Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number of Fixation Sites in Growing Children
JD Luck, BA1, Joseph Lopez, MD MBA1, Muhammad Faateh, MBBS1, Alexandra Macmillan, MA (Cantab) MBBS1, Robin Yang, MD DDS1, Edward H. Davidson, MA (Cantab) MBBS1, Arthur Nam, MD MS2, Michael Grant, MD PhD2, Anthony P. Tufaro, MD DDS1, Richard Redett, MD1, Paul N. Manson, MD1, Amir H. Dorafshar, MBChB1.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA.
PURPOSE: Currently, there is a relative paucity of data investigating the operative management of displaced pediatric zygomaticomaxillary complex (ZMC) fractures. The purpose of this study was to assess ZMC fracture management and associated complications in the pediatric population, and potentially describe a standard treatment paradigm for pediatric ZMC fractures.
METHODS: A retrospective cohort review was performed of all patients younger than 15 years-of-age presenting to a single institution with ZMC fractures from 1990-2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites.
RESULTS: A total of 36 patients with 44 unique ZMC fractures met our inclusion criteria. 32 ZMC fractures exhibited at least 2.0 millimeters of diastasis along at least one buttress (73%), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate when compared to one- and three-point fixation (0% vs. 75% and 75%, p = 0.01). The most common complications in the deciduous dentition age group in our series were midface retrusion and orbital-related complications including enophthalmos and strabismus/diplopia. Midface retrusion occurred exclusively in patients with deciduous dentition who suffered concomitant nasoorbitalethmoid (NOE) fractures. Rigid plate and screw fixation at the zygomaticomaxillary buttress (ZMB) was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40% vs. 50%, p = 0.76), and no patients were noted to develop dental complications.
CONCLUSION: Concomitant NOE and ZMC fractures place children younger than seven years of age at particularly high risk for developing maxillary hypoplasia, likely due in part to involvement of the nasomaxillary growth complex, wider soft tissue undermining necessary to access the fractures, and difficulty in re-establishing proper bony alignment. When feasible, two-point fixation including a permanent plate and monocortical screws at the ZMB may offer compromises between stability and future growth potential, and between fracture visualization and subperiosteal dissection. When considering patients with isolated ZMC fractures, the trend between two-point fixation and lower complication rates when compared to one- and three-point fixation remains, suggesting two-point fixation may offer additional benefits unrelated to future growth potential, such as in reestablishing pre-injury orbital volume and limiting periorbital dissection. The senior authors suggest that, when feasible, two-point fixation with plates and screws at the ZMB and zygomaticofrontal suture is an acceptable approach for the treatment of pediatric ZMC fractures to both adequately reduce and stabilize the ZMC segment while potentially reducing periorbital complications. However, the operating surgeon must ultimately use his or her judgment in determining the best fixation pattern for each patient.
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