper management of pediatric nasoorbitoethmoid (NOE) fractures. The purpose of this study was to examine the incidence, etiology, associated injuries, and management of these fractures. Furthermore, we sought to assess outcomes after trans-nasal wiring or suture canthopexy for type III NOE fractures.
Methods A retrospective cohort review was performed of all patients with NOE fractures who presented to a Level-1 trauma center from 1990-2010. Charts and CT imaging were reviewed and NOE fractures were labeled based upon the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics and outcomes were recorded. Uni- and multi-variate methods were employed to compare groups.
Results A total of 63 pediatric patients were identified in the study period. The sample’s mean age was 8.78±4.08 and 28.6% were female. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Motor vehicle collision was the most common mechanism of injury. Operative intervention was pursued in 16.7%, 46.4%, and 82.4% of type I, II, III NOE fractures, respectively. In patients with type III NOE fractures, one patient treated with suture canthopexy developed post-operative telecanthus while no patients with trans-nasal wiring developed telecanthus (p = 0.36). Type III NOE fractures were predictive of operative intervention when correcting for ISS and Age. For prediction purposes, the c-statistic was 0.80. Lastly, patients with type III NOE fractures have 39.56 times the odds of having a hospital length of stay of >7 days (vs. 1-4 days) compared to those with a type I fracture after adjusting for age and ISS (p-value = 0.0021).
Conclusion NOE fractures in children are extremely rare, and occur only after severe midfacial trauma. This 20-year retrospective study is the largest of its kind to date, and has led us to propose a data-driven treatment algorithm. Our analysis revealed that all type III NOE fractures should undergo operative management with special attention to preserving canthal integrity and managing calvarial-based injuries such as dural leaks and cranial bony defects. Furthermore, based on this 20-year experience, we now prefer trans-nasal wiring to address telecanthus after type III injuries. Given the low rate of post-traumatic adverse events, we recommend that all type I NOE fractures be treated conservatively with close observation. However, if NOE type I injuries are associated with nasal trauma sequelae (i.e. septal hematomas or nasal obstruction), this should not preclude the patient from operative management. Lastly, type II NOE fractures should be managed in a case-by-case basis. Older children (with permanent dentition) with open fractures or grossly displaced NOE fractures may require operative management but young children with closed, minimally displaced fractures may be managed with observation.
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