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Zygomaticomaxillary Complex Fractures Associated With Naso-orbito-ethmoid Fractures In Pediatric Patients: A 25-year Experience At The Johns Hopkins Children’S Center
Pooja S. Yesantharao, MS, Joseph Lopez, MD, MBA, Amy Chang, MPH, Jacqueline Hicks, MS, PhD, Maria L. Reategui, BA, Gianni Thomas, BA, Paul N. Manson, MD, Amir Dorafshar, MBChB, Richard J. Redett, MD.
Johns Hopkins Medicine, Baltimore, MD, USA.

PURPOSE: Naso-orbito-ethmoidal (NOE) fractures associated with ipsilateral ZMC fractures are more challenging injuries than ZMC fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. Because of differences in the craniofacial skeleton between children and adults, it is important to characterize combined ZMC-NOE fractures in children specifically, especially given that this injury pattern in adults leads to poorer long-term outcomes. This study investigated the etiology, treatment, and outcomes of combined ZMC and NOE fractures versus isolated ZMC fractures in pediatric patients.
METHODS: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with ZMC fractures. Patient data/outcomes were derived from the medical record and comparatively investigated between (1)combined ZMC-NOE and (2)isolated ZMC fracture cohorts.
RESULTS: Forty-nine patients had ZMC fractures in our 25-year study period, of whom forty-six had adequate clinical documentation and follow up. Seventeen of these patients had ipsilateral NOE injuries associated with their ZMC fracture. Both patient groups (isolated ZMC fractures versus combined ZMC and NOE fractures) were similar in terms of demographics. However, patients with combined ZMC-NOE fractures had longer median hospital lengths of stay than patients with ZMC fractures alone (9 vs. 5.5 days), and a greater proportion of patients with combined ZMC-NOE fractures required more extensive surgical approaches with coronal incision (57.1% vs. 11.8%, p=0.007). Approximately 88.2% of patients with combined ZMC-NOE fractures suffered complications versus 31.0% of patients with isolated ZMC fractures (adjusted odds ratio 58.2, p=0.001; Table 1). Furthermore, patients with combined ZMC-NOE fractures had greater incidence of postoperative facial deformity than those with ZMC fractures alone (adjusted odds ratio 6.72, p=0.032). Enophthalmos (41.2%), orbital dystopia (29.4%) and midface growth restriction (35.3%) were the most common postoperative deformities in patients with combined ZMC-NOE fractures, and were observed disproportionately in these patients compared to patients with isolated ZMC fractures. In fact, midface retrusion was seen exclusively in patients with combined ZMC-NOE fractures who had deciduous dentition.
CONCLUSION: This is the largest longitudinal study of combined ZMC-NOE fractures in pediatric patients. Our results demonstrate that high impact trauma can cause NOE fractures in association with ZMC fractures relatively commonly in this patient population. This injury pattern was found to cause significantly greater postoperative complications and deformity than isolated ZMC fractures alone, possibly due in part to inadequate surgical reduction in the context of a more complex fracture. Thus, pediatric patients presenting with this facial fracture pattern require greater attention at the time of operative repair to ensure adequate bony reduction, possibly through use of low-dose intraoperative imaging and custom splints. Furthermore, these patients require more extensive clinical follow-up and monitoring given a greater risk for long-term morbidity.


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